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Upper gastrointestinal bleeding (UGIB) continues to be a common gastrointestinal emergency that carries significant morbidity and mortality. The epidemiology of UGIB has been changing over the last few decades with an overall decrease in peptic ulcer disease and increase in the prevalence of other etiologies including vascular lesions and malignancy. Appropriate risk assessment and patient stratification are crucial to ensuring that optimal care is delivered to patients and some risk assessment tools have shown excellent ability to define a low-risk group who can be managed as outpatients safely. Regardless of the etiology of UGIB, resuscitative interventions by primary care providers remain the most important initial measures to improve the outcome for patients including hemodynamic stabilization, an appropriate blood transfusion strategy, with or without acid-lowering agents, while also providing subsequent urgent endoscopic assessment and intervention. In addition, with increasing use of antithrombotic agents in clinical practice and its associated risk of bleeding, the management of such agents in the acute setting has become a real challenge to all physicians. In this article, we provide an up-to-date, evidence-based, practical review of recent changes and advances in UGIB with a focus on non-variceal etiologies.

Background and Aim Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the standard of care in advanced pancreatic cancer. Its role in resectable disease, however, is controversial. This meta-analysis aims to ascertain the clinical outcomes of patients with resectable pancreatic cancer undergoing preoperative EUS-FNA compared to those going directly to surgery. Methods A literature search was performed from 1996 to April 2019 using MEDLINE, EMBASE, and ISI Web of Knowledge for studies comparing preoperative EUS-FNA to EUS without FNA in resectable pancreatic cancer for clinical outcomes. The primary outcome is overall survival (OS). Secondary outcomes include cancer-free survival, tumor recurrence and peritoneal carcinomatosis, and post-FNA-pancreatitis rate. Results Six retrospective studies were included. Preoperative EUS-FNA had better OS than the non-FNA group (WMD, 4.40 months [0.02 to 8.78]). Cancer-free survival did not differ significantly between the two groups (WMD, 2.08 months [−2.22 to 6.38]). EUS with FNA was not associated with increased rates of tumor recurrence or peritoneal carcinomatosis. Conclusion Preoperative EUS-FNA in resectable pancreatic cancer may be associated with significantly greater OS when compared to the non-FNA group, with no significant difference in the rates of tumor recurrence or peritoneal seeding. Important limitations of our meta-analysis include the lack of prospective controlled data, which are unlikely to emerge given feasible constraints.

Background Replacing histopathology evaluation of diminutive polyps with optical polyp diagnosis is considered a cost-effective approach. However, the widespread use of optical diagnosis is limited due to concerns about making incorrect optical diagnoses and the requirements of training, credentialing and auditing of performance. Aims This prospective study aimed to evaluate a simplified resect and discard strategy that is not operator dependent. Methods The study evaluated a resect and discard strategy that uses anatomical polyp location to classify colon polyps into non-neoplastic or low-risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and optical diagnosis, respectively. The primary outcome was ≥90% agreement with pathology in surveillance interval assignment. Results Overall, 1117 patients undergoing complete colonoscopy were included and 482 (43.1%) had at least one diminutive polyp. Surveillance interval agreement between the location-based resect and discard strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0% (95% CI = 0.96 - 0.98), surpassing the ≥90% benchmark. Optical diagnoses using NICE and Sano classifications reached 89.1% and 90.01% agreement, respectively (p Conclusions The location-based resect and discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥90% quality benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided. Funding Agencies None

Background Endoscopic procedures performed after-hours often require therapeutic interventions that are technically demanding for the endoscopist. The aim of this position paper is to provide guidance on the minimum standard of equipment that should be available on a mobile endoscopy cart for provision of a safe and effective after-hours emergency endoscopy service. The guidance is based on consensus among academic and community gastroenterologists in Canada. Methods A modified Delphi process was used to establish consensus among 9 participants. A list of statements was prepared by an expert panel of endoscopists. The statements were divided into three broad sections for what should be on an after-hours endoscopy cart including medications, nonendoscopic tools and therapeutic/diagnostic equipment. Consensus for being on the endoscopy cart was achieved when 75% or more of voting members indicated ‘agree’. Results For nonendoscopic tools, there was agreement for having sterile saline, sterile water, endoscope lubricant, various syringes, bite blocks (paediatric and adult size), a water pump with foot peddle, formalin jars for biopsy specimens, digital photo and printing capability and an overtube. For medications, there was agreement for having hyoscine butylbromide and epinephrine on the cart. For therapeutic/diagnostic tools, there was agreement for having biopsy forceps (standard and jumbo), polypectomy snares, sclerotherapy needles and agent (for a variceal bleed), band ligation kit, multipolar electrocautery probes, heater probe catheter, endoscopic clips, hemostatic powder and retrieval devices. Interpretation This position paper provides guidance on the minimum standard of items that should be on an after-hours endoscopy cart. Standardization of equipment may help improve safety and quality of after-hours endoscopic procedures.

Background Despite overall evidence in the literature favoring rectal indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its role in preventing potentially fatal complications is not well explored. Method A comprehensive electronic literature search was done to select randomized controlled trials (RCTs) comparing rectal indomethacin and placebo in preventing PEP. Methodological quality was assessed using the Cochrane risk of bias tool. Statistical heterogeneity was characterized. Random effect model meta-analysis was used. Several subgroup, sensitivity and aggregate subgroup data analyses were completed based on specific risk factors or patient characteristics to identify patient populations who may benefit most from rectal indomethacin. Results A total of eight out of 336 trials published between 2007 and 2016 (n=3324) were included. Analysis showed administering rectal indomethacin before rather than during or after ERCP significantly reduced PEP rates (odds ratio (OR): 0.56 [0.40–079]). Rectal indomethacin also significantly decreased the rate of moderate to severe PEP and death amongst all patients (OR: 0.53 [0.31–0.89] and 0.10 [0.02–0.65], respectively). Rectal indomethacin significantly prevented PEP in patients with sphincter of Oddi dysfunction (SOD) (OR: 0.49 [0.30–0.78]) and those undergoing biliary sphincterotomy (OR: 0.63 [0.42–0.95]), but not in those undergoing precut or pancreatic sphincterotomy or prophylactic pancreatic stent placement. Sensitivity analysis showed that the effect remained significant after two studies with high risk of bias were excluded. Conclusion Rectal indomethacin significantly decreases the occurrence of moderate to severe PEP and death in all patients, only if given before the procedure.

Objectives Balloon-assisted enteroscopy (BAE) is increasingly used for the evaluation of small bowel disorders. We quantified local diagnostic and therapeutic yields of BAE in patients with suspected small bowel diseases. Methods Adult patients undergoing BAE between January 2010 and July 2015 at McGill University Health Centre were included. Procedures were identified using a prospectively maintained database. Patients were excluded if procedure report was unavailable. Electronic medical records were reviewed. Analyses were restricted to patients who did not have a previous BAE. Results BAE was performed in 453 patients, including 421 anterograde cases. Patients had a mean age of 61.0 ± 17.5 years. Most common indications for referral were obscure gastrointestinal bleeding (OGIB) (n=207, 45.7%), abnormal imaging (n=88, 19.4%), suspected small bowel neoplasia (SBN) (n=39, 8.6%) and Crohn’s disease (CD) (n=31, 6.8%). A diagnosis was established in 216 procedures (47.7%). A pre-endoscopic indication of CD (odds ratio [OR]: 3.78; 95% Confidence Interval [CI], 1.60–8.90), OGIB (OR: 3.69, 95% CI, 2.03–6.71), suspected SBN (OR: 2.45; 95% CI, 1.06–5.65) and previous VCE (OR: 9.33; 95% CI, 3.24–26.90) were associated with abnormal findings. A therapeutic procedure was performed in 126 cases (28.3%). OGIB (OR: 7.00; 95% CI, 3.83–12.81), previous video capsule endoscopy (VCE) (OR: 7.86; 95% CI, 2.93–21.04) and suspected SBN (OR: 6.30; 95% CI, 2.58–21.04) were associated with performance of a therapeutic intervention. Complication rate was 1.6%, with bleeding in seven cases and one perforation. Conclusions In carefully selected patients, such as those with OGIB, Crohn’s disease and previous VCE, BAE was a safe procedure that led to the identification of abnormal findings and therapeutic interventions.

Aims Failed bowel preparation is common during colonoscopy, yet the optimal purgative regimen to use for the next attempt is unknown. The objective of this study was to compare the efficacy, tolerability, and safety of two regimens at supratherapeutic doses for use after failed bowel preparation. Methods A multi-centre phase III endoscopist blinded randomized controlled trial (NCT02976805) was conducted in patients who failed bowel preparation, using the US Multi-Society Task Force (USMSTF) definition of inability to exclude polyps >5 mm in size and requiring a shortened interval to next colonoscopy. Regimen A consisted of 15 mg of bisacodyl and 2 + 2 L of split dose polyethylene glycol electrolyte solution (PEG) and Regimen B consisted of 15 mg of bisacodyl and 4 + 2 L of split dose PEG. The primary outcome was adequate bowel preparation, defined as a Boston Bowel Preparation Scale (BBPS) total score ≥ 6 with all segment scores ≥ 2. Secondary outcomes were adequate bowel preparation using the USMSTF definition, median BBPS, adenoma detection (ADR), advanced adenoma detection (aADR), sessile serrated polyp detection (SSPDR), and cecal intubation (CIR). Adverse events were assessed at the time of the colonoscopy and 14 days later. Results Between February 2017 and December 2019, 250 subjects were screened at four academic centres in Canada, of which 195 were randomized: 96 to Regimen A and 99 to Regimen B. The mean (SD) age was 60.6 (11.4) years, 87 (45.1%) were female, and the median (IQR) total BBPS score at previous failed colonoscopy was 3 (1,4). Regimen B was not superior to Regimen A in achieving adequate bowel preparation using the BBPS definition (87.6% vs. 91.1%, p=0.45) or the USMSTF definition (85.4% vs 91.1%, p=0.24), nor was it superior with respect to the median BBPS score (7 vs 7, p=0.50), mean ADR (31.5% vs 37.8%, p=0.37), aADR (11.2% vs 18.9%, p=0.15), SSPDR (5.6% vs 8.9%, p=0.40) or CIR (92.1% vs 96.7%, p=0.19). Regimen A had a higher adherence rate (88.2% vs. 74.7%, p=0.02) and greater willingness to undergo the bowel preparation again (91.2% vs. 66.2%, p Conclusions Split dose 4L PEG with 15mg of bisacodyl is highly efficacious, well tolerated, and can be used for patients who previously failed first line bowel preparations. The additional 2L of PEG in Regimen B did not improve bowel preparation and was not as well tolerated. Funding Agencies AMOSO Opportunities Grant, Pharmascence Inc.

Background Previous studies have demonstrated that many graduating trainees may not have all of the skills needed to independently practice endoscopic retrograde cholangiopancreatography (ERCP) safely and effectively. As a part of competency-based learning curriculum development, it is essential to provide formative feedback to trainees and ensure they acquire the knowledge and skills for independent practice. Aims To assess the performance of advanced endoscopy trainees across Canada using the Canadian Direct Observation of Procedural Skills (CanDOPS) ERCP assessment tool. Procedural items evaluated include both technical (cannulation, sphincterotomy, stone extraction, tissue sampling, and stent placement) and non-technical (leadership, communication and teamwork, judgment and decision making) skills. Methods We conducted a prospective national multi-centre prospective study. Advanced endoscopy trainees with at least two years of gastroenterology training or five years of general surgery in North America and minimal experience performing ERCPs (less than 100 ERCP procedures) were invited to participate. The CanDOPS tool was used to measure every fifth ERCP performed by trainees over a 12-month fellowship training period. ERCPs were evaluated by experienced staff endoscopists at each study site under standard clinical protocol. Cumulative sum (CUSUM) analyses were used to generate learning curves. Results The data from five Canadian sites and 11 trainees participated in the study. A total of 261ERCP evaluations were completed. Median number of evaluations by site and trainee was 49 (IQR 31–76) and 15 (IQR 11–45). Median number of cases trainees performed prior to their ERCP training was 50 (IQR 25–400). There was a significant improvement in almost all scores over time, including selective cannulation, sphincterotomy, biliary stenting and all non-technical skills (P Conclusions This is the first ERCP performance evaluation tool that examines multiple technical and non-technical aspects of the procedure. Although trainee ERCP skills do improve during their training period, there exists a notable variability in time to competency for the different skills measured using the CanDOPS tool. Large prospective research is required to determine if competency is achieved using more stringent definitions of ERCP competency and to determine factors associated with reaching competency. Funding Agencies None

Background Submucosal injection (SI) is used for standard polypectomies or during complex endoscopic interventions. SI helps to facilitate endoscopic resection and to prevent complications such as bleeding or perforation. Aims We were interested to evaluate endoscopists practice patterns of using SI during routine standard polypectomy and complex endotherapeutic procedures. Methods An online survey using the Google Form application was distributed through medical societies. Survey domains included training and practice characteristics of participating endoscopists as well as questions regarding the use of SI products for endoscopy procedures. Results A total of 236 endoscopists (mainly from the US, Canada, and Europe) participated in the survey. About half (48%) of endoscopists start using SI for routine polypectomies when polyps are larger than 10 mm, while 37% of endoscopist report having a size threshold larger than 15mm for using SI (22% report using SI starting at >15 mm, and 15% report using SI starting at >20 mm). Only a minority (11%) of endoscopists report using SI for polyps Conclusions The use of SI is common during endoscopy procedures. For standard colorectal polypectomy procedures, most endoscopists start using SI only for polyps larger than 10mm. SI is used by endoscopists to prevent complications, improve endoscopic resection and to identify dysplastic tissue. Funding Agencies None

BACKGROUND: Current clinical practice assigns post-polypectomy surveillance intervals based on the number, size and histological aspects of polyps. AIMS: Our goal was to test a novel polyp-based resect and discard model that assigns surveillance intervals for small polyps based only on size and number of polyps. METHODS: A post hoc analysis was performed on patients enrolled in a prospective colonoscopy trial. We created a model for polyp-based surveillance interval allocation based on clinical experience for what the most likely pathology-based surveillance interval would be for certain scenarios. The primary outcome was the surveillance interval agreement of the polyp-based resect and discard strategy compared to histopathology and USMSTF based surveillance intervals. Secondary outcomes were the overall reduction in required pathology exams and the number of surveillance intervals that can be provided immediately to patients before leaving the endoscopy unit. In addition, we conducted a medical chart review to assess current clinical practise of surveillance interval guideline adherence at our institution. RESULTS: 457 patients (mean age 62.7, 49.4% female, 514 small polyps, 430 diminutive polyps) were enrolled in the study. When using the polyp-based resect and discard model, the assigned surveillance intervals were correct for 89,3% (95% CI: 0.86–92) of patients when compared to pathology-based surveillance interval assignment. When using the polyp-based model, 88,8% of patients can be provided with immediate surveillance interval recommendations compared to 47,7% when using the pathology-based surveillance interval allocation. When using the polyp-based model, 61.4% of pathology examinations can be omitted. Medical chart review showed that at our institution 43.8% of patients received a correct surveillance interval recommendation. CONCLUSIONS: The polyp-based resect and discard model reaches an almost 90% agreement compared to pathology-based surveillance interval allocation recommendations. This alternative model reduces the need for pathology examinations, increases the amount of patients that can be provided with immediate surveillance interval recommendations and has the potential to reduce colonoscopy-associated costs. Clinical adherence to pathology results and guideline recommendations was found to be low, but in the range of what has been previously reported in the literature. FUNDING AGENCIES: None

BACKGROUND: CRBSI are serious complications for patients on PN. Antimicrobial lock solutions have been used as a prophylaxis against CRBSI, however their efficacy in the PN population is unclear. AIMS: To conduct a systematic review on the efficacy of antimicrobial lock solutions to prevent CRBSI in patients on PN. METHODS: We performed a systematic search of EMBASE, MEDLINE, CENTRAL, ISI Web of Knowledge (from earliest date to December 2015) for randomized controlled trials (RCT) and observational studies evaluating the efficacy of antimicrobial locks compared to control solutions (heparin or saline) to prevent CRBSI in adult and pediatric PN patients. Two independent reviewers performed study selection and data extraction. Critical appraisal of possible bias was performed using the Cochrane Risk of bias tool (RCT) and ROBINS-I (observational studies). RESULTS: The literature search identified 771 citations, 112 were reviewed in full, and 19 studies were selected, totaling 536 patients, including 9 pediatric (122 patients) and 10 adult (414 patients) studies. Nine studies assessed an ethanol lock solution, 9 taurolidine, and 1 gentamycin. Two open-labeled RCT were included, both using taurolidine (Klek and Bisseling). The remaining studies were observational, and employed a pre- and post-design at moderate to high risk of bias. Methodological and clinical heterogeneity precluded pooling of the data by meta-analysis. All studies, except one by Klek who used taurolidine in low-risk patients, report lower CRBSI rate in the treatment group (ethanol, taurolidine ± citrate, and gentamycin lock) compared to controls (heparin or saline). The negative trial by Klek et al. documented 1 CRBSI (0.273/1000 catheter-days) in the taurolidine plus citrate arm, and none in the taurolidine or control arms (p=1.000). This finding is in contrast to Bisseling et al. who reported lower CRBSI rates (0.19 versus 2.02 CRBSI/1000 catheter-days, p=0.008), and longer mean infection-free survival in the taurolidine arm (641 (95% CI 556–727) vs 175 (95% CI 85–266) days, log-rank p

BACKGROUND: Endoscopic ultrasound-guided double bypass (EUS-DB) is a novel technique in the management of concomitant biliary and gastric outlet obstruction. It involves the creation of both an EUS-guided gastroenterostomy and hepatogastrostomy AIMS: To describe the first reported case in the literature (with video) of EUS-DB performed in collaboration with interventional radiology (IR) METHODS: A 54-year old male known for locally advanced pancreatic cancer was referred for recurrent cholangitis and gastric outlet obstruction despite previous duodenal stenting and transhepatic percutaneous biliary drainage (PTBD). Endoscopy confirmed complete obstruction of the duodenal stent due to tumor tissue ingrowth. A decision was made to proceed to EUS-DB to optimize nutritional status, biliary drainage, and patient comfort RESULTS: IR introduced a guidewire through the PTBD traversing the enteral stent and advanced to the jejunum. A 20 mm dilating balloon with an overlapping snare attached was then introduced over the PTBD wire and advanced across the enteral stent to the ligament of Treitz where the balloon was inflated under fluoroscopy. Overall, 500 ml of both saline and contrast was then injected percutaneously to dilate the small bowel segment proximal to the balloon. EUS-guided puncture of the balloon was performed transgastrically with a 19-gauge needle. Bursting of the balloon confirmed successful puncture in the desired jejunal segment. An 0.035-inch guidewire was then advanced through the needle and grasped with the snare and pulled through the percutaneous access thereby creating wire tension on both ends of the wire. Track dilation was performed with a 4 mm dilating balloon. A Lumen-apposing metal stent (15 x 10 mm) was then deployed under EUS guidance. Contrast injection confirmed a patent gastroenterostomy. Attention was then shifted to the HGS. Under EUS a dilated hepatic segment III left intrahepatic bile duct was visualized. A transgastric puncture of the duct was performed with a 19-gauge needle, followed by the advancement of an 0.035-inch guidewire into the common bile duct. The HGS track was then dilated using a 4mm dilating balloon followed by successful deployment of a 10 x 80 mm partially covered self-expanding metal stent. A full stent diet was initiated 48 hours post procedure with excellent tolerance. PTBD was removed 3 days later with the bilirubin having decreased by more than 50 % at the 1-week follow-up CONCLUSIONS: We describe the first reported EUS-guided double bypass performed in collaboration with IR. Combining endoscopic and interventional radiology techniques may enhance the safety and ease of this novel approach. Further studies; however, will be needed to validate this technique FUNDING AGENCIES: None

BACKGROUND: Endoscopic ultrasound guided hepatogastrostomy (EUS-HGS) is a popular approach to EUS-biliary drainage especially in the setting of concomitant gastric outlet obstruction. The main disadvantage of EUS-HGS is that it requires a dilated biliary system AIMS: A case report (with video) describing the first conversion of a percutaneous transhepatic biliary drain (PTBD) into an HGS in a non-dilated biliary system using EUS and interventional radiology (IR) techniques. METHODS: A 43-year old male underwent a staged R0 hepatic resection for colon cancer metastases, during which the common bile duct was fully transected. Bilateral PTBD were placed. Definitive stable drainage was required to allow adjuvant chemotherapy. The surgical option was a Roux-en-Y hepatico-jejunostomy. HGS was chosen as less invasive option allowing faster recovery and earlier initiation of chemo RESULTS: Under EUS guidance, a non-dilated segment II bile duct was punctured with a 19-gauge needle; however, given the small ductal caliber wire passage was not possible. Via the PTBD, 2 occlusive balloons were inserted into the target duct, with one central and one peripheral to the target puncture site. Saline was infused between the balloons, dilating the isolated bile duct segment. This eased the duct puncture and passage of an 0.035-inch guidewire. The wire; however, traveled peripherally in the bile ducts but was successfully grasped with a loop-snare (via PTBD access) and pulled out the PTBD track. With control of both ends of the wire, the hepatogastrostomy tract was easily dilated to 6 mm with a balloon inserted by PTBD. During tract dilation, A 10 mmx80 mm partially covered self-expandable metal stent was simultaneously loaded through the endoscope and advanced through the HGS tract immediately following deflation of the balloon thereby minimizing the time between dilation and stent insertion, to reduce bile leak. The stent was then successfully deployed with excellent spontaneous drainage of contrast. The patient was discharged 4 days later following check cholangiogram, normalization of bilirubin and removal of the PTBD. He was pain free with no evidence of bile leak CONCLUSIONS: We report the first successful conversion of PTBD to HGS using EUS and IR techniques in a non-dilated biliary system. Collaboration between endoscopists and IR can enhance the safety and feasability FUNDING AGENCIES: None

Excess body weight, as defined by the body mass index (BMI), has been associated with several diseases and includes subjects who are overweight (BMI≥25–29.9 kg/m2) or obese (BMI≥30 kg/m2). Overweight and obesity constitute the fifth leading risk for overall mortality, accounting for at least 2.8 million adult deaths each year. In addition around 11% of colorectal cancer (CRC) cases have been attributed to overweight and obesity in Europe. Epidemiological data suggest that obesity is associated with a 30–70% increased risk of colon cancer in men, whereas the association is less consistent in women. Similar trends exist for colorectal adenoma, although the risk appears lower. Visceral fat, or abdominal obesity, seems to be of greater concern than subcutaneous fat obesity, and any 1 kg/m2 increase in BMI confers additional risk (HR 1.03). Obesity might be associated with worse cancer outcomes, such as recurrence of the primary cancer or mortality. Several factors, including reduced sensitivity to antiangiogenic-therapeutic regimens, might explain these differences. Except for wound infection, obesity has no significant impact on surgical procedures. The underlying mechanisms linking obesity to CRC are still a matter of debate, but metabolic syndrome, insulin resistance and modifications in levels of adipocytokines seem to be of great importance. Other biological factors such as the gut microbita or bile acids are emerging. Many questions still remain unanswered: should preventive strategies specifically target obese patients? Is the risk of cancer great enough to propose prophylactic bariatric surgery in certain patients with obesity?

BACKGROUND: Patients with inflammatory bowel disease (IBD) are subject to several colonoscopies during their lifespan and subsequently several bowel preparations. Recent guidelines endorse the use of split-dose regimens, but only few data are available in IBD patients who are often excluded from trials for safety concerns. AIMS: We performed a systematic review and meta-analysis to determine any existing difference in terms of effectiveness, safety and tolerability between existing colon-cleansing products in the IBD population. METHODS: Systematic searches were performed (January 1980 - September 2016) using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials assessing preparations with or without adjuvants, given in split and non-split dosing, in high (>3L) or low-volume (2L or less) regimens. Bowel cleansing quality was the primary outcome. Secondary outcomes included patient willingness-to-repeat the preparation and side effects and complications. RESULTS: Out of 439 citations, 4 trials fulfilled our inclusion criteria (n = 449 patients). One trial (Lazzaroni et coll. 1993) assessed the impact of adding Simethicone to Polyethylene Glycol (PEG) 4L witch resulted in similar bowel cleansing effect but a better willingness to repeat. One other trial (Gould et coll 1982) compared senna to castor oil, again without any difference in term of bowel cleansing. Two trials compared the efficacy of PEG high-volume versus PEG low-volume associated to an adjuvant in split-dose regimens (Kim et al 2016, Manes et al 2016): PEG low-dose efficacy was not different to PEG high-dose; OR=0.84 (0.37; 1.92) A higher proportion of patients were willing to repeat low-volume preparations vs high-volume; OR 5.11 (1.31–20.0). CONCLUSIONS: In IBD population, PEG low-volume regimen seems not inferior to PEG high-volume to clean the colon, and yields improved tolerance. Further additional research is urgently required to compare contemporary products in this specific population. FUNDING AGENCIES: None

BACKGROUND: Existing guidelines on colorectal cancer (CRC) screening for individuals with a family history (FH) of CRC or adenoma have not been based on systematic reviews or comprehensive assessment of the quality (=trustworthiness) of evidence (QoE). AIMS: To systematically review the literature to inform the ongoing development of a Canadian Association of Gastroenterology-supported Canadian and US guideline on CRC screening for individuals with FH of nonhereditary CRC or adenoma. METHODS: Multiple parallel systematic review streams, informed by a series of 10 literature searches, gathered evidence on 4 principal questions around the 1) effect of FH of CRC (or adenoma) on an individual’s risk of CRC, 2) age at which screening should begin, 3) recommended screening tests, and 4) recommended testing intervals for individuals with FH of CRC or adenoma. The GRADE approach was used to assess the QoE. RESULTS: The relative risk (RR) of CRC among individuals with FH of 1 first-degree relative (FDR) with CRC was estimated to be approximately 2-fold greater than among those without. The RR increased with an increasing number of FDRs with CRC. A FH of only second-degree relatives was associated with no or minimally elevated risk. The risk of CRC was increased by FH of advanced adenoma, but not with FH of a non-advanced adenoma. The age-specific risk of CRC fell on a continuum: RR increased with decreasing age of affected FDR, and increasing age of the screened individual, but RR was elevated at all ages compared to those with no FH. All the above were of very low QoE. Using data on efficacy (QoE ranging from very low to high), patient preference (very low QoE), and cost-effectiveness (very low QoE), colonoscopy and FIT ranked highest among screening test for individuals with FH of a FDR with CRC. Data on the optimal interval for CRC screening were limited (very low QoE), but suggested a potential benefit of shorter intervals for some individuals with FH compared to those at average risk. CONCLUSIONS: A FH of CRC or advanced adenoma is associated with a clinically important increased risk of CRC, which falls on an age continuum. FUNDING AGENCIES: Canadian Partnership Against Cancer (CPAC)

Objectives. Many elderly patients are prescribed both low-dose aspirin (ASA), for cardiovascular protection and non-steroidal anti-inflammatory drugs (NSAIDs) for pain control. Compared with non-selective NSAIDs (NS-NSAIDs), celecoxib has a superior gastrointestinal (GI) safety profile in general. It is unclear, however, whether this fact holds good among patients taking ASA. We compared GI hospitalization rates among elderly patients taking celecoxib, NS-NSAIDs, celecoxib and ASA or NS-NSAIDs and ASA. Methods. This was a retrospective cohort study using Quebec government databases. All patients 65 yrs of age or older who filled a prescription for celecoxib or an NS-NSAID between April 1999 and December 2002 were included. Cox regression models were used to compare the GI hospitalization rates between the four exposure categories adjusting for potential confounders. Results. A total of 332 491 patients were included. Among 1 522 307 celecoxib prescriptions, 430 214 were filled by patients concurrently receiving ASA (celecoxib and ASA); 195 369 of 863 646 NS-NSAID prescriptions were filled by patients receiving ASA (NS-NSAID and ASA). Celecoxib without ASA was less likely than NS-NSAID without ASA to be associated with GI hospitalization [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.33–0.50]; celecoxib and ASA was also less likely to be associated with GI hospitalization than NS-NSAID and ASA (HR 0.62, 95% CI 0.48–0.80); GI hospitalization rates were similar for celecoxib and ASA and NS-NSAID without ASA (HR 1.01, 95% CI 0.81–1.25). Conclusion. Among elderly patients receiving cardiovascular protection with ASA and pain control with anti-inflammatory drugs, celecoxib may be safer with regards to GI toxicity than NS-NSAIDs.