Clinical impact of routine esophagram after peroral endoscopic myotomy.

BACKGROUND AND AIMS: It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM. METHODS: Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak. RESULTS: One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy. CONCLUSIONS: Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.

Long-Term Quality of Life Following Endoscopic Therapy Compared to Esophagectomy for Neoplastic Barrett's Esophagus.

INTRODUCTION: Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared. AIMS: We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy. METHODS: Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates. RESULTS: The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes. DISCUSSION: Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET.

Per-oral Endoscopic Myotomy Biopsies of Achalasia Patients Reveal Schwann Cell Depletion in the Muscularis Propria.

Achalasia is a neurodegenerative condition resulting in abnormal lower esophageal sphincter relaxation and impaired upstream esophageal body peristalsis.1 The pathophysiology and natural history of achalasia remain unclear, and evaluation of the histopathogenesis of achalasia has traditionally been challenging because the esophageal wall muscularis propria is not typically accessible via routine endoscopic biopsies.

Rectal indometacin dose escalation for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography in high-risk patients: a double-blind, randomised controlled trial.

BACKGROUND: Although rectal indometacin 100 mg is effective in reducing the frequency and severity of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients, the optimal dose is unknown, and pancreatitis incidence remains high. The aim of this study was to compare the efficacy of two dose regimens of rectal indometacin on the frequency and severity of pancreatitis after ERCP in high-risk patients. METHODS: In this randomised, double-blind, comparative effectiveness trial, we enrolled patients from six tertiary medical centres in the USA. Eligible patients were those at high risk for the development of pancreatitis after ERCP. We randomly assigned eligible patients (1:1) immediately after ERCP to receive either two 50 mg indometacin suppositories and a placebo suppository (standard-dose group) or three 50 mg indometacin suppositories (high-dose group). 4 h after the procedure, patients assigned to the high-dose group received an additional 50 mg indometacin suppository, whereas patients in the standard-dose group received an additional placebo suppository. The randomisation schedule, stratified according to study centre and with no other restrictions, was computer generated by an investigator who was uninvolved in the clinical care of any participants, distributed to the sites, and kept by personnel not directly involved with the study. These same personnel were responsible for packaging the drug and placebo in opaque envelopes. Patients, study personnel, and treating physicians were masked to study group assignment. The primary outcome of the study was the development of pancreatitis after ERCP. Analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01912716, and enrolment is complete. FINDINGS: Between July 9, 2013, and March 22, 2018, 1037 eligible patients were enrolled and randomly assigned to receive either standard-dose (n=515) or high-dose indometacin (n=522). Pancreatitis after ERCP occurred in 141 (14%) of 1037 patients-76 (15%) of 515 patients in the standard-dose indometacin group and 65 (12%) of 522 patients in the high-dose indometacin group (risk ratio [RR] 1·19, 95% CI 0·87-1·61; p=0·32). We observed 19 adverse events that were potentially attributable to study drug. Clinically significant bleeding occurred in 14 (1%) of 1037 patients-six (1%) of 515 patients in the standard-dose indometacin group and eight (2%) of 522 patients in the high-dose indometacin group (p=0·79). Three (1%) of 522 patients in the high-dose indometacin group developed acute kidney injury versus none in the standard-dose group (p=0·25). A non-ST elevation myocardial infarction occurred in the standard-dose indometacin group 2 days after ERCP. A transient ischaemic attack occurred in the high-dose indometacin group 5 days after ERCP. All 19 adverse events, in addition to the 141 patients who developed pancreatitis after ERCP, were considered serious as all required admission to hospital. We observed no allergic reactions or deaths at 30 day follow-up. INTERPRETATION: Dose escalation to rectal indometacin 200 mg did not confer any advantage compared with the standard 100 mg regimen, with pancreatitis incidence remaining high in high-risk patients. Current practice should continue unchanged. Further research should consider the pharmacokinetics of non-steroidal anti-inflammatory drugs to determine the optimal timing of their administration to prevent pancreatitis after ERCP. FUNDING: American College of Gastroenterology.

Adherence to CRC Screening and Surveillance Guidelines when Using Split-Dose Bowel Preparation.

GOAL: To prospectively assess physician recommendations for repeat colonoscopy in an average-risk screening cohort. BACKGROUND: Endoscopists' adherence to colorectal cancer screening and surveillance guidelines for repeat colonoscopy have not been well characterized. Furthermore, little is known about patient and colonoscopy factors that are associated with endoscopists' nonadherence to guideline recommendation. STUDY: This is a prospective cohort of average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. The primary outcome was assessment of physician recommendations for repeat colonoscopy. RESULTS: 462 participants were prospectively enrolled. 13.6% (62) had guideline-inconsistent recommendations. 89% of the guideline-inconsistent recommendations were for an earlier interval. Endoscopists' reports cited suboptimal bowel preparation as the most common reason for earlier repeat colonoscopy. On multivariable analysis, patient split-dose preparation noncompliance was significantly associated with guideline-inconsistent recommendation (OR = 2.7) even after adjusting for other patient or bowel preparation-related characteristics. Additionally, increased odds of guideline-inconsistent recommendation were associated with older age (>70 years old), higher BMI, having 3 or more polyps, having had at least two previous colonoscopies, suboptimal bowel preparation, and having taken at least 12 hours till clear bowel movement. CONCLUSIONS: Gastroenterologists are adherent to CRC screening and surveillance guidelines. Suboptimal bowel preparation is the most frequently cited factor in endoscopy reports leading to deviation from guidelines. Continued emphasis on optimization of bowel preparation, particularly patient compliance to split-dose regimen, is needed.

Early Splenic Flexure Intubation Competency Predicts Early Cecal Intubation Competency in Gastroenterology Fellows.

BACKGROUND: Trainees learn colonoscopy skills at varying speeds. We hypothesized that a fellow's ability to reliably reach the splenic flexure early in training could predict the number of procedures required to achieve competency in intubating the cecum. METHODS: This was a retrospective analysis of prospectively collected data. The most proximal site in the colon reached independently by GI fellows was recorded on consecutive colonoscopies. The number of procedures required to achieve splenic flexure intubation rate (SFIR) ≥ 90 % by cumulative summation learning curve and cecal intubation rate (CIR) ≥ 90 % by rolling average was calculated. Fellows were then dichotomized into "Early" versus "Late" learners based on the median number of procedures required to achieve SFIR ≥ 90 %. The number of procedures required to achieve CIR ≥ 90 % was then compared between the groups. RESULTS: Fellows achieved SFIR ≥ 90 % at a median of 37 colonoscopies. Fellows who achieved SFIR competency early achieved CIR ≥ 90 % at a mean of 208 procedures versus 352 procedures in the fellows who achieved SFIR competency late (p = 0.03). CONCLUSIONS: Data from a single academic medical center show that whether a trainee will learn endoscopy quickly compared to his/her peers can be predicted early in their endoscopy training by tracking SFIR. This knowledge could be used to customize endoscopy curriculum.

EUS Diagnostic Criteria for Chronic Pancreatitis: A Comparison of Conventional Versus Rosemont Criteria.

OBJECTIVE: To compare the Rosemont criteria, which are graded features chosen by experts in 2007, versus the conventional criteria, which require ≥ 3-5 of the 9 features that are "counted as equal," for the diagnosis of chronic pancreatitis by EUS. METHODS: This is a retrospective cohort study. EUS examinations were scored using both criteria, and the following categories compared: 3-CC versus "consistent with" chronic pancreatitis by RC; 3-CC versus "consistent with" and "suggestive of" chronic pancreatitis by RC; 5-CC versus "consistent with" chronic pancreatitis by RC; and 5-CC versus "consistent with" and "suggestive of" chronic pancreatitis by RC. RESULTS: There was a statistically significant difference between 3-CC and RC, either "consistent with" alone or both "consistent with" and "suggestive of" (p < 0.0001). Comparing 5-CC and "consistent with" showed a statistical difference (p = 0.0014), but no difference comparing 5-CC to "consistent with" and "suggestive of." CONCLUSION: CC diagnose more cases of chronic pancreatitis than RC when using 3-CC or when comparing 5-CC to "consistent with" chronic pancreatitis by Rosemont, indicating that the Rosemont criteria are more stringent.

The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement.

BACKGROUND: It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP). OBJECTIVE: To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk. DESIGN: Secondary analysis of randomized, controlled trial data. SETTING: University of Michigan and Indiana University. PATIENTS: A total of 577 clinical trial participants at elevated risk for PEP. INTERVENTIONS: Pancreatic stent placement. MAIN OUTCOME MEASUREMENTS: Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort. RESULTS: The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP. LIMITATIONS: Low event rate, FPS not prospectively captured. CONCLUSION: FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases.

Patient compliance and suboptimal bowel preparation with split-dose bowel regimen in average-risk screening colonoscopy.

BACKGROUND: Although split-dose bowel regimen is recommended in colon cancer screening and surveillance guidelines, implementation in clinical practice has seemingly lagged because of concerns of patient compliance. OBJECTIVES: To assess patient compliance with the split-dose bowel regimen and assess patient- and preparation process-related factors associated with compliance and bowel preparation adequacy. DESIGN: Prospective survey cohort. SETTING: Tertiary care setting. PATIENTS: Average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. MAIN OUTCOME MEASUREMENTS: Split-dose bowel regimen patient-reported compliance and bowel preparation adequacy with the Boston Bowel Preparation Scale score. RESULTS: Surveys and Boston Bowel Preparation Scale score data were completed in 462 participants; 15.4% were noncompliant with the split-dose bowel regimen, and suboptimal bowel preparation (score <5) was reported in 16% of all procedures. White (P = .009) and married (P = .01) subjects were least likely to be noncompliant, whereas Hispanic subjects and those who reported incomes of US$75,000 or less were most likely to be noncompliant (P = .004). Participants who were noncompliant with split-dosing were less likely to follow the other laxative instructions and more likely to have their colonoscopy appointment before 10:30 am. Compliance differed by bowel preparation type (P = .003, χ(2) test), with those who used MiraLAX showing the highest compliance, followed by polyethylene glycol electrolyte solution and other bowel preparations. Noncompliance with split-dose bowel preparation (odds ratio 6.7; 95% confidence interval, 3.2-14.2) was the strongest predictor of suboptimal bowel preparation. LIMITATIONS: Patient self-report, performed at tertiary care center. CONCLUSIONS: Overall, 1 in 7 patients do not comply with a split-dose bowel regimen. Ensuring compliance with the split-dose bowel regimen will reduce the risk of a suboptimal bowel preparation.

Do breaks in gastroenterology fellow endoscopy training result in a decrement in competency in colonoscopy?

BACKGROUND: Skills decay without practice, but the degree is task specific. Some experts believe that it is essential to teach endoscopy longitudinally to build and maintain endoscopic skills. OBJECTIVE: To determine whether breaks in gastroenterology fellow endoscopy training are associated with a decrement in competency in independent intubation of the cecum. DESIGN: Observational cohort of colonoscopies performed by gastroenterology fellows. SETTING: Academic fellowship program from July 2010 to March 2012. SUBJECTS: Twenty-four fellows. MAIN OUTCOME MEASUREMENTS: The adjusted change in the slope of cumulative summation learning curves for cecal intubation after breaks in training and the slope at the end of the subsequent endoscopy rotation. RESULTS: A total of 6485 colonoscopies were performed by 24 fellows with 87 breaks in training. The average break was 6 weeks (range 2-36 weeks). Seventy-five percent of the breaks were 8 weeks or less. For every additional 4 weeks, the slope after the break worsened by 0.022 (P = .06, maximum possible change = -1.0 to +1.0). By the end of the subsequent rotation, there was no association between the slope of the learning curve and the length of the break (P = .68). LIMITATIONS: This was an observational study of only 24 fellows with relatively few long breaks. Cecal intubation is only 1 component of overall competency in colonoscopy. CONCLUSIONS: There may be a very small decrement in fellows' abilities to intubate the cecum after a break in endoscopy training. Because these changes are so small, teaching endoscopy in blocks is probably adequate, if necessary to balance other clinical and research experience. However, further research is needed to determine whether a longitudinal endoscopy experience is superior for attaining and maintaining competency, to evaluate the effects of breaks longer than 8 weeks, and to determine whether the effects of breaks depend on the previous volume of experience with colonoscopy.

Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data.

OBJECTIVES: A recent large-scale randomized controlled trial (RCT) demonstrated that rectal indomethacin administration is effective in addition to pancreatic stent placement (PSP) for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. We performed a post hoc analysis of this RCT to explore whether rectal indomethacin can replace PSP in the prevention of PEP and to estimate the potential cost savings of such an approach. METHODS: We retrospectively classified RCT subjects into four prevention groups: (1) no prophylaxis, (2) PSP alone, (3) rectal indomethacin alone, and (4) the combination of PSP and indomethacin. Multivariable logistic regression was used to adjust for imbalances in the prevalence of risk factors for PEP between the groups. Based on these adjusted PEP rates, we conducted an economic analysis comparing the costs associated with PEP prevention strategies employing rectal indomethacin alone, PSP alone, or the combination of both. RESULTS: After adjusting for risk using two different logistic regression models, rectal indomethacin alone appeared to be more effective for preventing PEP than no prophylaxis, PSP alone, and the combination of indomethacin and PSP. Economic analysis revealed that indomethacin alone was a cost-saving strategy in 96% of Monte Carlo trials. A prevention strategy employing rectal indomethacin alone could save approximately $150 million annually in the United States compared with a strategy of PSP alone, and $85 million compared with a strategy of indomethacin and PSP. CONCLUSIONS: This hypothesis-generating study suggests that prophylactic rectal indomethacin could replace PSP in patients undergoing high-risk ERCP, potentially improving clinical outcomes and reducing healthcare costs. A RCT comparing rectal indomethacin alone vs. indomethacin plus PSP is needed.

A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis.

BACKGROUND: Preliminary research suggests that rectally administered nonsteroidal antiinflammatory drugs may reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In this multicenter, randomized, placebo-controlled, double-blind clinical trial, we assigned patients at elevated risk for post-ERCP pancreatitis to receive a single dose of rectal indomethacin or placebo immediately after ERCP. Patients were determined to be at high risk on the basis of validated patient- and procedure-related risk factors. The primary outcome was post-ERCP pancreatitis, which was defined as new upper abdominal pain, an elevation in pancreatic enzymes to at least three times the upper limit of the normal range 24 hours after the procedure, and hospitalization for at least 2 nights. RESULTS: A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03). CONCLUSIONS: Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00820612.).

Colorectal cancer screening compliance and contemplation in gynecology patients.

OBJECTIVE: Colorectal cancer screening (CRCS) should be a necessary part of gynecology (GYN) providers' preventive practices. The purpose of our study is to examine CRCS recommendations and adherence in this population. METHODS: A questionnaire was administered to a prospective cohort of patients awaiting health maintenance exams at six academic and private gynecology offices. Patients reported demographics, CRC/breast/cervical screening adherence, CRCS recommendations, and future likelihood of CRCS. RESULTS: A total of 461 women aged 51 years and older completed the questionnaire. Sixty-six percent of respondents were compliant with CRCS compared to 93% and 86% for breast and cervical cancer screening, respectively (p < 0.001). GYN providers recommended CRCS in 43% of patients. Sixty-three percent were planning to undergo future CRCS. On multivariable analysis, characteristics associated with CRCS adherence included (odds ratio, 95% confidence interval): older age (1.1 per year, 1.1-1.2), previous mammography (3.7, 1.4-9.7), family history (FH) of CRC/polyps (1.9, 1.0-3.4), friend with CRC (2.6, 1.5-4.7), and any doctor recommending CRCS (8.2, 4.6-14.7). CRCS rates were higher among patients who received a recommendation from a PCP (primary care provider) than from a GYN provider. Factors associated with intention to undergo CRCS include previous mammography (1.4, 4.2-12.0), any doctor recommendation (6.4, 3.7-11.0), and FH of CRC/polyps (3.5, 1.9-6.3). CRCS recommendations by both GYNs and PCPs had a greater impact on CRCS contemplation than those from a PCP or GYN alone. CONCLUSION: In gynecology patients, having multiple providers recommend CRCS increases the likelihood of patients' intentions to undergo CRCS. However, CRCS compliance is primarily driven solely by PCP recommendations. Regardless, strategies must be in place to prompt gynecologists and nurse practitioners to discuss CRCS in eligible patients.

Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens.

BACKGROUND: In inflammatory bowel disease (IBD) surveillance colonoscopy, an increased number of biopsy specimens correlates with a higher dysplasia detection rate. Larger biopsy specimens may also increase the diagnostic yield. OBJECTIVE: To compare a new jumbo forceps with a standard large-capacity forceps in obtaining diagnostically adequate IBD surveillance biopsy specimens. DESIGN: Prospective single-center study. PATIENTS AND METHODS: Twenty-four patients who were undergoing an IBD surveillance colonoscopy were enrolled. As part of standard IBD surveillance, 8 paired biopsy specimens were obtained from the rectosigmoid by using the jumbo forceps and a standard large-capacity forceps. OUTCOME MEASUREMENTS: Biopsy specimens were deemed adequate if they met all 3 of the following criteria: (1) length > or =3 mm, (2) penetration into the muscularis mucosa, and (3) < 20% crush artifact. RESULTS: The proportion of adequate biopsy specimens obtained with the jumbo forceps was significantly higher than that obtained with the large-capacity control forceps (67% vs 48%, P < .0001). The average length of the biopsy specimen obtained with the jumbo forceps was 4.00 mm (95% CI, 3.81-4.20 mm) compared with 3.19 mm (95% CI, 2.99-3.38 mm) with the large-capacity (control) forceps. LIMITATIONS: (1) No validated outcome measurement for the quality of GI biopsy specimens exists and (2) in this study, interobserver variability between pathologists was high. CONCLUSIONS: The jumbo forceps was superior to a standard large-capacity forceps in obtaining diagnostically adequate IBD surveillance biopsy specimens. Because biopsy specimens obtained with the jumbo forceps were larger, the use of this forceps for IBD surveillance will allow the endoscopist to sample a larger colonic mucosal surface area, potentially resulting in an increased dysplasia detection rate.

Does colonoscopy cause increased ulcerative colitis symptoms?

BACKGROUND: Ulcerative colitis (UC) patients often report symptom flares after colonoscopy. However, this has not been documented in the literature. OBJECTIVES: 1. Determine whether colonoscopy is associated with increased UC symptoms. 2. Determine whether there is a need for escalation of UC medications after colonoscopy. 3. Identify baseline variables associated with increased symptoms after colonoscopy. METHODS: Fifty-five outpatients with a history of UC, intact colon, and quiescent disease were enrolled in a prospective case-crossover study. Subjects were evaluated with the Simple Clinical Colitis Activity Index (SCCAI) before colonoscopy, 1 week and 4 weeks after colonoscopy. A mixed model analysis was used to accommodate nonindependence of repeated measurements on the same patients. RESULTS: Fifty-one (91%) subjects completed the study. Six subjects had clinical relapse defined by a score of 5 or greater on the SCCAI during the week after colonoscopy. Five subjects increased their 5-aminosalicylic acid (5-ASA) medications immediately postcolonoscopy, two of whom had a SCCAI 5 or greater. Multivariate modeling demonstrated a clear association between the week immediately after colonoscopy preparation and increased disease activity, with the time period being predictive of increased SCCAI (week 1 vs. week 4, P = 0.0127). The baseline SCCAI (P value < 0.0001) and prednisone use (P = 0.0120) were predictive of increased SCCAI postcolonoscopy. Thiopurines (P < 0.001) were protective against increased symptoms. CONCLUSIONS: In our study, 1 in 8 subjects had UC relapse by SCCAI immediately postcolonoscopy, and 1 in 10 subjects required an increase in their 5-ASA medications. Clinicians should be cognizant of this effect of colonoscopy in patients with UC.

Women patients' preference for women physicians is a barrier to colon cancer screening.

BACKGROUND: The preference of women patients for women physicians has been shown in many specialties. Women patients awaiting a lower endoscopy have been shown to have a preference for women endoscopists. The reasons for this preference and the strength of this preference have not been studied in the primary care setting. METHODS: A questionnaire was given to female patients who were waiting for primary care appointments at 4 offices. Patients reported sociodemographic characteristics, experiences with colorectal cancer (CRC), barriers to CRC screening, gender preference of their physician, the significance, and reasons for this preference. RESULTS: A total of 202 women patients aged 40 to 70 years (mean 53 years) completed the questionnaire. Of these patients, 43% preferred a woman endoscopist, and of these, 87% would be willing to wait >30 days for a woman endoscopist, and 14% would be willing to pay more for one. The most common reason (in 75%) for this gender preference was embarrassment. Univariate analysis revealed that gender of the primary care physician (PCP), younger patient age, current employment, and no previous history of colonoscopy were predictors of preference for a woman endoscopist. Of these variables, only female gender of the PCP (OR 2.84: 95% CI[1.49, 5.40]) and employment (OR 2.4: 95% CI[1.23, 4.67]) were positive predictors for a woman endoscopist preference by multivariable analysis; 5% stated that they would not undergo a colonoscopy unless guaranteed a woman endoscopist. The sole independent factor associated with adherence to screening was PCP recommendation (OR 2.93: 95% CI[1.63, 5.39]). CONCLUSIONS: Women patients frequently prefer a woman endoscopist, and this preference is reported as being strong enough to delay the procedure and to incur personal expense. It is an absolute barrier to endoscopy according to 5% in this subset of women surveyed. Interventions must be made in the primary care setting to address this issue and to increase the participation of women patients in CRC screening.