Introduction: Colorectal cancer (CRC) is the second leading cause of all cancer related deaths in the USA. Data from 2015 reveals that only 60-63% of adults 50 years and older had CRC screening. The National CRC Roundtable in coalition with the American College of Gastroenterology aimed to increase the rates of CRC screening to 80% by 2018. The use of colonoscopy for screening is dependent on the availability of the physician and the endoscopy center. The demand for colonoscopies is on the rise, and for many individuals weekdays may not be a reasonable time to undergo a procedure. The aim of this study was to evaluate the impact of improved access to colonoscopy by offering Saturday screenings as it relates to polyp detection and examine patient preference for weekend availability. Methods: During CRC awareness month (March 2018), gastroenterologists at Allegheny Health Network offered weekend screening colonoscopies at eight outpatient endoscopy centers. A survey outlining patient demographics and opinions on weekend screening were collected. Pathology results and adenoma detection rates (ADR) were collected one week after procedure completion. Results: A total of 80 patients underwent a colonoscopy, of which 59 (74%) were female and 67 (84%) were Caucasian. The majority of patients (87.5%) stated they were more likely to have a colonoscopy when offered on a weekend, with 74% of patients preferring bowel preparation on Friday followed by a Saturday procedure. In addition, 41 (51%) patients stated their main cause of delaying their screening colonoscopy was due to weekday employment. Pathology results revealed that 54 (67%) patients had at least one polyp, of which 35 (49%) had an adenoma (26 tubular, 8 sessile serrated, and 1 tubulovillous adenoma). Surveillance intervals also changed to 5, 3, and 1 year for 29, 9, and 4 patients, respectively. Conclusion: CRC is one of the most preventable cancers if caught early in its course. Our study highlights that many individuals delay their screening colonoscopy due to their inability to take off work. Weekend availability offers greater access to colonoscopy which can help prevent CRC. Treatment can cost up to $30,000 per patient once diagnosed. In turn, the cost of a screening colonoscopy is approximately $3,000. Saturday screenings provide a substantial impact in the mission to provide high quality care, improve patient experience, and decrease overall healthcare costs.2755_A Figure 1. Results from our 8-Question Survey from Saturday Screenings (N=80)2755_B Figure 2. Number of Patients with Adenomas2755_C Figure 3. Types of Adenomas Found
Introduction: Infliximab is a tumor necrosis factor- alpha inhibitor (TNFi) used in moderate-severe ulcerative colitis (UC). It may also treat autoimmune conditions, such as recalcitrant psoriasis. However, TNFi may paradoxically cause new onset or worsening of psoriasis in ∼5% of cases. We present a rare case of TNFi induced psoriasis in controlled UC. Case Description/Methods: A 37 y.o M with pmhx of L-sided UC (2011) on infliximab 10mg/kg every 8wks (endoscopic Mayo Score 0, histological remission), ANA+, palmoplantar pustular psoriasis (2019, steroid responsive), and folliculitis presented to clinic for new rash. He reported 3 months of pruritic scalp and was diagnosed with seborrheic dermatitis with folliculitis. Ketoconazole, clobetasol, and doxycycline were prescribed. Of note, he was on infliximab for 10y and transitioned to a biosimilar formula 3mos prior. He re-presented a week later for progressive rash without infectious or systemic symptoms. Physical exam noted numerous erythematous non-follicular based papules with scaling and serosanguineous drainage (Figure 1a). Prednisone was initiated for concern of doxycycline drug reaction. Urgent dermatology evaluation revealed likely TNFi induced pustular psoriasis flare and worsening plaque psoriasis. Given response to steroids, a long taper was prescribed. Punch biopsy confirmed TNFi induced psoriasiform eruption (Figure 1b). As further TNFi was contraindicated, plan was to start ustekinumab. Discussion: TNFi may result in new onset or exacerbation of existing psoriasis in 5% of cases, which typically occurs within days to months of initiation. This is paradoxical in that TNFi may be used to treat psoriasis. The pathophysiology of TNFi induced and classic psoriasis differ as its immuno-footprint mimics early psoriasis via innate immune factor overexpression vs adaptive immune factor activation as in chronic disease. Though steroid responsive, TNFi are relatively contraindicated in TNFi induced psoriasis. Upon discontinuation, patients typically improve and may even tolerate future re-challenge. A prior case report also notes improvement of this condition with ustekinumab use, which our patient was transitioned to.Our case is unique in that TNFi induced psoriasis developed after transitioning to a biosimilar TNFi formula despite tolerating it for years prior. It also highlights a rare side effect of TNFi in controlled UC. It reinforces the importance of early clinical recognition and is an additional indication for close dermatology followup in UC.Figure 1.: A) Numerous erythematous non-follicular based papules with scaling and serosanguineous drainage in right axilla. B) Psoriasiform epidermal acanthosis with dilated capillaries in papillary dermis and lymphocytic inflammation, 10x H&E stain.
Colorectal cancer (CRC) is the second leading cause of all cancer related deaths in the United States and Europe. Although the incidence has been decreasing for individuals' ≥ 50, it has been on the rise for individuals < 50.To identify potential risk factors for early-onset CRC.A population-based cohort analysis using a national database, Explorys, screened all patients with an active electronic medical record from January 2012 to December 2016 with a diagnosis of CRC. Subgroups were stratified based on age (25 - 49 years vs ≥ 50 years). Demographics, comorbidities, and symptom profiles were recorded and compared between both age groups. Furthermore, the younger group was also compared with a control group consisting of individuals aged 25-49 years within the same timeframe without a diagnosis of CRC. Twenty-data points for CRC related factors were analyzed to identify potential risk factors specific to early-onset CRC.A total of 68860 patients were identified with CRC, of which 5710 (8.3%) were younger than 50 years old, with 4140 (73%) between 40-49 years of age. Multivariable analysis was reported using odds ratio (OR) with 95%CI and demonstrated that several factors were associated with an increased risk of CRC in the early-onset group versus the later-onset group. These factors included: African-American race (OR 1.18, 95%CI: 1.09-1.27, P < 0.001), presenting symptoms of abdominal pain (OR 1.82, 95%CI: 1.72-1.92, P <0.001), rectal pain (OR 1.50, 95%CI: 1.28-1.77, P < 0.001), altered bowel function (OR 1.12, 95%CI: 1.05-1.19, P = 0.0005), having a family history of any cancer (OR 1.78, 95%CI: 1.67-1.90, P < 0.001), gastrointestinal (GI) malignancy (OR 2.36, 95%CI: 2.18-2.55, P < 0.001), polyps (OR 1.41, 95%CI: 1.08-1.20, P < 0.001), and obesity (OR 1.14, 95%CI: 1.08-1.20, P < 0.001). Comparing the early-onset cohort versus the control group, factors that were associated with an increased risk of CRC were: male gender (OR 1.34, 95%CI: 1.27-1.41), P < 0.001), Caucasian (OR 1.48, 95%CI: 1.40-1.57, P < 0.001) and African-American race (OR 1.25, 95%CI: 1.17-1.35, P < 0.001), presenting symptoms of abdominal pain (OR 4.73, 95%CI: 4.49-4.98, P < 0.001), rectal pain (OR 7.48, 95%CI: 6.42-8.72, P < 0.001), altered bowel function (OR 5.51, 95%CI: 5.19-5.85, P < 0.001), rectal bleeding (OR 9.83, 95%CI: 9.12-10.6, P < 0.001), weight loss (OR 7.43, 95%CI: 6.77-8.15, P < 0.001), having a family history of cancer (OR 11.66, 95%CI: 10.97-12.39, P < 0.001), GI malignancy (OR 28.67, 95%CI: 26.64-30.86, P < 0.001), polyps (OR 8.15, 95%CI: 6.31-10.52, P < 0.001), tobacco use (OR 2.46, 95%CI: 2.33-2.59, P < 0.001), alcohol use (OR 1.71, 95%CI: 1.62-1.80, P < 0.001), presence of colitis (OR 4.10, 95%CI: 3.79-4.43, P < 0.001), and obesity (OR 2.88, 95%CI: 2.74-3.04, P < 0.001).Pending further investigation, these potential risk factors should lower the threshold of suspicion for early CRC and potentially be used to optimize guidelines for early screening.
Objectives Acute pancreatitis (AP) is a leading cause of inpatient care among gastrointestinal conditions. Our study compares the management of AP and adherence to guidelines among teaching medicine, nonteaching medicine, and surgical services within the same center. Methods We performed a retrospective chart review of AP patients admitted to our center between January 2016 and January 2017 and analyzed the clinical and epidemiological data. Results Of 115 patients, 65% were admitted to medicine (IM), and 35% were admitted to surgery. Mean age was 53.9 (standard deviation [SD], 15) years, and 52% were males; 38.6% (n = 29) of IM patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 153 [SD, 44.98] mL/h on teaching and 113 [SD, 43.56] mL/h on the nonteaching service). Antibiotics were prescribed to 22.6% (n = 17) of IM patients. On the surgical service, 77.5% of patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 108.25 [SD, 1.19] mL/h); 52.5% of patients received antibiotics. Conclusions Adherence to guidelines for management of AP is inadequate, and nonuniformity exists across different services within the same institution. There is a need for quality improvement initiatives.
Introduction: Push enteroscopy (PE) and video capsule endoscopy (VCE) are both suggested diagnostic methods to investigate the small bowel in overt obscure GI bleeding (OGIB). VCE is often chosen for its well-established diagnostic yield, yet this could lead to prolonged hospital stay and delayed therapy. We aim to describe incidence of bleeding lesions identified by VCE that are potentially reachable by PE in patients hospitalized with overt OGIB Methods: 397 VCE reports of patients hospitalized at a single tertiary-care center between January 2013 and April 2016 were retrospectively reviewed. Thirty-six reports fulfilled initial screening criteria: indication being overt OGIB (with unrevealing repeat esophagogastroduodenoscopy and colonoscopy), presenting symptom described as melena or hematochezia, and VCE successfully completed with an identified culprit of bleeding. Four of the 36 patients had post-surgical anatomy and were excluded. The remaining 32 cases were included in this study. The locations of bleeding sources were estimated based on time measurements during VCE. These were classified as being likely accessible by PE if they were estimated within the proximal 90 cm of the small bowel. Results: Thirty-one percent (10/32) of cases identified culprit lesions that were likely accessible by PE. There was no significant association between the location of the bleeding lesions and common clinical or lab variables such as low hemoglobin (< 8gm/dL), high BUN/creatinine ratio (>20), use of NSAID/antiplatelet/anticoagulant, alcohol abuse, tobacco use, and type of lesion. Conclusion: Almost one-third of patients with overt OGIB presenting with melena/hematochezia and identifiable VCE lesions were found to have sources of bleeding potentially reachable by PE. Although the current guidelines leave the choice between a repeat esophagogastroduodenoscopy and PE to the provider, our findings suggest no identifiable factors that could guide the endoscopist's choice in this matter. Given our results, we suspect that proceeding with PE instead of a second esophagogastroduodenoscopy in hospitalized patients with overt OGIB presenting with melena/hematochezia may prove to be more timely and cost-effective from a therapeutic standpoint before proceeding with VCE. This assumption will yet require prospective confirmation.
