bluuebunny/crossref_metadata_2025 huggingface dataset:
1169 Travelers' Diarrhea, Single Dose Antibiotics, Acquisition of Multi-Drug Resistance and Associations With Functional Microbiome Characterization: Is There Any There There?
Authors: Johnson Ryan C. , Van Nostrand Joy D. , Tisdale Michele , Swierczewski Brett E. , Simons Mark P. , Connor Patrick , Fraser Jamie , Melton-Celsa Angela R. , Tribble David R. , Riddle Mark S.
Published: October 2019

INTRODUCTION:

Travelers’ diarrhea (TD) is a commonly diagnosed acute illness among those visiting tropical and sub-tropical regions with substantial consequences. While antibiotic treatment (with lopermaide) substantially reduces TD symptoms and duration, a growth in concerns about the off-target effects of TD treatment on the impact of resident microflora and the potential adverse effects associated with acquisition of multi-drug resistant organisms (MDRO). To date, most microbiome analyses have studied microbial structure/composition, while the functional capabilities of the gut microbiota remain largely unstudied. We set out to understand the functional properties of the gut microflora in response to TD acquired in diverse geographic regions, associations with different single-dose therapies, MDRO acquisition.

METHODS:

Fecal samples from USA & UK military service members in 3 continents that presented with acute watery TD were collected at acute presentation (day 1, prior to antibiotics), as well as 7 and/or 21 days following a single-dose of antibiotics (azithromycin (500 mg), levofloxacin (500 mg), or rifaximin (1650 mg) with loperamide). Each sample underwent culture and TaqMan RT-PCR analyses for pathogen detection and a limited set of ESBL-PE genetic probes. Purified DNA from each sample was analyzed using the HumiChip v2.0 microarray which contains over 150,000 DNA probes specific for genes involved in various functional processes including antibiotic resistance, virulence, stress responses, and nutrient metabolism.

RESULTS:

In total, 125 Day 1 samples, 64 Day 7 samples, and 105 Day 21 samples were available for analysis from 135 subjects. Ordination analysis revealed that subjects enrolled in each country had distinct functional profiles. While we did not observe overt differences in functional profiles between treatment groups, we observed an increase in functional diversity from day 1 to day 21 in the levofloxacin treatment group, relative to azithromycin and rifaximin groups. Additionally, we noted distinct geographical patterns of resistome patterns at baseline and post-illness, but lesser influence of antibiotic effects on post-treatment functional genomic composition.

CONCLUSION:

A thorough understanding of how antibiotics impact the functional properties of the gut microbiota will help inform future treatment options, antibiotic stewardship in TD patients, and the reduction of potential post-infective complications due to MDRO pathobionts.
1177 Multi-Drug Immunosuppression Post-Solid Organ Transplantation Is Associated With Increased Enteric Infection on Multiplex Gastrointestinal Pathogen PCR Testing
Authors: Hine Ashley M. , Joelson Andrew , Lebwohl Benjamin , Axelrad Jordan E.
Published: October 2019

INTRODUCTION:

Diarrhea is a common sequela of solid organ transplantation. Post-transplant diarrhea may be attributed to non-infectious causes including medications, however the contribution of infectious etiology is unclear. The objective of our study was to evaluate the relationship between post-transplant immunosuppression and enteric infection as detected by multiplex gastrointestinal PCR stool testing in solid organ transplant (SOT) recipients.

METHODS:

We performed a multicenter cross-sectional analysis of inpatient and outpatient SOT recipients who underwent stool testing with a FilmArray multiplex gastrointestinal pathogen PCR panel (GI PCR panel) during an acute episode of diarrhea from April 2016 to May 2019. The primary endpoint was the detection of any enteric pathogen. Patients were stratified by the number of major classes of immunosuppressive agents, including calcineurin inhibitors, anti-proliferative agents, and corticosteroids, at time of stool testing.

RESULTS:

We identified 232 SOT patients who underwent a GI PCR panel comprising 52 (23%) lung, 84 (36%) kidney, 41 (18%) heart, and 55 (24%) liver transplants. 92 (40%) tested positive for an enteric pathogen. Patients whose immunosuppressive regimen included 3 medications (n = 139) were more likely to have a gastrointestinal pathogen detected (63, 45%) compared to patients on 2 immunosuppressive medications (P = 0.02; Figure 1) Renal transplant patients were more likely to have an enteric pathogen detected (60%; P < 0.0001) compared to other organ types, and more likely to be on 3 immunosuppressive medications (P < 0.01). Viruses, specifically norovirus and sapovirus, and bacteria, including C. difficile and E. coli subtypes, were common in transplant recipients on 2 immunosuppressive agents (Table 1). Of 139 patients on 3 immunosuppressive agents, 89 (59%) were more likely to be on opportunistic infection prophylaxis for CMV and P. jiroveciipneumonia compared to those patients on 2 drugs (P < 0.001). In the 30 days following stool testing, all SOT recipients, regardless of the number of immunosuppressive drugs, were as likely to visit an emergency room (P = 0.57), require hospitalization (P = 0.66), or undergo endoscopic procedures for persistent GI symptoms (P = 0.78).

CONCLUSION:

Gastrointestinal infections, particularly enteric viruses, were common in SOT recipients who underwent a GI PCR panel for an episode of post-transplant diarrhea, with the highest proportion of positive results in patients maintained on 3 or more immunosuppressive agents.
1178 Accuracy of Glucose Breath Testing for Small Intestine Bacterial Overgrowth (SIBO) Using Endoscopy Aspirate Cultures as a Reference Standard: A Meta-Analysis
Authors: Jones Mitchell L. , Chuang Emil , Wahl Chris , Lee Shaoying N. , Kelly Colleen , Styli Jack
Published: October 2019

INTRODUCTION:

Small Intestinal Bacterial Overgrowth (SIBO) is associated with abnormally high bacterial counts in the small intestine. SIBO is under-diagnosed and there are significant limitations with currently available testing methods.

METHODS:

Two research databases (Google Scholar and Web of Science) were used to find relevant published literature using keywords including glucose breath test accuracy, endoscopy aspirate culture and small intestine bacterial overgrowth. Eleven studies with data on patients tested with both a glucose breath test and endoscopy aspirate culture were found. Fixed-effects and random-effects models were fit to the eleven studies’ data using the Metafor (Meta-Analysis Package for R). The mean positive and negative percent agreement across studies is estimated as the weighted average of each study’s percent agreement, where the weights are the inverse of the standard errors, squared, plus the variance of the random study effects.

RESULTS:

The homogeneity of effects across studies was tested with a Chi-square test and homogeneity of effects was rejected for both positive and negative percent agreement (c2 = 91.5 and 107.5, respectively, df = 10, P-value < 0.0001) (Table 1). The mean percent agreement across studies was estimated with both the fixed-effects and the random-effects models (Table 2). Figure 1 presents each study’s estimate of the positive and negative percent agreement, respectively, and their associated 95% confidence intervals, as well as the overall estimate and its 95% confidence interval.

CONCLUSION:

Heterogeneity was found in the study designs and the implementation of breath tests such as the differences in dose of the substrate (50g or 75-100g) and the duration of the breath test (120∼240min). Meanwhile, the endoscopy aspirate culture is also not completely standardized, as the amount of liquid collected, the site of collection and the technical details of the microbiological tests may differ. This heterogeneity in practice of the two tests certainly contributes to the heterogeneity in positive and negative percentage agreement observed between the two tests. The random effects models’ estimates of 54% positive agreement and 76% negative agreement indicate moderate to poor agreement between the breath test and endoscopy aspirate culture. Given these limitations, there is an unmet need for novel tools to evaluate patients suspected of SIBO.
1180 Novel Capillary Catheter System Is Superior to Conventional Small Bowel Aspiration Catheter: An Important Development for Small Bowel Microbiome Assessment
Authors: Sedighi Rashin , Pimental Mark , Mathur Ruchi , Gaddam Srinivas , Parodi Gonzalo , Lo Simon , Gupta Kapil , Jamil Laith H. , Rezaie Ali
Published: October 2019

INTRODUCTION:

The small intestine is an understudied frontier of microbiome research. While aspiration during endoscopy is considered the gold standard to assess small bowel bacteria, the tools for sterile retrieval are primitive and poorly validated. Moreover, endoscopic aspiration is time consuming and prone to contamination. Inspired by plants’ ability to draw water via capillary action, a novel multi-capillary sterile system was designed. We examined the suctioning time and volume capabilities of this catheter using various liquids compared to conventional aspiration catheters.

METHODS:

Liquids with varying viscosities (water, 25% glucose solution and povidone iodine 10%) were used to assess the aspiration efficiency of the capillary catheter (MicroLotus, Hobbs Medical Inc.) ex-vivo as compared to a conventional small bowel aspiration catheter (Hobbs Medical Inc.) (Figure 1). Viscosity ranged between 0.89 mPa*s for water to 18 mPa*s for povidone. In the first experiment, 8 ml of each liquid was placed in a test tube. Catheters were completely submerged in the liquid and suction was applied using a standardized suctioning technique (Alliance™ II Integrated Inflation device). Next, the same four liquids were placed in a petri dish to mimic the flat mucosal surface. The technique was repeated with 3mL (typical volume of small bowel aspirate). Each experiment was repeated 10 times.

RESULTS:

The conventional catheter suffered from air entering the catheter when not completely submerged which is typical of the small bowel surface. In terms of speed of aspiration, the capillary catheter was at least 10 times faster than the conventional catheter for all fluid viscosities (Figure 2). Capillary catheter demonstrated increasing superiority with increasing viscosity (R = 0.96). When comparing aspiration on a flat surface, aspiration times were 4.67 + 1.35, 9.65 + 2.03 and 23.52 + 3.30 seconds for water, glucose and povidone for the capillary catheter, and too long to measure for the conventional due to concomitant superfluous air entry due to catheter design.

CONCLUSION:

The capillary aspiration catheter system is superior to conventional aspiration catheter in suctioning liquids with various viscosities. This new system may improve aspiration time and quality for small bowel aspiration. Overall, this new system could save between 1 and 6 minutes in endoscopy time to obtain aspirates depending upon the viscosity of the aspirating fluid. Future in-vivo studies are needed to further assess the capillary catheter.
1182 Small Intestinal Bacterial Overgrowth (SIBO) Is Common in Patients With Ehlers-Danlos Syndrome (EDS)
Authors: Xiong Tingting , Baker Jason , Chey William D. , Nojkov Borko
Published: October 2019

INTRODUCTION:

EDS is a group of rare connective tissue disorders caused by defects in collagen synthesis. EDS patients frequently have chronic gastrointestinal (GI) symptoms. Delayed gastric emptying and colonic transit time are common in EDS, suggesting underlying GI dysmotility. The relationship between SIBO and EDS has not been studied. In this study, we aimed to assess the prevalence of SIBO by glucose hydrogen breath test (GBT) in EDS patients with GI symptoms. We also characterized the risk factors for SIBO in these patients.

METHODS:

This was a retrospective cohort study of adults with EDS from specialty clinics at University of Michigan (2000-2019) who completed GBT for suspected SIBO. Demographics, history, medications, and GBT findings were reviewed. Patients with documented structural disease (eg. neoplasm) were excluded. GI symptoms were prospectively collected from all patients at their GBT. A priori variables associated with SIBO were analyzed including: presence of diabetes, GERD, and gastroparesis; history of small bowel surgery or gastric bypass; use of opioids or proton pump inhibitors. Positive GBT for SIBO was defined as breath H2 rise ≥20 ppm within 90 min and/or CH4 rise ≥10 ppm at any time after glucose ingestion. Statistical methods included chi-square and t test. Univariate regression analysis assessed the relationship between tested variables and GBT outcome.

RESULTS:

A total of 600 EDS patients were identified and 327 (54.5%) had at least one GI symptom. GBT was performed in 39 patients (mean age 37.6 ± 12.9; 94.8% female; 92.3% Caucasian) for suspected SIBO. Common symptomatic indications in these patients are shown in Table 1. 15 patients (38.5%) had positive GBT by either H2 (n = 11; 28.2%) and/or CH4 (n = 7; 17.9%). There were no significant differences in demographic factors between EDS patients with positive and negative GBT. Symptomatically, the presence of bloating was associated with a positive GBT (P = 0.04) but there was no significant association between any other GI symptom and the GBT outcome. Diagnosis of GERD was significantly associated with a positive GBT (P = 0.04) and there was a trend towards significant association between IBS and positive GBT (P = 0.07). None of other tested variables predicted the GBT outcome.

CONCLUSION:

SIBO diagnosed by GBT is common in EDS patients with chronic GI symptoms. Our preliminary results suggest that SIBO should be particularly considered in EDS patients with bloating and GERD. Further study is needed to delineate this relationship.
1184 Durability of Rifaximin in the Treatment of Small Intestine Bacterial Overgrowth
Authors: Martinez Nicholas , Randall Charles W. , Vizuete John A.
Published: October 2019

INTRODUCTION:

Multiple antibiotics have been evaluated in the treatment of small intestinal bacterial overgrowth (SIBO). Although the response rates vary by treatment, the overall duration of response has not been clearly defined. Rifaximin (Xifaxan, Salix, Bridgewater, New Jersey, USA) has demonstrated potent activity against numerous pathogenic bacteria. We report our clinical experience with Rifaximin as a durable treatment option for SIBO.

METHODS:

205 records from 9 physicians at a single center were reviewed retrospectively. Chart review was performed from January 2010 through present. Patients underwent hydrogen breath testing in accordance with current consensus recommendations. Patients who were treated with Rifaximin were included for review. Patients less than 18 years old or those with incomplete follow up data were excluded. Patient demographics, antibiotic regimen, response to therapy, and duration of follow up were recorded. Clinical response was defined as patient reported response to underlying symptom (bloating, flatulence, pain, diarrhea) and physician assessment. Duration of response was defined as time to recurrence of initial symptoms from date of antibiotic treatment. Adverse events were defined as patient reported symptoms during treatment. Data were summarized and analyzed using Microsoft Excel v14.7.2. Chi-squared analysis was performed where appropriate.

RESULTS:

156 patients met criteria for review. One hundred twenty-two (78%) were women and 34 (22%) were men. The average age was 52 +/- 19 years. Most patients were treated with 550mg twice daily dosing (n = 108, 69%) with 10 days being the most common duration (n = 68, 44%). Forty-eight patients (31%) were treated with TID dosing for 7,10, or 14 days duration. Symptom relief was observed in 77% of all patients (n = 120). The median duration of symptom relief was 6 months (range 1-96), with a mean follow up time of 14 months. Response was not significantly different when stratified by gender (79% vs 67% for women and men, respectively; P = 0.15). BID dosing was associated with symptom improvement compared to TID dosing (83% vs 63%, P = 0.004). Side effects included: nausea (1.9%), diarrhea (1.3%), oral thrush (1.3%) and abdominal pain (0.6%).

CONCLUSION:

Treatment with Rifaximin resulted in clinical improvement in the majority of patients with SIBO. The median duration of symptom relief with Rifaximin treatment was 6 months. Further prospective data is needed to identify the optimal dosing regimen to maximize durability.
1186 Clostridioides difficile Infection in Patients With Celiac Disease
Authors: Kroner Paul T. , Kesler Alex M. , Jimenez Xavier A. , Simons-Linares Roberto , Raimondo Massimo
Published: October 2019

INTRODUCTION:

Patients with Celiac disease (CD) are at increased risk of infections, as evidenced by increased prevalence of tuberculosis, influenza, and sepsis. Alterations in immunity and microbiota can contribute to this predisposition. Although the prevalence of Clostridium difficile infection (CDI) continues to increase in the US, there is little data on the association and outcomes in patients with CD. The aim of this study was to assess inpatient prevalence, outcomes and resource utilization of patients with CD and CDI in the US in the past decade.

METHODS:

Retrospective cohort study using the NIS 2007 to 2016. All patients with CD were included using ICD9-10CM codes. Cohorts were stratified for CDI coexistence. None were excluded. The primary outcome was determining the association of CD with CDI. Secondary outcomes were determining the CDI inpatient prevalence trend in the CD patients, as well as mortality, morbidity, length of hospital stay (LOS), total hospital charges and costs, which were adjusted for inflation using the Consumer Price Index. Multivariate regression was used to adjust for age, gender, income in patient zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status.

RESULTS:

A total of 337,201 patients with CD were identified, of which 5,500 had associated CDI. Mean age was 55 years and 71% were female. The inpatient prevalence of CDI in patients with CD increased from 0.9/100,000 admissions in 2007 to 1.65/100,000 admissions in 2016. Patients with CD displayed increased adjusted odds (aOR:1.56, P < 0.01) of coexisting CDI compared to patients without CD. Patients with CD had lower odds of mortality, ICU, shock, multiorgan failure, hospital costs, charges, and LOS but increased odds of requiring TPN compared to the general population admitted population with CDI.

CONCLUSION:

Patients with CD had higher odds of CDI compared to non-CD patients, which could be attributed to CD-related gut mucosal integrity, immunological or microbiome alterations. The inpatient prevalence of CDI in patients with CD increased from 2007 to 2016. This may be a reflection of the general increase of CDI cases in the inpatient population and with improved CD diagnostic modalities. Patients with CD and CDI did show decreased morbidity/mortality and resource utilization, suggesting that the clinical course is less severe. Further studies should further assess the gut immunological and microbiome changes in CD to clarify potential factors associated with CDI.
1193 Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis (FAP): Risks, Benefits, and Changes in Management
Authors: Mehta Neal , Shah Ravi , Yoon Ji Yoon , O'Malley Margaret , LaGuardia Lisa , Mankaney Gautam , Bhatt Amit , Burke Carol A.
Published: October 2019

INTRODUCTION:

Nearly all patients with FAP will develop duodenal adenomas. Ampullary/duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging system. Guidelines recommend upper endoscopic surveillance with forward and side-viewing scopes to evaluate the duodenum and visualize the papilla. There is no consensus whether the papilla should be routinely biopsied or included in Spigelman staging. Some endoscopists refrain from biopsy of the papilla due to a theoretical risk of pancreatitis. No data is available to support this risk. We aim to identify the incidence of pancreatitis after biopsy of the papilla in FAP patients and the effect of biopsy on Spigelman stage.

METHODS:

This retrospective cohort study identified consecutive FAP patients at the Cleveland Clinic between 1/2011-12/2018. FAP patients with ≥1 endoscopy with biopsy of the duodenal papilla were included. Patients with history of foregut surgery were excluded. Medical records determined demographics, endoscopic data, and Spigelman staging with/without biopsy. Post-procedural pancreatitis was defined as 2/3 of typical symptoms, lipase 3 times upper limit of normal, or radiography consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD).

RESULTS:

273 FAP patients (52.4% male) with 792 EGDs with biopsy of the papilla were identified (Table 1). Cumulative times that the papilla was biopsied over the study period ranged from 1-8/patient. 2 patients developed pancreatitis. Of all EGDs with ampullary biopsy, 0.34% (3/792) developed post-procedural pancreatitis. The papilla appeared normal in 546/792 exams and 1 patient developed pancreatitis with biopsy of normal papilla. This patient was admitted for 4 days with mild acute pancreatitis (BISAP 1). The papilla was abnormal in 226 exams and 2 episodes of pancreatitis occurred in the same patient. This patient had a history of chronic pancreatitis due to alcohol abuse. Hospitalization wasn’t necessary for mild acute pancreatitis (BISAP 1). Biopsy of normal papilla increased Spigelman stage in 15 patients, one upstaged from Spigelman III to IV and had a pancreas-sparing duodenectomy.

CONCLUSION:

Pancreatitis after biopsy of the duodenal papilla is rare, especially in patients without a history of pancreatitis. Biopsy of normal papilla in FAP changes patient management. Physicians managing FAP should understand risks/benefits of biopsy of the papilla and include it in Spigelman staging.
1194 Small Intestinal Bacterial Overgrowth Is Common in Mast Cell Activation Syndrome
Authors: Weinstock Leonard B. , Brook Jill , Kaleem Zahid , Afrin Lawrence , Molderings Gerhart
Published: October 2019

INTRODUCTION:

Mast cell activation syndrome (MCAS) often presents with symptoms of irritable bowel syndrome (IBS). MCAS is a multi-systemic disorder caused by inappropriate mast cell (MC) activation causing inflammatory and allergic symptoms. IBS can be associated with small intestinal bacterial overgrowth (SIBO). This study determined the prevalence of SIBO in MCAS.

METHODS:

Patients with refractory gastrointestinal (GI) symptoms were evaluated for MCAS and SIBO. MCAS was diagnosed if there were typical symptoms of mast cell (MC) activation in 2 or more organ systems plus 1 or more of the following: elevation of MC chemical mediator(s), clinical improvement with MC-directed therapy, and/or increased intestinal MC density. SIBO diagnosis was based on a lactulose breath test (LBT) with ≥20 ppm hydrogen rise from baseline within 90 minutes. These LBT results were compared to our prior study of healthy controls. The effect of co-morbid syndromes and medication use was analyzed. Antibiotic therapy effects were a secondary aim. This study was IRB approved.

RESULTS:

There were 139 MCAS subjects (116 F, 23 M, 46.6 ± 16.9 years) and 30 controls (19 F, 11 M, 44 ± 14.0 years). GI symptoms preceded other MCAS symptoms in 66.2%. Symptoms included abdominal pain (87.1%), bloating (74.8%), constipation (66.9%), diarrhea (63.3%), nausea (61.9%), heartburn (54.0%), and dysphagia (29.5%). In these MCAS patients Rome 4 criteria for IBS-mixed (39.6%), IBS-constipation (22.3%), and IBS-diarrhea (18.7%) were met. SIBO was present in 30.9% MCAS subjects vs. 10% in controls (P = 0.023). Methane excretion in a plateau pattern was common in MCAS: 10.1% had levels ≥10 ppm and 24.5% had levels 3-9 ppm. Higher methane levels were associated with IBS-constipation compared to SIBO positive subjects: 42.9% vs. 9.3% (P = 0.02). Postural orthostatic tachycardia syndrome, hypermobile Ehlers-Danlos syndrome, MC density and mediators, proton pump inhibitors, thyroid supplements, and statins were not associated with LBT changes. Antibiotics were prescribed for 74 subjects: 67.6% had marked improvement, 5.4% had partial improvement, and 21.6% had no improvement in GI symptoms. Adverse events led to cessation of antibiotics in 9.5%.

CONCLUSION:

SIBO with hydrogen and methane plateau patterns are common in MCAS subjects. MCAS could cause SIBO due to alterations of the GI immune system or altered motility by local release of MC mediators. Antibiotic therapy appears to improve GI symptoms in MCAS patients.
1202 Long Term Outcomes Following Surgical Resection of Gastric Neuroendocrine Tumors
Authors: Ragheb Jonathan , Bahdi Firas , Mehta Neal , Butler Robert , Chahal Prabhleen , Stevens Tyler , Cruise Michael , Augustin Toms , McNamara Michael , Walsh R. Matthew , Bhatt Amit
Published: October 2019

INTRODUCTION:

Gastric neuroendocrine tumors vary in propensity for lymph node metastases, and this principle has guided management towards endoscopic, surgical or pharmacologic therapy. However, no consensus on optimal type of gastric surgery for gastric carcinoid and rate of recurrence or survival has been reached in North America. The goal of our study is to determine mortality and incidence of tumor recurrence among different surgical interventions for gastric neuroendocrine tumors.

METHODS:

All consecutive patients encountered at a tertiary referral center who underwent gastric surgery or endoscopic submucosal dissection (ESD) for biopsy proven gastric neuroendocrine tumor from April 1988 to January 2019 were entered into the study. Patients were categorized by proximal/wedge, distal/subtotal, total gastric resection, and ESD as well as by lymphadenectomy: none (D0), D1, or D2. Tumor grading was characterized as high (poorly differentiated, WHO 3) or low (well differentiated, WHO 1 & 2) as some patients preceded WHO classification. Recurrence and lymph node metastases were based on biopsy. Patient follow-up was determined by most recent encounter with gastroenterology or oncology provider within our health system. Date of decease was determined by Social Security Death Index query of all patients.

RESULTS:

Thirty patients were enrolled. Mean age of diagnosis was 63.9 ± 12.3 years old. Lymph node dissection practices were provider dependent but at least 62% did not have any lymphadenectomy. Mean follow up after surgery was 42.8 ± 12.8 months. Of those who underwent distal gastrectomy and ESD, no evidence of recurrence was noted. Two of 3 patients with recurrence had low grade tumors without lymphadenectomy. Mortality did not significantly vary with lymphadenectomy status (Figure 2). One 78-year-old patient did not survive post operatively after distal/subtotal gastrectomy with D1 lymphadenectomy due to sudden cardiac arrest 9 days after surgery.

CONCLUSION:

In our cohort, fewer gastric resections for GNETS include lymphadnectomy. Interestingly, recurrence was not statistically significantly associated with positive and negative lymph nodes or performance of lymphadenectomy. One limitation of this study is the scarcity of lymph node positive GNET.
1203 Low Viscosity Soluble Dietary Fibre for Gastroparesis Sufferers
Authors: Suresh Harsha , Zhou Jerry , Ho Vincent
Published: October 2019

INTRODUCTION:

Gastroparesis is a chronic idiopathic disorder which affects 125,000 people in Australia. The symptoms of gastroparesis can range from mild to very severe. Current management of gastroparesis involves enteral strategies such as prescription drugs, feeding tubes using jejunostomy and gastric electric simulation (GES). Medical practitioners currently recommend that gastroparesis sufferers take little to no fibre in their diet regardless of the severity of their symptoms but low-viscosity soluble fibres have been proposed as a solution for dietary fibre intake in mild to moderate gastroparesis sufferers.

METHODS:

The rheological properties of ten soluble dietary fibres were studied under normal and simulated gastric conditions. A clinical trial involving two soluble fibres (test fibres), one partially-soluble fibre (positive control) and no fibre (negative control) was approved under the UID H12254 at Western Sydney University, AUS. The clinical trial is used to study blood glucose absorption, symptoms and mouth-to-caecum emptying times of eligible patients after consumption of soluble dietary fibres under controlled conditions. The polysaccharide chain length and monosaccharide unit composition in these dietary fibres will be analysed using Q-ToF-MS.

RESULTS:

The rheological stress σ (Pa) at the visco-elastic relaxation modulus Gc under normal and simulated gastric conditions was characterised for 10 different fibres. There was a significant reduction in the rheological stress from normal to gastric conditions for three low-stress soluble fibres. Two of those three low-stress fibres and one medium-stress fibre were selected for the clinical trial. Preliminary results of the clinical trial (6 patients) indicate that most patients find the low-stress fibres more palatable than the medium-stress fibre based on the Gastroparesis Cardinal symptom Index (GCSI). No significant differences in postprandial blood glucose absorption over 3 hours were observed for both the low-stress and medium-stress fibres. The low-stress fibres also show no significant delay in gastric emptying up to 3 hours compared to the negative control using hydrogen breath test analysis.

CONCLUSION:

The preliminary results of the rheology and the clinical trial indicate that soluble fibres could be incorporated into the diet of a gastroparesis patient. We hope to summarize the rheological, chemical and clinical data about these fibres and provide the relevant information to dieticians and gastroenterologists.
1205 The Prevalence of Carcinoid Tumors of the Stomach in the USA: A Population-Based Study
Authors: Saleh Mohannad Abou , Sarmini Muhammad Talal , Rouphael Carol , Mansoor Emad , Chak Amitabh , Vargo John , Bhatt Amit
Published: October 2019

INTRODUCTION:

Most carcinoid tumors occur in the GI tract. Epidemiologic studies evaluating gastric carcinoid (GC) tumors were limited by small sample size. Our aim was to obtain an epidemiologic survey of GC tumors using population-based data in order to identify the prevalence and underlying associations.

METHODS:

A commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic medical records from 26 major integrated US healthcare systems. was used. We identified all patients aged 18 and older who were diagnosed with gastric carcinoid tumors between 1996 and 2018 based on Systematized Nomenclature Of Medicine – Clinical Terms (SNOMED-CT) and evaluated the prevalence of GC tumors. We also performed analyses to describe age-, race-, and gender-based distributions and to identify associations. Annual inpatient admissions trend was reviewed using the National Inpatient Sample (NIS) database 2008-20014 where all patients with GC were identified.

RESULTS:

Of the 62,881,700 individuals in the database, 1,590 were identified to have GC tumors with prevalence of 2.53/100,000. Individuals with GC tumors were more likely to be females [OR: 1.43; 95% CI 1.30 to 1.59, P < 0.0001], elderly (age >65) [OR: 4.26; 95% CI 3.56 to 4.70, P < 0.0001], Caucasians [OR: 2.18; 95% CI 1.95 to 2.44, P < 0.0001], smokers [OR: 3.01; 95% CI 2.61 to 3.47, P < 0.0001], with history of alcohol use [OR: 3.01; 95% CI 2.69 to 3.36, P < 0.0001], diabetes mellitus (DM) [OR: 9.76; 95% CI 8.84 to 10.78, P < 0.0001], pernicious anemia [OR: 122.00; 95% CI 104.03 to 141.99, P < 0.0001], obesity [OR: 6.38; 95% CI 5.74 to 7.10, P < 0.0001], family history of cancer [OR: 8.86; 95% CI 7.82 to 10.05, P < 0.0001], and multiple endocrine neoplasia type 1 [OR: 900.01; 95% CI 576.22 to 1405.75, P < 0.0001] (Figure 1). Prevalence in the past 5 years is on the rise in the Explorys database (Figure 2). Of the study group, 40 (3%) had total gastrectomy, 140 (9%) had subtotal gastrectomy, and 190 (12%) had surgical excision of the tumor. Using NIS database, we identified total of 53,281,476 inpatient admissions between 2008 and 20014 of which 1,334 were diagnosed with GC. The trend analysis showed that the number of annual inpatient admissions with GC is also gradually increasing as shown in Figure 3 (P < 0.001).

CONCLUSION:

This is the largest epidemiological study evaluating the prevalence of GC tumors. We estimated the prevalence rate of GC tumors to be 2.53/100,000. The overall prevalence is rising with increase in the annual admissions as well.
1208 Contemporary Prevalence and Predictors of Helicobacter pylori Infection in a U.S. Population
Authors: Peng Frederick B. , Nguyen Theresa H. , Emelogu Ikenna , Mallepally Niharika , Liu Yan , Thrift Aaron P. , El-Serag Hashem B. , Tan Mimi C.
Published: October 2019

INTRODUCTION:

The prevalence of Helicobacter pylori has been declining overall, but there is no current screening strategy in the U.S. to identify patients with H. pylori. We identified the prevalence and predictors of H. pylori infection among patients undergoing upper endoscopy with gastric biopsies in the Harris County Hospital System.

METHODS:

We identified consecutive patients undergoing upper endoscopy with gastric biopsies for any indication from two hospitals in the Harris County Hospital System in Houston, TX during 1/2015-12/2016. We abstracted sociodemographic, laboratory, endoscopic, and histopathologic data from the medical record to evaluate previous as well as active H. pylori infection seen on gastric biopsy. We determined the overall and race/ethnic specific prevalence of H. pylori infection. We evaluated associations between demographic, lifestyle, and endoscopic features with H. pylori infection in logistic regression models, reported as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS:

Of 943 patients who underwent gastric biopsies, 376 were men (39.9%) with mean age 53.0 years (SD 11.6 years). Most were Hispanics (51.1%) or blacks (26.0%) with a small proportion of whites (11.1%). The overall prevalence of H. pylori infection was 52.8% (n = 498), which was highest among Hispanics (60.2%), blacks (51.0%), and Asians (52.3%) compared to whites (21.9%). Of 943 patients, 486 (51.5%) were previously screened for H. pylori infection, and 301 (31.9%) had tested positive. Predictors of H. pylori included male sex (adjOR 1.53, 95% CI 1.10-2.13), race (vs. white, black adjOR 3.76, 95% CI 2.19-6.45; Hispanic adjOR 5.31, 95% CI 3.14-9.00; Asian adjOR 3.96, 95% CI 1.93-8.11), and proton pump inhibitor use (adjOR 1.50, 95% CI 1.10-2.05). Gastric polyps identified on endoscopy were associated with the absence of H. pylori (OR 0.57, 95% CI 0.37-0.88). There were no significant associations with age, family history of gastric cancer, smoking, alcohol use, or endoscopy indication.

CONCLUSION:

In this contemporary U.S. cohort of patients undergoing endoscopy with gastric biopsies, the overall prevalence of H. pylori infection is very high (52.8%). Black, Hispanic, and Asian race were associated with high H. pylori infection, and men were at higher risk of developing this infection. These findings call for developing a H. pylori screening strategy in certain high risk U.S. populations.
1211 Socio-Demographic Disparities in Gastric Cancer: A Population-Based Study
Authors: Rana Navpreet , Gosain Rohit , Lemini Riccardo , Groman Adrienne , Mukherjee Sarbajit
Published: October 2019

INTRODUCTION:

Gastric cancer is one of the leading causes of cancer-related mortality worldwide, with a global burden of 5.7% new cases each year and 8.2% of cancer-related deaths. Area of residence has been found to affect survival in different cancers but their impact on gastric cancer remains largely unknown. The purpose of this study is to address the potential disparities between the rural and urban populations affected by gastric cancer.

METHODS:

We conducted a retrospective study, analyzing different socio-demographic factors associated with populations affected by gastric cancer between 1973 and 2015. Data was obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses were performed to evaluate disease-specific survival (DSS) and overall survival (OS). Different socio-demographic factors including location of residence, that is urban area (UA) or rural area (RA), gender, race, insurance status and marital status were included in the analyses.

RESULTS:

A total of 68,959 [RA, N = 6,841; UA, N = 60,282] patients were included in the study. The incidence of gastric cancer was noted to have a steady decline during the studied time period, in both RA and UA. Majority of the study population was non-Hispanic white (N = 42,806, 62%) and male (N = 46,504, 67%). Univariate and multivariate analysis showed that RA had the worst DSS (univariate - HR = 1.15, P < 0.001; multivariate - HR = 1.13, P < 0.001) and OS (univariate - HR = 1.13, P < 0.001; multivariate HR = 1.11; P < 0.001) compared to UA. Similarly, DSS and OS was poor in uninsured and single patient population compared to insured patients and married couples respectively. Multivariate analysis further showed female patients had better DSS (HR = 0.91, P < 0.001) and OS (HR = 0.88, P < 0.001) in comparison to their male counterparts.

CONCLUSION:

This study identifies socio-demographic disparities in gastric cancer. Access to healthcare, variations in patient care, environmental and lifestyle factors as well as genomic differences are all potential factors that affect the OS. This is consistent with the available literature in gastric cancer, including studies demonstrating survival differences in different populations undergoing surgical treatment in the United States. Based on the above data, it is imperative for future health policy initiatives to address these disparities in an effort to improve OS.
1213 Barriers in Completion of H. pylori Eradication Testing in Predominantly Underserved Hispanic Resident Clinic: A Quality Improvement Project
Authors: Nagirimadugu Ankita , Rozenshteyn Frederick , Young Ari
Published: October 2019

INTRODUCTION:

We present a quality improvement study at a resident clinic serving predominantly underserved Hispanic/Latino patients to assess physician and patient adherence to completing H. Pylori stool test of cure, and provide sustainable interventions to increase rates of eradication.

METHODS:

A database of patients who had confirmed H. Pylori via stool testing from July 9, 2015–June 30, 2017 was created and reviewed retrospectively. The primary endpoint was to determine the rate of eradication confirmation and observe barriers in providing the standard of care. Secondary outcomes include delay in collection and treatment. Data analysis was completed with the student's T-Test and Z-Test.

RESULTS:

A total of 102 patients with confirmed H. Pylori were included in this study. Patient population was predominantly identified as Hispanic (72 patients), and English was the primary language in 59 (57.8%) patients. Average delay in collection of primary stool samples to make the diagnosis of H. Pylori was 7.14 days. Men vs. women average delay in completion of initial H. Pylori testing was noted to be 10 days vs. 4.9 days with a T-Score of 1.01 (P = 0.312). Hispanic vs. non-Hispanic patients average delay in completion of initial H. Pylori testing was noted to be 8.8 days vs. 3.5 days with a T-Score of 1.40 (P = 0.165). Standard of care treatment was prescribed for 90 (89.2%) patients. Primary care physicians ordered confirmation of eradication for 78 (76.4%) patients, and 63 (61.7%) patients successfully completed eradication testing. Men vs. women in completion of eradication testing were noted to be 61% vs. 79% with a Z-Score of -2.19 (P = 0.02). Completion rate of stool eradication testing amongst patients was found to be 79.5%.

CONCLUSION:

Key findings include 24% of patients were not ordered eradication testing likely secondary to high physician turnover. 20% of our patients that were ordered eradication testing did not complete it, due to improvement in initial symptoms and the cumbersome stool testing process. We plan to improve compliance by offering same day urea breath testing on site, which is a simpler, less time-consuming test for patients. Community outreach, H. pylori education pamphlets in Spanish and English, reminder phone calls, and standardized physician templates for H. pylori testing are also being considered and implemented at our clinic to improve the overall rate of successfully treating H. pylori infection.
1217 Gastroparesis Dietary Recommendations in Patients With Gastroparesis-Like Symptoms Are Only Effective in Normal Colon Transit Documented by Wireless Motility Capsule Methodology
Authors: Moshiree Baha , Hasler William , Lee Allen , Parkman Henry , McCallum Richard , Rao Satish , Nguyen Linda A. , Sarosiek Irene , Schulman Michael , Wo John M. , Kuo Braden
Published: October 2019

INTRODUCTION:

We previously reported a positive impact of gastroparesis diet recommendations on overall and individual symptoms in patients with suspected gastroparesis who show gastric emptying delays. In contrast, those with non-delayed gastric emptying showed only minimal benefits on this diet. The impact of gastroparesis diet recommendations in patients with delayed colon transit (DCT) based on Wireless Motility Capsule (WMC) testing has not been assessed. We hypothesized that patients with normal colon transit (NCT) presenting with upper GI symptoms respond to a gastroparesis diet while those with DCT do not respond.

METHODS:

Patients with suspected gastroparesis at 10 tertiary centers underwent concurrent WMC testing and gastric emptying scintigraphy. Several treatment recommendations, including a gastroparesis diet (low fat, low fiber and low residue diet with small-sized but frequent meals) were recommended for 31 patients with NCT and 15 with DCT. For this analysis, overall GCSI, and individual symptom scores from PAGI-SYM surveys (0 = none, 5 = very severe) at baseline and 6- month follow-up on the gastroparesis diet were related to the presence or absence of DCT defined as colon transit exceeding 59 hours by WMC.

RESULTS:

Gastroparesis diet recommendations were associated with overall GCSI and PAGI-SYM score reductions from 2.6 ± 1.1 to 2.1 ± 1.1 (P = 0.004) and 2.5 ± 1.1 to 1.9 ± 1.2 (P = 0.0004), respectively, in patients with NCT. Individual symptoms of bloating, fullness and diarrhea also improved with NCT (P < 0.02 for all) (Table 1). Constipation and lower abdominal pain scores did not differ pre- and post- gastroparesis diet recommendations. In patients with DCT, only constipation improved over 6 months (P = 0.04). This finding may be explained by increased use of laxatives in this group after DCT was found on WMC testing.

CONCLUSION:

This is the first study to show a differential impact of gastroparesis diet recommendations in patients with suspected gastroparesis based on colon transit findings by wireless motility capsules. A positive impact of the gastroparesis diet with long-term benefits on overall and individual symptoms up to 6 months in patients with suspected gastroparesis and normal colonic transit was seen. In contrast, patients with delayed colon transit had lesser benefits from gastroparesis diets. Whole gut transit testing with WMC may differentiate responders and non-responders to the gastroparesis diet based on colonic transit times.
1221 Trends in Incidence, Survival, and Mortality of Gastric Cancer in the United States: A Surveillance, Epidemiology, and End Results (SEER) Database Study 1975-2016
Authors: Asif Samia , Saeed Lyla , Zafar Yousaf
Published: October 2019

INTRODUCTION:

Using Surveillance, Epidemiology, and End Results (SEER) data, we examined epidemiological associations between patient characteristics and the incidence and survival in gastric cancer in the US.

METHODS:

Patients diagnosed with stomach cancer between 1975-2016 were identified in SEER registries. We incorporated SEER 9 and 18 registries to calculate incidence, race/ethnicity and disease characteristics. Cox regression was used to estimate survival from SEER follow up data.

RESULTS:

Males (M) had higher incidence rates (IR) than females (F): 10.0/105 vs 5.3/105. Observed IR have been decreasing on average 1.5%/year over last 10 years. IR increases with age; for any age group, it is higher for: M than F; black M than white M and black F than white F. IR are highest in ages 65 years and above compared to ages below 65 (36.7/105 vs 3.1/105) and highest in Asian-Pacific Islander (API) populations, Blacks (B), Hispanics (H), American Indian/Alaskan Native, non-Hispanic white (NHW) and Whites (W) in decreasing order. For each ethnicity, IR is higher in M than F. In 2016, W constituted 69.2% of prevalent cases, while B, H and API constituted 12.6, 11.3 and 7.1% respectively. Mortality rates (MR) decreased from 8.51/105 to 3.02/105 between 1975-2016. MR increases with age for both M and F; between 2012-16 it is highest in B (5.5/105), API (5.3/105), H (5.1/105), American Indian/Alaskan Native (3.4/105), W (2.7/105) and NHW (2.4/105) in decreasing order. 5-year survival improved from 15% in 1975-77 to 32% in 2009-2015. For F, 5-year survival is 36%, higher in BF than WF (39.5% vs 35%). In M, 5-year survival is 30%, lower for BM compared to WM (27%vs 29%). Adenocarcinoma comprised 80% of all cases reported; others included epidermoid and squamous cell carcinoma and sarcoma/soft tissue tumors (0.8, 0.8 and 0.2% respectively). Rest were documented as other specific or unspecified tumors. Distant disease comprised (36%) of reported cases, compared to localized (26%), regional (26%) and unknown/un-staged (10%) disease. 5-year survival rates were highest for localized (69%) compared to regional (31%), distant (5%) and unknown/un-staged (23.0%) disease.

CONCLUSION:

Epidemiological trends show improved 5-year survival in gastric cancer among all ethnicities. Advance age and distant disease portend poor outcome. Since black women have better outcome than black men, we postulate that the disease pathogenesis varies by gender and races without considering confounding factors.