© 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY
Letters to the Editor 1089
Harvard Medical School , Boston , Massachusetts , USA . Correspondence: Joseph Feuerstein, MD , Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School , 330 Brookline Avenue E / Dana 501 , Boston, Massachusetts 02215 , USA . E-mail: [email protected]
Terminal Ileitis Found Upon Imaging: Is It Always Crohn ’ s Disease?
Teresa Pinto Pais , MD 1 , S ó nia Fernandes , MD 1 ,
Carlos Fernandes , MD 1 , Iolanda Ribeiro , MD 1
and Jo ã o Carvalho , MD 1
doi:10.1038/ajg.2014.114
To the Editor: Terminal ileitis (TI), defi ned
as infl ammation of the terminal ileum, is
a common condition in clinical practice
and is classically associated with Crohn ’ s
disease (CD). However, a wide variety
of diseases may be associated with ileitis
( 1,2 ). Diagnosis of the specifi c cause of
ileitis is of paramount importance because
misdiagnosis may result in critical delays or
errors in patient management ( 3 – 5 ). None-
theless, distinguishing between the various
forms of ileitis remains a test of clinical acu-
men. Accurate diagnosis is suggested by a
detailed history and physical examination,
by laboratory testing, and by ileocolonos-
copy and / or radiological evaluation.
To study the diff erent entities associated
with TI in clinical practice, we reviewed
all patients with confi rmed imaging of TI
on ultrasound admitted to our depart-
ment over four consecutive years. An
observational, descriptive, longitudinal
study was performed, with a retrospective
review of demographics, clinical presenta-
tion, laboratory data, treatment, and fol-
low-up. Abdominal ultrasonography was
performed in all patients and was comple-
mented with computed tomography when
necessary. Sonographic features compati-
ble with TI included hypoechogenic mural
thickening of the terminal ileum and hyp-
oechoic enlarged mesenteric lymph nodes
( 6 ). Th e diagnosis of ileal CD was based on
clinical, endoscopic, and histopathological
data. Acid-fast bacilli smear and culture
were performed in ileal biopsy specimens.
An infectious etiology was presumed when
there was clinical, analytical, and imag-
ing remission aft er empirical antibiotic
therapy, or when confi rmed by isolation
of pathogenic microorganisms in stool
cultures.
Th is study assessed 62 patients with a
median age of 38.2 years (18 – 82), with a
slight predominance of females (56.4 % ).
Th e main form of presentation was abdom-
inal pain (93.5 % ) and diarrhea (67.7 % ). All
patients presented with ultrasonographic
features of TI, which were corroborated
by computed tomography in 62.9 % . In this
study, infectious etiology was confi rmed
in 62.9 % ( n = 39) of patients, CD was
diagnosed in 32.2 % ( n = 20), and ileum
cancer in 4.9 % (ileal lymphoma — 2, ade-
nocarcinoma — 1). Fecal pathogens were
identifi ed in 7 patients: Campylobacter — 3,
Yersinia — 2, and Salmonella — 2. No para-
sitic or tuberculosis infection was identifi ed.
On comparing the groups with confi rmed
CD and infectious ileitis, we found in the
fi rst group higher median values of serum
infl ammatory parameters (C-reactive pro-
tein: 9.8 vs. 7.4 mg / dl; leukocyte count:
16.650 vs. 11.170 / μ l), lower hemoglobin
levels (10.45 vs. 13.5 g / dl, t- test, P =0.03),
and a longer inpatient period (10 vs. 5 days).
Patients diagnosed with CD maintain long-
term follow-up in our outpatient clinic.
In the current study, the diagnosis of CD
of the ileum was confi rmed histopatholog-
ically in 32.2 % of patients with imaging of
TI. We highlight that infl ammation of the
terminal ileum is not always CD, and infec-
tious etiology is a common cause (62.9 %
in our study). Th e diff erential diagnosis of
TI found on imaging, although sometimes
diffi cult, is of critical importance to avoid
further unnecessary diagnostic workup
and inappropriate treatment.
CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais,
MD.
Specifi c author contributions: Teresa Pinto
Pais was involved in planning and conduct-
ing the study, collecting and interpret-
ing data, and writing the paper. She has
approved the fi nal draft submitted. S ó nia
Fernandes was involved in planning the
study, interpreting data, and draft ing the
manuscript. She has approved the fi nal draft
submitted. Carlos Fernandes was involved
in collecting and interpreting data. He has
approved the fi nal draft submitted. Iolanda
Ribeiro was involved in collecting and
interpreting data. She has approved the fi nal
draft submitted. Jo ã o Carvalho was involved
in planning the study, interpreting data, and
draft ing the manuscript. He has approved
the fi nal draft submitted.
Financial support: None.
Potential competing interests: None.
REFERENCES 1 . Dilauro S , Crum-Cianfl one NF . Ileitis: when it
is not Crohn’s disease . Curr Gastroenterol Rep 2010 ; 12 : 249 – 58 .
2 . Greaves ML , Pochapin M . Asymptomatic ileitis: past, present, and future . J Clin Gastroenterol 2006 ; 40 : 281 – 5 .
3 . Lee YJ , Yang SK , Byeon JS et al. Analysis of colonoscopic fi ndings in the diff erential diagno-sis between intestinal tuberculosis and Crohn’s disease . Endoscopy 2006 ; 38 : 592 – 7 .
4 . Jeong SH , Lee KJ , Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy . J Gastroenterol Hepatol 2008 ; 23 : 51 – 5 .
5 . Chang HS , Lee D , Kim JC et al. Isolated termi-nal ileal ulcerations in asymptomatic individu-als: natural course and clinical signifi cance . Gastrointest Endosc 2010 ; 72 : 1226 – 32 .
6 . Ledermann HP , B ö rner N , Strunk H et al. Bowel wall thickening on transabdominal sonography . Am J Roentgenol 2000 ; 174 : 107 – 17 .
1 Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho , Vila Nova de Gaia , Portugal . Correspondence: Teresa Pinto Pais, MD , Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho, Rua Concei ç ã o Fernandes , 4434-502 Vila Nova de Gaia , Portugal . E-mail: [email protected]
Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics
Rena Yadlapati , MD 1 , Andrew Gawron , MD 1 , 2
and Rajesh N. Keswani , MD 1
doi:10.1038/ajg.2014.115
To the Editor: Quality metrics for colonos-
copy are increasingly being measured and
reported, as procedure quality correlates
The American Journal of GASTROENTEROLOGY VOLUME 109 | JULY 2014 www.amjgastro.com
1090 Letters to the Editor
with its eff ectiveness in reducing colorec-
tal cancer incidence and mortality ( 1,2 ).
Patient satisfaction ratings (PSRs) are also
publicly reported and may be eventually
tied to reimbursement in clinical practice.
PSRs are additionally being utilized in con-
cert with other measures to determine pro-
vider performance and health-care quality
( 3 – 6 ). However, previous studies have
failed to validate a relationship between
PSRs and surgical procedure quality ( 4 ). As
a result, we sought to investigate whether
patient satisfaction correlates with estab-
lished indicators of colonoscopy quality, an
area that has not been studied previously.
We performed a retrospective review of
PSRs and colonoscopy quality for endo-
scopists at a single-center tertiary care
teaching institution from September 2012
to August 2013. Endoscopists were included
if they were attending gastroenterologists
and performed more than 50 colonoscop-
ies over 1 year. Th is study was approved by
the Institutional Review Board.
All patients undergoing endoscopic
procedures at our institution are asked to
complete an 11-question outpatient vali-
dated survey developed by Press Ganey
Associates (South Bend, IN) assessing
their procedure experience ( 6 ). Th e PSR
is measured by calculating the percent-
age of responses with a score of 5 (rep-
resenting “ very good ” ) on a scale of 1 – 5.
Physician quality indicators for screening
colonoscopies including adenoma detec-
tion rate (ADR), withdrawal time (WT)
in normal screening colonoscopies, and
cecal intubation rate are also measured.
Th e relationship between patient satisfac-
tion and quality indicators was determined
using Spearman ’ s rank-order correlation.
Statistical analyses were performed using
STATA 12.0 (College Station, TX).
During the 1-year period 1,688 patient
satisfaction surveys were collected and 6,761
screening colonoscopies were performed.
Th e mean screening colonoscopy volume
per physician was 687 (229 – 1179) ± 301.
Twenty-one endoscopists (5F:16M) were
included in this study: 48 % were in private
practice and 52 % were in academic practice.
Th ere was no signifi cant diff erence in PSRs
and practice type. Median time in clinical
practice aft er training was 15 years (inter-
quartile range = 22), and did not correlate
with patient satisfaction ( r = − 0.11).
Th e overall mean PSR was 75.6 % (64 –
84 % ) ± 5.5 % . Th e mean ADR, WT, and cecal
intubation rate were 29 % (12 – 51 % ) ± 10.8 % ,
10.5 (3.1 – 19.2) ± 4.5 min, and 98.6 % (96.3 –
100 % ) ± 1.2 % , respectively. Th ere was weak
or no correlation between PSRs and ADR
( r = 0.22), WT ( r = 0.02), and cecal intu-
bation rate ( r = 0.24). We found a strong
positive correlation between ADR and WT
( r = 0.60; Table 1 ).
Th ere was a moderate, statistically sig-
nifi cant, inverse correlation between PSR
and physician sex ( r = − 0.57, P < 0.01).
However, there was no signifi cant diff er-
ence when comparing female with male
physician ADR, WT, or cecal intubation
rate ( Table 2 ). In addition, female endo-
scopists saw a disproportionately greater
number of female patients compared with
male endoscopists (75 % vs. 55 % , P < 0.01).
Th is is the fi rst study to suggest that
patient satisfaction is not related to estab-
lished colonoscopy quality indicators. Our
analyses did, however, reproduce a correla-
tion between widely accepted quality indi-
cators such as ADR and WT ( 7 ). Although
PSRs may refl ect an institution ’ s ability to
provide good service as part of the patient
experience, our study challenges their role
as a measure of colonoscopy quality.
Patient satisfaction is likely infl uenced
by several factors that are unrelated to pro-
cedure quality. For instance, it is possible
that polyp detection and removal results in
longer procedure time and emotional dis-
tress, which could negatively aff ect patient
satisfaction. Th is study also suggests a cor-
relation between PSRs and physician gen-
der. Th ese are interesting areas that require
further investigation.
In conclusion, this analysis demon-
strates that patient satisfaction is not a
reliable metric of colonoscopy quality,
and further work should be carried out
before patient satisfaction is promoted
as a surrogate measure for colonoscopy
quality.
CONFLICT OF INTEREST Guarantor of the article: Rena Yadlapati,
MD.
Specifi c author contributions: Rena
Yadlapati and Andrew Gawron: study concept
and design, acquisition of data, analysis and
interpretation of data, draft ing of manu-
script, approval of fi nal draft submitted; Raj
Keswani: Principal Investigator, study super-
vision, study concept and design, acquisition
of data, analysis and interpretation of data,
draft ing of manuscript, approval of fi nal
draft submitted.
Financial support: None.
Potential competing interests: None.
Table 1 . Colonoscopy variables and their correlation with PSRs
Variable Mean (range) ± s.d. Correlation with PSRs ( r )
ADR 29.2 (11.5 – 51.2) ± 10.7 0.17
WT (min) 10.5 (3.1 – 19.2) ± 4.5 0.88
Cecal intubation ( % ) 98.6 (96.0 – 99.0) ± 1.18 0.26
ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.
Table 2 . Colonoscopy quality indicators and PSRs for male and female endoscopists
Male endoscopists ( n =16) Female endoscopists ( n =5) P value
ADR, mean 29.8 (11.6 – 51.2) ± 11.8 27.6 (20.0 – 37.4) ± 6.9 0.69
WT, mean 10.1 (3.1 – 19.2) ± 4.6 11.8 (7.7 – 19.0) ± 4.3 0.46
Cecal intubation rate, mean 98.7 (96.3 – 99.9) ± 1.3 98.4 (97.9 – 99.3) ± 0.6 0.68
PSR, mean 77 (71 – 84) ± 4.5 70 (64 – 76) ± 4.5 < 0.01
ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time.
© 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY
Letters to the Editor 1091
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Vogelaar I et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths . N Engl J Med 2012 ; 366 : 687 – 96 .
2 . Lieberman DA , Weiss DG , Bond JH et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Aff airs Cooperative Study Group 380 . N Engl J Med 2000 ; 343 : 162 – 8 .
3 . Centers for Medicare & Medicaid Services . Medicare program: hospital inpatient value-based purchasing program . Fed Regist 2011 ; 76 : 2454 – 91 .
4 . Lyu H , Wick EC , Housman M et al. Patient satisfaction as a possible indicator of quality surgical care . JAMA Surg 2013 ; 148 : 362 – 7 .
5 . Pascoe GC . Patient satisfaction in primary health care: a literature review and analysis . Eval Program Plann 1983 ; 6 : 185 – 210 .
6 . Hospital Consumer Assessment of Healthcare Providers and Systems 2013 (Accessed 29 December 2013, at http://www.hcahpsonline.org/home.aspx ) .
7 . Barclay RL , Vicari JJ , Doughty AS et al. Colonoscopic withdrawal times and adenoma
detection during screening colonoscopy . N Engl J Med 2006 ; 355 : 2533 – 41 .
1 Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University , Chicago , Illinois , USA ; 2 Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University , Chicago , Illinois , USA . Correspondence: Rena Yadlapati, MD, Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University , Chicago , Illinois 60611 , USA . E-mails: [email protected] and [email protected]