This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.

Background and Aims Patients with complex colon polyps were traditionally referred for surgery to avoid adverse events associated with endoscopic resection. Recent advances in endoscopic imaging as well endoscopic hemostasis and clip closure allow for the use of endoscopic mucosal resection (EMR) as an alternative to surgery for such lesions. To determine the outcome of treatment of complex colon polyps with EMR as an alternative to surgery, we conducted a retrospective observational study. Methods Two hundred three patients with complex colon polyps referred to an EMR center as an alternative to surgery. Patients underwent a protocol driven EMR.. The primary endpoint was the complete resection rate. Secondary endpoints were safety, residual adenoma rate, and incidence of missed synchronous polyps. Results EMR was performed in 155 patients and was deferred in 48 patients who were referred to surgery. EMR specimens revealed benign polyps in 149 and cancer in 6 patients. EMR adverse events occurred in seven patients, requiring hospitalization in five of them. None of the patients died of their adverse events. Surveillance colonoscopy at 4-6 months after resection of a benign lesion in 137 patients revealed residual adenoma at the scar site in 6 patients and additional synchronous precancerous lesions in 117 patients that were not removed by the referring endoscopist. None underwent surgery for failure of EMR. The overall precancerous lesion burden was 2.83 per patient, the adenoma burden was 2.13 per patient, and the serrated polyp burden was 0.69 per patient. Conclusions EMR can be used instead of surgery for complex colon polyps in 75 percent of patients with few adverse events and few residual adenomas at resection sites. In addition, careful repeat examination of the entire colon for synchronous lesions overlooked by the referring endoscopist is required for the majority of patients.

Background Standards for detection of adenomas during screening colonoscopy are widely used to measure examination quality. No such standards exist for sessile serrated adenomas. Objective To measure both the adenoma detection rate (ADR) and sessile serrated adenoma detection rate (SSADR) during screening colonoscopy before and after quality improvement/financial incentive measures. Design Retrospective determination of baseline ADR/SSADR by the endoscopist, followed by prospective collection of data after informing physicians of baseline detection rates. Setting Tertiary cancer center with large cancer screening program. Patients A total of 2833 average-risk colorectal cancer screening patients ages 50 to 75 undergoing initial colonoscopy. Interventions/data collection Electronic medical record for indication and demographics, endoscopy report and pathology report. Main outcome measurements Detection rates of adenomas and sessile serrated adenomas by gender. Results Overall ADR in males and females was 50.6% and 36.6%, respectively. Overall detection of advanced adenomas in males and females was 12.4% and 6.5%, respectively. Overall SSADR in males and females was 10.1% and 7.1%, respectively. In 108 patients (3.8% of entire group) SSAs were the only premalignant lesions found. Detection rates of both types of premalignant polyps improved over time but did not reach statistical significance. Limitations Single-center experience with limited sample size and small group of endoscopists. Conclusions ADRs far in excess of current standards are achievable. Cecal withdrawal time is associated with ADR. Prevalence of SSA rivals that of advanced adenomas and is greater than current medical literature suggests. The combination of monitoring and financial incentives did not result in statistically significant improvement in ADR.

BACKGROUND & AIMS The adenoma detection rate (ADR) is a quality metric tied to interval colon cancer occurrence. However, manual extraction of data to calculate and track the ADR in clinical practice is labor-intensive. To overcome this difficulty, we developed a natural language processing (NLP) method to identify patients, who underwent their first screening colonoscopy, identify adenomas and sessile serrated adenomas (SSA). We compared the NLP generated results with that of manual data extraction to test the accuracy of NLP, and report on colonoscopy quality metrics using NLP. METHODS Identification of screening colonoscopies using NLP was compared with that using the manual method for 12,748 patients who underwent colonoscopies from July 2010 to February 2013. Also, identification of adenomas and SSAs using NLP was compared with that using the manual method with 2259 matched patient records. Colonoscopy ADRs using these methods were generated for each physician. RESULTS NLP correctly identified 91.3% of the screening examinations, whereas the manual method identified 87.8% of them. Both the manual method and NLP correctly identified examinations of patients with adenomas and SSAs in the matched records almost perfectly. Both NLP and manual method produce comparable values for ADR for each endoscopist as well as the group as a whole. CONCLUSIONS NLP can correctly identify screening colonoscopies, accurately identify adenomas and SSAs in a pathology database, and provide real-time quality metrics for colonoscopy.

Post-surgical gastroparesis (PSG) is recognized as a consequence of vagal nerve injury following upper abdominal surgery. It has been well documented following vagotomy for peptic ulcer surgery. With the increasing role of surgical treatment in the management of GERD and morbid obesity, PSG is now being diagnosed after fundoplication and bariatric surgery. PSG has also been reported after heart and lung transplantation, possibly due to opportunistic viral infection or motor-inhibitory effects of the immunosuppressive drugs, in addition to vagal nerve injury. Initial postoperative management of PSG should be conservative as many symptoms following abdominal surgery resolve with time. This occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input or vagal reinnervation occurs. Persistent symptoms are difficult to manage and require a multidisciplinary team approach. Gastric electrical stimulation has shown promise in small series.

Background: Rituximab is effective in treating several cancers. Little is known about gastrointestinal adverse events associated with rituximab. We describe the clinical, endoscopic, and histologic features of rituximab-associated colitis (RC) at a tertiary care cancer center. Methods: We conducted a retrospective study of cancer patients who had received rituximab and had undergone a colonoscopy between 2000 and 2018. Patients with competing etiologies for colitis were excluded. Results: Of the 13,717 patients who had received rituximab during the study period, 1660 had undergone colonoscopy. Among them, 70 (4%) had RC. Median time from rituximab treatment to RC onset was 181 days. Fifty-three patients had clinical gastrointestinal symptoms: 39 had diarrhea, 19 had abdominal pain, 11 had blood per rectum, and 5 had a concurrent fever. The median duration of symptoms was 21 days. Fifty patients (71%) received treatment for RC: immunosuppressive therapy in 12, antimicrobial agents in 21, antimotility agents in 42, and supportive care in 42. Nine patients had mucosal ulceration on endoscopy, and 52 had features of active inflammation on histology. Thirty-nine patients needed hospital admission, and 2 needed intensive care unit admission. One patient had colonic perforation that required surgical intervention. Patients who had abnormal endoscopic findings needed more frequent hospitalization (P=0.024) and more treatment for RC (P=0.001). Conclusions: RC is usually a mild disease requiring supportive care only. Nonetheless, on rare occasions, it can be severe enough to lead to colonic perforation and intensive care unit admission. Steroids used with the chemotherapeutic regimen can hamper RC severity.

Mutational processes and signatures that drive early tumorigenesis are centrally important for early cancer prevention. Yet, to date, biomarkers and risk factors for polyps (adenomas) that inordinately and rapidly develop into colon cancer remain poorly defined. Here, we describe surprisingly high mutational profiles through whole-genome sequence (WGS) analysis in 2 of 4 pairs of benign colorectal adenoma tissue samples. Unsupervised hierarchical clustered transcriptomic analysis of a further 7 pairs of adenomas reveals distinct mutational signatures regardless of adenoma size. Transitional single nucleotide substitutions of C:G>T:A predominate in the adenoma mutational spectrum. Strikingly, we observe mutations in the TGF-β pathway and CEA-associated genes in 4 out of 11 adenomas, overlapping with the Wnt pathway. Immunohistochemical labeling reveals a nearly 5-fold increase in CEA levels in 23% of adenoma samples with a concomitant loss of TGF-β signaling. We also define a functional role by which the CEA B3 domain interacts with TGFBR1, potentially inactivating the tumor suppressor function of TGF-β signaling. Our study uncovers diverse mutational processes underlying the transition from early adenoma to cancer. This has broad implications for biomarker-driven targeting of CEA/TGF-β in high-risk adenomas and may lead to early detection of aggressive adenoma to CRC progression.

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