system in 74/76 (97%) of cases.
Grading correlated weakly with self-reported caecal intuba- M1079
tion rates and multiple choice question (MCQ) scores (r=0.24 and 0.27, p<0.01). Overall
27/30 candidates felt the DOPS assessment was fair/very fair, while 27/32 felt the MCQ was
fair/very fair. Of the assessors, 12/16 felt the DOPS was valid/very valid, while 17/17 felt
the overall process was fair/very fair. It is possible for candidates to fail the accreditation
process repeatedly and yet be able to continue their routine National Health Service colonos-
copy practice without sanctions. In countries that do not adopt the “driving test”, e.g. USA,
Canada, there is no evidence that the quality of colonoscopy in these countries is inferior.
Concerns about a two-tier service, and roll out of similar tests in other aspects of clinical
practice have not been adequately addressed. CONCLUSION: For trained colonoscopists
with proven satisfactory performance outcomes, it is not clear if the addition of a “driving
test” is necessary to select screening colonoscopists.
M1077
Eosinophilic Oesophagitis. An Overlooked Entity?
Shamaila Butt, Debbie Ramdass, Kalpesh Besherdas
Background Eosinophilic oesophagitis (EO) is characterized by an eosinophilic infiltration
of the oesophageal mucosa. The main symptoms in adults include recurrent dysphagia and
frequent episodes of oesophageal food impaction. Chest pain has also been documented as
a symptom. The diagnosis is based on endoscopic findings (multiple concentric rings, furrows,
white plaques and strictures) and histological confirmation (more than 15 eosinophils per
high-power field). In one series upto 41% of the patients with dysphagia or bolus impaction
in the oesophagus with no evident stenotic lesions had EO. To make the diagnosis it has
been recommended that biopsies from the oesophagus are obtained from multiple sites
(proximal, middle and distal). But how often in clinical practice is this diagnosis considered?
Aims To assess the frequency of oesophageal biopsy in patients with dysphagia or chest
Ponce J, Mearin F, Balboa A, Ponce
pain with a macroscopically normal mucosa at endoscopy. Methods This was a single centre
retrospective analysis of patients undergoing endoscopy for dysphagia and chest pain. Patients
M, Gonzalez MA, Zapardiel J.
were identified using the Unisoft reporting system over a period of 4 yrs from July 2005
to November 2009. Patients with a macroscopically normal endoscopy were further scrutin-
Compliance and Results Achieved
ized to see if biopsies to exclude EO were obtained. Results A total of 108 out of 584 (18%)
patients with dysphagia were found to have normal endoscopies. Of these only 7/108 (7%)
With a GERD Clinical Practice
underwent oesophageal biopsies. In the chest pain group, 24 patients out of a total of 44
(55%) were found to have normal endoscopies. Of these only 1 patient was biopsied to
Guideline. Gastroenterology (2010).
assess for EO. Conclusions Large numbers of patients are endoscoped for dysphagia and
Volume 138, Issue 5, Supplement 1,
chest pain. When endoscopy is normal for these indications, biopsies to exclude EO is
infrequently performed. In our study population therefore, the diagnosis of EO may have
May 2010, Pages S-327 (DOI:
been easily overlooked. More awareness of this diagnosis in patients with dysphagia to solid
food and chest pain amongst endoscopists is required.
10.1016/S0016-5085(10)61506-5)
M1078
Large Proportions of Patients With Renal Failure Have Significant Upper GI
Findings at Endoscopy. Results From a Tertiary Referral Centre
Shamaila Butt, Simon M. Greenfield, Martyn J. Carter, David Rowlands, Ian R. Sargeant
Background The demand for endoscopy is ever increasing as is the rise in overall costs of
endoscopy and waiting times. Adherence to appropriate indications is essential to prevent
the rise in proportions of negative and hence unnecessary endoscopies. Patients with chronic
renal impairment are one group of patients who may have significant gastrointestinal symp-
toms and often form an important number of referrals to the endoscopy unit for upper GI
endoscopy. These patients are of variable complexity and often have multi-organ disease.
Anaemia can often be the indication for referral despite this being part of the disease complex.
We wanted to investigate the indications and endoscopic findings in renal patients from a
busy tertiary referral centre. Aims To assess the findings at gastroscopy in patients with
renal failure from a renal tertiary referral centre. Methods A single centre, retrospective
analysis of renal patients who were referred for gastroscopy. Patient details were obtained
from the CIPTS database by isolating patients under the named renal physician referrer.
Gastroscopy reports between 2006 until April 2009 were obtained and analysed for indica-
tions and diagnosis at endoscopy. Results A total of 90 gastroscopies in 73 patients were
conducted during the study period. The age range was 45 to 92 and 58% were male
patients. 86% of the gastroscopies were inpatient procedures. The majority of indications
for gastroscopies included anaemia, haematemesis or melaena and these accounted for the
indication 75 times either alone or in combination. Out of 90 gastroscopies 31(34%) were
considered as normal. Those gastroscopies in the normal category included reports of normal
gastroscopies, hiatus hernias or minimal gastritis. All else was classed as abnormal (66%).
Erosive lesions within the upper GI tract were diagnosed 47 times in the 90 reports (52%).
These included oesophageal, gastric and duodenal ulcers, mallory weiss tears, duodenal
erosions, and pyloric and duodenal stenoses. 3 reports had cancer (1 duodenal, 2 oesopha-
geal), and vascular lesions (angiodysplasia, telangiectasia, portal gastropathy, varices) were
reported 14 (16%) times. Conclusions Two-thirds of patients with renal failure referred for
an upper GI endoscopy have abnormal findings. The majority have erosive disorders as
opposed to vascular lesions as previously reported to be associated in the literature. Our
study demonstrates a high pick-up rate of in-patients with renal failure and we recommend
that the threshold to endoscopy in such patients should be low, and anaemia should not
be ascribed to one of chronic disease without performing a gastroscopy.
S-327
Improving Adherence to Guidelines When Managing Non-Variceal Upper
Gastrointestinal Bleeding: A National Cluster Randomized Trial of a
Multifaceted Strategy
Alan N. Barkun, Ian A. Hawes, David Armstrong, Martin Dawes, Allan Donner, Larry W.
Stitt, Robert A. Enns, Janet Martin, Paul Moayyedi, Joseph Romagnuolo, Peter Tugwell
AGA Abstracts
Background: The management of non variceal upper gastrointestinal bleeding (NVUGIB)
has evolved with poor compliance to international guidelines. Aims: Is adherence to guidelines
improved with a national, multifaceted intervention. Methods: This one-year cluster random-
ized trial, stratified hospitals by region and size, and allocated sites to a control group or
to receive a set of interventions targeting health care workers, based on a national needs
analysis. These included distribution of published guidelines, a generic algorithm, a stratifica-
tion scoring system, written reminders, facilitation of multidisciplinary guideline education
groups, and case-base workshops. All were implemented over a 12-month period after
randomization with performance feedback and benchmarking. Outcomes were based on a
review of patient charts (23 prior to randomization [period 1] and 20 every 4 months
thereafter [periods 2, 3, and 4]), and included the primary outcome of change in adherence
rates to key guidelines in endoscopic and pharmacological management adjusted according
to baseline site characteristics, and possible site inter-dependence, for periods 4 versus 1.
Adherence rates to other recommendations were also noted, as were continued bleeding,
re-bleeding and mortality. Results: 20 sites were randomized to the experimental group and
22 to the control group. They were comparable for institution size, and geographic location.
The intervention components were delivered starting at 1 and up to 9 months following
randomization. The primary analysis compared 825 (intervention: 400, control: 425, period
1) to 749 (intervention: 358, control: 391, period 4) patients. Site-level analysis yielded
adherence rates for the primary outcome of 12% and 7% for periods 1 and 4 for the
intervention group, and 7% and 6% for the control group, respectively (P=0.492). Adherence
rates to the other guidelines also decreased over time, and did not differ between both
groups, varying between 5% and 93% depending on the specific recommendation. Patient
outcomes were similar in both groups. Significance: This national trial suggests poor adher-
ence to guidelines for the most critical aspects of management in NVUGIB, and highlights
the need for measuring outcomes when attempting to alter health care provider behavior.
M1080
Compliance and Results Achieved With a Gastroesophageal Reflux Disease
Clinical Practice Guideline
Julio Ponce, Fermin Mearin, Agustín Balboa, Marta Ponce, Miguel A. Gonzalez, Javier
Zapardiel
Many recommendations and clinical practice guidelines (CPG) about gastroesophageal reflux
disease (GERD) diagnosis and therapy have been published. However, in most cases its
utility has not been tested. Aim: To evaluate compliance and results obtained with the
GERD-CPG developed and published by the Spanish Association of Gastroenterology in
collaboration with the Spanish Association of Family Physicians and the Cochrane Centre.
Methods: A multicentric, prospective, observational study was performed in 301 patients
with GERD's typical symptoms that were attended by gastroenterologists and had to be
assisted according to CPG recommendations. Results: Upper digestive endoscopy was indic-
ated in 123 patients (41%): in 50 because alarm symptoms and in 32 because age older
than 50 years. Esophagitis was diagnosed in 72 (59%): 23 degree A, 28 degree B, 18 degree
C and 3 degree D. The CPG adhesion for alarm symptoms presence was good (98%: 50 of
51 patients), although endoscopy was indicated in 33% (32 of 97) patients older than 50
years without alarm symptoms (no recommended by the CPG). Treatment with proton
pump inhibitors (PPI) was prescribed to 298 patients (99%). There was adhesion to the
CPG's recommendations in most of the cases (80%); the indicated dose was lower (half) in
5% and higher (double) in 15%. The adhesion to treatment duration was 69%; the lack of
adhesion (31%) was because 4 weeks treatment in patients with esophagitis C-D (1%) and
8 weeks in esophagitis A-B (8%) or without endoscopic study (22%). Therapeutic response
was higher, although not reaching statistically significant difference, in cases with good
adhesion to the recommended doses by the CPG (95% vs. 85%). Conclusions: Compliance
of GERD-CPG by gastroenterologists is quite good, although a trend to indicate endoscopy
in patients older than 50 years without alarm symptoms and treatments with higher PPI
doses and longer duration than recommended was observed. Diagnosis of severe esophagitis
is extremely infrequent, even in selected patients for endoscopy. Therapeutic response
trended to be better when following CPG recommendations.
M1081
How Good is Our Patients' Bowel Preparation for Screening Colonoscopy?
Ioan Sporea, Alina Popescu, Ramona Asai, Roxana Sirli, Mirela Danila, Silvana Vulpie,
Simona I. Bota
Colonoscopy became the main strategy for colorectal cancer screening in several countries.
Colonoscopic evaluation every 5 years was the previous strategy for screening, but recently,
every 10 years screening colonoscopy was proposed. For this strategy to be effective, the
bowel has to be very well prepared, in order to be able to evaluate the entire mucosa of
the colon and to be sure that no lesion is missed. The aim of our study is to find if the
patients referred for colonoscopy to our department are well prepared or not. Material and
method: we prospectively evaluated the bowel preparation before screening colonoscopy,
using the Boston bowel preparation scale (BBPS) (a 4 point scoring system applied to the
3 broad regions of the colon: right colon, transverse colon and left colon, each part being
evaluated from 0 and 3 as follows: 3 = entire mucosa of the segment well seen, 2 = minor
amount of residual staining, 1 = segments not well seen due to residual stool or/and opaque
liquid, 0 = unprepared segment), with a maxim of 9 points (perfectly cleaned colon). All
the evaluated patients were outpatients, and the bowel preparation was performed with PEG
solution (we recommended 4 liters of PEG solution). Results: we evaluated 107 patients.
The mean Boston score in these patients was 5.6±1.5. Considering a BBPS score of 8 or 9
AGA Abstracts