GI Potpourri 2015 Spencer A. Wilson, MD Northside Gastroenterology 4/28/2017 2:20 AM GI Potpourri 2015 Spencer A. Wilson, MD Northside Gastroenterology Medical Director, Digestive Health Center St. Vincent’s Hospital, Indianapolis © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Key Topics in GI for 2015 SCENIC Guidelines – IBD Surveillance Optimal polypectomy technique Comparison of H. pylori treatments Proton pump inhibitors and cardiovascular risks

SCENIC GUIDELINES Consensus statement on surveillance and management of dysplasia in inflammatory bowel disease Gastroenterology March 2015 Gastrointestinal Endoscopy March 2015

INTRODUCTION Increased risk of colorectal cancer (CRC) in long-standing UC or extensive CD . Most cases of CRC arise from dysplasia and surveillance colonoscopy is recommended to detect dysplasia. Dr. Waleed Khalid Mahrous

IBD Surveillance Current U.S. guidelines (2014) recommend obtaining at least 33 random biopsy specimens from all segments of the colon as the foundation of endoscopic surveillance Initiate surveillance 8 years after symptom onset UC: left-sided or pancolitis CD: colitis involving > 1/3 of colon Every 1-3 years Exact interval debated Annually if: FHx CRC, active inflammation, stricture/pseudopolyps, Hx dysplasia, PSC

IBD Surveillance 33 random colon biopsies samples < 1% of the colon mucosa Goal was to identify “invisible” dysplasia White light (standard vs high-definition); narrow-band imaging/NBI; chromoendoscopy However, with new endoscopic technologies, investigators report that most dysplasia in inflammatory bowel disease (IBD) is visible

IBD Surveillance A unifying consensus was needed to address (1) How should surveillance colonoscopy for detection of dysplasia be performed? (2) How should dysplasia identified at colonoscopy be managed? SCENIC IBD surveillance guidelines were developed to address these questions

Chromoendoscopy Randomized, back-to-back trials and case-control studies 2-fold to 3-fold increase in per patient dysplasia detection 4-fold to 5-fold increase in per lesion dysplasia detection

Chromoendoscopy

Chromoendoscopy

SCENIC Guidelines - Summary High-definition is favored over standard definition for performance of surveillance Chromoendscopy is recommended as an adjunct to high-def colonoscopy Narrow band imaging is not a replacement for high-def, white light colonoscopy or chromoendoscopy

SCENIC Guidelines - Summary No specific recommendation on performance of random biopsies was made for patients undergoing high-def, white light colonoscopy plus chromoendoscopy 60 % of panel members disagree with performing random biopsies during chromoendoscopy Suggests the standard of care no longer requires random biopsies with high-def chromoendoscopy

SCENIC Guidelines - Summary No longer use the terms: DALM (dysplasia-associated lesion or mass) “Adenoma-like” or “non-adenoma like” When dysplasia is detected, it should be described as: “endoscopically resectable” or “non-endoscopically resectable” May also describe lesions as polypoid or non-polypoid

SCENIC Guidelines - Summary After complete removal of endoscopically resectable polypoid dysplasia, surveillance is recommended rather than colectomy After complete removal of endoscopically resectable non-polypoid dysplasia, surveillance is recommended rather than colectomy For patients with endoscopically “invisible” dysplasia, referral to an endoscopist with expertise in expertise in IBD chromoendoscopy surveillance is recommended

SCENIC Guidelines - Concerns Potential barriers to use of chromoendoscopy : Additional preparation and time required for chromoendoscopy Need to train endoscopists in this technique Need to develop quality measures and assess performance after training Procedure-related costs These issues were discussed in detail by a subgroup of the panel, and their report will appear in a separate publication. Dr. Waleed Khalid Mahrous

Optimal Polypectomy Technique Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial  Gastrointestinal Endoscopy March 2015

Optimal Polypectomy Technique Complete polyp removal during colonoscopy is critical for prevention of colorectal cancer 8.8 – 50% of interval colorectal cancers may be attributable to incomplete polypectomy Polypectomy technique varies widely among endoscopists, especially for polyps < 10 mm

Optimal Polypectomy Technique Cold forceps polypectomy is generally preferred by endoscopists for polyps < 10 mm Technically “easier” Less coordination between endoscopist and RN/tech Tissue retrieval simplified Less potential risk of bleeding or perforation However, previous studies have suggested that cold snare is more effective than cold forceps for < 10 mm polypectomy … this represents the first randomized, controlled trial to address this issue

Optimal Polypectomy Technique

Optimal Polypectomy Technique

Optimal Polypectomy Technique Conclusions: For polyps < 10 mm, cold snare polypectomy is superior to cold forceps polypectomy and is the recommended technique for small/diminutive colon polyp removal Other studies have shown that cold snare polypectomy is more efficient Cold forceps typically requires 2.5 bites per polyp for visual eradication

Comparison of H. pylori Treatments “Triple therapy” or Pylera thought to be 85-90% effective as first-line therapy PPI+bismuth+metro+tetra (Pylera) PPI+clarith+amox/metro As antibiotic resistance of H. pylori increases, eradication rates of standard triple therapy (PPI+Clarith+amox/metro) decreases “Comparative effectiveness and tolerance of treatments for Helicobacter pylori: Systematic review and network meta-analysis”. BMJ August 2015

Comparison of H. pylori Treatments

Comparison of H. pylori Treatments

Comparison of H. pylori Treatments Current first-line treatments less effective than previously thought In general, longer therapy is associated with higher eradication albeit at greater risk of side-effects Eradication rates influenced by regional antimicrobial resistance patterns

PPIs and CV Risks PPIs are often prescribed for inappropriate indications and for excessive duration 30-50% of prescriptions Growing body of literature implicates PPIs in a multitude of adverse events 1988 Omeprazole 1991 UK 1995 US Lansoprazole 1994 Pantaprazole 1999 Rabeprazole 2001 Esomeprazole

PPIs and CV Risks FDA approved labeling updates or published safety alerts 2009 - Decreased clopidogrel efficacy Based on in-vitro platelet aggregation studies “Real-world” clinical data is lacking 2011 - Hypomagnesimia 2012 - C. difficile-associated diarrhea 2014 - Vitamin B12 deficiency 2014 - Acute interstitial nephritis

PPIs and CV Risks PLoS One “data mining” study – BMJ June 2015 In 93,000 GERD patients from 1994-2012, exposure to PPI associated with 16% increase in MI risk Also, 2-fold increase in CV mortality In contrast, no increase risk with H2-blockers This data was sharply criticized by GI experts due to inability to account for GERD risk factors (ie, metabolic syndrome, obesity, etc.) which are independent risk factors for CV events. Moreoever, 4000 people would need to take PPI to cause an MI in 1 patient

PPIs and CV Risks “Incidence of cardiovascular events and gastrointestinal bleeding in patients receiving clopidogrel with and without proton pump inhibitors: An updated meta-analysis”. Open Heart 2015 23,000 patients from 3 RCTs and 5 propensity-matched cohort studies In contrast to the PLoS One data, researchers found no clinically significant adverse effect for combination clopidogrel + PPI PPI use thought to be marker of patient’s CV risk but not necessarily causative PPI + clopidogrel associated with reduced risk for upper GI bleeding

PPIs and CV Risks Some more bad news for PPIs this year … JAMA 2016 In 10,000 patients, PPI associated in a dose-depend fashion with incident chronic kidney disease In 74,000 german patients > 75 y/o, patients taking regular PPI were significantly more likely to develop dementia

QUESTIONS …… ?