Srinivas Ramireddy2,4, William a. Ross2. 1Department of ... Anderson Cancer Center, Houston, TX; 3Gastroenterology, Hepatology and Nutrition, University of ...
Abstracts interval between ingestion of PEG bowel preparation (and likely other similar preparations) and sedation is safe.
count at the time of procedure
Pre-procedure platelet count
Procedures where biopsy was performed (N)
ⱕ25,000 per L 26,000 - 50,000 per L 51,000-75,000 per L Total % Bleeding risk overall
Biopsy related bleeding
Procedures where polypectomy was performed (N)
Polypectomy related bleeding
1 0 0 6 16 2 1 1 0 8 17 2 4% (of 45 2% (of polypectomies) 398 endoscopies) Comparison of mean platelet count between endoscopies with and without pre-procedural platelet transfusion 315 23.93⫾8.6 0(A) Procedures with prior (ⱕ24 262 24.72⫾9.20 hours) platelet transfusion and mean platelet count prior to transfusion 136 37.60 ⫾ 9.21 58 41.86⫾6.6 2(B) Procedures without platelet transfusion and mean platelet count prior to procedure T-test, p value; comparing (A) ⬍0.001 — ⬍0.001 — and (B) 95% CI 10.962,14.806 — 10.256, 25.592 —
415 Evaluating Safety of Gastrointestinal (GI) Endoscopy, Mucosal Biopsy and Polypectomy in Patients With Thrombocytopenia Somashekar G. Krishna*2,1, Bhavana Bhagya Rao2,3, Jeffrey H. Lee2, Srinivas Ramireddy2,4, William a. Ross2 1 Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH; 2Department of Gastroenterology, Hepatology and Nutrition, University of Texas at MD Anderson Cancer Center, Houston, TX; 3Gastroenterology, Hepatology and Nutrition, University of Texas-Houston medical school, Houston, TX; 4General Internal medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL Background: Patients with thrombocytopenia are assumed to be at higher risk for spontaneous or procedure related GI bleeding. The safety of performing endoscopy in this patient group has not been determined in large studies. Objective: To determine the safety of GI endoscopy, standard forceps biopsy and polypectomy in cancer patients with thrombocytopenia. Methods: Retrospective review of endoscopic procedures performed in adult patients with pre-procedure platelet (plt) count (#) ⬍75,000/L between 1/1/2008 and 6/30/2012 at a tertiary cancer center. Results: A total of 617 endoscopic procedures (351 EGDs, 90 colonoscopies and 176 sigmoidoscopies), performed in 395 patients (225 male, mean age⫽54.8⫾15.8 years) were reviewed. The primary diagnosis included 332 cases (84.1%) of hematological malignancies. The most common indications were suspected GI graft versus host disease (GVHD, 47.3%) and symptoms suggestive of GI bleeding (37.1%). Platelets were transfused prior (ⱕ24 hours) in 424 (68.7% of 617) endoscopies; with their pre-transfusional plt # found to be lower than those who received no transfusion. (24,950/L vs. 37,250/L, p⫽0.001). Standard forceps biopsies (bxs) were obtained in 398 (64.5% of 617) procedures with mean plt # of 40,568⫾1,204/L (table 1). Bleeding due to bx was seen in 8 (2%). Bleeding was immediate in 7 and required intervention in 5 cases (hemoclips-4, epinephrine injection-1; table 2). Delayed bleeding from the bx site occurred in 1 case and was managed by hemoclip. Follow up of patients who were biopsied (including those with bx related bleed) for 3 days showed no significant increase in blood or plt requirements. Among 398 endoscopies with biopsies, 44.7% had significant pathology, with definitive GI-GVHD being the most common diagnosis (66% of 329 endoscopies done to evaluate for GVHD). A total of 45 polyps were removed in 17 colonoscopies with mean plt # of 42,882⫾8,971/L (table 1). Immediate bleeding at polypectomy site was seen in 2 patients following hot snare and cold forceps polypectomies (table 2), with risk of bleeding being 4%. Mean hemoglobin prior to procedure (9.67 g/dL) did not significantly decrease following polypectomy (9.16 g/dL) and blood transfusion requirements did not increase. Variceal banding (n⫽5), colon decompression tube (n⫽4), and percutaneous gastrostomy tube placement (n⫽8) were performed with a mean plt # of 38,800/L, 43,750/L and 48,200/L respectively, without any bleeding or other complications. Conclusion: This study represents the largest endoscopic experience reported in thrombocytopenic patients. The incidence of standard forceps bx and polypectomy related bleeding was elevated but bleeding was typically minor and easily controlled. Thus thrombocytopenia should not be a deterrent to endoscopic biopsies nor should it rule out other interventions such as polypectomy. Table 1. Number and outcome of endoscopic interventions based on platelet
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46 295 57 398
Table 2. Control of bleeding secondary to standard forceps biopsy and polypectomy Forceps biopsy related bleeding
Modality applied Mild ooze stopped spontaneously Hemoclip Epinephrine injection Delayed bleeding Gold probe cautery Total *After epinephrine injection
Polypectomy associated bleed
2 4 1 1 8
1*
1 2
416 Feeding After Percutaneous Endoscopic Gastrostomy: Experience of Early Versus Delayed Feeding William J. Cobell*, Alisha M. Hinds, Roxanne G. Lim, Shoba Theivanayagam, Syed Akbar, Rahul Nayani, Michelle L. Matteson, Abhishek Choudhary, Srinivas R. Puli, Matthew L. Bechtold Division of Gastroenterology, University of Missouri - Columbia, Columbia, MO Background: Percutaneous endoscopic gastrostomy (PEG) is a common procedure performed for patients unable to sufficiently ingest nutrients or medications by mouth. Despite being performed by gastroenterologists and surgeons, the timing of feeding initiation after PEG placement has varied considerably. Multiple randomized trials and meta-analyses have demonstrated that early feeding ⱕ 4 hours after PEG is a reasonable option. However, many physicians continue to delay feedings to the next day or 24 hours. In our institution, we have performed early feeding after PEG for many years. Therefore, we evaluated the safety and effect of early feeding (ⱕ 4 hours) after PEG in our tertiary-care center. Methods: A retrospective, single tertiary-care center study of 444 patients who underwent PEG between June 2006 and December 2011 was performed after IRB approval. Patients were identified by CPT codes for PEG. Early feeding was defined as feeding ⱕ 4 hours while delayed feeding was defined as feeding ⬎ 4 hours. Outcomes after feeding, including mortality (24 hour, 24-72 hour, and 3-30 days) and complications (wound infection, melena, vomiting, leakage, stomatitis, other) were noted for both groups. Statistical analysis was performed by using Fisher’s exact test and t-test. Results: 444 patients underwent PEG from 2006-2011 with mean age of 62.3 ⫾ 16.7 years and mean BMI of 28.0 ⫾ 12.3. PEGs were performed by gastroenterologists (308) and surgeons (136) and as inpatients (368) and outpatients (76). The mean time of feeding after PEG was 10.8 ⫾ 10.1 hours (early 3.2 ⫾ 0.9 hours, delayed 17.0 ⫾ 10.0 hours) with 197 patients receiving early (ⱕ 4 hours) feeding while 247 patients receiving delayed (⬎ 4 hours) feeding. No statistically significant differences were noted between the early (ⱕ 4 hours) feedings versus the delayed (⬎ 4 hours) for overall morality within 30 days (16 vs 19, p⫽0.72) and overall complications (45 vs 57, p⫽1.00). Furthermore, no statistically significant differences were noted between early
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB150
