BACKGROUND: Practice audit is an important component of continuing professional development that may more readily be undertaken if it were less complex. This qualitative study assessed the use of personal digital assistants to facilitate data collection and review. METHODS: Personal digital assistants programmed with standard questionnaires related to upper gastrointestinal endoscopies (Practice Audit in Gastroenterology-Endoscopy ['PAGE-Endo']) and colonoscopies (PAGE-Colonoscopy ['PAGE-Colo']) were provided to Canadian gastroenterologists, surgeons and internists. Over a three-week audit period, participants recorded indications, and the expected (E) and reported (R) findings for each procedure. Thereafter, participants recorded compliance with reporting, the ease of use and value of the PAGE program, and their willingness to perform another audit. RESULTS: Over 15 to 18 months, 173 participants completed PAGE-Endo (6168 procedures) and 111 completed PAGE-Colo (4776 procedures). Most respondents noted that PAGE was easy to use (99%), beneficial (88% to 95%), and that they were willing undertake another audit (92% to 95%). In PAGE-Endo, alarm features were prevalent (55%), but major reported findings were less common than expected: esophagitis (E 29.9%, R 14.8%), esophageal stricture (E 8.3%, R 3.6%), gastric ulcer (E 17.0%, R 4.7%), gastric cancer (E 4.3%, R 1.0%) and duodenal ulcer (E 11.5%, R 5.7%). In PAGE-Colo, more colonoscopies were performed for symptom investigation (55%) than for screening (25%) or surveillance (20%). There were marked interprovincial variations with respect to sedation, biopsies and technical aspects of colonoscopy. CONCLUSION: Secure, real-time data entry with review of aggregate and individual data in the PAGE program provided an acceptable, straightforward methodology for accredited practice audit activities. PAGE has considerable potential for continuing professional development in gastroenterology and other specialties.

Canada↗

PubMed2006

Commonly used preparations for colonoscopy: efficacy, tolerability, and safety--a Canadian Association of Gastroenterology position paper.

INTRODUCTION: The increased demand for colonoscopy, coupled with the introduction of new bowel cleansing preparations and recent caution advisories in Canada, has prompted a review of bowel preparations by the Canadian Association of Gastroenterology. METHODS: The present review was conducted by the Clinical Affairs group of committees including the endoscopy, hepatobiliary/transplant, liaison, pediatrics, practice affairs and regional representation committees, along with the assistance of Canadian experts in the field. An effort was made to systematically assess randomized prospective trials evaluating commonly used bowel cleansing preparations in Canada. RESULTS: Polyethylene glycol (PEG)-; sodium phosphate (NaP)-; magnesium citrate (Mg-citrate)-; and sodium picosulphate, citric acid and magnesium oxide (PSMC)-containing preparations were reviewed. Regimens of PEG 2 L with bisacodyl (10 mg to 20 mg) or Mg-citrate (296 mL) are as effective as standard PEG 4 L regimens, but are better tolerated. NaP preparations appear more effective and better tolerated than standard PEG solutions. PSMC has good efficacy and tolerability but head-to-head trials with NaP solutions remain few, and conclusions equivocal. Adequate hydration during preparation and up to the time of colonoscopy is critical in minimizing side effects and improving bowel cleansing in patients receiving NaP and PSMC preparations. All preparations may cause adverse events, including rare, serious outcomes. NaP should not be used in patients with cardiac or renal dysfunction (PEG solution is preferable in these patients), bowel obstruction or ascites, and caution should be exercised when used in patients with pre-existing electrolyte disturbances, those taking medications that may affect electrolyte levels and elderly or debilitated patients. Health Canada's recommended NaP dosing for most patients is two 45 mL doses 24 h apart. However, both safety and efficacy data on this dosing schedule are lacking. Many members of the Canadian Association of Gastroenterology expert panel administer both doses within 24 h, as studied in clinical trials, after careful one-on-one discussion of risks and benefits in carefully selected patients. Safety data on PSMC and combination preparations in North America are limited and clinicians are encouraged to keep abreast of developments in this area. CONCLUSIONS: All four preparations reviewed provided effective bowel cleansing for colonoscopy in the majority of patients, with varying tolerability. Adequate hydration is essential in patients receiving the preparations.

Colonoscopy↗

PubMed2005

The yield and the predictors of esophageal pathology when upper endoscopy is used for the initial evaluation of dysphagia.

BACKGROUND: The utility of EGD when used as an initial test for the evaluation of dysphagia is unclear. The objective was to determine the yield and the predictive factors of significant pathology when EGD is performed as the initial test to evaluate dysphagia. METHODS: This is a retrospective analysis of a computerized database. Data on patients who underwent EGD for dysphagia were retrieved from the endoscopy database of 6 endoscopy units. Patients who had undergone prior esophageal evaluation, failed EGD, or who had a history of prior upper-GI pathology were excluded. Univariate and multivariable logistic regression analyses were performed to evaluate any relation between endoscopic findings and presenting clinical features. RESULTS: A total of 1649 patients with dysphagia (mean age 56.7 years, standard deviation 16.4; M:F 3:2) were analyzed. Abnormal findings at EGD were found in 70% (1150) of the patients, and a major pathology was seen in 54% (898). Male gender (p=0.0001), heartburn (p=0.0007), and odynophagia (p=0.0001) predicted the presence of major pathology. Cancer was found in 4% (70) of patients and was predicted by male gender (p=0.0002), age (p=0.01), and weight loss (p=0.04). The esophagus was normal in 29% (483) of patients and was predicted by female gender (p=0.0001) and the absence of heartburn (p=0.0004) but not age. There was a lack of details on patients' presentation and clinical history and an absence of long-term clinical follow-up. CONCLUSIONS: EGD is an effective and an appropriate tool for the initial evaluation of patients presenting with dysphagia. Early EGD should be considered, particularly, in male patients aged more than 40 years old who concomitantly report heartburn, odynophagia, or weight loss.

Abdominal Pain↗

PubMed2005

A randomized trial comparing omeprazole, ranitidine, cisapride, or placebo in helicobacter pylori negative, primary care patients with dyspepsia: the CADET-HN Study.

BACKGROUND: The management of Helicobacter pylori negative patients with dyspepsia in primary care has not been studied in placebo-controlled studies. METHODS: H. pylori negative patients with dyspepsia symptoms of at least moderate severity (> or =4 on a seven-point Likert scale) were recruited from 35 centers. Patients were randomized to a 4-wk treatment of omeprazole 20 mg od, ranitidine 150 mg bid, cisapride 20 mg bid, or placebo, followed by on-demand therapy for an additional 5 months. Treatment success was defined as no or minimal symptoms (score < or = 2 out of 7), and was assessed after 4 wk and at 6 months. RESULTS: Five hundred and twelve patients were randomized and included in the intention-to-treat (ITT) analysis. At 4 wk, success rates (95% CI) were: omeprazole 51% (69/135; 43-60%), ranitidine 36% (50/139, 28-44%), cisapride 31% (32/105, 22-39%), and placebo 23% (31/133, 16-31%). Omeprazole was significantly better than all other treatments (p < 0.05). The proportion of patients who were responders at 4 wk and at 6 months was significantly greater for those receiving omeprazole 31% (42/135, 23-39%) compared with cisapride 13% (14/105, 7-20%), and placebo 14% (18/133, 8-20%) (p= 0.001), but not ranitidine 21% (29/139, 14-27%) (p= 0.053). The mean number of on-demand study tablets consumed and rescue antacid used was comparable across groups. Economic analysis showed a trade-off between superior efficacy and increased cost between omeprazole and ranitidine. CONCLUSION: Treatment with omeprazole provides superior symptom relief compared to ranitidine, cisapride, and placebo in the treatment of H. pylori negative primary care dyspepsia patients.

Adult↗

PubMed2005

Evidence-based recommendations for short- and long-term management of uninvestigated dyspepsia in primary care: an update of the Canadian Dyspepsia Working Group (CanDys) clinical management tool.

The present paper is an update to and extension of the previous systematic review on the primary care management of patients with uninvestigated dyspepsia (UD). The original publication of the clinical management tool focused on the initial four- to eight-week assessment of UD. This update is based on new data from systematic reviews and clinical trials relevant to UD. There is now direct clinical evidence supporting a test-and-treat approach in patients with nondominant heartburn dyspepsia symptoms, and head-to-head comparisons show that use of a proton pump inhibitor is superior to the use of H2-receptor antagonists (H2RAs) in the initial treatment of Helicobacter pylori-negative dyspepsia patients. Cisapride is no longer available as a treatment option and evidence for other prokinetic agents is lacking. In patients with long-standing heartburn-dominant (ie, gastroesophageal reflux disease) and nonheartburn-dominant dyspepsia, a once-in-a-lifetime endoscopy is recommended. Endoscopy should also be considered in patients with new-onset dyspepsia that develops after the age of 50 years. Conventional nonsteroidal anti-inflammatory drugs, acetylsalicylic acid and cyclooxygenase-2-selective inhibitors can all cause dyspepsia. If their use cannot be discontinued, cotherapy with either a proton pump inhibitor, misoprostol or high-dose H2RAs is recommended, although the evidence is based on ulcer data and not dyspepsia data. In patients with nonheartburn-dominant dyspepsia, noninvasive testing for H pylori should be performed and treatment given if positive. When starting nonsteroidal anti-inflammatory drugs for a prolonged course, testing and treatment with H2RAs are advised if patients have a history of previous ulcers or ulcer bleeding.

Age Factors↗

PubMed2004

Tissue adhesives and fibrin glues.

Explore the source record for details and available documents.

Cyanoacrylates↗

PubMed2004

The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.

OBJECTIVES: From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting. METHODS: Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes. RESULTS: One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata. CONCLUSIONS: These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.

Aged↗

PubMed2004

A Canadian clinical practice algorithm for the management of patients with nonvariceal upper gastrointestinal bleeding.

AIM: To use current evidence-based recommendations to provide a user-friendly clinical algorithm for the management of upper gastrointestinal bleeding, adapted to the Canadian environment. METHODS: A multidisciplinary consensus group of 25 participants representing 11 national societies used a seven-step approach to develop recommendations according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. A small writing subgroup subsequently created the algorithm. RESULTS: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding secondary to ulcer disease should be tested and treated for Helicobacter pylori infection. CONCLUSIONS: This algorithm should facilitate appropriate risk stratification, use of endoscopic therapy and the appropriate utilization of proton-pump inhibition to optimize the care of patients with upper gastrointestinal bleeding. The algorithm should be customized to the resources of individual medical centres. Its application should be studied with appropriate outcomes recorded and validation performed.

Algorithms↗

PubMed2003

Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.

BACKGROUND: The management of patients with acute nonvariceal upper gastrointestinal bleeding has evolved substantially over the past 10 years amid a paucity of published consensus guidelines. PURPOSE: To provide evidence-based management recommendations that address clinically relevant issues. REVIEW AND CONSENSUS PROCESSES: A multidisciplinary consensus group of 25 voting participants representing 11 national societies used a 7-step approach to develop recommendation statements according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. The quality of the evidence, the strength of the recommendation, and the level of consensus were graded according to recognized classifications. MAIN FINDINGS: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. The placement of endoscopic clips for endoscopic hemostasis appears promising. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding should be tested for Helicobacter pylori infection and receive eradication therapy if infection is present. FUTURE DIRECTIONS: The efficacy of newer endoscopic therapeutic technologies, the optimal regimen of proton-pump inhibition, and the roles of other pharmacologic agents require further research.

Endoscopy, Gastrointestinal↗

PubMed2003

Cost-effectiveness of alternative approaches in the management of dyspepsia.

OBJECTIVES: To assess the cost-effectiveness of alternative initial strategies in the management of uninvestigated dyspepsia in adult patients presenting to a primary care physician in Canada. METHODS: Clinical decision-making was modeled based on outcomes data from the literature and expert opinion. Costs were obtained from official reimbursement lists, and a detailed microcosting analysis of a gastroscopy. Costs were analysed over a one-year period after initial presentation, including consideration of a single relapse of symptoms. The main outcome was a symptomatic cure. The seven management strategies based on different initial tests were endoscopy, double-contrast barium meal, empirical eradication therapy, empirical antisecretory treatment, urea breath test (UBT), laboratory serology, and sequential testing (laboratory serology followed, if Helicobacter pylori positive, by UBT). RESULTS: In patients under age 45, endoscopy, double-contrast barium meal, and sequential testing were not cost-effective approaches. UBT was the most effective and most costly strategy costing 8,238 dollars per additional patient cure compared with laboratory serology. In patients over age 45, UBT was again the most effective and most costly strategy, but endoscopy was the most reliable in detecting gastric cancers. Clinical variables that impacted these findings were the probability of symptomatic relapse in patients with nonulcer dyspepsia (NUD) after successful versus failed H. pylori eradication, the probability of finding a duodenal ulcer (DU) in a young dyspeptic patient, the specificity of UBT, and the prevalence of H. pylori in patients with DU. CONCLUSIONS: A "test-and-treat" approach was favored, with UBT being the most effective but most costly initial test in adult dyspeptics under age 45. The choice of the most cost-effective approach is dependent on the benefits of H. pylori eradication in patients with NUD. In patients over age 45, UBT is the most effective and most costly, but endoscopy results in the early detection of most gastric cancers.

Canada↗

PubMed2003

Cost-effectiveness of routine endoscopic biopsies for Helicobacter pylori detection in patients with non-ulcer dyspepsia.

BACKGROUND: The role of endoscopic biopsies in the detection of Helicobacter pylori in patients with nonulcer dyspepsia is poorly defined. This study assesses the cost-effectiveness of performing routine biopsies for the detection of H pylori at upper endoscopy in these patients. METHODS: Clinical decision-making was modeled based on outcomes data from published articles and expert opinion. The target group was adults, less than 45 years of age, with nonulcer dyspepsia as defined by a normal endoscopy. Costs, expressed in Canadian dollars, were tabulated over a 1-year time horizon. The main outcome was relief of symptoms, defined as the absence of symptom persistence or recurrence over the 12 months. A strategy of performing a biopsy for the detection of H pylori with a rapid urease test during gastroscopy was compared with that of not performing a biopsy. In addition, as a secondary analysis, the cost-effectiveness of obtaining a biopsy specimen for histopathologic evaluation in patients after a negative rapid urease test was evaluated. RESULTS: A strategy of endoscopy with biopsy and rapid urease testing costs 3940 dollars per additional symptom-free patient as compared with endoscopy without biopsy. This result was sensitive to the difference in symptomatic recurrence rate at 1 year between patients in whom H pylori was successfully and unsuccessfully eradicated, which in this analysis, was set at 9.9%. Only when the difference in symptomatic recurrence in patients with successful versus unsuccessful eradication fell to less than 4% was endoscopy with biopsy over 10,000 dollars per cured patient greater than endoscopy without biopsy. The conclusions were otherwise robust when varying the values of other variables across clinically relevant ranges. There was little additional benefit associated with histopathologic assessment of biopsy specimens in patients with a negative rapid urease test and the cost per additional cure was 25,529 dollars. CONCLUSIONS: In adults with nonulcer dyspepsia under age 45 years undergoing endoscopy, routine procurement of a biopsy specimen for detection of H pylori was more costly yet more effective compared with not obtaining a specimen. The cost-effectiveness of a biopsy is dependent on the benefits of H pylori eradication in this patient population. The less likely a patient with nonulcer dyspepsia is to become asymptomatic after successful H pylori eradication, the more costly a strategy of routinely obtaining a specimen at endoscopy. The additional cost of sending a specimen for histopathologic analysis if the rapid urease test is negative does not appear warranted based on cost-effectiveness considerations.

Adult↗

PubMed2003

Patient nonadherence to medication in inflammatory bowel disease.

OBJECTIVE: The aim of this study was to identify determinants of nonadherence to medication in outpatients with established inflammatory bowel disease (IBD). METHODS: Ten gastroenterologists and 153 of their IBD patients participated in this prospective study. Demographic, clinical, and psychosocial characteristics, as well as patient-physician discordance, were assessed at an office visit. Nonadherence to medication was assessed 2 wk later. Separate generalized estimating equations were used to identify determinants of nonadherence. RESULTS: Physicians averaged 47.9 yr in age (range 30.1-57.5 yr), and 90% were male. Patients averaged 37.0 yr (SD = 15.1), and 87 (56.9%) were female. In all, 63 patients (41.2%) were nonadherent to medication; of these, 51 (81.0%) indicated unintentional nonadherence, 23 (36.5%) intentional nonadherence, and 11 (17.5%) both. Overall nonadherence was predicted by disease activity (OR = 0.55, p = 0.0022), new patient status (OR = 2.14, p = 0.0394), disease duration (OR = 0.50, p = 0.0001), and scheduling a follow-up appointment (OR = 0.30, p = 0.0059), whereas higher discordance on well-being was predictive only in psychologically nondistressed patients (p = 0.0026 for interaction). Unintentional nonadherence was predicted by age (OR = 0.97, p = 0.0072), new patient status (OR = 2.80, p = 0239), and higher discordance on well-being in psychologically nondistressed patients (p = 0.0504). Intentional nonadherence was predicted by disease duration (OR = 0.55, p = 0032), scheduling a follow-up appointment (OR = 0.12, p = 0.0001), certainty that medication would be helpful (OR = 0.99, p = 0.0409), and total patient-physician discordance (OR = 1.59, p =.0120). CONCLUSIONS: These findings suggest that the therapeutic relationship, as well as individual clinical and psychosocial characteristics, influence adherence to medication.

Adult↗