Purpose. —To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients. Data Identification. —Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports. Study Selection. —Independent review of 269 articles identified 63 relevant randomized trials for inclusion. Data Abstraction. —We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial. Results. —The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non—English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09). Conclusions. —Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH—altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis. (JAMA. 1996;275:308-314)

Stress Ulcer Prophylaxis in Critically Ill Patients Resolving Discordant Meta-Analyses

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for screening for colorectal cancer (CRC) in asymptomatic individuals without personal history of CRC or polyps, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews, and primary studies regarding colonoscopy for screening for colorectal cancer was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy in these circumstances. RESULTS: Available evidence for CRC screening comes from small case-controlled studies, with heterogeneous results, and from indirect evidence from randomized controlled trials (RCTs) on fecal occult blood test (FOBT) screening and studies on flexible sigmoidoscopy screening. Most guidelines recommend screening colonoscopy every 10 years starting at age 50 in average-risk individuals. In individuals with a higher risk of CRC due to family history, there is a consensus that it is appropriate to offer screening colonoscopy at < 50 years. EPAGE II considered screening colonoscopy appropriate above 50 years in average-risk individuals. Panelists deemed screening colonoscopy appropriate for younger patients, with shorter surveillance intervals, where family or personal risk of colorectal cancer is higher. A positive FOBT or the discovery of adenomas at sigmoidoscopy are considered appropriate indications. CONCLUSIONS: Despite the lack of evidence based on randomized controlled trials (RCTs), colonoscopy is recommended by most published guidelines and EPAGE II criteria available online (http://www.epage.ch), as a screening option for CRC in individuals at average risk of CRC, and undisputedly as the main screening tool for CRC in individuals at moderate and high risk of CRC.

/pdf/appropriateness-of-colonoscopy-in-europe-epage-ii-screening-4gi5dcpcmk.pdf

Appropriateness of colonoscopy in Europe (EPAGE II). Screening for colorectal cancer

Background and Aims: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea.

Methods: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed.

Results There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%).

Conclusions Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal.

© 2002 Blackwell Science Asia Pty Ltd

Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea.

Background: The evaluation of patients with abdominal discomfort is challenging and patient selection for endoscopy based on symptoms is not reliable. We evaluated the diagnostic value of fecal calprotectin in patients with abdominal discomfort. Methods: In an observational study, 575 consecutive patients with abdominal discomfort referred for endoscopy to the Department of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland, were enrolled in the study. Calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. The presence of a clinically significant finding in the gastrointestinal tract was the primary endpoint of the study. Final diagnoses were adjudicated blinded to calprotectin values. Results: Median calprotectin levels were higher in patients with significant findings (N = 212, median 97 μg/g, IQR 43-185) than in patients without (N = 326, 10 μg/g, IQR 10-23, P 50 years, the diagnostic precision remained unchanged (AUC 0.889 vs. 0.832, P = 0.165). Conclusion: In patients with abdominal discomfort, fecal calprotectin is a useful non-invasive marker to identify clinically significant findings of the gastrointestinal tract, irrespective of age.

/pdf/value-of-fecal-calprotectin-in-the-evaluation-of-patients-3tu05uta14.pdf

Value of fecal calprotectin in the evaluation of patients with abdominal discomfort: an observational study

Objective Patients with dyspepsia with alarm features are suspected of having upper gastrointestinal (GI) malignancy; however, the true value of alarm features in predicting an underlying malignancy for patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper GI malignancy is uncertain. The aim of the present study was to determine the diagnostic accuracy of alarm features in predicting upper GI malignancy by reviewing an endoscopic database consisting of >100 000 Chinese patients. Methods A retrospective analysis of prospectively collected data was conducted in a single tertiary medical centre. Consecutive patients who underwent oesophagogastroduodenoscopy (OGD) for dyspepsia in 1996–2006 were enrolled. The data including gender, age, symptoms, and endoscopic and pathological findings were analysed. The main outcome measure was the diagnostic accuracy of individual alarm feature. Results 102 665 patients were included in the final analysis. Among all the 4362 patients with malignancy, 52% (2258/4362) had alarm features. Among 15 235 patients who had alarm features, 2258 (14.8%) were found to have upper GI malignancy. The pooled sensitivity and specificity of the alarm features were 13.4% and 96.6%, respectively. Only the feature of dysphagia in patients between 36 and 74 years old had a positive likelihood ratio (PLR) >10 for malignancy prediction, while all other alarm features in other age groups had a PLR Conclusions For uninvestigated Chinese patients with dyspepsia with high background prevalence of H pylori infection and upper GI malignancy, alarm features and age, except for dysphagia in patients between 36 and 74 years old, had limited predictive value for a potential malignancy; therefore, prompt endoscopy may be recommended for these patients. However, less invasive, inexpensive screening methods with high diagnostic yield are still needed to reduce unnecessary endoscopy workload.

https://gut.bmj.com/content/gutjnl/59/6/722.full.pdf

Alarm features and age for predicting upper gastrointestinal malignancy in Chinese patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper gastrointestinal malignancy: an endoscopic database review of 102 665 patients from 1996 to 2006

Following the introdcution of the fiberoptic gastroscope in the sixties and of the colonoscope in the early seventies, endoscopy has gradually supplanted gastrointestinal radiography as the initial diagnostic study for the majority of patients with suspected gastrointestinal pathology, except for conditions such as suspected small bowel disease, which are not readily accessible to endoscopic evaluation. Upper and lower gastrointestinal endoscopies together now represent the most frequent procedures performed in the US health care system, totaling almost 5 000 000 proce

The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE): project and methods.

Colorectal cancer is an important component of the burden of disease in developed countries because it is widespread and has a high morbidity and mortality rate [1]. In Europe, the annual age-standardized incidence (world population) of colorectal cancer is between 20 and 45 per 100000 among males and between 15 and 30 per 100000 among females [2]. Incidence rates increase in a regular fashion with age [2 -4 ] . "Screening, in the context of colorectal cancer, identifies individuals who are more likely to have colorectal cancer or adenomatous polyps from among those without signs or symptoms of the disease" [1]. Screening may detect cancers at an early stage. If detected at an early stage, treatment may be curative and improve prognosis. Screening may be acceptable to many patients and general­ ly feasible in practice.

14. Appropriateness of Colonoscopy: Screening for Colorectal Cancer in Asymptomatic Individuals

Almost all cancers of the colon and rectum are carcinomas that develop from the mucosal epithelium. Cancer of the colon and of the rectum are generally considered together under the heading of colorectal cancers. Most of these can­ cers are adenocarcinomas, and the development of carcino­ ma from an adenomatous polyp is considered to be the most common developmental feature of colorectal cancer. Patients with previous adenomatous polyps or colorectal cancer have an increased risk of developing a further can­ cer. In Europe, the annual age-standardized incidence (world population) of colorectal cancer is between 20 and 45 per 100000 among males and between 15 and 30 per 100000 among females [1]. Incidence rates increase in a regular fashion with age [1 -3 ] .

13. Appropriateness of colonoscopy: surveillance after curative resection of colorectal cancer.

Dyspepsia is a very common set of clinical symptoms. Clear-cut scientific evidence of the effectiveness of diag­ nostic schemes is unavailable for most clinical situations related to dyspepsia. For this and other reasons, practice patterns vary widely. The development of explicit detailed criteria of appropriateness of use of endoscopy is an at­ tempt to produce best available evidence (based on a vali­ dated panel process and expert j udgmen t ) where better evi­ dence is lacking, with the aim to assist the clinician in dai­ ly decision making.

https://serval.unil.ch/resource/serval:BIB_10421.P001/REF.pdf

1. Appropriateness of gastroscopy: dyspepsia.

in November 1998, a multidisciplinary European expert panel convened in Lausanne, Switzerland, to discuss and develop criteria for the appropriate use of gastrointestinal endoscopy, a widely-used procedure, regarded as highly ac­ curate and safe. The R A N D appropriateness method was chosen for this purpose, because it al lows the development of appropriateness criteria based on publ ished evidence and supplemented by explicit expert opinion. A detailed de­ scription of the R A N D appropriateness method, including the literature search process [1], and of the whole process , as well as the global results of the panel [2], are published as separate articles in this issue of the Journal . The litera­ ture review was based on a systematic search of Medl ine , Embase and the Cochrane Library conducted up to the end of 1997 and completed with some key articles publ ished in 1998. Updating and revision of the literature review is cur­ rently ongoing.

10. Appropriateness of colonoscopy: diarrhea.

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