BACKGROUND & AIMS:Reports of mailed fecal immunochemical test (FIT) outreach effectiveness over time are minimal. We aimed to better evaluate a mailed FIT program with longitudinal metrics. METHODS:A total of 10,771 patients aged 50 to 75 years not up-to-date with colorectal cancer screening were randomized to intervention or usual care. The intervention arm received an advanced notification call and informational postcard prior to a mailed FIT. Usual care was at the discretion of the primary care provider. Patients were followed for up to 2.5 years. The primary outcome was the difference in cumulative proportion of completed FIT screening between arms. Screening was further examined with the proportion of time up-to-date, consistency of adherence, and frequency of abnormal FIT. RESULTS:The cumulative proportion of FIT completion was higher in the outreach intervention (73.2% vs 55.1%; P < .001). The proportion of time covered by screening was higher in the intervention group (46.8% vs 27.3%; D19.6%; 95% confidence interval, 18.2%-20.9%). Patients assigned to FIT outreach were more likely to consistently complete FITs (2 completed of 2 offered) (50.1% vs 21.8%; P < .001). However, for patients who did not complete the FIT during the first cycle, only 17.1% completed a FIT during the second outreach cycle. The number and overall proportion of abnormal FIT was significantly higher in the outreach intervention (6.9% Outreach vs 4.1% Usual Care; P < .01).

INTRODUCTION: Nivolumab, an immune checkpoint inhibitor, is an immunotherapy that has shown remarkable benefit in treating a wide range of cancers. However, by activating the immune system, these agents can cause immune-related adverse events (irAE). The gastrointestinal (GI) system is commonly affected, and typically presents with lower GI inflammation, such as colitis. Upper GI involvement is rarely reported. We present a case of nivolumab-associated duodenitis refractory to systemic corticosteroids but resolved after treatment with infliximab. CASE DESCRIPTION/METHODS: A 61-year-old man with a history of squamous cell carcinoma of the head and neck presented with intense cramping abdominal pain several weeks after nivolumab initiation. Given concerns for an irAE, he was initially treated with prednisone for 2 weeks, with minimal improvement in symptoms. He underwent esophagogastroduodenoscopy (EGD), which showed granularity and erythema of the duodenum with pathology consistent with duodenitis. He was referred to our institution, and treated with a course of IV solumedrol, which resulted in worsening abdominal pain and severe (grade 3) watery diarrhea. He was admitted to the hospital, and infliximab 5 mg/kg was initiated for suspected steroid-resistant immune checkpoint inhibitor-associated duodenitis/enterocolitis. He was noted to have rapid improvement in diarrhea and abdominal pain within 24 hours, with total resolution within nine days. After a second infusion of infliximab, he underwent a small bowel enteroscopy, which was unremarkable. His rapid improvement following infliximab further confirmed suspicion for an immune-checkpoint inhibitor medicated duodenitis/enterocolitis. DISCUSSION: As the use of checkpoint inhibitor immunotherapy grows, it is imperative that gastroenterologists be able to recognize and promptly treat GI immune-related adverse events, especially less common presentations involving the upper GI tract. Our case of nivolumab-associated duodenitis is an example of a rare immune-related adverse event that was refractory to steroids but responded to infliximab. Given no clear guidelines for duration of infliximab treatment, recommendations were extrapolated from IBD literature, with subsequent infusions recommended at two and six weeks. It has been reported that one-third to two-thirds of patients with immune-related GI toxicities do not respond to high dose systemic steroids or experience a relapse of symptoms. These are the patients that should be considered for infliximab.

INTRODUCTION: Esophageal food bolus impaction is a true gastrointestinal emergency. While most cases resolve spontaneously, up to 20% require emergent upper endoscopy (EGD). No prior studies have been done in the United States to explore how patient symptoms may predict persistent obstruction at the time of endoscopy. Our aim was to determine symptoms that reliably predict complete impaction in efforts to quickly recognize those who need emergent EGD at time of presentation. METHODS: This is a retrospective cohort study of 83 patients who presented to the emergency room with suspected food bolus impaction between 1/2013 and 5/2018 at a tertiary care academic medical center. Electronic health records were reviewed to determine presenting symptoms and initial treatment course. Exclusion criteria were age < 18, history of esophageal malignancy, or presence of an esophageal stent. Descriptive statistics, univariate and multivariate analysis were performed. RESULTS: During the study period 52 of 83 (63%) patients underwent an EGD for suspected food bolus impaction. Patients who underwent EGD were more likely to have received glucagon (P = 0.004) and to have presented with sialorrhea (P = 0.001), as compared to patients who did not undergo EGD. 42 of 52 (81%) patients who underwent EGD had an overt food bolus impaction identified. Predictors of overt impaction at EGD were glucagon administration (P = 0.02), underlying esophageal pathology (P = 0.01), and sialorrhea on presentation (P = 0.01). 30 of 42 (71%) patients with overt food impaction were found to have complete obstruction. These patients were more likely to have received glucagon (P = 0.04), have an earlier EGD (P = 0.04), and have symptoms of odynophagia (P = 0.003), sialorrhea (P = 0.001), and regurgitation (P = 0.006), as compared to patients with partial obstruction. On multivariate analysis, sialorrhea (P = 0.001) and odynophagia (P = 0.023) were symptoms predictive of EGD, and only sialorrhea (P = 0.01) was predictive of persistent food impaction at EGD. CONCLUSION: Sialorrhea and glucagon administration were independently associated with the need for EGD during admission. Sialorrhea was the only symptom predictive of persistent impaction found on EGD. Sialorrhea along with odynophagia were most predictive of complete obstruction as compared to partial. These symptoms on presentation may help triage patients in need of more emergent EGD.

No abstract

No abstract