Browsing by Author "Pawa, Swati"

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    ASGE Guideline on role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: Methodology and Review of Evidence
    (Elsevier, 2023) Fujii-Lau, Larissa L.; Thosani, Nirav C.; Al-Haddad, Mohammad; Acoba, Jared; Wray, Curtis J.; Zvavanjanja, Rodrick; Amateau, Stuart K.; Buxbaum, James L.; Wani, Sachin; Calderwood, Audrey H.; Chalhoub, Jean M.; Coelho-Prabhu, Nayantara; Desai, Madhav; Elhanafi, Sherif E.; Fishman, Douglas S.; Forbes, Nauzer; Jamil, Laith H.; Jue, Terry L.; Kohli, Divyanshoo R.; Kwon, Richard S.; Law, Joanna K.; Lee, Jeffrey K.; Machicado, Jorge D.; Marya, Neil B.; Pawa, Swati; Ruan, Wenly; Sawhney, Mandeep S.; Sheth, Sunil G.; Storm, Andrew; Thiruvengadam, Nikhil R.; Qumseya, Bashar J.; Medicine, School of Medicine
    Biliary strictures of undetermined etiology pose a diagnostic challenge for endoscopists. Despite advances in technology, diagnosing malignancy in biliary strictures often requires multiple procedures. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the available literature on strategies used to diagnose undetermined biliary strictures. Using a systematic review and meta-analysis of each diagnostic modality, including fluoroscopic-guided biopsies, brush cytology, cholangioscopy, and endoscopic ultrasound fine needle aspiration or biopsy, the American Society of Gastrointestinal Endoscopy (ASGE) Standards of Practice committee provides this guideline on modalities used to diagnose biliary strictures of undetermined etiology. This document summarizes the methods used in the GRADE analysis to make recommendations, while the "Summary and Recommendations" document contains a concise summary of our findings and final recommendations.
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    ASGE Guideline on the role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: Summary and Recommendations
    (Elsevier, 2023) Fujii-Lau, Larissa L.; Thosani, Nirav C.; Al-Haddad, Mohammad; Acoba, Jared; Wray, Curtis J.; Zvavanjanja, Rodrick; Amateau, Stuart K.; Buxbaum, James L.; Calderwood, Audrey H.; Chalhoub, Jean M.; Coelho-Prabhu, Nayantara; Desai, Madhav; Elhanafi, Sherif E.; Fishman, Douglas S.; Forbes, Nauzer; Jamil, Laith H.; Jue, Terry L.; Kohli, Divyanshoo R.; Kwon, Richard S.; Law, Joanna K.; Lee, Jeffrey K.; Machicado, Jorge D.; Marya, Neil B.; Pawa, Swati; Ruan, Wenly; Sawhney, Mandeep S.; Sheth, Sunil G.; Storm, Andrew; Thiruvengadam, Nikhil R.; Qumseya, Bashar J.; Medicine, School of Medicine
    This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the diagnosis of malignancy in patients with biliary strictures of undetermined etiology. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and addresses the role of fluoroscopic-guided biopsies, brush cytology, cholangioscopy, and endoscopic ultrasound (EUS) in the diagnosis of malignancy in patients with biliary strictures. In the endoscopic work-up of these patients, we suggest the use of fluoroscopic-guided biopsies in addition to brush cytology over brush cytology alone, especially for hilar strictures. Especially for patients with, non-diagnostic sampling we suggest the use of cholangioscopic and EUS-guided biopsies; the former for non-distal and the latter for distal strictures or those with suspected spread to surrounding lymph nodes and other structures.
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    ASGE Guideline on the Role of Ergonomics for Prevention of Endoscopy-related Injury (ERI): Methodology and Review of Evidence
    (ASGE, 2023-10) Pawa, Swati; Kwon, Richard S.; Fishman, Douglas S.; Thosani, Nirav C.; Shergill, Amandeep; Grover , Samir C.; Al-Haddad , Mohammad; Amateau, Stuart K.; Buxbaum , James L.; Calderwood , Audrey H.; Chalhoub, Jean M.; Coelho-Prabhu, Nayantara; Desai, Madhav; Elhanafi, Sherif E.; Forbes, Nauzer; Fujii-Lau, Larissa L.; Kohli, Divyanshoo R.; Machicado , Jorge D.; Marya, Neil B.; Ruan, Wenly; Sheth, Sunil G.; Storm, Andrew C.; Thiruvengadam, Nikhil R.; Wani, Sachin; Qumseya, Bashar J.; Medicine, School of Medicine
    This guideline document was prepared by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy using the best available scientific evidence and considering a multitude of variables including but not limited to adverse events, patient values, and cost implications. The purpose of these guidelines is to provide the best practice recommendations, which may help standardize patient care, improve patient outcomes, and reduce variability in practice. We recognize that clinical decision-making is complex. Guidelines, therefore, are not a substitute for a clinician’s judgment. Such judgements may at times seem contradictory to our guidance because of many factors that are impossible to fully consider by guideline developers. Any clinical decisions should be based on the clinician’s experience, local expertise, resource availability, and patient values and preferences. This document is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating for, mandating, or discouraging any particular treatment. Our guidelines should not be used in support of medical complaints, legal proceedings, and/or litigation, as they were not designed for this purpose.
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    ASGE Guideline on the Role of Ergonomics for Prevention of Endoscopy-related Injury (ERI): Summary and Recommendations
    (ASGE, 2023-10) Pawa, Swati; Kwon, Richard S.; Fishman, Douglas S.; Thosani, Nirav C.; Shergill, Amandeep; Grover , Samir C.; Al-Haddad, Mohammad; Amateau, Stuart K.; Buxbaum, James L.; Calderwood , Audrey H.; Chalhoub, Jean M.; Coelho-Prabhu, Nayantara; Desai, Madhav; Elhanafi, Sherif E.; Forbes , Nauzer; Fujii-Lau, Larissa L.; Kohli , Divyanshoo R.; Machicado, Jorge D.; Marya, Neil B.; Ruan, Wenly; Sheth, Sunil G.; Storm, Andrew C.; Thiruvengadam, Nikhil R.; Qumseya, Bashar J.; Medicine, School of Medicine
    This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled “Methodology and Review of Evidence,” which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI.
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    Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019
    (Elsevier, 2020-10-01) Elmunzer, B. Joseph; Spitzer, Rebecca L.; Foster, Lydia D.; Merchant, Ambreen A.; Howard, Eric F.; Patel, Vaishali A.; West, Mary K.; Qayed, Emad; Nustas, Rosemary; Zakaria, Ali; Piper, Marc S.; Taylor, Jason R.; Jaza, Lujain; Forbes, Nauzer; Chau, Millie; Lara, Luis F.; Papachristou, Georgios I.; Volk, Michael L.; Hilson, Liam G.; Zhou, Selena; Kushnir, Vladimir M.; Lenyo, Alexandria M.; McLeod, Caroline G.; Amin, Sunil; Kuftinec, Gabriela N.; Yadav, Dhiraj; Fox, Charlie; Kolb, Jennifer M.; Pawa, Swati; Pawa, Rishi; Canakis, Andrew; Huang, Christopher; Jamil, Laith H.; Aneese, Andrew M.; Glamour, Benita K.; Smith, Zachary L.; Hanley, Katherine A.; Wood, Jordan; Patel, Harsh K.; Shah, Janak N.; Agarunov, Emil; Sethi, Amrita; Fogel, Evan L.; McNulty, Gail; Haseeb, Abdul; Trieu, Judy A.; Dixon, Rebekah E.; Yang, Jeong Yun; Mendelsohn, Robin B.; Calo, Delia; Aroniadis, Olga C.; LaComb, Joseph F.; Scheiman, James M.; Sauer, Bryan G.; Dang, Duyen T.; Piraka, Cyrus R.; Shah, Eric D.; Pohl, Heiko; Tierney, William M.; Mitchell, Stephanie; Condon, Ashwinee; Lenhart, Adrienne; Dua, Kulwinder S.; Kanagala, Vikram S.; Kamal, Ayesha; Singh, Vikesh K.; Pinto-Sanchez, Maria Ines; Hutchinson, Joy M.; Kwon, Richard S.; Korsnes, Sheryl J.; Singh, Harminder; Solati, Zahra; Willingham, Field F.; Yachimski, Patrick S.; Conwell, Darwin L.; Mosier, Evan; Azab, Mohamed; Patel, Anish; Buxbaum, James; Wani, Sachin; Chak, Amitabh; Hosmer, Amy E.; Keswani, Rajesh N.; DiMaio, Christopher J.; Bronze, Michael S.; Muthusamy, Raman; Canto, Marcia I.; Gjeorgjievski, V. Mihajlo; Imam, Zaid; Odish, Fadi; Edhi, Ahmed I.; Orosey, Molly; Tiwari, Abhinav; Patwardhan, Soumil; Brown, Nicholas G.; Patel, Anish A.; Ordiah, Collins O.; Sloan, Ian P.; Cruz, Lilian; Koza, Casey L.; Okafor, Uchechi; Hollander, Thomas; Furey, Nancy; Reykhart, Olga; Zbib, Natalia H.; Damianos, John A.; Esteban, James; Hajidiacos, Nick; Saul, Melissa; Mays, Melanie; Anderson, Gulsum; Wood, Kelley; Mathews, Laura; Diakova, Galina; Caisse, Molly; Wakefield, Lauren; Nitchie, Haley; Waljee, Akbar K.; Tang, Weijing; Zhang, Yueyang; Zhu, Ji; Deshpande, Amar R.; Rockey, Don C.; Alford, Teldon B.; Durkalski, Valerie; Medicine, School of Medicine
    Background & Aims The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. Methods Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. Results A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76–1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80–2.12) were not associated independently with mechanical ventilation or death. Conclusions Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.
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    Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019
    (Elsevier, 2021-07) Elmunzer, B. Joseph; Spitzer, Rebecca L.; Foster, Lydia D.; Merchant, Ambreen A.; Howard, Eric F.; Patel, Vaishali A.; West, Mary K.; Qayed, Emad; Nustas, Rosemary; Zakaria, Ali; Piper, Marc S.; Taylor, Jason R.; Jaza, Lujain; Forbes, Nauzer; Chau, Millie; Lara, Luis F.; Papachristou, Georgios I.; Volk, Michael L.; Hilson, Liam G.; Zhou, Selena; Kushnir, Vladimir M.; Lenyo, Alexandria M.; McLeod, Caroline G.; Amin, Sunil; Kuftinec, Gabriela N.; Yadav, Dhiraj; Fox, Charlie; Kolb, Jennifer M.; Pawa, Swati; Pawa, Rishi; Canakis, Andrew; Huang, Christopher; Jamil, Laith H.; Aneese, Andrew M.; Glamour, Benita K.; Smith, Zachary L.; Hanley, Katherine A.; Wood, Jordan; Patel, Harsh K.; Shah, Janak N.; Agarunov, Emil; Sethi, Amrita; Fogel, Evan L.; McNulty, Gail; Haseeb, Abdul; Trieu, Judy A.; Dixon, Rebekah E.; Yang, Jeong Yun; Mendelsohn, Robin B.; Calo, Delia; Aroniadis, Olga C.; LaComb, Joseph F.; Scheiman, James M.; Sauer, Bryan G.; Dang, Duyen T.; Piraka, Cyrus R.; Shah, Eric D.; Pohl, Heiko; Tierney, William M.; Mitchell, Stephanie; Condon, Ashwinee; Lenhart, Adrienne; Dua, Kulwinder S.; Kanagala, Vikram S.; Kamal, Ayesha; Singh, Vikesh K.; Pinto-Sanchez, Maria Ines; Hutchinson, Joy M.; Kwon, Richard S.; Korsnes, Sheryl J.; Singh, Harminder; Solati, Zahra; Willingham, Field F.; Yachimski, Patrick S.; Conwell, Darwin L.; Mosier, Evan; Azab, Mohamed; Patel, Anish; Buxbaum, James; Wani, Sachin; Chak, Amitabh; Hosmer, Amy E.; Keswani, Rajesh N.; DiMaio, Christopher J.; Bronze, Michael S.; Muthusamy, Raman; Canto, Marcia I.; Gjeorgjievski, V. Mihajlo; Imam, Zaid; Odish, Fadi; Edhi, Ahmed I.; Orosey, Molly; Tiwari, Abhinav; Patwardhan, Soumil; Brown, Nicholas G.; Patel, Anish A.; Ordiah, Collins O.; Sloan, Ian P.; Cruz, Lilian; Koza, Casey L.; Okafor, Uchechi; Hollander, Thomas; Furey, Nancy; Reykhart, Olga; Zbib, Natalia H.; Damianos, John A.; Esteban, James; Hajidiacos, Nick; Saul, Melissa; Mays, Melanie; Anderson, Gulsum; Wood, Kelley; Mathews, Laura; Diakova, Galina; Caisse, Molly; Wakefield, Lauren; Nitchie, Haley; Waljee, Akbar K.; Tang, Weijing; Zhang, Yueyang; Zhu, Ji; Deshpande, Amar R.; Rockey, Don C.; Alford, Teldon B.; Durkalski, Valerie; North American Alliance for the Study of Digestive Manifestations of COVID-19; Medicine, School of Medicine
    BACKGROUND & AIMS: The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. METHODS: Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. RESULTS: A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death. CONCLUSIONS: Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.
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    EUS-directed transgastric interventions in Roux-En-Y Gastric Bypass anatomy: a multicenter experience
    (Elsevier, 2022-05) Ghandour, Bachir; Shinn, Brianna; Dawod, Qais M.; Fansa, Sima; El Chafic, Abdul Hamid; Irani, Shayan S.; Pawa, Rishi; Gutta, Aditya; Ichkhanian, Yervant; Paranandi, Bharat; Pawa, Swati; Al-Haddad, Mohammad A.; Zuchelli, Tobias; Huggett, Matthew T.; Bejjani, Michael; Sharaiha, Reem Z.; Kowalski, Thomas E.; Khashab, Mouen A.; Medicine, School of Medicine
    Background and Aims Placement of a Lumen Apposing Metal Stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS Guided Transgastric Interventions (EDGI) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS guided transgastric ERCP (EDGE) outcomes have been reported, there is a paucity of data on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGI. Methods This is a retrospective study involving 9 centers (8 USA, 1 Europe) and included patients with RYGB who underwent EDGI between 06/2015 and 09/2021. The primary outcome was the technical success of EDGI. Secondary outcomes included adverse events, length of hospital stay, and fistula follow-up and management. Results 54 EDGI procedures were performed in 47 patients (mean age 61yr, F 72%), most commonly for the evaluation of a pancreatic mass (n=16) and management of pancreatic fluid collections (n=10). A 20mm LAMS was utilized in 26 patients and a 15mm LAMS in 21, creating a gastrogastrostomy (GG) in 37 patients and jejunogastrostomy (JG) in 10. Most patients (n=30, 64%) underwent a dual-session EDGI, with a median interval of 17d between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (+/-FNA/B) (n=28) and EUS-guided cystgastrostomy (n=8). The mean procedural time was 97.6 ± 78.9 mins. Technical success was achieved in 52 (96%). AEs occurred in 5 (10.6%) patients, of which only 1 (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), while delayed spontaneous LAMS migration occurred in 2 (4.3%). 4 of the 5 LAMS migration events were managed endoscopically, and one required surgical repair. LAMS anchoring was found to be protective against LAMS migration (p=0.001). The median duration of hospital stay was 2.1 ± 3.7d. Of the 17 patients who underwent objective fistula assessment endoscopically/radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In one case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. Conclusion EDGI is effective and safe for the diagnosis and management of pancreatobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems effective.
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    Prolonged Gastrointestinal Manifestations After Recovery From COVID-19
    (Elsevier, 2023) Elmunzer, B. Joseph; Palsson, Olafur S.; Forbes , Nauzer; Zakaria , Ali; Davis, Christian; Canakis, Andrew; Qayed, Emad; Bick, Benjamin; Pawa, Swati; Tierney, William M.; McLeod, Caroline G.; Taylor, Jason; Patel, Harsh; Mendelsohn, Robin B.; Bala, Gokul; Sloan, Ian; Merchant, Ambreen A.; Smith, Zachary L.; Sendzischew Shane, Morgan A.; Aroniadis, Olga C.; Ordiah, Collins O.; Ruddy, Johannah M.; Simren, Magnus; Tack, Jan; Drossman, Douglas; Medicine, School of Medicine
    Background & Aims Acute enteric infections are well known to result in long-term gastrointestinal (GI) disorders. Although COVID-19 is principally a respiratory illness, it demonstrates significant GI tropism, possibly predisposing to prolonged gut manifestations. We aimed to examine the long-term GI impact of hospitalization with COVID-19. Methods Nested within a large-scale observational cohort study of patients hospitalized with COVID-19 across North America, we performed a follow-up survey of 530 survivors 12–18 months later to assess for persistent GI symptoms and their severity, and for the development of disorders of gut-brain interaction (DGBIs). Eligible patients were identified at the study site level and surveyed electronically. The survey instrument included the Rome IV Diagnostic Questionnaire for DGBI, a rating scale of 24 COVID-related symptoms, the Gastrointestinal Symptoms Rating Scale, and the Impact of Events–Revised trauma symptom questionnaire (a measure of posttraumatic stress associated with the illness experience). A regression analysis was performed to explore the factors associated with GI symptom severity at follow-up. Results Of the 530 invited patients, 116 responded (52.6% females; mean age, 55.2 years), and 73 of those (60.3%) met criteria for 1 or more Rome IV DGBI at follow-up, higher than the prevalence in the US general population (P < .0001). Among patients who experienced COVID-related GI symptoms during the index hospitalization (abdominal pain, nausea, vomiting, or diarrhea), 42.1% retained at least 1 of these symptoms at follow-up; in comparison, 89.8% of respondents retained any (GI or non-GI) COVID-related symptom. The number of moderate or severe GI symptoms experienced during the initial COVID-19 illness by self-report correlated with the development of DGBI and severity of GI symptoms at follow-up. Posttraumatic stress disorder (Impact of Events–Revised score ≥33) related to the COVID-19 illness experience was identified in 41.4% of respondents and those individuals had higher DGBI prevalence and GI symptom severity. Regression analysis revealed that higher psychological trauma score (Impact of Events–Revised) was the strongest predictor of GI symptom severity at follow-up. Conclusions In this follow-up survey of patients 12–18 months after hospitalization with COVID-19, there was a high prevalence of DGBIs and persistent GI symptoms. Prolonged GI manifestations were associated with the severity of GI symptoms during hospitalization and with the degree of psychological trauma related to the illness experience.