1. 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
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2. Key Topics in GI for 2015 SCENIC Guidelines – IBD Surveillance
Optimal polypectomy technique
Comparison of H. pylori treatments
Proton pump inhibitors and cardiovascular risks

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Chromoendoscopy

11. Chromoendoscopy

12. 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

13. 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

14. 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

15. 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

16. 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

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

19. 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

20. 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

21. Optimal Polypectomy Technique

22. Optimal Polypectomy Technique

23. 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

25. 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

26. Comparison of H. pylori Treatments

27. Comparison of H. pylori Treatments

28. 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

29. 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

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

31. PPIs and CV Risks PLoS One “data mining” study – BMJ June 2015
In 93,000 GERD patients from , 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

32. 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

33. 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

34. QUESTIONS …… ?