bluuebunny/crossref_metadata_2025 huggingface dataset:
139 Is Smoking Associated With an Increased Risk of Diverticulitis?
Authors: Maddika Srikanth , Then Eric O. , John Febin , Aloreidi Khalil , Gayam Vijay , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Diverticulitis is inflammation of a previously existing diverticulum. Complicated diverticulitis is characterized by the formation of phlegmon, abscess, obstruction or perforation. Recent meta-analysis proved a positive association between tobacco and diverticulosis, but there is a lack of robust data on the effect of tobacco smoking on diverticulitis.

METHODS:

We retrospectively analyzed patients hospitalized with diverticulitis (via ICD-9 codes) in 2016 using the Nationwide Inpatient Sample (NIS) Database. Our primary end point was to establish a relationship between patients diagnosed with diverticulitis and tobacco smokers. We also analyzed the relationship between smoking and the presence of complicated versus non-complicated diverticulitis. Finally we analyzed the relationship between the presence of diverticulitis with race and gender. Univariate and multivariate logistic regression models were developed using STATA software version 15.

RESULTS:

A total of 331,999 patients with diverticulitis were included in our study population. We found that patients with diverticulitis were 35% more likely to be tobacco smokers than non-smokers (OR: 1.359; CI: 1.329–1.389; P-value: 0.000). This relationship was stronger in patients with complicated diverticulitis where 49% were more likely to be tobacco smokers than non-smokers (OR: 1.495; CI: 1.451–1.540; P-value: 0.000). In addition patients with complicated diverticulitis presented at a younger age in tobacco smokers than in non-smokers (mean age: 59.23 vs 61.55; P-value: 0.0001). On multivariate analysis adjusting for possible confounding factors we found that smoking (OR: 1.30; CI: 1.27–1.33; P-value: 0.00), Caucasian race (OR: 1.731; CI: 1.596–1.878; P-value: 0.000), female gender (OR: 1.09; CI: 1.07–1.11; P-value: 0.00), and colon cancer (OR: 1.07; CI: 1.01–1.15; P-value: 0.02) were all associated with an increased likelihood of diverticulitis. In contrast, diverticulitis was 14% less likely to occur in black patients (OR: 0.865; CI: 0.793–0.944; P-value: 0.001).

CONCLUSION:

We conclude there is a positive association between tobacco smoking and diverticulitis. Smoking increases the risk of complicated diverticulitis and this tends to occur at a younger age compared to non-smokers. Incidence of diverticulitis is more common in whites and least common among blacks when compared to other races. Given these findings more robust measures should be implemented to help young adults quit smoking tobacco.
144 Efficacy and Safety of NER1006 Versus Standard Bowel Preparations: A Meta-Analysis of Randomized Phase 3 Clinical Trials
Authors: Maida Marcello , Macaluso Fabio Salvatore , Sinagra Emanuele , Ventimiglia Marco
Published: October 2019

INTRODUCTION:

The efficacy of bowel cleansing is essential for a quality colonoscopy, especially in the setting of colorectal cancer screening. Unfortunately, suboptimal bowel preparation is still observed in 25% of procedures. Recently, a very low-volume 1L PEG solution (NER1006) has been introduced on the evidence of three phase 3 randomized controlled trials. We conducted a meta-analysis to explore cleansing success, adenoma detection rate (ADR), and safety profile of NER1006 versus standard bowel preparations.

METHODS:

PubMed/Medline and Embase were systematically searched through April 2019 by two independent reviewers (M.M. and F.S.M.) for randomized phase 3 clinical trials comparing the effectiveness of NER1006 versus standard bowel preparations.

RESULTS:

Three RCTs (four arms, 2151 participants) met the inclusion criteria and were included in the meta-analysis (Table 1). The analysis showed a significant higher overall cleansing success for patients receiving NER1006 compared with standard preparations both using the Harefield Cleansing Scale (HCS) (OR 1.29; 95% CI 1.02–1.61; P = 0.031, I2 = 0%, 2151 participants) and the Boston Bowel Preparation Scale (BBPS) (OR 1.43; 95% CI 1.15–1.78; P = 0.001, I2 = 0%, 2151 participants) (Figure 1a,b), as well as a significant greater high-quality cleansing of the right colon both when assessed with the HCS (OR 2.26; 95% CI 1.44–3.54; P < 0.001, I2 = 70%, 2151 participants) and with the BBPS (OR 1.74; 95% CI 1.09–2.79; P = 0.021, I2 = 66%, 2151 participants) (Figure 1c,d). The pooled estimate of the NER1006 effect on ADR showed no significant difference in terms of overall ADR (OR 1.03; 95% CI 0.85–1.24; P = 0.773, I2 = 0%, 2151 participants), and a higher, although not significant, ADR of the right colon (OR 1.24; 95% CI 0.85–1.79; P = 0.262, I2 = 38%, 2151 participants) (Figure 2a,b). When considering the impact of NER1006 on mild to moderate treatment-emergent adverse events (TEAEs), we observed a significant pooled estimate of number of TEAEs (OR 2.25; 95% CI 1.81–2.80; P < 0.001, I2 = 0%, 2060 participants) and of patients with TEAEs (OR 1.80; 95% CI 1.36–2.38; P < 0.001, I2 = 0%, 2060 participants) (Figure 2c,d). No serious adverse events occurred.

CONCLUSION:

Compared with standard bowel preparations, NER1006 showed a higher overall cleansing success, a greater high-quality cleansing of the right colon and a higher, although not significant, ADR of the right colon. NER1006 showed a higher incidence of mild to moderate TEAEs, in the absence of serious adverse events.
147 Colorectal Mucosal Schwann Cell Hamartomas in a Community Gastroenterology Practice
Authors: Sadiq Bitaal , Nunez Matthew , Sannapaneni Shilpa , Hoelscher Amanda , Lager Donna J. , Jain Rajeev , Fourment Chris , Ritter Timothy E.
Published: October 2019

INTRODUCTION:

Mucosal Schwann cell hamartoma (MSCH) is a benign mucosal lesion composed of spindle cells surrounding colonic crypts that can arise anywhere in the colon; usually in the rectosigmoid. Most reports of colonic MSCH are limited to case reports and two case series from tertiary-care academic settings involving 20 and 26 patients. Our retrospective study is the first to describe the characteristics of colorectal MSCH in a community gastroenterology practice.

METHODS:

We retrospectively identified patients with colorectal MSCH from the pathology database of a large, community gastroenterology practice of 157 physicians in Texas and Louisiana working at 24 outpatient centers. Data were collected from consecutive patients diagnosed with MSCH from 2015–2019. MSCH were confirmed by positive immunohistochemical staining for S-100. Historical data recorded included the endoscopic size and appearance of the polyps, location, indication(s) for colonoscopy, and patient age, sex, and race.

RESULTS:

184 colorectal MSCH from 179 patients were identified out of a total of 335,635 colon specimens. The median age of 59 years (range, 40–84). Sixty percent were female, 67% were White, and 25% were Black. The most common indications for colonoscopy were screening (55%), polyp surveillance (35%) and diagnostic (35%), which often overlapped. The polyps were described as sessile (65%), pedunculated (2%), mixed sessile/pedunculated (1.6%), and not specified (32%). The average size was 3.8 mm (range, 1–15 mm), and most were in the distal colon and rectum (77%) followed by transverse (11%) and proximal colon (10%). One MSCH was at an anastomosis and in one, the site was not specified.

CONCLUSION:

This large retrospective series is the first to describe colorectal MSCH in a community gastroenterology practice. Additionally, the large number of patients provides a better description of MSCH characteristics in comparison to prior small case series. MSCH were most commonly found during screening and surveillance colonoscopies in patients who were older, female and white. Most were located in the distal colon and rectum. Colorectal MSCHs are found infrequently at an approximate rate of 1 every 4 years by a community gastroenterologist, or 0.05% of colonoscopy biopsies.
150 Abdominal Tuberculosis in the 21st Century in Peru: A Description of 22 Cases
Authors: Torres Luis , Macalupú Juan Carlos , Bellido Alvaro , Pinto Jose , Espinoza-Ríos Jorge
Published: October 2019

INTRODUCTION:

The diagnosis of abdominal tuberculosis (AT) remains complicated, although it's a common pathology in developing countries. A high degree of clinical suspicion is always needed in order to ensure its rapid detection. We aimed to describe and analyze the epidemiological, clinical and radiological features of patients diagnosed with abdominal tuberculosis: tuberculous lymphadenopathy, gastrointestinal, visceral and peritoneal tuberculosis (TB).

METHODS:

A prospective study was conducted between 2015 and 2016 and patients diagnosed with AT based on clinical, endoscopic and histopathologic features were collected. The clinical, epidemiological and radiological features were described by frequencies and percentages and then analyzed in Stata 12 to evaluate the associations between them.

RESULTS:

A total of 22 patients were included: 17 males (77%) with a mean age of 38.6 years. Twelve patients (55%) had only one type of AT and 10 patients (45%) had more than one. The most common diagnosis was gastrointestinal TB (14 cases, 64%), followed by peritoneal TB (10 cases, 45%), tuberculous lymphadenopathy (8 cases, 36%) and visceral TB (2 cases, 9%). The former showed 6 presentations: ileocecal (8 cases, 57%), colorectal (7 cases, 50%), duodenal (3 cases, 21%), gastric (2 cases, 14%), esophageal (1 case, 7%) and jejunal (1 case, 7%). The most important antecedents were HIV infection (11 cases, 52%), TB contact (9 cases, 43%) and pulmonary TB and alcoholism (7 cases, 33% each one). The most common symptoms were abdominal pain and weight loss (19 cases, 90% each one), anorexia (17 cases, 81%), fever (15 cases, 71%), nocturnal sweating (13 cases, 62%), chronic diarrhea (12 cases, 57%), cough (11 cases, 52%) and abdominal distension (11 cases, 52%). The physical findings were ascites (8 cases, 38%) and hepatosplenomegaly (5 cases, 24%), and the principal complication was lower gastrointestinal bleeding (5 cases, 24%). Radiological findings consistent with pulmonary tuberculosis were also common (13 cases, 62%). Only abdominal distention and ascites showed statistical association with peritoneal tuberculosis (Fisher's exact = 0.0001 and 0.008 respectively).

CONCLUSION:

Abdominal pain, B symptoms and chronic diarrhea are the most important manifestations of AT. Hence attention must be paid in patients with this symptoms, especially if they are immunocompromised. In these subjects abdominal distension and ascites seem to suggest the diagnosis of peritoneal TB.
153 Clinical Features of Radiotherapy-Related Proctocolitis
Authors: Abu-Sbeih Hamzah , Tang Tenglong , Tran Cynthia N. , Wang Yinghong
Published: October 2019

INTRODUCTION:

Radiotherapy is an effective treatment for various malignancies. Especially when used in close proximity to GI tract, it carries risk for causing proctocolitis. We aimed to characterize radiotherapy-induced proctocolitis (RiPC) in a tertiary cancer center.

METHODS:

This is a retrospective cohort study of cancer patients who suffered RiPC between January 2010 and December 2018. Logistic regression analyses were used to assess factors associated with RiPC bleeding and treatment requirement.

RESULTS:

Of 61399 patients who received radiotherapy to the abdomen and pelvis, 7185 among them had endoscopy evaluation; among them, 135 (2%) had confirmed RiPC. Median age was 60 years. Half patients were males. Most patients were of white race (85%). Prostate cancer was the most common malignancy (39%), followed by rectosigmoid and anal cancers (21% and 20%, respectively). Most patients received external beam radiotherapy. The median dose of radiotherapy was 55 Gy for a median of 30 sessions (IQR, 27–35). Median time from first radiotherapy to RiPC is 15 days (IQR, 9–22). Diarrhea was the most common symptom (44%) followed by blood per rectum (39%). Median duration of RiPC symptoms is 28 (10–90) days. Eighty patients received antimotility agents, 36 received enema or suppository corticosteroids, and 13 received intravenous fluids. Twelve patients required hospitalization and 2 needed ICU-level care. Thirty-five patients had recurrence of RiPC after a median of 18 months. Mucosal bleeding occurred in 30% of patients, ulcerations in 16%, and strictures in 6% (Table 1). Thirty-five patients received endoscopic treatment with APC; among them, 15 needed a repeat treatment. Higher doses of radiotherapy, longer durations, and intensity modulated radiotherapy were associated with increased risk of bleeding (P < 0.05). Other factors associated with risk of bleeding from RiPC are listed in Table 2. Older male patients who received chemotherapy known to cause GI toxicity or higher doses or longer duration of radiotherapy were more likely to receive medical treatment for RiPC (P < 0.05). Inflammation of rectum was associated with less frequent complications compared with inflammation of the rest of the colon (Table 3).

CONCLUSION:

RiPC is a rare but devastating toxicity of radiotherapy that might recur in 26% of cases. Endoscopy is a useful tool for the diagnosis and treatment of RiPC. Colonic involvement was associated with RiPC complications.
154 Short-Term Efficacy of the Vaginal Bowel-Control Device in Improving Fecal Incontinence in Women: A Meta-Analysis of Prospective Studies
Authors: Zhang Allison , Doherty Bryan , Guss Debra , Notar-Francesco Vincent
Published: October 2019

INTRODUCTION:

The vaginal bowel-control system (VBCS) is a novel design consisting of a reversible dynamic vaginal balloon insert that mimics the continence mechanism in the rectum to help control fecal incontinence (FI) in women. We performed a meta-analysis using data from four prospective open-label trials that investigated the efficacy and safety of this novel device at 1- or 3-month intervals.

METHODS:

PubMed, EMBASE and Cochrane Library databases were searched by two independent investigators using the terms fecal incontinence and vaginal bowel control, vaginal control, vaginal device, or vaginal. Only studies where a VBCS was used and where the response in FI was followed for 1 month or longer were included. Case reports were excluded and there were no case series or randomized controlled trials found. Meta-analysis using the fixed-effect model was performed to illustrate the pooled estimates.

RESULTS:

Four prospective open-label proof of concept clinical trials were identified. All patients were above 18 years of age and the size of the studies ranged from 5 to 63 patients. Patients were followed for 3 months in three studies and for 1 month in one study (n = 9). A response in FI was defined as a >50% improvement in the number of incontinent episodes compared to baseline in 3 out of the 4 studies, with the fourth study (n = 5) defining clinical improvement as a subjective qualitative improvement experienced by the patients. There was little heterogeneity across the studies. The overall estimated proportion of patients experiencing a response in FI was 85%, with a 95% confidence interval (CI) of 0.77 to 0.90. The overall adverse event rate was 18% with a 95% CI of 0.11 to 0.26. No patients experienced severe adverse events in any of the studies. Patient satisfaction was 89% with a 95% CI of 0.82 to 0.94.

CONCLUSION:

While recognizing that the number and quality of the studies available on the VBCS to treat FI are limited, the current analysis provides preliminary evidence that the VBCS may be considered a non-invasive, reversible, safe, and efficacious tool to control symptoms of FI in women in the short term, while achieving adequate patient satisfaction. Further validation on the practicality of this device can only be attained through long-term, large controlled studies, preferably randomized controlled trials.
157 Clinical Burden of Recurrent Clostridioides difficile Infection: A Real-World Data Analysis
Authors: Stong Laura , Nelson Winnie W. , Feuerstadt Paul , Boules Mena , Sacks Naomi , Portelli Alexandria , Healey Bridget , Lang Kathleen , Dahdal David N.
Published: October 2019

INTRODUCTION:

Clostridioides difficile infection (CDI), especially recurrent CDI (rCDI), is associated with high morbidity and resource utilization, imposing significant burden on the US healthcare system. This study evaluated the association of rCDI with medical procedures, complications, and medication use after an index CDI episode.

METHODS:

We performed a retrospective analysis of commercial claims data from the IQVIA PharMetrics Plus™ database for patients aged 18–64 years with CDI episodes requiring inpatient stay with CDI diagnosis code (ICD-9-CM 008.45; ICD-10-CM A04.7, A04.71, A04.72) or an outpatient medical claim for CDI plus a CDI treatment. We considered index CDI episodes from 1/1/2010 to 6/30/2017, including only those patients who were observable 6 months a priori and 12 months after the index episode. Each CDI episode was followed by a 14-day claim-free period after the end of treatment to distinguish rCDI from continuous CDI. rCDI was defined as another CDI episode within an 8-week window immediately after the claim-free period. Medication use, procedures, and complications were calculated over 12 months and stratified by number of rCDI episodes.

RESULTS:

46,571 patients with an index CDI episode were included, of whom 3,129 (6.7%) experienced 1 rCDI, 472 (1.0%) experienced 2 rCDI, and 134 (0.3%) had 3 or more rCDI episodes. Mean (SD) age was 47.4 (12.7) years, and 62.4% were female (similar across rCDI groups; Table 1). Mean baseline Charlson Comorbidity Index (CCI) scores were 1.15, 1.54, 1.83, and 2.29 for those with no rCDI, 1 rCDI, 2 rCDI, and 3+ rCDI episodes, respectively. Vancomycin was the most commonly prescribed antibiotic during follow-up (Table 2). Follow-up prescription rates of metronidazole decreased with increasing rCDI episodes. In the 12-month follow up, sepsis occurred in 16.5% of patients with no rCDI, 27.3% with 1 rCDI, 33.1% with 2 rCDI, and 43.3% with 3+ rCDI episodes; subtotal colectomy or diverting loop ileostomy was performed as a follow-up procedure for 4.6%, 7.3%, 8.9%, and 10.4% of patients, respectively, in the four study groups (Figure 1).

CONCLUSION:

There appears to be a stepwise increase in number of rCDI episodes associated with increasing baseline CCI score. During the 12 months after index CDI episode, the frequency of sepsis and colectomy increased in parallel to the number of CDI recurrences. Prevention of rCDI is an important step to reduce the burden of such complications.
159 The Role of Loperamide in Conjunction With Fecal Microbiota Transplantation (FMT) for Recurrent Clostridioides difficile Infection (rCDI)
Authors: Nayi Vipul , Brandt Lawrence , Aroniadis Olga
Published: October 2019

INTRODUCTION:

FMT has been shown to be a highly effective therapy for rCDI. It has been proposed that giving loperamide prior to FMT could further improve the effectiveness of FMT for rCDI because it can increase the amount of time donor stool is in contact with the recipient's colon before being expelled. Older studies, however, suggest that the use of loperamide during CDI may predispose to megacolon. The goal of this study was to evaluate whether loperamide given before FMT for treatment of rCDI, improves resolution rates.

METHODS:

A retrospective observational cohort study was conducted at Montefiore Medical Center in the Bronx, NY of pts 18–75 yrs old who underwent FMT for treatment of rCDI from 2014 to 2017. rCDI was defined as ≥3 bouts of CDI with recurrence of symptoms within 8 weeks of completion of antibiotic therapy. Participants were excluded if they had severe or complicated CDI; had IBD, IBS or a motility disorder; were immunocompromised; or did not complete the follow-up telephone survey. Data pertaining to loperamide use before FMT and resolution of diarrhea were obtained by chart review and telephone survey of participants. Cure of rCDI was defined as resolution of diarrhea at 8 weeks of FMT. Bivariate analyses were performed to compare rCDI cure rates and adverse events between those who did and did not take loperamide before FMT.

RESULTS:

15 pts who underwent FMT for rCDI met inclusion criteria. Most participants were female (n = 12, 80%). Mean age was 53 ± 20 yrs. Participants had undergone an average of 2.5 ± 0.7 different courses of antibiotics before FMT. 14 of 15 pts reported resolution of diarrhea at 8 weeks (93%). 6 of the 15 pts took loperamide peri-procedurally (40%), all of whom experienced cure of rCDI compared with 8 of 9 pts who did not take loperamide (100% vs 89%, respectively; P > 0.99). Pt-reported FMT-related adverse events included subjective fever (n = 2, 13.3%), lactose intolerance (n = 1; 0.7%), celiac disease (n = 1, 0.7%) and rectal bleeding (n = 1, 0.7%), all of which occurred in the group who did not take loperamide.

CONCLUSION:

In our cohort, FMT was highly successful for the treatment of rCDI. rCDI cure was similar between groups who did and did not receive loperamide, which may be attributable to the overall high rCDI cure rates reported. In our small study, loperamide did not result in increased FMT-related adverse events. A future trial randomizing patients with rCDI to loperamide vs placebo might provide additional insight.
160 Endoscopic Full-Thickness Resection of Gastrointestinal Lesions With the Over-The-Scope Device: A Single Center Experience
Authors: Fahmawi Yazan , Kumar Manoj , Bercier Baret , Mando Rufaat , Mizrahi Meir
Published: October 2019

INTRODUCTION:

While endoscopic transmural resection (EMR) and endoscopic submucosal dissection (ESD) are the conventional endoscopic resection methods for gastrointestinal (GI) lesions, endoscopic full-thickness resection (eFTR) is a promising minimally invasive modality for gastrointestinal lesions resection with good outcomes and less complications compared to EMR and ESD. Full thickness resection device (FTRD) is an over-the-scope device that has been developed for one-step eFTR. In this study, we report our experience with FTRD for GI lesions.

METHODS:

We retrospectively analyzed data from 17 patients who underwent eFTR with FTRD at our institution. Complete resection (R0), technical success, and clinical outcomes were studied.

RESULTS:

The indications for eFTR were recurrent/residual adenoma (12 cases), primary non-lifting adenoma (2 cases), submucosal lesions resection (2 cases), and early carcinoma (1 case). Eleven patients were males and six were females. The median age was 60 years (range 32–84). Locations of the lesions were: (3) in the cecum, (8) in the ascending colon, (2) in the transverse colon, (2) in the hepatic flexure, (1) in the rectum, and (1) in the stomach. Technical success rate was 13/17 (76%). Three of the unsuccessful attempts were due to inability to advance the endoscope to the cecum in one case and inability to pull up fibrotic lesions in the other two cases. The fourth unsuccessful case was due to device malfunction as the lesion was snared but the clip was not deployed. The mean maximum diameter of lesions after resection was 18.3 mm (range 13–22). R0 resection rate was 14/14 (100%). Microscopic full-thickness resection was achieved in 43% (6/14). The median procedure time was 67 minutes (range 31–140). The case with the device malfunction was complicated by perforation and delayed minor bleeding. The perforation was managed during the procedure with hemostatic clips. Another case had delayed minor bleeding without requiring blood transfusion. All patients were discharged on the same day except patients with complication as they required 1–2 days of inpatient observation.

CONCLUSION:

Discussion eFTR using FTRD is a safe minimally invasive procedure with good clinical outcomes. eFTR is currently indicated for treatment of non-lifting lesions, incomplete polypectomy, submucosal.
171 Role of Toxin A/B and GDH Negativity Differentiating Colonization Versus Active Infection in Presence of Positive PCR Results
Authors: Curras-Martin Diana , Copca-Alvarez Albino , Carson Michael P. , Rojtman Albert , Liu Edward
Published: October 2019

INTRODUCTION:

2018 IDSA guidelines recommend testing for Clostridioides difficile infection (CDI) in patients with 3 loose bowel movements in 24 hours and known risk factors for CDI. Optimal testing strategy is not clear although a two-step algorithm is now recommended: glutamate dehydrogenase [GDH] plus toxin EIA; GDH plus toxin, arbitrated by PCR; or PCR plus toxin. C. diff PCR is a sensitive test and can indicate CDI but also may reflect colonization. Many institutions use PCR testing solely in CDI diagnosis, leading to potential overdiagnosis. The aim of this study was to determine, among patients with positive PCR samples at Meridian hospitals, whether a positive GDH and toxin would correlate better with clinical diagnosis of CDI than positive PCR/neg GDH.

METHODS:

Chart reviews of patients positive for toxigenic C.Diff by PCR that detects the tcdC gene was performed. Positive PCR samples were also tested for GDH and toxin A/B by enzyme immunoassay (EIS) using C. DIFF QUIK CHEK COMPLETE (QCC; TechLab, Blacksburg, VA, USA) between 12/2018 and 1/2019 at our institution. Clinical and lab data were obtained to help determine accuracy of lab test results.

RESULTS:

110 patients were positive for PCR and tested also for GDH/toxin. 73 (66%) were female, mean age was 67 years. Primary outcome: 16% (n = 18) were PCR positive but negative for both GDH and Toxin A/B. Among the 92 who were [GDH+], 45 (49%) were also [toxin A/B+]. Among those who were [GDH+] and [GDH−], at the time of diagnosis there were no statistically significant differences between the following: temperature, leukocytosis, creatinine or albumin at time of diagnosis, prior history of CDI, active malignancy, PPI use, recent laxative use, enteral nutrition or iodinated oral contrast (Tables 1 and 2). The mean number of days until diarrhea resolution was longer among [GDH-] (n = 18, 5.3 days) versus [GDH+] (n = 81, 3.6 days). Most patients were treated with oral Vancomycin.

CONCLUSION:

This data shows that a positive PCR for CDI was associated up to a 16% false positive rate with negative GDH. GDH status was not associated with significant differences in measured variables. The primary strength is this is the largest cohort reporting this type of analysis. The limitations of the study include incomplete retrospective clinical data obtained from EMR notes regarding morbidities that could explain the differences in time to resolution of diarrhea. Further study with more data is warranted and subset analysis of GDH+ with +/− Toxin EIA should be done.
188 Egg Breakfast Diet vs. Clear Liquid Diet Before Colonoscopy
Authors: Poudel Rosina , Winstead Nathaniel
Published: October 2019

INTRODUCTION:

The current regimen of clear liquid diet prior to colon prep is uncomfortable and often fraught with various issues resulting in non-compliance. This has lead to poor colonoscopy preparations delaying diagnosis and treatment, and raising healthcare costs. Recently better-tolerated diets have been studied one of which involves the “low residue diet.” This diet involves various food items that are believed to not only have a short GI course, but also stimulate gut motility. Among them include boiled or scrambled eggs. Several studies have been undertaken with results generally favorable for the low residue diet. No studies, to our knowledge, have been done specifically targeting a low socioeconomic population that may have limited food access or low literacy rates making it difficult to follow specific instructions. This study was designed to target such a group by devising simple and affordable instructions with the overall goal to increase patient satisfaction, compliance, and obtain adequate prep quality.

METHODS:

A single blinded study was devised that involved 72 patients, with 36 patients in the experimental arm (Egg Breakfast/Low Residue) and 36 patients, age and gender matched, in the conventional arm (Clear Liquid Diet). Study was carried out at a single hospital center with the following exclusion criteria: egg allergy, known history of gastroparesis or chronic constipation. Patients were instructed to have 1–2 boiled/scrambled eggs in the morning prior to colonoscopy and continue with clear liquids and then the standard bowel prep that evening. The performing gastroenterologist was not aware of which patients were in the study.

RESULTS:

The quality of the colonoscopy preparations was separated in poor, fair, adequate, and good. The results revealed 75% (27) of the patients in the experimental group with either adequate or good prep quality versus 72% (26) in the conventional group. This left 25% for poor/fair prep in the experimental and 28% in the conventional.

CONCLUSION:

In conclusion, the data collected yielded comparable results between the two arms. Moreover, when considering factors such as tolerably or satisfaction, Egg Breakfast Diet appears to be superior to conventional. Thus, this study despite targeting a challenging group of a low socioeconomic population with poor access to resources, limited funds, low literacy rates achieved its overall goal to increase patient satisfaction yet still maintain standard if not better results with colonoscopy prep quality.
196 Caffeine Consumption and the Colonic Mucosa-Associated Gut Microbiota
Authors: Gurwara Shawn , Dai Annie , Ajami Nadim , El-Serag Hashem B. , Graham David Y. , Jiao Li
Published: October 2019

INTRODUCTION:

Studies have demonstrated health benefits of caffeine consumption, including decrease in cardiovascular disease, diabetes, and liver diseases. The exact mechanisms are not known. Caffeine consumption may possibly modulate the gut microbiome and therefore affect health and disease risk. We examined the association between caffeine consumption and the composition and structure of the colonic-gut microbiota.

METHODS:

In this study, 34 participants underwent a screening colonoscopy and had endoscopically normal colons. We obtained a total of 97 snap-frozen colonic mucosa biopsies from various segments of colon from these individuals. Microbial DNA was extracted, and subsequently amplified for the 16S rRNA gene V4 region and sequenced using the Illumina MiSeq platform. We analyzed the sequencing data using the UPARSE and SILVA database for operational taxonomic unit (OTU) classification. Self-administered BLOCK Food Frequency Questionnaire was used to ascertain daily caffeine consumption. We compared the diversity and relative abundance of bacterial taxonomies by high (≥82.9 mg) vs. low (<82.9 mg) consumption of caffeine. False discover rate (FDR) P-values were reported and <0.05 indicated statistical significance.

RESULTS:

The alpha diversity was the greatest in high caffeine consumers (Shannon index P < 0.0001). The beta diversity differed significantly between high vs. low caffeine drinkers (P = 0.0001). The composition of microbiomes did not differ at the phylum level based on caffeine consumption. At the genus level, high caffeine consumption was associated with increased relative abundance of Faecalibacterium (P < 0.0005) and Roseburia (P = 0.02), but decreased levels of Erysipelatoclostridium (P value <0.001) and an OTU belonging to the Lachnospiraceae family (Unc8895) (P < 0.0005). The observed association was seen regardless of age and dietary quality. Other bacteria commonly detected in gut microbiomes, including Odoribacter, Dialister, Fusicatenibactor, Alistipes, Blautia, and multiple members of Lachnospiraceae, were significantly more abundant (P < 0.05) in participants with higher caffeine consumption (Table 1).

CONCLUSION:

Higher caffeine consumption was associated with increased richness and evenness of the mucosa-associated gut microbiota, and higher relative abundance of anti-inflammatory bacteria, such as Faecalibacterium and Roseburia and lower levels of potentially harmful Erysipelatoclostridium.
200 Diagnostic Yield of Colonoscopy in Young Adults With Lower Gastrointestinal Symptoms in Multicenter Midwest Cohort
Authors: Lu Ray , Dave Devashree , Klair Jagpal S. , Kassim Thamer , Ashfaq Muhammad , Chandra Subhash , Murali Arvind
Published: October 2019

INTRODUCTION:

Serious gastrointestinal (GI) pathologies are common in older adults compared to young adults (≤40 years). There is a lack of data on the diagnostic yield of colonoscopy and flexible sigmoidoscopy in young adults with lower GI symptoms. We aimed to evaluate diagnostic yield of colonoscopy and compare overall diagnostic yield of colonoscopy versus flexible sigmoidoscopy in young adults with lower GI symptoms.

METHODS:

We reviewed diagnostic colonoscopies performed in young adults by 18 gastroenterologists at two different academic institutions between October 2016 to April 2019. Patients with family history of colorectal carcinoma were excluded. Diagnostic yield was calculated based on proportion of abnormal colonoscopy defined as having inflammatory bowel disease (IBD), microscopic colitis, advanced adenoma, or colorectal cancer (CRC). Presence of pathologies in left colon was considered for diagnostic yield of sigmoidoscopy.

RESULTS:

We included 454 patients with mean (SD) age was 31 (3) years, 162 (36%) were males and mean (SD) BMI was 30 (8.5). BRBPR was the indication for colonoscopy in 194 (43%) patients, 260 (57%) patients had colonoscopy for other lower GI symptoms (abdominal pain, diarrhea, constipation) but without BRBPR (Table 1). The overall diagnostic yield (DY) of colonoscopy in young adults with lower GI symptoms was 16%; IBD was seen in 43 (10%) patients, microscopic colitis 10 (2%), and advanced neoplasia/CRC 20 (4%) (Table 1). Overall DY in patients with BRBPR was significantly higher than patients without BRBPR (22% vs 11%, P = 0.001) (Table 2). The DY for IBD was also higher in young adults with BRBPR vs without BRBPR (15% vs 6%, P = 0.003) (Table 2). The overall DY was higher with colonoscopy compared to the predicted DY with flexible sigmoidoscopy (13.5% vs 9%) (Table 3).

CONCLUSION:

Significant proportions of young adults with BRBPR have abnormal pathology (22%) justifying endoscopic evaluation. For other lower GI symptoms, necessity of endoscopic evaluation should be determined clinically on a case-to-case basis as diagnostic yield is low. Colonoscopy rather than flexible sigmoidoscopy should be first line endoscopic evaluation in young patients with BRBPR due to the risk of missing IBD and advanced adenomas.
209 Improving the Diagnostic Stewardship of Clostridioides difficile Infection in a Health System
Authors: Elkafrawy Ahmed A. , Tomaw Andrew , Numan Laith , Saeed Lyla , Kaddourah Osama , Bennett Nicholas T. , Boyd Sarah
Published: October 2019

INTRODUCTION:

Clostridioides difficile infection (CDI) has been a significant burden for the US health care system in the US with an increasing number of cases diagnosed with CDI annually. Infectious Diseases Society of America (IDSA) and American College of Gastroenterology (ACG) have made recommendations for improved testing of C. difficiletoxin (CDT). This study aims to evaluate a quality improvement initiative to limit inappropriate CDT testing based on established testing criteria.

METHODS:

In December 2017 a new policy was implemented for CDT testing by polymerase chain reaction (PCR) in the eight acute care hospitals in the midwestern United States. The microbiology lab was granted authority to reject specimens for testing of CDT if the stool sample was formed, the patient had less than three loose bowel movements within 24 hours, used laxatives in the last 48 hours, was tested positive for CDT in the past 14 days or negative in the past 7 days. We performed a 12-month period pre and post-implementation assessment for patients with completed orders for CDT detection by PCR and the number of patients who were diagnosed with CDI over the defined periods. We looked at total tests performed as well as patients who had initial test orders canceled by the lab and then a second order which met the criteria for testing in the same hospital admission. These subgroups were classified to a positive or negative testing result for the CDT test. Patients characteristics, indicators of CDI severity, and clinical comorbidities were correlated between both groups.

RESULTS:

The number of completed orders for CDT detection with PCR and the number of cases diagnosed with CDI over the 12 months after policy application decreased by 36% and 35% respectively (Figures 1 and 2). 360 patients had CDT testing rejected by the lab post-implementation. Only 80 patients had CDT testing reordered and 16 patients of these tests were positive. In a comparison of the reordered testing, the only independent predictors of a positive test were age above 63-year-old (P 0.013) and serum creatinine (SCr) above 1.5 gm/dl (P 0.025) (Table 1).

CONCLUSION:

Stricter criteria for CDT testing decreased the number completed CDT ordered tests by 36% and overall CDI cases by 35%. Age greater than 63 and SCr above 1.5 gm/dl may be considered as indications for CDT testing even without fulfilling the criteria for testing. Further prospective studies are needed to identify other risk factors that should be considered independently for CDT testing.
221 Risk of Bone Density Loss in Microscopic Colitis
Authors: Greenberg Ian , Yen Eugene
Published: October 2019

INTRODUCTION:

Microscopic colitis (MC) is an inflammatory bowel disease of the colon that presents with chronic watery diarrhea. These patients have many risk factors for osteoporosis including female predominance, mean age in the 60s, lower body-mass index (BMI) and active smoking. Additionally the mainstay of therapy is a corticosteroid, budesonide. Bone density has not been rigorously studied in the population. Our aim was to evaluate for bone mineral density in patients with a diagnosis of MC with and without the use of corticosteroids.

METHODS:

We queried our prospective MC patient registry at NorthShore University HealthSystem, a clinical database of biopsy-confirmed patients with MC. Patients were included if they had a dual energy X-ray absorptiometry (DEXA) scan. DEXA measurements of the radius, femoral neck, and lumbar spine were used to evaluate bone mass. Baseline clinical factors were also collected, particularly tobacco use, BMI, and treatments for MC including corticosteroids. In this case-control study, age and gender-matched controls without diarrhea served as the control population.

RESULTS:

Of the 192 subjects in our registry, only 94 patients had undergone or had available bone density evaluations. The mean age at diagnosis was 69 years (range 42–91), with 91% female. No significant difference in rates of osteoporosis or osteopenia was observed in patients with MC (OR 1.58 [95% 0.75–3.30, P = 0.22]). Bone loss, defined as osteopenia or osteoporosis, was present in 82% of MC patients, compared to 75% in the controls. 76% of patients with MC received prolonged treatment with budesonide, and 24% received no steroids. A significant difference in bone mass was not appreciated between MC patients treated with a steroid, compared to controls (OR 1.15 [95% 0.33–4.03, P < 0.83]).

CONCLUSION:

Patients with MC have increased rates of osteopenia or osteoporosis compared to controls. However, our control cohort had a significantly higher degree of bone loss than current US estimates of 45–55%, which likely affected our statistical significance. Thus, bone loss is an underappreciated but important problem in microscopic colitis. With increased awareness, DEXA scans should be performed routinely in MC patients, particularly in those who have known risk factors for osteoporosis.
222 Biofeedback Therapy for Dyssynergic Defecation Is Effective Among Patients With Opioid Exacerbated Constipation
Authors: Spilman Samantha , Kunkel David
Published: October 2019

INTRODUCTION:

Up to 90% of patients on opioids complain of constipation (Wurzelmann et al, 2007). Among opioid users, causes of chronic constipation can be multifactorial and related to other contributing factors such as dyssynergic defecation (DD). Biofeedback (BFB) therapy has been shown to be effective in patients with DD, but has not been studied among those who have DD and are on opioids.

METHODS:

This study was a retrospective analysis of patients enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. For patients that had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each BFB visit.

RESULTS:

117 patients met criteria, of these, 20 patients were on active opioid therapy. Compared to those not on narcotic analgesics, opioids users were more likely to have a higher baseline defecation index (DI), intrarectal pressure divided by intra-anal pressure during simulated defecation (0.669 vs. 0.456 P < 0.0007). Decreased rectal sensation at baseline was seen in 20% of opiate patients and 19% of those not on opioids (P = 1.0). Opiate users compared to those not on narcotic analgesics also had a lower baseline health rating on the SF-36 scale (3.9 vs. 3.4 1-5 Likert scale P = 0.05) and were more likely to withdraw before completing a full course of BFB (P < 0.01). On stool diary, opiate users did not report a significant improvement in global bowel satisfaction rating (2.9 to 4.2, 10-point Likert scale P = 0.13), in contrast to non-opiate users who did repot improvement (2.7 to 4.9, P < 0.0001). Opiate users, however, had a significant decrease in number of stooling medications used (1.8 to 1.1 P = 0.04). On HR-ARM, there was a greater change in DI among non-opiate users as compared to opiate users. After BFB, opiate users effectively normalized their dyssynergia (79% improved) (P < 0.0001). Non-opiate users also showed significant improvement in normalizing their dyssynergia (74%) (P < 0.0001).

CONCLUSION:

Patients with opioid exacerbated constipation and DD showed meaningful clinical improvement in both subjective outcomes as well as manometric parameters. While they had lower baseline health rating at the outset and did not report significant improvement in global bowel satisfaction rating, unlike the non-opioid users, they nevertheless clearly benefited from BFB therapy. Overall, this data suggests that opioid users with DD may benefit from enrollment in BFB therapy.
236  Young Adults With Adenomas: How Does Their Risk for Metachronous Advanced Adenomas Compare With Older Adults?
Authors: Anderson Joseph C. , Butterly Lynn F. , Robinson Christina N.
Published: October 2019

INTRODUCTION:

Recent increases in colorectal cancer (CRC) incidence in adults less than 50 years of age have led to more colonoscopies in this age group. As a result, there is an increasing number of adults <50 with adenomas detected. We used data from the New Hampshire Colonoscopy Registry (NHCR) to explore whether these younger adults with adenomas are at higher risk for future advanced findings than older patients, potentially requiring closer follow-up.

METHODS:

Our cohort was NHCR participants with at least one adenoma and/or serrated polyp on index exam and a follow-up colonoscopy at least 1 year after the index exam. Outcomes were the absolute and adjusted metachronous risks of advanced adenomas (AA: adenomas >1 cm, with villous elements or high-grade dysplasia, or CRC) and large (>1 cm) serrated polyps (SP). Incomplete exams and patients with IBD or genetic familial syndromes were excluded. We present absolute risk and adjusted risks from a logistic regression model stratified by age at index colonoscopy (<40, 40–49, 50–59, and 60+ (ref)). Covariates include findings on previous and index colonoscopy, sex, smoking, body mass index (BMI), time to follow-up (months), bowel preparation quality, and family history of CRC.

RESULTS:

Time to follow-up did not vary with age in our sample of 10,116 adults (Table 1). Absolute risk for metachronous AA was lower for younger patients (P < 0.0001) (Table 1), with the lowest risk in patients <40, similar risks in the 40–49 and 50–59 groups, and highest risk in patients >60. Adjusting for covariates did not change findings (P = 0.003). Because younger adults were less likely to have index AAs, we performed a sensitivity analysis, excluding index exams with AAs, and observed no changes in results (P = 0.003). The metachronous risk for large SPs was not significantly associated with age (Table 2).

CONCLUSION:

Younger adults with index adenomas have a lower risk for metachronous AAs than patients >50. These data suggest that younger adults are not at higher risk for metachronous advanced neoplasia than older adults. The data also suggest that surveillance intervals recommended by current guidelines for adults >50 years may be safe to apply to younger adults.
241 A Care Model for Optimization of Colorectal Cancer Screening in Western Pennsylvania
Authors: Umar Shifa , Cole Rita , Syed Aslam , Shankar Pallavi , Neff Carole , Fischer Michael , Reynolds Samuel , Snyder Gabrielle , Thakkar Payal , Aoun Elie , Farah Tony , Thakkar Shyam , Farah Katie
Published: October 2019

INTRODUCTION:

Our Health Network and insurance provider collaborated to focus on a Care Model for colorectal cancer (CRC) screening to address barriers to screening. This Care Model corresponds to a manner in which healthcare services are delivered while outlining best practices and services to patients as they progress through stages of colon cancer (Figure 1). Well-known barriers to CRC screening include lack of transportation, lack of primary care physician (PCP) involvement and education, apprehension about the prep and/or complications, and certain ethnicities.

METHODS:

Our Health Network and insurance provider worked together on the GI Care Model to address underutilization of CRC. The team interviewed PCP practices in the region to identify their processes for screening. The team performed a geographical analysis identifying screening rates for Western PA and the city of Pittsburgh by zip code and socioeconomic status. Transportation status, PCP status, age, and ethnicity as well as socioeconomic status were evaluated. The team then used this information to implement initiatives targeted at reducing and eliminating these barriers.

RESULTS:

PCPs expressed lack of updated knowledge regarding the latest colon cancer guidelines and challenges in scheduling a procedure. 122 healthcare professionals attended the webinar series in the first quarter. Feedback was overwhelmingly positive with requests for further education on a quarterly basis. Screening rates were higher if a patient had a PCP vs no PCP (Table 1). A Best Practices Alert was generated and sent by massmail to all healthcare practitioners across the region which outlined the latest recommendations with respect to screening. Difficulties in scheduling were optimized by providing flow diagrams of the scheduling process. We found that the strongest correlation to a lack of screening was lack of a vehicle (Table 2). The PALS (People Able to Lend Support) volunteer program was implemented for patients who had no vehicle. A patient education program (Doc Talks) was also offered to patients in the community at selective health insurance retail stores. Opportunity to answer questions and address fears of procedure were discussed.

CONCLUSION:

The GI Care Model has made significant progress in increasing awareness, education, access, and identification of common barriers which contribute to underutilization of CRC screening in our region. We will be addressing the barriers by ethnicity in future months as part of our Care Model.