Introduction: Due to increased morbidity and mortality of inadvertent blind feeding tube placements, we implemented an enteral nutrition inpatient pilot at our tertiary care facility. We created a “tubes service” in an effort to provide more timely nutrition in a safe manner to improve quality of care. We aimed to reduce risk of adverse events as well as to provide more timely nutrition safely by also minimizing radiation from x-ray. Methods: We piloted the enteral nutrition platform with GI fellow placement of NG/post pyloric feeding tubes under direct visualization without use of endoscopy for failed blind bedside NG placements. A data collection form was created to measure results (Figure1a). We incorporated the Resource Intensive Care (RIC) Nurses onto our team. GI provided an in-service for critical care staff on the enteral nutrition platform. The RIC Nurse service went live after each nurse was deemed competent based on a competency evaluation developed by the GI lead physician (Figure1b). Collaboration with IT Services for use of this platform to capture images of proper placement was confirmed for medical record documentation and for reduction of x-ray usage. GI will support failed attempts endoscopically. Results: GI fellows placed 50 tubes with no adverse events from February 2020 - December 2020. This number excludes 3 months of the initial pandemic period and excluded COVID 1 patients. Average time from consult to placement was 9 hours compared to reported time from consult to blind placement averaging ∼21 hours. From March -April 2021, 16 (100%) tubes were placed successfully in the ICUs by our dedicated RIC nurse team. One attempt was hindered due to hiatal hernia. Average times from consult to placement averaged 4 hours. Conclusion: Bedside placement of feeding tubes with built-in camera technology allows for a safer, more effective, and more efficient method for delivery of enteral nutrition for inpatients. A cost/ benefit analysis shows a potential $840.20 in savings per patient with decreased need for x-rays, decreased risk of adverse events, earlier time to feeding and decreased length of stay. Out of 66 successful placements, it is an estimated total potential savings of $55,453. We will expand this service to other hospitals within our large health system to include COVID1 patients moving forward..

Introduction: Bowel preparations are often not adequate in the hospital setting due to lack of nursing documentation, lack of follow through to achieve bowel prep efficacy by the prescriber, and patient risk factors. Methods: We performed a baseline analysis of current state inpatient bowel prep adequacy. We collaborated with our EPIC team for development of a new EPIC order set for split dose preps, and a nursing workflow to assess for bowel cleanliness following prep intake (Figure 1a). The EPIC order set included timing for AM/PM colonoscopies, options for high risk patients who would need salvage prep, and built-in nursing orders for patients unable to tolerate prep. We provided hard stops for nursing documentation to ensure that all information was recorded regarding amount of prep consumed. GI fellows did a 7 AM check on day of procedure to ensure prep completion. Bowel prep assessment measured consistency, color and sediment of stool to identify readiness for colonoscopy to the GI lab by indicating green for readiness and red if not ready. In-service education was provided to GI Fellows and nursing on utilization of the EPIC order set. Training was provided for nurse educators and staff. Adequate administration of prep was reviewed with pharmacy. Results: Pre-intervention data showed 106 (48.0%) inadequate inpatient bowel preps with 18.6% colonoscopies needing repeat procedures during same hospitalization. This resulted in a 41 day increase in length of stay (LOS) over the 7 month period. Post-intervention data showed 51 (30.4%) inadequate preps resulting in a 17.6% reduction from baseline (p=0.0005). Only 2.4% colonoscopies were repeated during the same hospitalization with only a 4 day increase in LOS. This was a 16.2% (p=0.0001) reduction from baseline. Cost savings estimated at $56,869. The addition of salvage prep after same day 7 AM evaluation by GI fellows provided the greatest impact in bowel prep adequacy. Conclusion: Inpatient colonoscopies are often repeated due to poor bowel prep due to several factors including patient tolerability, lack of documentation of intake, and lack of follow-up by clinician to ensure completion of prep intake. Repeat colonoscopy due to poor prep leads to increased LOS, cost, and decreased patient satisfaction. We propose the above interventions which describe a proactive, not reactive, approach to optimizing bowel prep efficacy and LOS, decreasing cost, and improving patient satisfaction.Figure 1.: Split Dose Bowel Preparation Order SetTable 1.: Bowel Preparation Results: Pre- and Post- Intervention

Background and Aims: Patients with Inflammatory bowel disease (IBD) are at an increased risk of developing herpes zoster (HZ). The effectiveness of the recombinant zoster vaccine (RZV) in patients with IBD is unknown. Methods: In this retrospective cohort study using Explorys (October 2017-April 2020; IBM Corporation, Somers, NY, USA), the effectiveness of RZV for the prevention of HZ in patients with IBD > 50 years was compared to general population aged > 50 years. Rates of de-novo HZ were compared between patients with IBD and the general population and stratified by number of RZV doses received. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results: The overall proportion of IBD patients > 50 years who received HZ vaccination with the live zoster vaccine (ZVL) or RZV was low (n = 11320, out of 112,200 IBD patients in the cohort). A total of 1670 patients received RZV. Receipt of the RZV resulted in a significantly lower rate of HZ in IBD patients (OR 0.36, 95% CI 0.23-0.56) compared to the general population (OR 0.74, 95% CI 0.59-0.92). However, despite vaccination, patients with IBD who received the RZV were still 3-times more likely to develop HZ during the study follow up period compared to the general population receiving the RZV (OR 3.06, 95% CI 1.87- 5.02) and unvaccinated IBD patients were 6-times more likely to develop HZ compared to general population (OR 6.21, 95% CI 6.02-6.41). Conclusion: The recombinant zoster vaccine is effective in reducing the risk of HZ in patients with IBD compared to the general population. During our follow up period, patients with IBD, however, still remain at an increased risk for HZ despite vaccination. (c) 2021 Elsevier Ltd. All rights reserved.

Introduction: Gastrojejuncolic fistula is a rare and late complication of previous gastroenterostomy with Billroth II reconstruction for peptic ulcer disease. It is thought to be secondary to a chronic stomal ulcer. Clinical presentation involves feculent vomiting, chronic diarrhea, weight loss and malnutrition. The diagnostic work-up typically includes oral contrast-enhanced imaging and/or endoscopy. Here, we introduce a case of gastrojejunocolic fistula presenting as a late complication of Billroth II gastrojejunostomy. Case Description/Methods: A 51-year-old man presented with chronic diarrhea, intermittent feculent vomiting, significant weight loss, and fatigue. He has a history of perforated NSAID-induced peptic ulcer status post partial gastrectomy with Billroth II gastrojejunostomy six years ago, and marginal ulcerations. Symptoms were ongoing for 4 months and progressively worsening. Prior upper and lower endoscopic evaluations were non-diagnostic. Labs were significant for hypokalemia, hypoalbuminemia, and hypoproteinemia. Initial CT scan did not show evidence of intestinal obstruction. Metabolic, hormonal and infectious work up, including Clostridium difficile, was unrevealing. Repeat upper endoscopy for video capsule placement showed evidence of feculent liquid in gastric cavity (Figure 1A). The anatomy was consistent with previous partial gastrectomy with gastrojejunostomy; a clean base marginal ulcer was noted (Figure 1B). Efferent jejunal limb was characterized by healthy appealing mucosa. Another luminal tract was identified at the anastomosis leading into the transverse colon (Figure 1B-C), raising suspicion of a gastrojejunocolic fistula. Small bowel follow-through subsequently revealed contrast passing preferentially in the jejunum with retrograde flow into the transverse colon, confirming gastrojejunocolic fistula (Figure 1D). The patient was started on total parenteral nutrition given his malabsorption and sarcopenia. Future treatment plan includes surgical takedown of fistula once nutritionally optimized. Discussion: The diagnosis of gastrojejunocolic fistulas is often delayed owing to the condition's rarity. A high index of suspicion should be kept in patients with history of gastric surgery presenting with feculent vomiting, chronic diarrhea, weight loss and malnutrition. Oral contrast-enhanced imaging and detailed endoscopic exam can confirm diagnosis. Definitive management involves surgical repair of the fistula.Figure 1.: Endoscopy shows (A) feculent material in gastric cavity, (B) gastrojejunostomy with marginal ulcer (yellow arrow); gastrojejunocolic fistula (red arrow) and (C) transverse colon visualized after traversing gastrojejunocolic fistula. (D) Small bowel follow-through showing contrast passing preferentially in the jejunum (blue arrow) with retrograde flow into the transverse colon (red arrow).

Background: Up to 50% of gastroenterology fellows report burnout.In 2017, the Accreditation Council for Graduate Medical Education (ACGME) revised Common Program Requirements mandating all training programs address well-being.Retreats are one method of promoting well-being, but little guidance has been published on the use of retreats.Methods: Our section chief, program directors, and senior fellows held planning meetings to discuss purpose, content, location, and clinical coverage for the retreats.Fellows' feedback each year helped to refine subsequent retreats.The first two retreats were held January 26, 2018 and March 1, 2019.Results: The planning committee agreed upon a wellness-focused retreat located away from the medical center at a section member's home.Retreats were held on Fridays mid-year, with second/third year fellows covering clinical duties from 5PM the Thursday prior through the following weekend to allow fellows an extended reprieve.A senior faculty member donated $300 for food the first year, and up to $500 per year was set aside in the fellowship budget for subsequent years.In the first two years, 11 first year fellows participated in retreats and 10 of 11 fellows (91%) completed post-retreat surveys.All fellows thought the purpose of the retreats -wellness -was clear and were 'very satisfied' with the time of year of the retreat (10 of 10, 100%) .Most fellows were 'very satisfied' or 'somewhat satisfied' with the day of the week (10 of 10, 100%) and clinical coverage (10 of 10, 100%) for the retreat.Most (9 of 10, 90%) fellows preferred to have faculty present for some but not all of the retreat.Feedback on activities from each retreat are noted in Table 1 andTable 2. Fellows reported that the retreat exceeded expectations, felt faculty and senior fellows genuinely cared about their well-being, and hoped the retreat would expand to all fellowship classes in the future.Fellows were most engaged during the patient experience, re-reading of personal statements, game time, and while sharing ups/downs of first year and strengths about one another.Fellows were least engaged while using personality test to discuss team dynamics.Main takeaways from the retreats included the impact of incivility on team performance, ubiquitous battle for work-life balance, importance of friends, need to ask for help, and humanness of fellows in training.Changes recommended for future retreats included greater variety of faculty involvement and more games and/or unstructured time.Discussion The first two years of a first-year gastroenterology fellows' retreat was well-received, low cost to implement, and provided meaningful time to pause, reflect, and bond with colleagues.Further research should focus on determining best practices for large and small programs, as well as metrics to capture the impact of retreats on well-being.

BACKGROUND:An association between bariatric surgery and development of de-novo inflammatory bowel disease (IBD) has been observed.AIM:To evaluate further the association among bariatric surgery, weight loss medications, obesity and new-onset IBD.METHODS:Using Explorys, a population-based Health Insurance Portability and Accountability Act compliant database, we estimated the prevalence of de-novo IBD among patients treated with bariatric surgery (Roux-en-Y gastrojejunostomy, laparoscopic sleeve gastrectomy or gastric banding) (n = 60 870) or weight loss medications (orlistat, phentermine/topiramate, lorcaserin, bupropion/naltrexone and liraglutide) (n = 193 790) compared with obese controls (n = 5 021 210), between 1999 and 2018.RESULTS:The prevalence of de-novo IBD was lower among obese patients exposed to bariatric surgery (7.72 per 1000 patients) or weight loss medications (7.22 per 1000 patients) compared with patients with persistent obesity not exposed to these interventions (11.66 per 1000 patients, P < 0.0001). The risk reduction for de-novo IBD was consistent across bariatric surgeries and weight loss medications with the exception of orlistat which was not associated with a reduction in risk for de-novo IBD compared with the persistent obese control cohort.CONCLUSION:Obese patients undergoing treatment with bariatric surgery or weight loss medications are at a lower risk for developing de-novo IBD compared with persistently obese controls not exposed to these interventions. These data suggest that obesity and ineffective management of obesity are risk factors for de-novo IBD. Further research is needed to confirm these observations and understand potential mechanisms.

Achieving adequate bowel preparation is challenging and critical to achieve a good quality colonoscopy.Delays due to inadequate bowel prep interfere with medical care, require repeat procedure, increase length of stay and cost of care.In addition, documentation is scant in relation to bowel prep intake.The American Society of Gastrointestinal Endoscopy (ASGE) guidelines recommend split-dose prep.We aim to study the barriers and implement changes that will improve quality of inpatient bowel prep in a tertiary-care center. We conducted a retrospective review of inpatient colonoscopies over a 7 month period to establish baseline current state of inadequate colonoscopy preparation and repeat procedures. Intervention included education of the gastroenterology fellows regarding the electronic medical record order set for split-dose bowel preparation, evaluation of prep adequacy at 7AM using a 5-point Nursing Bowel Prep Assessment Tool(NBPAT) and same day additional prep administration for patients with inadequate stool output.Prospectively, data was collected post intervention for 7 months and analyzed.Barriers were identified for further intervention. We reviewed 221 inpatients who had a colonoscopy over a 7 month period. The data showed 106 (48%) of the patients had inadequate prep, with 41(19%)patients requiring repeat inpatient colonoscopy during the same hospitalization. After intervention (Table 1), 215 inpatients who had colonoscopy were analyzed.Of these 78 (36%)patients had inadequate prep and only 11(5%)patients required repeat colonoscopy.The spilt-dose bowel prep was ordered the majority of time in both groups.However, documentation of prep was poor at the appropriate times of prep intake and only occurred for 21(10%)patients.The number of inadequate preps post-intervention decreased to 12% (p=0.0113). Cost analysis was performed for a patient having more than one inpatient procedure due to inadequate prep. It included the cost for performing the colonoscopy and the cost for one day increase in length of stay.The average cost was estimated to be approximately $1,537 per repeat procedure.With the decrease in repeat inpatient colonoscopies due to inadequate prep during the same hospitalization, the cost savings was approximated to be $46,110 for the 7 month duration for this simple intervention alone (Figure 1). Our study shows that a significant decrease in inadequate bowel prep for colonoscopy can be achieved by educating the providers on the split dose prep order-set, early morning bowel-prep assessment and proactive additional sameday prep.As a result, we revised our current bowel prep order.However, we identified that even though the prep was ordered as split dose, documentation of intake times and tolerability was lacking.As such, next phase implementation will involve identifying high risk patients and giving additional prep accordingly.Figure 1Cost Repeat Colonoscopy During Same HospitalizationView Large Image Figure ViewerDownload Hi-res image Download (PPT)

INTRODUCTION: Roughly 1.2M feeding tubes are placed annually in the US, most of which are placed without direct visualization. The current state within our Network is blind bedside placement with x-ray confirmation. The cost of blind placement is $1.46M annually, with potential additional cost due to complications (airway placement, pneumothorax, death), delayed nutrition/administration of medications, and cost of x-ray. We identified 3 adverse events which occurred over a 3-year time period with blind placement, resulting in 2 deaths and 1 lung placement. Subspecialty departments have expressed frustration for lack of a “tubes service” in an effort to provide more timely nutrition in a safe manner as well as avoid need for x-rays. METHODS: In an effort to improve quality of care to patients, optimize time to tube placement, and ensure accurate placement eliminating need for x-rays, an enteral nutrition platform was implemented with GI fellow training and placement of NG and post-pyloric tubes under direct visualization without the use of endoscopy. The inpatient service received consults for failed bedside NG placements via a specific EPIC order set. Each fellow was required to participate in a demo on proper device use and per form 2 live placements with industry and lead physician providing at-elbow assistance. The Program Director developed an instruction sheet which was made a part of the curriculum, Figure 1. with the first 50 placements to be confirmed by x-ray. RESULTS: The service began in February 2020 and 10 consults had been received thus far. The GI fellows achieved a 100% success using tube with direct visualization. X-ray confirmed proper placement with no adverse events. Average time from consult to placement was 10 hours and time from consult to use was less than 24 hours, Figure 2. Xinying et al reported time from consult to blind placement was an average of ∼21 hours. Given the COVID-19 pandemic, fellow training was halted and 2 competent fellows continued to place tubes eliminating the need for transport and x-ray during that critical time. CONCLUSION: The tube service was well accepted in our hospital. An initial cost/benefit analysis shows a potential $840.20 in savings per patient (Table 1) with decreased need for x-rays, elimination of adverse events as direct visual capability, earlier time to feeding and decreased length of stay. Further cost/benefit will be analyzed as we expand throughout our very large health system.Figure 1Figure 2Table 1

INTRODUCTION: Implementation of GI Quality Improvement Consortium (GIQuIC) in a large tertiary care system can be challenging. We successfully launched GIQuIC which in 14 total hospitals and endoscopy centers with 48/85 physicians trained in GIQuIC to date. METHODS: Physician apprehension regarding measuring quality as well as constraints with appropriate documentation in the EMR have historically made quality improvement challenging. An alternative method involves a physician champion who can relate to provider frustrations while maintaining educational goals and streamlining documentation. We took a specialized approach in training our physicians (Figure 1).Initial training conducted by the physician champion involved overview of GIQuIC benefits and expectations. At 12 weeks, further training on requirements including best practice guidelines and documentation was provided. Questions were reviewed with GIQuIC and endowriter software companies with answers communicated to physicians. Side-by-side training with the data manager working individually with each physician was executed before, during, and after go live date. Tip sheets were given to physicians for quick reference (Figure 2). RESULTS: Initial variability was noted in documentation, surveillance recommendations, bowel prep, risk assessment and cecum photo documentation. GIQuIC measure criteria and documentation tips were re-communicated to physicians by email, faculty meetings, and in person. Physician scorecards were developed and de-identified reports were reviewed at quarterly faculty meetings with individual correction plans implemented. Follow-up data showed better adherence to guidelines (Figure 3). CONCLUSION: GIQuIC provides an ongoing peer-based performance assessment, implementation of quality indicators to close care gaps, and improvement of quality of care to patients by standardizing documentation and limiting variability in which metrics are measured via specific data points. Our 1:1 training approach improved physician compliance and created a more positive culture. We believe that a personalized approach for education initiatives to improve the quality of care improves acceptance from healthcare providers which overall improves the culture of quality long-term.Figure 1.: GIQuIC Implementation Process.Figure 2.: Endowriter Tip Sheets.Figure 3.: GIQuIC Summary Trend.

INTRODUCTION: The United States is currently experiencing an unprecedented outbreak of the coronavirus During the peak phase of the pandemic in order to conserve resources and minimize risk of transmission, many elective screening colonoscopies were cancelled The quality team at our institute developed an educational program via telemedicine and internet-"COLorectal Outreach Via Internet and Dial-in-19 (COLOVID-19)" utilizing patient resources provided by ACG and ASGE Our aim was to continue our colorectal cancer screening outreach initiative and provide an avenue for patients to reschedule screening colonoscopies METHODS: A document about colon cancer screening with instructions for rescheduling procedures was prepared by a group of physicians and nurses (Figure 1) A list of cancelled screening colonoscopies was generated by the practice manager from March 23 to May 15, 2020 Nurses, fellows, physicians and practice staff provided outreach to patients whose screening colonoscopy was rescheduled The checklist was shared as part of the patient's online electronic health record (EHR) which allowed for two way conversation between the medical provider and patient Any patients not reached via EHR received a telephone call and the check- list was also mailed RESULTS: Figure 2 describes the algorithm of our workflow We reached out to 871 patients whose screening colonoscopies were cancelled from March 23 to May 15, 2020 274 patients did not have access to online EHR chart and received the COLOVID-19 point checklist via mail and telephone call The remaining patients (n = 597) received the list via EHR and 286 patients confirmed receipt of the checklist via the EHR Patients who did not confirm receipt of the checklist (n = 311) were contacted via telephone and 213 patients had the checklist mailed to them In summary 44 1% of the patients received the COLOVID-19 via internet and 55 9% via telephone and mail Figure 3 shows the results and patient comments CONCLUSION: We developed the COLOVID-19 point checklist to ensure a continuum of education and communication with respect to colorectal cancer awareness and prevention during the time of the COVID-19 pandemic Through this process, patients had adequate follow-up for cancelled screening colonoscopies and were not lost to follow-up Patients expressed positive feedback and all procedures have been rescheduled to date

INTRODUCTION: Colonoscopy remains the "gold standard" for detection of polyps and precancerous lesions that may lead to CRC, yet there is still approximately 1/3 of patients who remain unscreened. Evidence suggests that fear of bowel prep is a key reason many patients avoid colonoscopy. Patients indicate bowel prep as being the worst part of the colonoscopy and are reluctant to undergo the procedure again. There is also confusion on how to take the prep and lack of clarity of prep instructions. Patients often experience side effects such as abdominal pain, nausea, and vomiting from the prep. As such, patients may have sub-optimal bowel prep resulting in incomplete colon visualization, missed colon pathology, and need for repeat procedure. METHODS: In surveying 300 patients undergoing outpatient colonoscopy, 16% said they delayed colonoscopy due to fear of bowel prep. We enhanced our instructions based on dissatisfaction with current state prep instructions. A guide was developed to avoid misinterpretation and confusion of instructions which can be reasons for poor prep quality. We created the guide to heighten clarity, improve compliance and tolerability, and created a streamline method for promotion. RESULTS: A 10 page prep guide (Figure 1) was prepared for patients on what to expect the days leading up to colonoscopy (Figure 2). Beginning 14 days prior to colonoscopy, instructions are given regarding process including prep pick-up, identification of designated driver, and contacting their physician with medication questionsFigure 1.: Colonoscopy Prep Guide.Figure 2.: What To Expect While Preparing for you Colonoscopy.Figure 3.: Prep Instructions.. One week prior, the patient is reminded to pick up prep and to stop supplements. One to 3 days prior, we explain diet regimen, when/how to start the prep, and what to bring that day. Specific instructions are included on how to take the prep and a description of stool form when prep is complete (Figure 3). The day of colonoscopy, the patient is given instructions regarding when to arrive, and what happens before, during, and after the colonoscopy. CONCLUSION: We developed this step-by-step prep guide to enhance bowel prep for outpatient colonoscopies. The guide will be shared with patients across our large health system in July 2020. Evaluation of bowel prep quality and patient satisfaction will be analyzed and compared to the past with possible areas identified for future improvements.

INTRODUCTION: Kratom is an herbal product derived from Mitragyna speciosa trees and was originally used by indigenous peoples of southeast Asia. Ingestion is thought to relieve fatigue, diarrhea, and general pain. There are fewer than five reported cases in the literature from North America detailing kratom-induced liver injury and only one with specific hepatic histologic findings. This is the case of a 30-year-old male who ingested kratom and presented with dark urine and jaundice with labs showing liver injury. Liver biopsy revealed cholestatic injury. This case is significant because it temporally relates the use of kratom with liver injury and contributes unique histologic findings. CASE DESCRIPTION/METHODS: The patient is a 30-year old male with a history of diabetes who presented with one week of dark urine and light, chalky stools and one day of yellow eyes. He did not endorse drug or acetaminophen use. Vitals were unremarkable. Labs revealed alkaline phosphatase 556, AST 125, ALT 308, total bilirubin 5.7, and direct bilirubin 4.5. Computed tomography (CT) of the abdomen and pelvis was conducted and was unremarkable. A chronic liver disease panel including hepatitis A, B, and C, iron studies, ceruloplasmin, alpha-1 antitrypsin level, mitochondrial antibody, and liver-kidney microsomal antibody were negative with the exception of a ferritin 405 and an anti-smooth muscle antibody 1:20 titer. Liver ultrasound revealed a coarsened liver echotexture. The patient admitted to ingesting kratom powder with water to help him sleep for the past 4-6 weeks. A liver biopsy was conducted with the histology seen in Figures 1 and 2. It revealed inflammation with hepatocellular and canalicular cholestasis without fibrosis suggesting kratom-induced liver injury. With supportive care, one month labs had normalized and are shown in the accompanying Figure 3. DISCUSSION: Kratom is a derivative of Mitragyna speciosa trees and is used to treat fatigue, myalagias, and pain. It has been shown in rare cases to cause intrahepatic cholestasis and related liver enzyme elevation, following two weeks of ingestion. It can also be accompanied by kidney and bone marrow injury. Liver histology seen in Figures 1 and 2 from our patient is consistent with hepatocellular and canalicular cholestasis with portal areas showing focally prominent eosinophils. Similar findings were also seen in one prior reported case. This case contributes unique histologic findings to the body of evidence that kratom is associated with liver injury.

INTRODUCTION: Colorectal cancer screening remains underutilized with 66–67% of adults 50–75 years old being up to date with screening. The National CRC Roundtable and the ACG aimed to increase screening rates to 80% by 2018. To achieve this goal, screening colonoscopy was provided on Saturdays to improve access and provide for patients who could not take a day off of work. We evaluated the impact of improved access to colonoscopy through Saturday screenings. METHODS: In March 2018, Fall 2018, March 2019, colonoscopies were scheduled with 28 different providers on 12 Saturdays at 8 different sites. Patients were asked to complete a brief survey to capture demographics and reasons for choosing a Saturday for their colonoscopy. Pathology results and adenoma detection rates were collected and analyzed 1 week after procedure. RESULTS: 220 colonoscopies were scheduled and 214 procedures performed with 6 no-show/cancellations. 207 surveys were completed. Public awareness for Saturday colonoscopies was provided through our Network hospital and healthcare insurance provider websites as well as physician practices, and social media. The mean age of participants was 55 years with the majority being Caucasian and female. Post procedure results were analyzed for the number and size of polyps, polyp pathology, and resultant surveillance intervals. Of the 207 procedures, 37.7% (n = 78) of patient has at least one adenoma. Figure 1 shows breakdown of adenoma type by number of patients. Surveillance intervals changed to 5, 3 and 1 year for 37% (n = 76), 14% (n = 30), and 3% (n = 6) of patients, respectively (Figure 2). We also found that 86% of patients were more likely to complete their colonoscopy if scheduled on a Saturday. 42% indicated that the major reason for delay in scheduling was inability to take a day off of work (Table 1). CONCLUSION: The impact of Saturday colonoscopies within our large Network and surrounding community is evidenced by the overwhelming response that patients would be more likely to complete their screening colonoscopy on a Saturday, if offered. The convenience of non-traditional Saturday scheduling provides substantial positive impact in our mission to improve colorectal cancer screening rates in Western Pennsylvania and to provide high quality care as well as with improved patient experience.

INTRODUCTION: Our Health Network and insurance provider collaborated to focus on a Care Model for colorectal cancer (CRC) screening to address barriers to screening. This Care Model corresponds to a manner in which healthcare services are delivered while outlining best practices and services to patients as they progress through stages of colon cancer (Figure 1). Well-known barriers to CRC screening include lack of transportation, lack of primary care physician (PCP) involvement and education, apprehension about the prep and/or complications, and certain ethnicities. METHODS: Our Health Network and insurance provider worked together on the GI Care Model to address underutilization of CRC. The team interviewed PCP practices in the region to identify their processes for screening. The team performed a geographical analysis identifying screening rates for Western PA and the city of Pittsburgh by zip code and socioeconomic status. Transportation status, PCP status, age, and ethnicity as well as socioeconomic status were evaluated. The team then used this information to implement initiatives targeted at reducing and eliminating these barriers. RESULTS: PCPs expressed lack of updated knowledge regarding the latest colon cancer guidelines and challenges in scheduling a procedure. 122 healthcare professionals attended the webinar series in the first quarter. Feedback was overwhelmingly positive with requests for further education on a quarterly basis. Screening rates were higher if a patient had a PCP vs no PCP (Table 1). A Best Practices Alert was generated and sent by massmail to all healthcare practitioners across the region which outlined the latest recommendations with respect to screening. Difficulties in scheduling were optimized by providing flow diagrams of the scheduling process. We found that the strongest correlation to a lack of screening was lack of a vehicle (Table 2). The PALS (People Able to Lend Support) volunteer program was implemented for patients who had no vehicle. A patient education program (Doc Talks) was also offered to patients in the community at selective health insurance retail stores. Opportunity to answer questions and address fears of procedure were discussed. CONCLUSION: The GI Care Model has made significant progress in increasing awareness, education, access, and identification of common barriers which contribute to underutilization of CRC screening in our region. We will be addressing the barriers by ethnicity in future months as part of our Care Model.

Radiation exposure during endoscopic retrograde cholangiopancreatography is known, however, data in relation to radiation usage is unclear. We evaluate radiation exposure using fluoroscopy dose (FD) and time (FT). A prospective analysis of 197 patients undergoing endoscopic retrograde cholangiopancreatography was completed. Univariate and multivariate analyses were performed to determine characteristics associated with higher FD and FT. The mean FT was 307 seconds; the mean FD was 16.5 centigray. On univariate and multivariate analysis, indication of common bile duct stricture and pancreatic stricture, interventions including dilation and the use of plastic stents placement, procedures that were moderately or very difficult, and procedures that used magnification and high-resolution images were associated with higher FD± and longer FT. Indications of common bile duct stricture and pancreatic stricture as well as interventions of dilation, plastic stents placement, and procedures that are moderately or very difficult, involve high-resolution image leading to a higher radiation exposure. Special care should be considered in these settings.

A 55-year-old incarcerated man with a history of depression presented to the emergency department with abdominal pain.The patient reported that he ingested 6 pieces of metal in an attempt to commit suicide.Abdominal X-ray showed ingested foreign objects suspicious for scrap metal.An upper endoscopy revealed a pair of reading glasses and ten metal electric connectors in the fundus and body of stomach (Figure 1).The foreign bodies were successfully removed with the use of snares, rat tooth forceps, and endoscopic baskets (Figure 2).Multiple devices had to be used due to variation in size and shape of the ingested foreign bodies.A foreign body hood was used throughout the procedure to avoid mucosal damage.

We present the case of a 73-year-old female with IgG kappa light chain multiple myeloma (MM) diagnosed in 2012, complicated by renal failure on dialysis and multiple pathologic fractures involving spine and hips. It was initially treated with Bortezomib and Dexamethasone, which had to be discontinued due to painful neuropathy. Subsequently patient was started on Lenalidomide maintenance therapy. 3 years after her diagnosis she presented to the hospital with complaints of nausea, bloody vomitus and passing dark tarry stools for 2 days. She was noted to be anemic with hemoglobin of 6.5 gm/dl at admission, which was significantly worse from her baseline of 9-10 gm/dl. Patient was resuscitated and underwent an endoscopy within 24 hours of presentation. Endoscopy revealed innumerable non-bleeding nodules ranging from 4-8 mm in the gastric antrum, body and fundus. The two largest nodules in the gastric body measured approximately 2.5 cm's. These 2 nodules were ulcerated, with stigmata of recent bleeding. These lesions were friable, felt to be of malignant origin and hence not amenable to endoscopic intervention. Cold forceps biopsies were obtained from the nodules in the stomach. Pathology of these lesions was reported as gastric mucosal infiltration by plasma cell myeloma. Immunohistochemistry was positive for CD-138, MUM-1, CD-10, CD-45, and BCL-2. Cytoplasmic kappa chains were visualized by Fluorescence in situ hybridization (FISH). Epstein-Barr Virus stain was negative. Gastrointestinal plasmacytomas in the course of MM are rare ( < 0.9%). Presentation as GI bleed secondary to infiltration of the stomach from metastatic MM is even rare and fewer than 10 cases have been reported thus far. Several mechanisms may contribute to the pathogenesis of GI bleeding in MM, including amyloid infiltration of gut wall resulting in capillary fragility, platelet or coagulation abnormalities, pre-existing gastric ulcers secondary to treatment with corticosteroids and infrequently, direct infiltration in the form of plasmacytomas. Upper endoscopy is the mainstay of diagnosis and treatment but recurrent GI bleed may require surgical resection of the involved area. Aggressive concurrent treatment of MM with chemo-radiation is also warranted.Figure 1Figure 2Figure 3

Background Colonoscopies performed in the aft ernoon (PM) have been shown to have lower adenoma detection rates (ADR) compared to those in the morning (AM).Endoscopist fatigue has been suggested as a possible reason.Colonoscopies tend to be technically more challenging in female patients.Furthermore, women have a lower incidence of adenomas then men.Th e impact of the timing of colonoscopy based on sex has not been studied.We hypothesized that any decrease in ADR in PM colonoscopies would be more pronounced in female patients when compared to male patients.Methods We retrospectively reviewed colonoscopies performed for screening or surveillance in our outpatient endoscopy center from January 2008 to December 2011.Complete colonoscopies with a documented cecal intubation were included.All patients with a history of colorectal cancer or colonic resection, inadequate bowel preparation, or incomplete data were excluded.Results A total of 2305 patients (1207 female) were included.Overall, ADR was signifi cantly higher in AM than in PM procedures.Multivariate analysis demonstrated that ADR for females was lower in PM than in AM colonoscopies (odds ratio [OR] 0.63, 95% confi dence interval [CI] 0.44-0.91,P=0.015).Th ere was a non-signifi cant trend towards a lower ADR for males in PM (OR 0.84, 95% CI 0.62-1.15,P=0.28).Females had a prolonged intubation time and a longer procedure time.Conclusion Th e diff erence in ADR between AM and PM procedures seems to apply mainly to female patients.No signifi cant change in ADR was noted in male patients in the aft ernoon.