Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER project

Current status of quality control in screening esophagogastroduodenoscopy and the emerging role of artificial intelligence

Esophagogastroduodenoscopy (EGD) screening is being implemented in countries with a high incidence of upper gastrointestinal (UGI) cancer. High-quality EGD screening ensures the yield of early diagnosis and prevents suffering from advanced UGI cancer and minimal operational-related discomfort. However, performance varied dramatically among endoscopists, and quality control for EGD screening remains suboptimal. Guidelines have recommended potential measures for endoscopy quality improvement and research has been conducted for evidence. Moreover, artificial intelligence offers a promising solution for computer-aided diagnosis and quality control during EGD examinations. In this review, we summarized the key points for quality assurance in EGD screening based on current guidelines and evidence. We also outline the latest evidence, limitations, and future prospects of the emerging role of artificial intelligence in EGD quality control, aiming to provide a foundation for improving the quality of EGD screening.

Helicobacter pylori Infection and Peptic Ulcer Disease in Symptomatic Children in Southern Vietnam: A Prospective Multicenter Study

BACKGROUND

Helicobacter pylori (H. pylori) remains a major cause of gastroduodenal diseases. We aimed to evaluate the burden of this infection, particularly peptic ulcer disease in Vietnamese children.

METHODS

We enrolled consecutive children referred for esophagogastroduodenoscopy at two tertiary children's hospitals in Ho Chi Minh City, from October 2019 to May 2021. Children treated with proton pump inhibitors during the last two weeks or antibiotics for four weeks, and those having a previous or interventional endoscopy were excluded. H. pylori infection was diagnosed with either a positive culture or positive histopathology combined with a rapid urease test, or with a polymerase chain reaction of the urease gene. The study was approved by the Ethics Committee and written informed consent/assent was obtained.

RESULTS

Among 336 enrolled children aged 4-16 (mean: 9.1 ± 2.4 years; 55.4% girls), H. pylori infection was positive in 80%. Peptic ulcers were detected in 65 (19%), increasing with age, and 25% with anemia. cagA+ strains were detected at a higher rate in children with ulcers.

CONCLUSIONS

Prevalence of H. pylori and peptic ulcers is high among symptomatic Vietnamese children. It is crucial to have a program for early detection of H. pylori to reduce ulcer risk and gastric cancer later.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Pediatric Endoscopy Quality Improvement Network Pediatric Endoscopy Reporting Elements: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality procedure reports are a cornerstone of high-quality pediatric endoscopy as they ensure the clear communication of procedural events and outcomes, guide patient care and facilitate continuous quality improvement. The aim of this document is to outline standardized reporting elements that achieved international consensus as requirements for high-quality pediatric endoscopy procedure reports.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used Delphi methodology to identify key elements that should be found in all pediatric endoscopy reports. Item reduction was attained through iterative rounds of anonymized online voting using a 6-point scale. Responses were analyzed after each round and items were excluded from subsequent rounds if ≤50% of panelists rated them as 5 ("agree moderately") or 6 ("agree strongly"). Reporting elements that ≥70% of panelists rated as "agree moderately" or "agree strongly" were considered to have achieved consensus.

RESULTS

Twenty-six PEnQuIN group members from 25 centers internationally rated 63 potential reporting elements that were generated from a systematic literature review and the Delphi panelists. The response rates were 100% for all three survey rounds. Thirty reporting elements reached consensus as essential for inclusion within a pediatric endoscopy report.

DISCUSSION

It is recommended that the PEnQuIN Reporting Elements for pediatric endoscopy be universally employed across all endoscopists, procedures and facilities as a foundational means of ensuring high-quality endoscopy services, while facilitating quality improvement activities in pediatric endoscopy.

ENETS standardized (synoptic) reporting for endoscopy in neuroendocrine tumors

Despite efforts from various endoscopy societies, reporting in the field of endoscopy remains extremely heterogeneous. Harmonisation of clinical practice in endoscopy has been highlighted by application of many clinical practice guidelines and standards pertaining to the endoscopic procedures and reporting are underlined. The aim of the proposed "standardised reporting" is to (1) facilitate recognition of gastrointestinal neuroendocrine neoplasms (NEN) on initial endoscopy, (2) to enable interdisciplinary decision making for treatment by a multidisciplinary team, (3) to provide a basis for a standardised endoscopic follow-up which allows detection of recurrence or progression reliably, (4) to make endoscopic reports on NEN comparable between different units, and (5) to allow research collaboration between NEN centres in terms of consistency of their endoscopic data. The ultimate goal is to improve disease management, patient outcome and reduce the diagnostic burden on the side of the patient by ensuring the highest possible diagnostic accuracy and validity of endoscopic exams and possibly interventions.

Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group

Background and Objectives

Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units.

Methods

A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting.

Results

EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up.

Conclusions

Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.

Nomenclature and semantic descriptions of ulcerative and inflammatory lesions seen in Crohn's disease in small bowel capsule endoscopy: An international Delphi consensus statement

BACKGROUND

In the medical literature, the nomenclature and descriptions (ND) of small bowel (SB) ulcerative and inflammatory (U-I) lesions in capsule endoscopy (CE) are scarce and inconsistent. Inter-observer variability in interpreting these findings remains a major limitation in the assessment of the severity of mucosal lesions, which can impact negatively on clinical care, training and research on SB-CE.

OBJECTIVE

Focusing on SB-CE in Crohn's disease (CD), our aim is to establish a consensus on the ND of U-I lesions.

METHODS

An international panel of experienced SB-CE readers was formed during the 2016 United European Gastroenterology Week meeting. A core group of five CE and inflammatory bowel disease (IBD) experts established an Internet-based, three-round Delphi consensus but did not participate in the voting process. The core group built illustrated questionnaires, including SB-CE still frames of U-I lesions from patients with documented CD. Twenty-seven other experts were asked to rate and comment on the different proposals for the ND of the most frequent SB U-I lesions. For each round, we used a 6-point rating scale (varying from 'strongly disagree' to 'strongly agree'). The consensus was reached when at least 80 % of the voting members scored the statement within the 'agree' or 'strongly agree' categories.

RESULTS

A 100% participation rate was obtained for all the rounds. Consensual ND were reached for the following seven U-I lesions: aphthoid erosion, deep ulceration, superficial ulceration, stenosis, edema, hyperemia and denudation.

CONCLUSION

Considering the most frequent SB U-I lesions seen in CE in CD, a consensual ND was reached by the international group of experts. These descriptions and names are useful not only for daily practice and medical education, but also for medical research.

Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group

BACKGROUND AND AIM

In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia.

METHODS

A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI² G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements.

RESULTS

Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology.

CONCLUSION

This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.

What defines quality in small bowel capsule endoscopy

Small bowel capsule endoscopy is considered a first-line diagnostic tool for the investigation of small bowel diseases. Gastroenterological and endoscopic societies have proposed and established measures known as quality indicators, quality measures or performance measures for the majority of endoscopic procedures, in order to ensure competence, healthcare quality and define areas requiring improvement. However, there is a paucity of publications describing small bowel capsule endoscopy quality indicators. Hereby, we attempt to identify and describe a number of pre-procedure, intra-procedure and post-procedure quality indicators, regarding process measures in small bowel capsule endoscopy, after a comprehensive review of the literature.

Reporting systems in gastrointestinal endoscopy: Requirements and standards facilitating quality improvement: European Society of Gastrointestinal Endoscopy position statement

To develop standards for high quality of gastrointestinal endoscopy, the European Society of Gastrointestinal Endoscopy (ESGE) has established the ESGE Quality Improvement Committee. A prerequisite for quality assurance and improvement for all gastrointestinal endoscopy procedures is state-of-the-art integrated digital reporting systems for standardized documentation of the procedures. The current paper describes the ESGE's viewpoints on requirements for high-quality endoscopy reporting systems. The following recommendations are issued: Endoscopy reporting systems must be electronic.Endoscopy reporting systems should be integrated into hospital patient record systems.Endoscopy reporting systems should include patient identifiers to facilitate data linkage to other data sources.Endoscopy reporting systems shall restrict the use of free text entry to a minimum, and be based mainly on structured data entry.Separate entry of data for quality or research purposes is discouraged. Automatic data transfer for quality and research purposes must be facilitated.Double entry of data by the endoscopist or associate personnel is discouraged. Available data from outside sources (administrative or medical) must be made available automatically.Endoscopy reporting systems shall enable the inclusion of information on histopathology of detected lesions; patient's satisfaction; adverse events; surveillance recommendations.Endoscopy reporting systems must facilitate easy data retrieval at any time in a universally compatible format.Endoscopy reporting systems must include data fields for key performance indicators as defined by quality improvement committees.Endoscopy reporting systems must facilitate changes in indicators and data entry fields as required by professional organizations.

On the importance of developing a new generation of breath tests for Helicobacter pylori detection

State-of-the-art methods for non-invasive detection of the Helicobacter pylori (H. pylori) infection have been considered. A reported global tendency towards a non-decreasing prevalence of H. pylori worldwide could be co-influenced by the functional limitations of urea breath tests (UBTs), currently preferred for the non-invasive recognition of H. pylori in a clinical setting. Namely, the UBTs can demonstrate false-positive or false-negative results. Within this context, limitations of conventional clinically exploited H. pylori tests have been discussed to justify the existing need for the development of a new generation of breath tests for the detection of H. pylori and the differentiation of pathogenic and non-pathogenic strains of the bacterium. This paper presents the results of a pilot clinical study aimed at evaluating the development and diagnostic potential of a new method based on the detection of the non-urease products of H. pylori vital activity in exhaled gas. The characteristics of breath of adolescents with H. pylori-positive and H. pylori-negative functional dyspepsia, together with a consideration of the cytotoxin-associated gene A (CagA) status of H. pylori-positive subjects, have been determined for the first time using innovative point-contact nanosensor devices based on salts of the organic conductor tetracyanoquinodimethane (TCNQ). The clinical and diagnostic relevance of the response curves of the point-contact sensors was assessed. It was found that the recovery time of the point-contact sensors has a diagnostic value for differentiation of the H. pylori-associated peptic ulcer disease. The diagnostically significant elongation of the recovery time was even more pronounced in patients infected with CagA-positive H. pylori strains compared to the CagA-negative patients. Taking into account the operation of the point-contact sensors in the real-time mode, the obtained results are essential prerequisites for the development of a fast and portable breath test for non-invasive detection of cytotoxic CagA strains of H. pylori infection. The relaxation time of the point-contact nanosensors could be selected as a diagnostic criterion for non-invasive determination of H. pylori-associated destructive lesions of the gastroduodenal area in adolescents, using the point-contact spectroscopic concept of breath analysis. This can subsequently be implemented into a 'test-and-treat' approach for the management of uninvestigated dyspepsia in populations with a high prevalence of H. pylori (according to the Maastricht III and IV Consensus recommendations).

Optimized sedation improves colonoscopy quality long-term

Background. Quality monitoring and improvement is prerequisite for efficient colonoscopy. Aim. To assess the effects of increased sedation administration on colonoscopy performance. Materials and Methods. During Era 1 we prospectively measured four colonoscopy quality indicators: sedation administration, colonoscopy completion rate, adenoma detection rate, and early complications rate in three cohorts: cohort A: intention for total colonoscopy cases; cohort B: cohort A excluding bowel obstruction cases; cohort C: CRC screening-surveillance cases within cohort B. We identified deficiencies and implemented our plan to optimize sedation. We prospectively evaluated its effects in both short- (Era 2) and long-term period (Era 3). Results. We identified that sedation administration and colonoscopy completion rates were below recommended standards. After sedation optimization its use rate increased significantly (38.1% to 55.8% to 69.5%) and colonoscopy completion rate increased from 88.3% to 90.6% to 96.4% in cohort B and from 93.2% to 95.3% to 98.3% in cohort C, in Eras 1, 2, and 3, respectively. Adenoma detection rate increased in cohort C (25.9% to 30.6% to 35%) and early complications rate decreased from 3.4% to 1.9% to 0.3%. Most endoscopists increased significantly their completion rate and this was preserved long-term. Conclusion. Increased sedation administration results in long-lasting improvement of colonoscopy quality indicators.

Colon capsule endoscopy is feasible to perform after incomplete colonoscopy and guides further workup in clinical practice

BACKGROUND

Colon capsule endoscopy (CCE) could be an option to examine the colon after incomplete colonoscopy.

OBJECTIVE

To investigate the extent that CCE complements incomplete colonoscopy and guides further workup.

DESIGN

Prospective, follow-up study.

SETTING

Three tertiary-care centers.

PATIENTS

Consecutive outpatients after colonoscopy failure; 1-year study period.

INTERVENTION

Patients underwent CCE either immediately after colonoscopy or were rescheduled. Further investigations were guided by the results of CCE. Patients were followed as long as 2 years.

RESULTS

We studied 75 outpatients; 39 had a screening colonoscopy. One third of the patients underwent CCE immediately after colonoscopy. Overall, CCE reached or went beyond the colon segment at which colonoscopy stopped in 68 patients (91%). CCE technically complemented difficult colonoscopy independently of whether same-day CCE was performed (24 [96%]) or was not performed (44 [88%]). CCE detected additional significant findings in 36% of the same-day CCE cases and in 48% of the rescheduled ones. Two patients in the same-day group and 13 in the rescheduled CCE group underwent further colon examination that revealed additional significant findings in 3 of them. Ten percent of the patients reported mild adverse events (AE). If needed, 63 participants (84%) were willing to repeat CCE. Follow-up has not identified symptomatic missed colon cancers.

LIMITATIONS

Selected patient population, first-generation colon capsule, old preparation scheme.

CONCLUSION

CCE performed immediately or at a scheduled date after colonoscopy failure is feasible and safe. CCE after incomplete colonoscopy appears to yield significant findings, guide further workup, and has high patient acceptance.

Standardized endoscopic reporting

The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken word. The efforts leading to the "Minimal Standard Terminology" (MST) of gastrointestinal endoscopy offer a standardized model for description of endoscopic findings. With a combination of lesion descriptors and descriptor attributes, this system gives guidance to appropriate descriptions of lesions and also has a normative effect on endoscopists in training. The endoscopic report includes a number of items not related to findings per se, but to other aspects of the procedure, formal, technical, and medical. While the MST sought to formulate minimal lists for some of these aspects (e.g. indications), they are not all well suited for the inherent structure of the MST, and many are missing. Thus, the present paper offers a recommended standardization also of the administrative, technical, and other "peri-endoscopic" elements of the endoscopic report; important also are the numerous quality assurance initiatives presently emerging. Finally, the image documentation of endoscopic findings is becoming more obvious-and accessible. Thus, recommendations for normal procedures as well as for focal and diffuse pathology are presented. The recommendations are "minimal," meaning that expansions and subcategories will likely be needed in most centers. Still, with a stronger common grounds, communication within endoscopy will still benefit.

Helicobacter pylori Infection in European children with gastro-duodenal ulcers and erosions

BACKGROUND

To analyze risk factors associated with gastro-duodenal ulcers and erosions in children.

METHODS

Open, prospective, multicenter, case-control study carried out in 11 European countries in patients with gastric or duodenal ulcers/erosions and 2 age-matched controls each. Possible risk factors were recorded. Logistic regression models were performed with adjustment for centers and age groups.

RESULTS

Seven-hundred thirty-two patients (244 cases, 153 with erosions only and 91 with ulcers, and 488 controls) were recruited. Children receiving antimicrobials or acid suppressive drugs before endoscopy were excluded (202 cases/390 controls remained for risk factor analysis). Helicobacter pylori was detected more frequently in cases than controls but only in 32.0% versus 20.1% in controls (P = 0.001). Independent exposure factors for gastric ulcers were male gender (P = 0.001), chronic neurologic disease (P = 0.015), chronic renal disease (P < 0.001) and nonsteroidal anti-inflammatory drug consumption (P = 0.035). Exposure factors for duodenal ulcers were H. pylori infection (P < 0.001) and steroid consumption (P = 0.031). Chronic renal disease was the only independent factor associated with gastric erosions (P = 0.026), those associated with duodenal erosions being H. pylori infection (P = 0.023), active smoking (P = 0.006) and chronic arthritis (P = 0.008). No risk factor was identified in 97/202 (48.0%) cases.

CONCLUSIONS

H. pylori remains a risk factor for duodenal, but not for gastric lesions in children in countries with low prevalence of infection. No risk factor could be identified in half of the children with gastro-duodenal ulcers/erosions.

Frequency and risk factors of gastric and duodenal ulcers or erosions in children: a prospective 1-month European multicenter study

There are no solid figures of the frequency of ulcer disease during childhood in Europe. We assessed its frequency and analyzed known risk factors.

PATIENTS AND METHODS

Ulcers, erosions, indications, and risk factors were recorded in all children undergoing an upper gastrointestinal endoscopy in a prospective study carried out during 1-month simultaneously in 19 centers among 14 European countries.

RESULTS

Ulcers and/or erosions were observed in 56 out of 694 children. Children with ulcers/erosions were significantly older than those without lesions (10.3+/-5.5 vs. 8.1+/-5.7 years, P=0.002). Helicobacter pylori infection was present in 15 of 56 children (27%) where NSAIDs were used in eight, steroids in five, immune-suppressive drugs in five, antibiotics in six, antacids in one, H2-blockers in six and proton pump inhibitors in eight children (more than one risk factor was detected in 32 of 56 children). No risk factors were observed in 24 of 56 children (43%). The main indications for endoscopy were epigastric or abdominal pain (24%) and suspicion of gastroesophageal reflux disease (15%). Similarly, epigastric tenderness, hematemesis, melena, and weight stagnation were significantly associated with ulcers/erosions, whereas sex, H. pylori infection, socioeconomic and lifestyle factors were equally distributed.

CONCLUSION

Although limited by the short-time duration and the heterogeneity of the patients included throughout the 19 centers, our study shows a frequency of 8.1% of ulcers and/or erosions in children, occurring mainly in the second decade of life. H. pylori infection and gastrotoxic medications were less frequently implicated than expected.

PillCam Colon capsule endoscopy does not always complement incomplete colonoscopy

BACKGROUND

There are no data on the role of PillCam Colon capsule (PCC) endoscopy for examination of the colon in incomplete colonoscopy cases.

OBJECTIVE

To evaluate whether PCC endoscopy can complete colon examination after failure of conventional colonoscopy to visualize the cecum.

SETTING

Three tertiary centers.

STUDY DESIGN

Retrospective case series.

PATIENTS

Patients who underwent PCC endoscopy after incomplete colonoscopy from January to June 2008.

INTERVENTIONS

Conventional colonoscopy and PCC endoscopy.

RESULTS

By using PCC, we studied 12 patients who had incomplete colonoscopy. Six patients had an obstructing tumor of the left side of the colon, and, in 6 cases, there were technical difficulties to complete colonoscopy. PCC endoscopy visualized the rectum in 1 case. The capsule did not reach the site where colonoscopy stopped in 6 of the 12 cases, ie, 3 left sited tumors and 3 with technical difficulties. Moreover, in 1 of the 3 cases in which the capsule passed the site where colonoscopy stopped, poor bowel preparation precluded the accurate examination of the colon. Four patients underwent a third colon examination (3 barium enemas and 1 virtual CT colonoscopy). There were no adverse events related to PCC endoscopy.

LIMITATIONS

A retrospective study and a selected patient population. Data may not be applicable to other settings.

CONCLUSION

In this retrospective case series of patients with incomplete colonoscopy, PCC endoscopy did not always satisfactorily examine the colon.

Impact of observer variability on the usefulness of endoscopic images for the documentation of upper gastrointestinal endoscopy

OBJECTIVE

Endoscopy is an observer-dependent diagnostic method, which, until recently, has lacked precise guidelines for written reports. There is an increasing demand for improvement in endoscopy records, which may necessitate the supplementation of image documentation. The aim of this study was to estimate interobserver as well as intra-observer variability in the assessment of images from gastroscopy.

MATERIAL AND METHODS

We designed an Internet interface presenting endoscopy images, accompanied by a multiple-choice questionnaire for assessing pathology in the images. Ten images from the distal oesophagus and 10 images from the pyloric antrum were chosen. In order to study interobserver variability, physicians with varying endoscopy experience were invited to complete the questionnaire. The physicians were re-invited 5 months later to assess the same images again, this time in order to assess intra-observer variability. Kappa statistics were used for analysis of agreement.

RESULTS

Initially, 13 of 20 invited physicians responded. Interobserver agreement varied between poor (kappa<0.2) and moderate (0.4<kappa<0.6). In the second part of the study, 10 of 11 invited physicians responded. Intra-observer agreement varied between moderate (0.4<kappa<0.6) and good (0.6<kappa<0.8). A higher level of experience does not imply either better interobserver or better intra-observer agreement. Images of concise endoscopy findings, such as the presence of an ulcer, resulted in better agreement than did the assessment of images of less definable findings.

CONCLUSION

The variability in the interpretation of endoscopy images is large. We therefore believe that systematic inclusion of a set of images into endoscopy reports will improve their quality.

Gastrointestinal endoscopic terminology coding (GET-C): a WHO-approved extension of the ICD-10

Technological developments have greatly promoted interest in the use of computer systems for recording findings and images at endoscopy and creating databases. The aim of this study was to develop a comprehensive WHO-approved code system for gastrointestinal endoscopic terminology. The International Classification of Diseases, 10th edition (ICD-10), and the ICD-10 clinical modification (ICD-10-CM) were expanded to allow description of every possible gastrointestinal endoscopic term under conditions defined by the WHO. Classifications of specific gastrointestinal disorders and endoscopic locations were added. A new chapter was developed for frequently used terminology that could not be classified in the existing ICD-10, such as descriptions of therapeutic procedures. The new extended code system was named Gastrointestinal Endoscopic Terminology Coding (GET-C). The GET-C is a complete ICD-10-related code system that can be used within every endoscopic database program for all specific endoscopic terms. The GET-C is available for free at http://www.trans-it.org/.

Terminology and global standardization of endoscopic information: Minimal Standard Terminology (MST)

Since 1994, following the leading efforts by the European Society for Gastrointestinal Endoscopy, Organisation Mondiale d'Endoscopie Digestive (OMED) has succeeded in compiling minimal number of terms required for computer generation of digestive endoscopy reports nicknamed MST (Minimal Standard Terminology). Though with some insufficiencies, and though developed only for digestive endoscopy, MST has been the only available terminology that is globally standardized in medicine. By utilizing the merits of a unified, structured terminology that can be used in multiple languages we can utilize the data stored in different languages as a common database. For this purpose, a standing, terminology-managing organization that manages and maintains and, when required, expands the terminology on a global level, is absolutely necessary. Unfortunately, however, the organization that performs version control of MST (OMED terminology, standardization and data processing committee) is currently suspending its activity. Medical practice of the world demands more and more specialization, with resultant needs for information exchange among specialized territories. As the cooperation between endoscopy and pathology has become currently the most important problem in the Endoscopy Working Group of Integrating Healthcare Enterprise-Japan (IHE-J,) the cooperation among different specialties is essential. There are DICOM or HL7 standards as the protocols for storage, and exchange (communication) of the data, but there is yet no organization that manages the terminology itself astride different specialties. We hereby propose to establish, within IEEE, for example, a system that promotes standardization of the terminology that can transversely describe a patient, and that can control different societies and groups, as far as the terminology is concerned.

Computer-assisted diagnosis system in digestive endoscopy

The purpose of this paper is to present an intelligent atlas of indexed endoscopic lesions that could be used in computer-assisted diagnosis as reference data. The development of such a system requires a mix of medical and engineering skills for analyzing and reproducing the cognitive processes that underlie the medical decision-making process. The analysis of both endoscopists experience and endoscopic terminologies developed by professional associations shows that diagnostic reasoning in digestive endoscopy uses a scene-object approach. The objects correspond to the endoscopic findings and the medical context of examination and the scene to the endoscopic diagnosis. According to expert assessment, the classes of endoscopic findings and diagnoses, their primitive characteristics (or indices), and their relationships have been listed. Each class describes an endoscopic finding or diagnosis in an intensive way. The retrieval method is based on a similarity metric that estimates the membership value of the case under investigation and the prototype of the class. A simulation test with randomized objects demonstrates a good classification of endoscopic findings. The correct class is the unique response in 68% of the tested objects, the first of multiple responses in 28%. Four descriptors are shown to be of major importance in the classification algorithm: anatomic location, shape, color, and relief. At the present time, the application database contains approximately 150 endoscopic images and is accessible via Internet. Experiments are in progress with endoscopists for the validation of the system and for the understanding of the similarity between images. The next step will integrate the system in a learning tool for junior endoscopists.

Autoimmune pancreatitis is closely associated with gastric ulcer presenting with abundant IgG4-bearing plasma cell infiltration

BACKGROUND

Autoimmune pancreatitis is characterized by high serum IgG4 concentrations and lymphoplasmacytic infiltration. Because of the diversity of extrapancreatic involvement in this disease, the present study sought to identify other associated GI-tract lesions.

METHODS

EGD findings were compared between a group of 23 patients with autoimmune pancreatitis undergoing ERCP for obstructive jaundice and 230 age- and gender-matched control patients. To clarify the histopathologic differences found between these two groups, the histopathologic findings (Updated Sydney System) and the immunohistochemistry of each IgG subclass were compared between 8 patients with autoimmune pancreatitis and gastric ulcer, and 23 control patients with gastric ulcer from which biopsy specimens had been obtained.

RESULTS

Gastric ulcer was found significantly more frequently in patients with autoimmune pancreatitis compared with control patients (34.8% vs. 13.5%; p=0.007). There was no significant difference between the groups with respect to the frequency of other GI lesions. Four of 8 gastric ulcers in patients with autoimmune pancreatitis were linear, with the long axis perpendicular to the incisura on the lesser curvature of the stomach. The activity score for the gastric lesions was significantly lower in patients with autoimmune pancreatitis compared with control patients (mean score 0.38 vs. 1.08; p=0.012). There were no significant differences in histopathologic findings with respect to inflammation, atrophy, metaplasia, or Helicobacter pylori scores between the two groups. IgG4-bearing plasma cells were significantly more abundant in gastric lesions in patients with autoimmune pancreatitis compared with those in control patients (mean score 1.75 vs. 0.39; p=0.0008).

CONCLUSIONS

Autoimmune pancreatitis is closely associated with gastric ulcer with abundant IgG4-bearing plasma cell infiltration.

Building and evaluation of a structured representation of pharmacokinetics information presented in SPCs: from existing conceptual views of pharmacokinetics associated with natural language processing to object-oriented design

OBJECTIVE

Develop a detailed representation of pharmacokinetics (PK), derived from the information in Summaries of Product Characteristics (SPCs), for use in computerized systems to help practitioners in pharmaco-therapeutic reasoning.

METHODS

Available knowledge about PK was studied to identify main PK concepts and organize them in a preliminary generic model. The information from 1950 PK SPC-texts in the French language was studied using a morpho-syntactic analyzer. It produced a list of candidate terms (CTs) from which those describing main PK concepts were selected. The contexts in which they occurred were explored to discover co-occurring CTs. The regrouping according to CT semantic types led to a detailed object-oriented model of PK. The model was evaluated. A random sample of 100 PK texts structured according to the model was judged for completeness and semantic accuracy by 8 experts who were blinded to other experts' responses.

RESULTS

The PK text file contained about 300000 words, and the morpho-syntactic analysis extracted 17520 different CTs. The context of 592 CTs was studied and used to deduce the PK model. It consists of four entities: the information about the real PK process, the experimental protocol, the mathematical modeling, and the influence of factors causing variation. Experts judged that the PK model represented the information in 100 sample PK texts completely in 89% of cases and nearly completely in the other 11%. There was no distortion of meaning in 98% of cases and little distortion in the remainder.

CONCLUSION

The PK model seems to be applicable to all SPCs and can be used to retranscribe legal information from PK sections of SPCs into structured databases.

Diagnostic yield and clinical implications of push enteroscopy: results from a nonspecialized center

BACKGROUND Push enteroscopy is increasingly used as an investigative tool for the evaluation of gastrointestinal bleeding, and studies from specialized centers have shown an overall diagnostic yield of push enteroscopy in such patients ranging from 38% to 75%. The aim of our study was to characterize the yield and clinical effect of push enteroscopy to determine the applicability of prior observations to other academic centers. STUDY We retrospectively studied patients who underwent push enteroscopy between January 1995 and December 2000 at our institution. Detailed clinical history, endoscopic findings, endoscopic therapy, and subsequent medical treatment were obtained through review of medical records and our endoscopic database. Medications prescribed after enteroscopy and whether medical management was affected by the findings of push enteroscopy were also recorded. RESULTS Over the 6-year study period, 126 patients (48% men; mean age, 62 years; range, 15-91 years) underwent push enteroscopy. The most common indications for push enteroscopy were gastrointestinal bleeding in 57 patients (45%) and iron-deficiency anemia in 32 (25%). The results of push enteroscopy were normal in 44 patients (35%), and the most frequent endoscopic lesions were angiectasias in 24 patients (19%), gastric erosions in 10 (8%), gastric ulcer in four (3%), jejunal ulcer in three (2%), and esophagitis in three (2%). The identified lesions (n = 89) were within reach of a standard upper endoscope in 42 patients (47%). Endoscopic therapy was performed in 12 patients (13%), and the management of 50 patients (40%) was changed based on findings at push enteroscopy. CONCLUSIONS Push enteroscopy has a high diagnostic yield, similar to reports from specialized centers suggesting the potential clinical benefit of more widespread use.