bluuebunny/crossref_metadata_2025 huggingface dataset:
408 WATS Brushings Are More Sensitive for Detecting Intestinal Metaplasia in Barrett’s Esophagus Than Concurrent Forceps Biopsies: Results From a National Registry
Authors: Cotton Cary , Chaletsky David , Moloney Brian , Malik Zubair , Trindade Arvind , Gordon Stuart , Yachimski Patrick , Khan Abraham , Schnoll-Sussman Felice , Shafa Shervin , Smith Michael S. , Shaheen Nicholas J.
Published: October 2019

INTRODUCTION:

Forceps biopsies (FB) are used to sample the esophageal mucosa for intestinal metaplasia (IM) to diagnose BE, confirm eradication of BE, and detect recurrence after treatment. FB are limited by their focal field of sampling. Wide area transepithelial sample biopsy with three-dimensional computer-assisted analysis (WATS3D, CDx Diagnostics, Suffern, NY) samples a wider area of mucosa, but its sensitivity in routine clinical settings is incompletely understood. Our aim was to determine the sensitivity of WATS compared to FB for IM in patients undergoing surveillance of non-dysplastic BE (NDBE).

METHODS:

The WATS Registry is an ongoing multicenter U.S. study enrolling subjects undergoing WATS as part of usual care at 13 sites. Patients are aged 18 to 80 and are enrolled in one of three categories: screening endoscopy for gastroesophageal reflux symptoms without a history of BE, surveillance endoscopy for already-diagnosed BE without prior endoscopic eradication therapy, or surveillance endoscopy for BE following eradication therapy. We analyzed all endoscopy visits where subjects underwent both WATS and FB for surveillance of prevalent, treatment naïve NDBE with not less than 1 cm of columnar mucosa. Given that all these subjects previously had both endoscopic and histologic evidence of BE, FB or WATS not demonstrating IM was assumed to represent sampling error. We calculated the sensitivity of WATS and FB for IM, manifest by goblet cell metaplasia, with 95% asymptotic confidence limits.

RESULTS:

This analysis included 454 endoscopies of patients with a previous diagnosis of BE, presenting for surveillance and undergoing both FB and WATS. We observed a higher (p = 0.005) overall sensitivity of WATS (63.0% (95% CL 58.6 – 67.4%) than FB (53.7% (95% CL 49.2 – 58.3%)) of diagnosing IM (Figure). In addition to the patients with IM on FB, greater than 1/3 more subjects (36%, 87/244) had IM on WATS. The sensitivity of WATS for IM was similar across demographic groups (Table). Sensitivity of both FB and WATS increased with the length of BE being sampled.

CONCLUSION:

WATS has higher sensitivity for detecting IM compared to concurrent FB in patients with a previous history of BE. The addition of WATS to FB in these patients results in an overall additional 36% detection of IM. Given the included patients had previously demonstrated IM in visible segments of columnar epithelium in the esophagus, the incremental yield of WATS likely represents sampling error by FB.
409 Risk Factors of Readmission to Hospital for Eosinophilic Esophagitis in United States: A National Readmission Database Analysis
Authors: Eke Ransome , Leonov Andrey
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EoE), once considered a rare entity, is becoming a commonly encountered gastroenterological condition. In addition to increased clinical recognition of EoE, rising EoE related hospitalization in the United States have been reported. Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database, we aimed to identify factors associated with readmissions in population with EoE.

METHODS:

We performed a retrospective cohort study using 2012-2014 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases-9th Revision, Clinical Modification (ICD-9-CM) codes, we identified patients with discharge diagnoses of EoE (530.13) and ascertained other related comorbidities (asthma (493.XX) and esophageal reflux (530.81)) during index admission. We evaluated patients with EoE related hospitalization, from January 2012 to November 2014, and analyzed readmissions over 90 days after discharge. Logistic regression analyses were used to examine the factors associated with risk of 90-day readmission.

RESULTS:

Among 6,877 hospitalizations of EoE patients, 407 (3%) were readmitted within 90 days of the index hospitalization resulting in average annual excess charge of roughly $4 million. The common reasons for readmission were foreign body in the esophagus (6%) and dysphagia (7%). Ninety-eight of readmitted EoE cases were ages 19 years or above, and common comorbidities associated with readmissions were GERD (25%) and asthma (26%). In multivariable analysis of patients with EoE, female compared to males (OR 1.94, 95%CI: 1.16–3.24) and having co-morbid asthma compared to no-asthma comorbidity (OR 1.39, 95%CI: 1.25–3.14) were associated with a significant increase in odds of readmission. There was no significant difference in risk of readmission by the type of insurance.

CONCLUSION:

In a national sample of inpatients with EoE, the risk of 90-day readmission was significantly associated with female and having asthma co-morbidity. These factors may represent targets for interventions to prevent frequent hospital readmission in this population.
410 Barrett’s Esophagus and Obstructive Sleep Apnea: Is There a Link?
Authors: Radadiya Dhruvil K. , Devani Kalpit H. , Charilaou Paris , Patel Pranav D. , Young Mark , Reddy Chakradhar
Published: October 2019

INTRODUCTION:

Barrett’s esophagus (BE) is a precursor lesion for esophageal adenocarcinoma. While some studies suggest relationship between obstructive sleep apnea (OSA) and GERD. Studies linking BE to obstructive sleep apnea (OSA) remains limited. Here, we hypothesized that OSA is independently associated with presence of Barrett’s esophagus.

METHODS:

We used the Nationwide Inpatient Sample (NIS) database from the year 2016 for this study. We identified patient with obstructive sleep apnea and Barrett’s esophagus using ICD-10-CM codes. Patients less than 18 years old were excluded from the study. Clinical factors associated with Barrett’s esophagus (age >50, white race, GERD, male gender, hiatal hernia, obesity and smoking) were also extracted from the database. We performed multivariate logistic regression to control for confounding factors associated with BE. All statistical analyses were performed using SAS 9.4.

RESULTS:

Out of 6,028,636 patients, 6.4% patients had OSA in year 2016. Prevalence of Barrett’s esophagus in OSA was 0.75%. We divided patients in two groups based on diagnosis of OSA. The mean age of the OSA population was 63.2 year, 40.8% were male, and 72% were white. Proportion of patients with age more than 50 year was high in OSA group (84.7%). Smoking and hiatal hernia were equally distributed among two groups. OSA group had higher prevalence of GERD, obesity and BE as shown in Table 1. Age more than 50, male gender, and white race were associated with almost 2-fold increase likelihood of having BE as shown in table 2. Patients with hiatal hernia are 7 times more likely to have BE (OR: 7.4, P < 0.0001). For unclear reason, obesity was associated with marginally lower risk of BE (OR: 0.935, P < 0.0001). Patients with OSA had 30% more chance of having BE compared to patient without OSA (OR: 1.293, 95% CI: 1.270 – 1.317, P < 0.0001). AUC (Area Under Curve) for this model was 0.81.

CONCLUSION:

OSA is an independently associated with higher likelihood of Barrett’s esophagus even after adjusting for potential confounders. Further studies can be pursued to reinforce the finding so that OSA can be included as a factor for screening for BE.
414 The Association Between Cigarette Smoking and Gastroesophageal Reflux Disease in Japan: Analysis of Symptoms and Endoscopic Findings
Authors: Ihara Sozaburo , Sakitani Kosuke , Fujiwara Hiroaki
Published: October 2019

INTRODUCTION:

Cigarette smoking is regarded as a weak or moderate risk factor of gastroesophageal reflux disease (GERD), and smoking cessation may reduce GERD symptoms. However, the evidence for these associations is limited. This study aimed to investigate the effects of cigarette smoking or smoking cessation on the development of GERD by using endoscopic findings and the Gastrointestinal Symptom Rating Scale (GSRS).

METHODS:

The subjects were 848 patients who received upper endoscopy and answered the GSRS questionnaire as health checkup at our hospital in Japan. The patients were divided into three groups; non-smoking, smoking-cessation, and current-smoking group (322, 371 and 155 patients, respectively). Endoscopic findings of GERD were graded by the Los Angeles classification, and grade B or more were defined as severe GERD. The GSRS questionnaire is an interview-based seven-graded rating scale including the questions on heart burn and acid regurgitation. The prevalence of patients with positive GSRS scores (i.e. 2 or more) was compared between three groups. Data were analyzed statistically using the Kruskal-Wallis, Mann-Whitney U, or chi-square test.

RESULTS:

The overall prevalence of endoscopic GERD and positive GSRS scores on heart burn and acid regurgitation was 19.2, 14.5, and 19.7%, respectively. The prevalence of patients with severe endoscopic GERD in smoking group was significantly higher than that in non-smoking group (OR: 4.64; 95% CI: 1.47-14.67; P = 0.007). In contrast, the prevalence of patients with positive GSRS scores on heart burn in smoking group was significantly lower than that in non-smoking group (OR: 0.46; 95% CI: 0.26-0.80; P = 0.006). As for smoking cessation, there was no significant difference in the prevalence of patients with severe endoscopic GERD between smoking-cessation and current-smoking group (OR: 0.37; 95% CI: 0.11-1.18; P = 0.149). Also, there was no significant difference in positive GSRS scores between smoking-cessation and current-smoking group (heart burn; P = 0.077, and acid regurgitation; P = 0.871).

CONCLUSION:

Cigarette smoking increases risk of developing endoscopic GERD severity, while not developing GERD symptoms. Upper endoscopy may be useful for Japanese using cigarette even if they have no GERD symptoms. Although smoking cessation is not associated with improvement of endoscopic GERD severity in this study, prospective studies should be performed to evaluate the effects of smoking cessation on GERD.
415 External Validation of the Progression in Barrett’s Score in a Prospective Multicenter BE Cohort
Authors: Codipilly Don C. , Kennedy Kevin , Plevak Matthew , Dierkhising Ross , Lansing Ramona , Johnson Michele , Parasa Sravanthi , Sharma Prateek , Iyer Prasad
Published: October 2019

INTRODUCTION:

Endoscopic surveillance guidelines in Barrett’s esophagus (BE) to detect progression to high grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) are based solely on dysplasia grade. Given low rates of progression, identification of predictors (and scores) of progression may help to focus surveillance or intervention in those at higher risk. We aimed to assess predictors of progression and externally validate the Progression in Barrett’s (PIB) score in an independent multicenter prospective BE and EAC cohort.

METHODS:

The EA and Barrett’s esophagus (EABE) registry is a prospective cohort of patients recruited from three medical centers. Progressors were defined as those with the development of HGD or EAC more than 12 months after initial diagnosis. Demographic and clinical variables were abstracted. The annual incidence rate and predictors of progression were assessed using univariate and multivariable Cox proportional hazards analysis. The ability of the PIB score (incorporating weighted scores for male gender, smoking (ever versus never), BE length and confirmed LGD) to risk stratify the cohort into low (0-10 points), intermediate (11-20 points) and high risk (> 20 points) groups was assessed.

RESULTS:

429 patients were included. 84% were men, with a mean (SD) age of 61.5 (9.9) years. 65% were ever smokers and most (76.7%), had NDBE at diagnosis. Mean (SD) maximal BE segment length was 5.9 (3.2) cm. Eighty-two patients (19.1%) progressed to HGD (n = 65) or EAC (n = 17) over a median (IQR) follow up of 7.5 (3.7, 12.5) years. Annual incidence rates of progression to EAC and EAC/HGD were 0.5% and 2.0% respectively. Univariate and multivariable predictors of progression are displayed in Table 1. The PIB score divided patients into three groups (Table 2) with progressively increasing rates of progression. The risk in the high risk group was three fold higher than the low risk group (P = 0.024). The risk in the intermediate group was twofold higher but not statistically significantly higher (P = 0.13). The PIB score had a c-statistic score of 0.76 in the original cohort. In this cohort the c-statistic value was lower at 0.64, suggesting moderate performance.

CONCLUSION:

Male sex and BE length predicted progression in this independent multicenter cohort. The PIB score was also able to risk-stratify patients in this validation cohort with the high risk cohort being 3x more likely to progress compared to the low risk cohort.
420 Assessing the Prevalence of Gastroesophageal Reflux in Gastroparesis: Putting the G Back in GERD
Authors: Bensinger Andrew , Clayton Steven
Published: October 2019

INTRODUCTION:

Patients with gastroparesis experience a wide range of symptoms from early satiety to frequent emesis and severe abdominal pain. However, few studies have evaluated concomitant underlying esophageal pathology or frequency of gastroesophageal reflux episodes in patients diagnosed with gastroparesis. Prolonged gastric emptying may lead to increased intra-gastric pressure and volume of gastric contents that may result in increased frequency of distal esophageal reflux events. The aim of this study was to assess for significant differences in total duration of distal esophagus acid exposure and number of gastroesophageal reflux events as detected by impedance pH testing between gastroparesis and control cohorts.

METHODS:

A retrospective analysis of 84 patient charts who underwent both 4-hour gastric emptying studies and 24-hour ambulatory pH testing was performed. Patients with gastroparesis, as documented by abnormal 4-hour gastric emptying studies, were compared with age and gender matched controls. Patients taking PPI during testing were excluded from the study. Percent of total distal esophageal time pH < 4 (nl < 4%) and impedance values (nl< 53) were compared between the gastroparesis and control groups. Continuous variables were analyzed using independent 2-tailed t-test, while categorical values were evaluated using a chi squared analysis.

RESULTS:

Forty-two gastroparesis patients (9 men and 33 women, median age 46 years old, range 19-81 years old) underwent 24-hour ambulatory pH monitoring while off of PPI. When comparing total mean impedance events during pH testing, the gastroparesis cohort experienced significantly more episodes of distal esophageal reflux events, 61.27 ± 11.34 vs 45.81 ± 7.72 (P = 0.028), respectively. Mean percent total distal time for esophageal pH < 4.0 was higher for the gastroparesis group when compared to controls, 4.79 ± 1.48% vs 3.31 ± 1.15% (P = 0.125), respectively.

CONCLUSION:

This pilot study demonstrates that patients meeting criteria for gastroparesis by gastric emptying study have significantly higher number of reflux episodes than those with normal gastric emptying. Trends toward a higher percentage of total distal esophageal acidity exposure time and a higher proportion of the gastroparesis group meeting diagnostic criteria for GERD were also seen. In the future, expanding sample sizes to better investigate these preliminary trends will be beneficial to better understand the association of GERD and gastroparesis.
426 Prevalence of Gastroparesis in Achalasia: A U.S. Population-Based Study
Authors: Lal Pooja , Saleh Mohannad Abou , Mansoor Emad , Cooper Gregory S.
Published: October 2019

INTRODUCTION:

Patients with achalasia often present with symptoms including bloating, early satiety and abdominal discomfort suggesting there might be an underlying concomitant gastric motility dysfunction. Moreover, treatments such as botulinum toxin injection are efficacious in both achalasia and gastroparesis. There are a lack of studies in the literature examining the association between achalasia and gastroparesis. We hypothesized that patients with achalasia would have a higher prevalence of gastric motility dysfunction, contributing, in part to the upper GI symptoms. The aim of this study was to compare the prevalence of gastroparesis in achalasia to the general population using a large population based commercial database.

METHODS:

The database used was Explorys Inc. (Cleveland, OH, USA) which contains electronic health records from 26 major integrated US healthcare systems. We identified patients with achalasia who were diagnosed with gastroparesis in the last 5 years based on Systemized Nomenclature of Medicine – Clinical Terms and compared it to patients with gastroparesis in the general population without achalasia.

RESULTS:

Of the 36,825,640 active patients within the last 5 years in the database, we identified 19,630 (0.05%) patients who had a diagnosis of achalasia and 104,140 (0.28%) patients with gastroparesis out of which only 600 (0.57%) were related to diabetes mellitus. A total of 990 cases of gastroparesis were observed in patients with achalasia, and 103,150 cases of gastroparesis in patients without achalasia. The overall Relative Risk (RR) of developing gastroparesis in patients with achalasia was 17.96 (95% CI 16.90 to 19.10; P < 0.0001) compared to general population without achalasia. Patients aged 18-64 (RR 20.50, 95% CI 18.94 to 22.39, P < 0.0001) and those aged ≥ 65 (RR 10.24, 95% CI 9.38 to 11.19, P < 0.0001) both had an increased risk of developing gastroparesis. Gender-based and race-based relative risk are shown in Table 1.

CONCLUSION:

Gastroparesis has a higher prevalence among people with achalasia compared to general population, with a relative risk of nearly 18. This increase in risk is seen across all age-groups. The findings of this analysis prove that there might be an underlying pathophysiological relationship between the esophageal and gastric motility disorders.
431 Late Stage Diagnosis of Esophageal Adenocarcinoma in Veterans: Could Screening Be Made More Effective?
Authors: Sharma Anamay , Blum Andrew , Chak Amitabh , Faulx Ashley
Published: October 2019

INTRODUCTION:

The prognosis of EAC is very poor largely due to presentation at late stage, ineffective systemic therapy and high morbidity and mortality associated with surgical treatment. The detection and surveillance of Barrett’s Esophagus (BE) is the only strategy for prevention and early detection of EAC. ACG guidelines recommend endoscopic screening of men with chronic GERD and risk factors for developing Barrett’s Esophagus. A recent study from the Michael E. DeBakey VA Medical Center demonstrated that only ∼25% of patient diagnosed with EAC had had prior upper endoscopy. This study aimed to determine what proportion of veterans present with late stage EAC and evaluate whether there was an opportunity to perform endoscopic screening prior to diagnosis.

METHODS:

This was a retrospective chart review, done at the Louis Stokes Cleveland VA Medical Center. Patients with diagnosis of esophageal adenocarcinoma from 2007 to 2017 were included. Data were gathered for age, gender, race, history and duration of GERD, prior upper endoscopy, prior Barrett’s diagnosis, stage at diagnosis, smoking behavior, family history etc. A simple descriptive analysis of all variables were performed.

RESULTS:

A total of 113 patients met inclusion criteria. Of these, 111 (98.2%) were men, and 107 (94.7%) were Caucasians. Total 52 (46%) patients presented as stage 4. Of these 52 patients, 20 had history of chronic GERD and 17 had PCP visit at least 1 year before diagnosis. Total fifty three (46%) patients had a documented history of chronic GERD. 43 of 53 patients (81%) had at least one visit to PCP office within 1 year of cancer diagnosis. Based on ACG guidelines 42 (97.6 %) of these 43 patients met criteria for screening for Barrett’s Esophagus, however only 16 of these 42 (38%) had prior upper endoscopy. 14 of these were diagnosed with Barrett’s esophagus.

CONCLUSION:

These results suggest that majority of patients with GERD symptoms had regular visit to outpatient clinic (81%), and there was missed opportunity to screen them. Better awareness among primary care physicians is needed to increase screening rate for Barrett’s Esophagus
433 Incidence, Admission Rates, and Economic Burden of Adult Emergency Visits for Esophageal Cancer: Data From the National Emergency Department Sample, 2006 to 2014
Authors: Singh Dhruv P. , Kandlakunta Harika , Garg Sushil
Published: October 2019

INTRODUCTION:

Esophageal cancer accounts for 1% of cancers diagnosed in the United States and the seventh most common cause of cancer-related mortality among men in the United States, with a 5-year survival rate of 19%. With an estimated $1.5 billion in direct medical costs in 2010, we look at ED utilization by this group of patients and analyze the economic burden and trends in ED visits and inpatient admissions over a 9-year period

METHODS:

The Nationwide Emergency Department Sample (NEDS; 2006-2014) was interrogated to identify patients with a primary diagnosis of esophageal cancer (ICD-9 CM code). The yearly incidence of ED visits, rates of hospitalization, length of stay (LOS), and total charges associated with ED or subsequent inpatient stays were assessed. As secondary analysis, survey logistic regression model was used to determine predictors of hospitalization.

RESULTS:

A total of 46,431 esophageal cancer-related ED visits were identified during this time period. Overall, early readmission visits increased overall from 6,295 in 2006 to a peak of 6,837 in 2014. The mean ED charges per visit, adjusted to inflation increased significantly from $1,401 in 2006 to $3,168 in 2014, while the mean total charges incurred by patients who were admitted to the hospital also increased from $41,009 in 2006 to $61,809 in 2014. Hospitalization rates decreased from 83.5% in 2006 to 78.8% in 2014 but in-hospital deaths decreased from 11.4% in 2006 to 8.7% in 2014. The average LOS in the hospitals decreased from 7.8 to 7.2 days.

CONCLUSION:

Increasing ED visits and charges associated with esophageal cancer are concerning. While hospitalization rates are slightly decreased during this 9-year period, there is an alarming uptrend in mortality rates which needs to be explored further. The results of our study suggest that further exploring factors that are associated with the recent upsurge in mortality may lead to the development of interventions that will significantly reduce in-hospital deaths.
439 Risk of Air Leak and Mucosal Injury in Esophageal POEM After Prior Myotomy
Authors: Samo Salih , Jain Anand , Hamo Falak , Abdelfatah Mohamed Magdy , Xia Liang , Chen Huimin , Patel Vaishali , Mekaroonkamol Parit , Keilin Steven , Cai Qiang
Published: October 2019

INTRODUCTION:

Peroral endoscopic myotomy (POEM) is deemed to be more challenging with more periprocedural adverse events. We aimed to assess the risk of air leak and mucosal injury in POEM after prior myotomy (Heller’s myotomy [HM] or POEM), the Redo POEM, in addition to extubation time when air leak occurs.

METHODS:

A retrospective study comparing Redo POEM to an index POEM at a tertiary center from March 2016 to August 2018. Table 1 summarizes the data collected. Air leak was defined by subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and/or pneumothorax documented by physical exam and/or imaging. Difficult procedures were determined by endoscopist impression as challenging or based on difficulty creating submucosal tunnel and/or difficulty performing myotomy.

RESULTS:

We identified 21 cases of Redo (1st myotomy: HM in 8/21, POEM in 13/21) and 56 cases of index POEM. One case had two prior HMs and two cases had HM and POEM each before Redo POEM. The results are summarized in Table 1. The Redo group was younger with more difficult procedures encountered, shorter myotomy length (due to difficulty with myotomy) and longer procedure time. There were more mucosal injuries with more clips used to close them in the Redo group. Short myotomy (≤5 cm) was performed in 5 cases in the Redo group (23.8%) and 5 cases in the index POEM (8.9%). There was a trend toward more air leak in the Redo group, but it was not statistically significant. Air leak was seen in 14/77 (18.2%) cases in the study. Extubation time was longer in cases with air leak (Table 2). Postprocedural symptoms did not predict air leak. Procedure difficulty did not predict air leak or mucosal injury. No intervention was required for air decompression and there was no ICU admission pertinent to air leak or mucosal injury in either group.

CONCLUSION:

Redo POEM appears to be more challenging, takes longer time to perform with a shorter than intended myotomy. Mucosal injuries are more common and more clips are used to close them. Air leak tends to be higher in Redo POEM, but not statistically significant. The incidence of air leak was likely underestimated as imaging was not routinely obtained for all procedures. Air leak is associated with a slight delay in postprocedural extubation time, but it does not appear to affect the overall procedural outcomes or prolong hospitalization. Postprocedural symptoms and procedure difficulty did not predict air leak or mucosal injury.
448 Wide Area Transepithelial Sampling (WATS) Augments Detection of Barrett’s Esophagus and Associated Dysplasia in Patients With a Hiatal Hernia
Authors: Smith Michael S. , Odze Robert
Published: October 2019

INTRODUCTION:

Detection of BE and associated dysplasia is important prior to referral for endoscopic surveillance or treatment. Use of WATS with computer-assisted analysis, as an adjunct to forceps biopsy (FB), has been shown to markedly improve detection of both BE and dysplasia in both screening and surveillance cohorts (CDx Diagnostics, Suffern NY). Our aim was to assess the effect of a hiatal hernia (HH), a condition that leads to difficulty in performing routine forceps biopsies, on the utility of WATS in detection of BE and dysplasia.

METHODS:

Patients enrolled in IRB-approved trials where both FB and WATS were performed in the same endoscopy were eligible for inclusion. Cases were excluded if prior endoscopic ablation was documented. Data, including length of salmon-colored mucosa (SCM), HH size, FB and WATS results were aggregated and de-identified prior to analysis.

RESULTS:

A total of 4677 patients met study criteria (Table 1). For the entire cohort, the adjunctive yield for WATS in addition to FB was 111% for detection of any BE as well as associated dysplasia. Additional BE detection was less in the presence of a clinically significant hiatal hernia (HH) measuring at least 2 cm in axial length (116% vs 79% for any BE, P < 0.0001). However, augmented dysplasia detection remained constant at 111%. There was no significant change in detection of additional BE as hernia size increased in length (87% for HH< 2 cm, 81% for HH 2-4 cm, 72% for HH >4 cm). Of note, dysplasia detection rates increased with the length of SCM regardless of HH size (80% for < 1 cm, 120% for 1-3 cm, and 133% for 3+ cm), though there were insufficient dysplastic cases to reach statistical significance. Upstaging of non-dysplastic to dysplastic BE occurred when WATS was used regardless of HH size, with significantly higher rates for BE segments at least 3 cm in length (2% vs 14%, P = 0.0012). Similarly, the rate at which NDBE was upstaged to dysplastic BE by WATS was significantly higher when a HH was 2 cm or greater in length (2.17% vs 9.47%, P = 0.013).

CONCLUSION:

WATS improves the diagnostic yield of both BE and associated dysplasia above that achieved with FB, regardless of the presence or absence of a HH. Sampling the distal esophagus with FB above a HH can be technically challenging. WATS may provide the endoscopist with an easier and more effective means of confirming a BE diagnosis and identifying associated dysplasia.
451 Lower Basal Esophagogastric Junction Pressures Associated With Regurgitation Severity
Authors: Lalehzari Mona , Chaudhuri Subhajyoti , Gaeta Marina , Nguyen Mytien , Ryabtsev Roman , Masoud Amir , Sanchez Mayra
Published: October 2019

INTRODUCTION:

It is thought that regurgitation is brought on by changes in esophageal pressure ultimately causing a transient relaxation in the lower esophageal sphincter (LES) with resultant regurgitation. However, it is unknown if the severity of regurgitation symptoms experienced by a patient are related to the basal LES pressure. Our hypothesis is that patients with more severe regurgitation symptoms have lower basal LES pressures.

METHODS:

A retrospective chart review was completed on all patients referred to our tertiary care hospital for esophageal manometry testing with impedance in 2016. Basal LES pressure (as measured on manometry), regurgitation severity (as reported on pre-manometry patient questionnaire), age, and sex were recorded for each patient. Only patients who reported both regurgitation symptoms and specified severity were included in the final analyses. Mean LES pressures were compared between regurgitation severities and P-values were calculated for all pairwise comparisons.

RESULTS:

Of the 354 patients referred for manometry, 167 patients (41 males, mean age 54.6; 126 females, mean age 55.6) endorsed regurgitation. Of those 167 patients, 62 reported their symptoms as “mild”, 61 as “moderate”, 29 as “severe”, and 15 as “very severe”. The average LES pressure was 33.22 mmHg for those with mild regurgitation, 27.98 for moderate, 23.94 for severe, and 19.02 for very severe (P = 0.03). There was also a statistically significant difference in LES pressures between mild and severe regurgitation (P=0.03) and mild and very severe regurgitation (P = 0.01).

CONCLUSION:

Overall, it is known that transient relaxations in LES pressure lead to regurgitation. However, we aimed to assess if there is a difference in basal LES pressures amongst patients who experience regurgitation symptoms, as perhaps a lower basal pressure makes a patient more prone to experiencing more severe regurgitation. There was a statistically significant difference in basal LES pressures amongst patients with varying severities of regurgitation. Future studies should look at pH testing to note if there is an actual increase in proximal acid exposure in patients with lower basal LES pressures and more severe regurgitation.
455 Esophageal Granular Cell Tumors: A Retrospective Institutional Analysis
Authors: Baba Tilak R. , Woo Stephanie , Shafa Shervin , Rastogi Pawan
Published: October 2019

INTRODUCTION:

Granular Cell Tumor (GCT) is generally a benign neoplasm derived from Schwann cells. Less than ten percent of GCTs are found in the gastrointestinal (GI) tract and most common site in the GI tract has been reported to be the esophagus. The current existing literature is limited. Given the rarity of these lesions, the management of GCTs remain a clinical challenge for gastroenterologists. Here we present a case series of thirteen esophageal GCTs and their characteristics, diagnosis and management.

METHODS:

We conducted a retrospective review of all cases of pathologically confirmed GCTs from 2010 to 2018 at our institution from our endoscopic pathology database. Data were collected regarding demographics, endoscopic, endosonographic appearance and presence of any malignant transformation.

RESULTS:

Thirteen total patients were identified. Mean age was 43.6 years. Six patients were females. All esophageal lesions were noted to be in the mid-distal esophagus. Majority of the lesions were subcentimeter. Mean size of the lesions was 8.2 mm. Most common endoscopic features were nodularity (11/13 cases) and white-yellow appearance (8/13). Endoscopic ultrasound (EUS) was conducted in 11/13 cases and the lesions appeared hypoechoic in the majority of cases (6/11). Extension of the lesion was limited to the submucosa in all except one case. Endoscopic mucosal resection (EMR) was performed in 8/13 cases. Pathologic diagnosis of GCT was confirmed using immunohistochemical stain of S100 in 8/13 cases. None of the cases showed any evidence of malignancy from the initial endoscopic resection or biopsies.

CONCLUSION:

Our institutional review of esophageal cases of GCTs not only highlights the rarity of GCTs, but provides endoscopic and endosonographic features of esophageal GCT. Based on our cohort of patients, GCTs most commonly present in mid-distal esophagus with a white-yellowish hue. Patients are generally asymptomatic. EUS findings suggest lesions are hypoechoic and arise from the submucosal layer. Given this location, lesions can be removed in entirety through EMR, which will also allow for greater depth of resection. Overall, mucosectomy may serve as an adequate modality for removal of these apparent benign lesions. Our preliminary finding delineates the success of en bloc resectability of esophageal GCTs less than 2 cm in size. Additional studies would be needed to better establish a more definitive management algorithm of esophageal GCTs and the role of endoscopic mucosal resection.
456 Impact of Endoscopic Surveillance on Detection of Dysplasia Progression in Patients With Barrett's Esophagus Who Have Undergone Complete Eradication of Intestinal Metaplasia
Authors: Um Phoebe S. , Chan Megan Q. , Walker Jon P. , Perry Kyle A.
Published: October 2019

INTRODUCTION:

Barrett's esophagus (BE) affects up to 15% of patients with gastroesophageal reflux disease and poses high risk of progression to esophageal adenocarcinoma (EAC). While radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) are effective treatments for dysplastic BE, risk of recurrence remains even after complete eradication of intestinal metaplasia (CEIM). Currently, endoscopic surveillance intervals after RFA ± EMR are informed only by expert opinion and weak evidence. It is unclear if current guidelines are cost-effective or suitable for all patients. The purpose of this study is to assess for variation in surveillance intervals and rates of recurrence in BE patients with high grade dysplasia (HGD).

METHODS:

A retrospective review of medical records was performed for 70 BE patients who underwent RFA ± EMR for biopsy-proven HGD between January 1, 2010 until November 30, 2018 and received at least 1 surveillance endoscopy with biopsies at 1 year after completion of treatment. These patients were analyzed for adherence to the ACG guidelines of an endoscopy every 3 months for the first year after treatment and for recurrence of dysplasia or development of EAC.

RESULTS:

At 1 year post treatment completion, CEIM was achieved in 48.6% of patients and non-dysplastic BE was achieved in 32.9% of patients. The average time between the first 4 surveillance intervals was 5.5 months. 14 of 70 patients were adherent to ACG guidelines, and 56 received endoscopies less frequently than recommended. Of the 14 patients who were adherent, 6 developed recurrent dysplasia (1 low grade dysplasia (LGD), 4 HGD) and 1 developed T1b carcinoma at one year. Of the 56 patients who received surveillance endoscopies less frequently than recommended, 7 developed recurrent dysplasia (4 LGD, 3 HGD) at one year.

CONCLUSION::

Adhering to ACG surveillance guidelines following RFA±EMR treatment for HGD is difficult and requires close attention to the scheduling of these BE patients. Although our sample size is small, our study showed that the recurrence of dysplasia was not significantly reduced in individuals that were adherent to the ACG guidelines when compared to those that received surveillance less frequently than recommended. Further studies are needed to inform the development of evidence-based guidelines that identify recurrence or progression of dysplastic BE early, while minimizing the costs of over-surveillance.
461 Obstructive Sleep Apnea Is Associated With an Increased Risk of Barrett's Esophagus
Authors: Hadi Yousaf , Naqvi Syeda Fatima , Khan Adnan Aman , Kupec Justin T.
Published: October 2019

INTRODUCTION:

Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index (BMI) and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established.

METHODS:

Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy (EGD) at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups based on the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables.

RESULTS:

1091 patients met inclusion criteria. 60.9% were female, and mean age of participants was 53.5 years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with Barrett's esophagus (P values < 0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, BMI, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of Barrett's esophagus when compared with those without OSA [P < 0.001, Odds Ratio 3.26 (1.72-6.85)]. The risk increased with increasing severity of OSA, categorized in apnea-hyponea index increments of 10. In a separate multivariable regression model where OSA was graded in AHI increments of 10, an increased risk for Barrett's esophagus with every 10 point increase in AHI was found (OR 1.10, 95% CI: 1.02 – 1.19). BMI, evaluated in increments of 5, was not associated with BE. The association of OSA with BE remained unchanged in a separate model incorporating a binary variable with BMI of greater than 30 used as a surrogate for central adiposity.

CONCLUSION:

OSA is associated with Barrett's esophagus, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for Barrett's esophagus due to its potential for causing esophageal cancer.
464 The Burden of Chronic Gastrointestinal Diseases Among the Uninsured: A Free Clinic Study
Authors: Song Ethan , Aponte Alexandra , Swanson Justin , Patel Artish , Shah Nirav , Segarra Daniel , MacDonald Madeline , Mirza Abu-Sayeef
Published: October 2019

INTRODUCTION:

Uninsured and under-insured patients with high comorbidity burden are associated with high costs and high needs. GI diseases make up a significant portion of comorbidity burden and annual health expenditures. There is limited data on GI illnesses among the uninsured. The objective of this study is to do a preliminary evaluation of the burden of chronic GI illness in the uninsured community of Tampa Bay, Florida.

METHODS:

A retrospective query of an IRB approved database of 5076 patients seen across nine free clinics in the Tampa Bay area in 2017 revealed 760 patients with GI illness. Demographics, substance abuse, prevalence of GI illnesses including GERD, metabolic syndrome, irritable bowel syndrome, inflammatory bowel disease, ulcers, hemorrhoids, hepatitis, chronic liver disease, gallstones, and pancreatitis, were analyzed. Statistical analysis was performed with R 3.5.3.

RESULTS:

GI patients had a preponderance to be female (62.5%) and Hispanic (57.0%). GERD was the most prevalent condition (13.5%) followed by chronic liver disease (3.6%), GI ulcer (3.2%), hemorrhoids (2.2%), hepatitis C (1.6%), metabolic syndrome (1.5%), gallstones (1.2%), inflammatory bowel syndrome (1.0%), pancreatitis (0.6%), hepatitis B (0.4%), Crohn's disease (0.1%), and hepatitis A (0.1%). Most patients with GI illness have had a history of smoking (34.4% vs. 21.9%, P < .001) or alcohol consumption (30.2% vs. 24.1%, P < .001). Patients with chronic GI illness had more average visits per year than those who did not have chronic GI illness (3.7 vs 2.2 visits per year, P < 0.001). Compared to patients without GI illness, patients with GI illness were older (Mean: 48.7 vs. 39.8 years, SD: 13.1 vs. 17.1, P < .001).

CONCLUSION:

Patients with chronic GI illness tended have more clinic visits, were more likely to have a comorbid history of smoking and alcohol consumption, and were older than those without GI illness. More education and preventative resources should be directed toward the most common GI illnesses such as GERD, chronic liver disease, and ulcers. Further evaluation of the low-income community is required to identify community level solutions and management strategies for chronic GI illness.
467 Human Milk Oligosaccharides Improve All the Central Symptoms of Irritable Bowel Syndrome: A Multi-Center, Open Label Trial
Authors: Palsson Olafur S. , Peery Anne , Seitzberg Dorthe , Amundsen Ingvild D. , McConnell Bruce , Simrén Magnus
Published: October 2019

INTRODUCTION:

Altered gut microbiota is increasingly seen as a potential factor in irritable bowel syndrome (IBS) pathophysiology. Human milk oligosaccharides (HMOs) have been shown in healthy adults to increase the abundance of bifidobacteria, which are reported to be depleted in IBS. HMOs may also have beneficial impact on gut motility and visceral pain. We conducted a multi-center, open label trial in patients with IBS (Rome IV criteria plus physician diagnosis) to assess the potential for HMOs to support normal bowel habits and improve other bowel symptoms of IBS.

METHODS:

Subjects were recruited from 17 sites across the United States. The subjects took 5 grams of the HMOs 2'fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) in a 4:1 mix daily by mouth for 12 weeks. Bowel habits, IBS symptoms and quality of life were assessed at baseline and every 4 weeks during the intervention. Results were analyzed with Intention-to-Treat (ITT) methodology (last observation carried forward for non-completers), using repeated measures Analysis of Variance.

RESULTS:

A total of 317 subjects (70.7% females; mean age 44.0 years, range 18-93 years) received the study product; 136 with constipation predominant, 85 with diarrhea predominant, 95 with mixed, and 1 with unspecified IBS. The full 12-week intervention was completed by 245 subjects. In the ITT analyses, the subjects showed a significant reduction from baseline to 12 weeks in total percentage of abnormal bowel movements (Bristol Stool Form Scale types 1, 2, 6, or 7), overall IBS Symptom Severity Score, abdominal pain severity and bloating severity, as well as improvement in health-related quality of life (see Table 1 and Figures 1 and 2). Most of the symptom improvement occurred in the first 4 weeks of intervention. Younger age was predictive of greater improvement in stool consistency and abdominal pain severity. The study product was well tolerated by most patients. The only common side effects were mild GI symptoms such as abdominal discomfort, distension and flatulence.

CONCLUSION:

Our findings suggest that oral supplementation with 2'FL and LNnT can provide nutritional support that significantly reduces abnormal stool consistency, abdominal pain and bloating and improves health-related quality of life in IBS sufferers of all subtypes. However, the results from this open label trial need to be followed up by a randomized controlled trial.
472 Impact of Plecanatide on Symptoms and Quality of Life for Patients With Chronic Idiopathic Constipation: Analysis of PAC-SYM and PAC-QOL From Two Phase III Clinical Trials
Authors: Brenner Darren M. , Franklin Howard , Sayuk Gregory S.
Published: October 2019

INTRODUCTION:

Plecanatide, a 16-amino acid analog of human uroguanylin, activates guanylate cyclase-C receptors in the small intestine in a pH-sensitive manner to induce fluid secretion and peristalsis. This analysis looks at whether plecanatide improved global symptoms and health-related quality of life (HRQOL) in patients with chronic idiopathic constipation (CIC) from 2 large-scale, randomized, double-blind, placebo-controlled, phase 3 studies.

METHODS:

Patients (N = 2683) who met modified Rome III criteria were randomized to placebo, plecanatide 3mg, or 6mg QD for 12 weeks and included in the phase 3 intention-to-treat populations. Baseline characteristics were comparable between groups and across studies. CIC symptoms and HRQOL were evaluated using the Patient Assessment of Constipation–Symptoms (PAC-SYM) and Patient Assessment of Constipation–Quality of Life (PAC-QOL) scales, respectively. The PAC-SYM measured patients' constipation symptom experience and severity over time, including abdominal, rectal, and stool symptoms of constipation. The PAC-QOL evaluated patients' HRQOL perceptions with constipation and rated patients' worries and concerns, physical discomfort, psychosocial discomfort, satisfaction, and overall effects on HRQOL. Scales were rated from 0 to 4 with reductions in scores indicating improvement. Efficacy analyses evaluated each plecanatide dose vs placebo.

RESULTS:

Statistically and clinically significant improvements in PAC-SYM (∼ −0.75-point changes; Table 1) and PAC-QOL (∼ −1.0-point change; Table 2) were observed at Weeks 4, 8, and 12 for both plecanatide 3 mg and 6 mg vs placebo across both studies. Plecanatide-treated patients reported significant improvements vs placebo in all PAC-SYM domain scores, except in Study 2 for abdominal symptoms. Significant improvements in plecanatide arms vs placebo were seen in 3 of 4 PAC-QOL domain scores (worries and concerns, physical discomfort, satisfaction). The most common adverse event (AE) was diarrhea (3 mg, 4.6%; 6 mg, 5.1%; placebo, 1.3%). Discontinuation rates due to AEs were 4.1% (3 mg), 4.5% (6 mg), and 2.2% (placebo), with low discontinuation due to diarrhea (3 mg, 1.9%; 6 mg, 1.8%; placebo, 0.4%).

CONCLUSION:

Patients who received plecanatide 3mg and 6mg had statistically and clinically significant improvements in global constipation symptoms and HRQOL at all measured time points. Plecanatide treatment was associated with a low incidence of AEs and was well tolerated.