bluuebunny/crossref_metadata_2025 huggingface dataset:
2887 Bowel Preparation Adequacy in a Direct Access Screening Program
Authors: Francis Gloria , French Brenda , Ahuja Amisha , Garrido Daniel , Daskalakis Constantine , Kastenberg David
Published: October 2019

INTRODUCTION:

Direct access colonoscopy (DAC) pathways facilitate access to colon cancer screening. However, the absence of a pre-procedure office visit may increase the risk for inadequate colon cleansing, particularly in patients (pts) already at high risk for this. The aim of this pilot study was to establish non-inferiority of preparation (prep) adequacy for high-risk patients receiving high-dose (HD) purgative versus average-risk patients receiving standard-dose (SD) prep.

METHODS:

This was a retrospective single academic center study. HD assignment for DAC was based on any of the following criteria: chronic constipation (<3 BM/week), medications (narcotics, tricyclics, or calcium channel blockers), diabetes mellitus (DM) on medication, stroke, BMI >35, or prior inadequate prep. All pts received a PEG based prep. HD was defined as >2L PEG-ELS/vitamin C (MoviPrep®), >4L of PEG-ELS, or >2L PEG 3350-sports drink. Prep adequacy (BBPS of ≥2 per segment) was compared between the HD and SD groups, with a 12% relative margin of non-inferiority (relative risk = 0.88). Assuming an overall 85% adequacy rate, 140 patients per group would give the study 80% power. Secondary outcomes were comparison of inadequate prep risk factors between study groups.

RESULTS:

We identified 1,522 pts who received DAC over 11 months. 156 pts were excluded due to no electronic prep order or non-PEG prep use. These interim analyses are based on all 59 HD pts and a subset of 140 of the 1307 SD pts. The adequacy rates were 92% for HD (54/59) versus 99% for SD (139/140), failing to establish non-inferiority (P-value = 0.17). Predictably, HD pts were more likely than SD pts to have prior inadequate preparation (19% vs. 0%), to be obese (68% vs. 39%), to have chronic constipation (15% vs. 6%), to have DM on medication (32% vs. 16%), and to be using narcotics (10% vs. 5%) or tricyclics (5% vs. 1%).

CONCLUSION:

Despite miss-assignment of many pts high risk for inadequate prep to SD, we found high rates of adequate cleansing in all DAC pts. Improper prep assignment and retrospective design allowing examination of only electronic (and not telephone) orders likely contributed to fewer pts than expected in the HD arm. This interim analysis does not establish non-inferiority of the HD prep for pts high risk for prep failure. Future efforts will focus on analyzing and correcting the cause for pt miss-assignment and prospectively evaluating prep adequacy in these two groups.
2898 Factors Influencing the Length of Hospital Stay in Patients With Non-Variceal Upper Gastrointestinal Bleeding
Authors: Rassameehiran Supannee , Tetangco Eula Geralyn , Tan George , Rakvit Ariwan
Published: October 2019

INTRODUCTION:

Upper gastrointestinal bleeding (UGIB) is one of the most common GIemergencies, which frequently requires hospitalization. This condition accounts for 400,000 hospital admissions per year and costs more than $2 billion annually. The purpose of our study was to identify risk factors associated with prolonged hospital stay in non-variceal UGIB patients.

METHODS:

We conducted a retrospective study through an electronic medical record review of patients admitted at University Medical Center, Lubbock, Texas between January 2012 and December 2015. Patients older than 18 years with UGIB identified by the ICD-9 diagnosis code 578.9 (hemorrhage of gastrointestinal tract, unspecified) were enrolled into the study. Admissions were excluded if patients did not undergo EGD or if they had documented underlying cirrhosis. Statistical Package for Social Sciences (SPSS™) version 22 was used for statistical analysis.

RESULTS:

143 patients met inclusion criteria. 83 were men (58.0%), 92 were Caucasian (64.3%), 33 were Hispanic (22.4%), and the mean age was 60.9 + 17.1 years. 33% of patients requiring FFP transfusion underwent endoscopic therapy. The mean length of stay (LOS) was significantly increased in patients requiring endoscopic therapy, FFP transfusion, and inthose who had underwent EGD after 24 hours. LOS was also significantly increased in patients that presented with acute kidney injury (AKI) or hypoalbuminemia. There was no correlation between prolonged hospital stay and Glasgow-Blatchford bleeding score, pre-endoscopic Rockall score, Rockall score, AIMS65 score, shock index score, PRBC transfusion, the use of NSAIDs, antiplatelet drugs, or anticoagulants.

CONCLUSION:

Our study demonstrates that delayed EGD (after 24 hours), endoscopic therapy, the need for FFP transfusion, and acute kidney injury are associated with prolonged hospital stay. Coagulopathy requiring FFP transfusion and AKI reflects the severity of UGIB. Urgent EGD and endoscopic intervention in these patients may decrease the LOS and improve outcomes.
2902 Using Data Aggregation to Determine Thematic Knowledge Transfer and Lasting Performance Change in Multiple Continuing Education Activities on IBD
Authors: Faler Whitney E. , Perez Jan S. , Tordoff Shari , Gross Tara , Salinas Gregory D.
Published: October 2019

INTRODUCTION:

Often, implications of the effect of CME is difficult to determine due to reliance on single data points of pre-post knowledge questions. Using aggregation methodology, we were able to thematically combine the assessments of 3 similar educational activities to determine the immediate and lasting effect of education on IBD practice.

METHODS:

Surveys were designed based on learning objectives of 3 accredited CME activities on IBD. Outcomes measurements were taken directly before and after the activities, as well as 3-months after activity completion. This 3-month follow-up sample was matched at the same time to a control sample of clinicians who did not participate in the education.

RESULTS:

Based on the themes of the pre-post questions, we were able to aggregate the scores of the three activities and determine overall changes in understanding key risk factors, establishing appropriate goals, choice of guideline-based therapy, and knowledge of clinical trials. Compared to pre-activity, learners had significant improvements in each of these areas, showing effectiveness of the education. Hodge's g effect sizes were run on all pre-post data to better compare the effect of education across themes. The most robust effects were seen in recognizing risk factors (g = 0.75) and clinical trial results (g = 0.71) while more modest effects were seen in establishing goals of treatment (g = 0.40) and selecting treatment (g = 0.59). Some of this modest effect seen in establishing goals can be attributed to a high baseline level of knowledge (a pre-score of 70.8%). However, looking at the scores of learners compared to a control group of similar clinicians that did not attend the education, robust effects can be seen even 30 days after the activity. Assessment of risk had an effect of 0.67 while establishing goals (g = 0.81) and treatment choice (g = 0.85) had even higher effects.

CONCLUSION:

Aggregating the outcomes of multiple educational activities allows us to understand effect by theme, providing opportunities to inform key stakeholders of the value of educational interventions. Further it allows educators opportunities to understand the continuing need of the community that has not attended these activities, and focus future interventions on improving areas where they are needed most.
2905 Adherence to the Crohn's and Colitis Foundation's IBD Anemia Care Pathway: Treatment of Iron Deficiency Anemia in IBD
Authors: Blaney Hanna , Mathew Antony , Snelling Robin , England Julie , Duong Camille , Shaver Courtney , Keum Yo Sup , Johnson Christopher
Published: October 2019

INTRODUCTION:

Anemia is the most common systemic complication of inflammatory bowel disease (IBD), with reported prevalence up to 74%. Anemia is associated with worse disease outcome and quality of life. However, anemia in this population is often underdiagnosed and untreated. The Crohn's and Colitis Foundation (CCF) recently published a care pathway for anemia. Our aim was to assess adherence to the CCF's IBD Anemia Care Pathway in treatment of iron deficiency anemia (IDA) at a tertiary referral center in Texas.

METHODS:

A retrospective chart review including patients 18 years of age and older in our electronic record system with IBD who had a CBC, an outpatient encounter with gastroenterology, and no hospitalizations from 2014-2018. Demographic, laboratory, and anemia treatment was extracted from electronic records. IDA was defined per the CCF anemia care pathway. Active IBD was defined by elevated CRP and/or fecal calprotectin.

RESULTS:

341 patients were included in the analysis, 65 (19%) of which had IDA. Of these anemic patients, 43 (66%) had CD and 16 (32%) had UC, with 1 (2%) patients unspecified. 34 (52%) patients had evidence of active IBD, with 3 (9%) receiving IV iron and 10 (29%) receiving oral Fe. In the 31 patients with inactive IBD, 3 (10%) patients received IV iron and 5 (16%) received oral Fe.

CONCLUSION:

Active IBD is known to decrease enteral iron absorption and current recommendations encourage parenteral treatment of iron deficiency in patients with IDA and active IBD. In this study, we demonstrate that a limited number of patients with active IBD and IDA received recommended parenteral iron. These results demonstrate that system-wide education is needed regarding recommended IDA treatment based on IBD activity. Future studies at our institution aim to improve this trend.
2910 Immunization Rates in Inflammatory Bowel Disease Patients at the G.V. (Sonny) Montgomery VA Medical Center
Authors: Iqbal Sara , Paine Elizabeth
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) patients are more prone to developing vaccine-preventable illnesses and therefore vaccinating these patients in our outpatient clinics needs to be a priority. In light of this crucial IBD patient care need, we conducted a quality improvement project centered on rates in the Gastrointestinal (GI) clinics at the G.V. (Sonny) Montgomery VA Medical Center.

METHODS:

We provided same educational session for both GI fellows and GI nurse practitioners and reviewed the rates in each group for two months before and after this session. During the four-month study period, 29 IBD patients were seen by fellows and 34 by nurse practitioners.

RESULTS:

During the four-month study period, 29 IBD patients were seen by fellows and 34 by nurse practitioners. For the fellow cohort, 19 IBD patients were seen before the educational intervention and 10 patients were seen after it. Nurse practitioners saw 12 patients before and 22 patients after the educational sessions. GI fellows' vaccine administration increased after the educational session for Zoster, pneumovax, Hepatitis A, and Hepatitis B. GI Nurse practitioners' vaccination of IBD patients increased after the session for Zoster, influenza, and pneumonia vaccines. Overall, the GI nurse practitioners had higher vaccination rates than the GI fellows before and after the educational sessions.

CONCLUSION:

Our study showed that GI fellows who rotated in the VA GI Clinic on alternate months had more difficulty in making sure that IBD patients were current on their vaccinations as compared to the GI nurse practitioners who regularly follow their IBD patients in continuity. This study also showed that a one-time educational session can improve vaccination rates but is unlikely to result in complete compliance with vaccine guidelines. Periodic reinforcement and monitoring of these vaccine rates will need to be done. Other observations made during the study included that the nurse practitioners have a clinic note template addressing vaccine status in their treatments plans; however, GI fellows have not incorporated this template. This template was felt to make a great difference in terms of the documentation, reminder about vaccines during the next clinic visit and simple inquiry about the vaccinations. In light of this, moving forward, incorporation of this note template into all IBD clinic visits is recommended.
2921 Correlation Between the Cumulative Risk of Surgery and Timing of Anti-TNF Initiation in Crohn's Disease
Authors: Jahandar Donya R. , Young Chase K. , Hamdeh Shadi , Kalot Mohamad , Makki Maha , Olyaee Mojtaba
Published: October 2019

INTRODUCTION:

Despite their effectiveness in the management of Crohn's disease (CD), anti-tumor necrosis factor medications' use is often delayed until patients fail conventional therapy. There is more evidence in the literature that the early use of anti-TNF in the disease course may improve the long-term outcomes and decrease the risk of complications. However, the optimal time to start these agents is not well defined. In our study, using patient data at the University of Kansas Medical Center, we aimed to determine the cumulative risk of surgery based on the use of anti-TNF agents during the disease course.

METHODS:

A retrospective cohort study was conducted evaluating CD patients on anti-TNF agents (infliximab, adalimumab, and certolizumab pegol) seen at the University of Kansas Medical Center until May 2018. The primary outcome was the cumulative risk of surgery based on anti-TNF initiating time.

RESULTS:

A total of 229 patients with CD were enrolled, 143 in the early anti-TNF alpha group and 86 in the late group. Total of 128/229 required surgery. Our analysis demonstrated a positive correlation between the cumulative incidence of surgery and the duration between diagnosis and initiating anti-TNF alpha therapy. In fact, initiating anti TNF at the time of diagnosis prevented the need for surgery for 80-100% of patients. Whereas initiating anti TNF within 10 years of diagnosis prevented the need for surgery in 50% of the patients and more than 80% of patients who started anti-TNF alpha therapy after 20 years of diagnosis had a need for surgery.

CONCLUSION:

Our study suggests an increased risk of surgery in Crohn's disease patients with the late use of anti-TNF. Early initiation of anti-TNF alpha therapy at the time of diagnosis was associated with the least risk of the need for surgery.
2942 Cenicriviroc (CVC) for the Treatment of Liver Fibrosis in Adults With Nonalcoholic Steatohepatitis (NASH): AURORA Phase 3 Study Design
Authors: Anstee Quentin M. , Neuschwander-Tetri Brent A. , Wai-Sun Wong Vincent , Abdelmalek Manal F. , Younossi Zobair , Alkhouri Naim , Yuan Jiacheng , Pecoraro Maria Lucia , Seyedkazemi Star , Fischer Laurent , Bedossa Pierre , Goodman Zachary , Sanyal Arun
Published: October 2019

INTRODUCTION:

CVC, a novel, oral, and potent inhibitor of C-C chemokine receptor types 2 and 5, was well tolerated and demonstrated clinically meaningful antifibrotic activity in a 2-year Phase 2b study. The AURORA Phase 3 study will assess the efficacy and safety of CVC for the treatment of liver fibrosis in adults with NASH.

METHODS:

AURORA is a global, multicenter, randomized, double-blind, placebo-controlled study (NCT03028740) which will enroll 2000 subjects to evaluate a surrogate histology endpoint in the first 1200 subjects and clinical outcomes in the totality of enrolled subjects (∼2000 subjects) (Figure 1). Subjects will be randomized 2:1 to receive CVC 150 mg or placebo orally once daily with food. Adults aged 18–75 years with histologic diagnosis of NASH and Stage 2 or 3 liver fibrosis per NASH Clinical Research Network classification will be enrolled (≥60% with Stage 3). Subjects with cirrhosis or other known causes of chronic liver disease will be excluded. Liver biopsies will be performed at screening and Months 12 and 60 and will be evaluated by a central pathologist. An online tool (AURORA Toolbox) was developed to help assess the individual risk of fibrotic NASH (low, intermediate, or high) to inform pre-screening and whether to conduct a new liver biopsy during screening.

RESULTS:

The primary endpoint of improvement in fibrosis by ≥1 stage (NASH Clinical Research Network) AND no worsening of NASH (lobular inflammation or hepatocellular ballooning) on liver histology at Month 12 relative to screening biopsy will be evaluated in the first 1200 enrolled subjects. The key secondary endpoint will be improvement in fibrosis by ≥2 stages AND no worsening of NASH. Another primary endpoint to be evaluated in all 2000 enrolled subjects will be time to first occurrence of any adjudicated events of mortality (all causes), progression to cirrhosis (defined by NASH fibrosis Stage 4), liver transplant, Model for End-Stage Liver Disease score ≥15, ascites, or liver decompensation. The study will be terminated when adjudicated events have been accrued in 367 unique subjects overall. Safety, patient-reported outcome measures, serum hepatic fibrosis indices, liver stiffness measure, and biomarkers of systemic inflammation will also be evaluated.

CONCLUSION:

The AURORA Phase 3 study aims to confirm the efficacy and safety of CVC for the treatment of liver fibrosis in adults with NASH.
2956 The Utility of Repeating Paracentesis in Patients With Cirrhosis and Low SAAG Ascites
Authors: Salazar Miguel , El-Khider Faris , Mbachi Chimezie , Elkhouly Mohamed A. , Mathew Madhu , Vohra Ishaan , Kumapley Rudolf , Paintsil Isaac , Simons-Linares C. Roberto
Published: October 2019

INTRODUCTION:

The use of serum-ascites albumin gradient (SAAG) is widely stablish and a key part for the workup of ascites. It can differentiate portal hypertension (cirrhosis) from non-portal hypertension causes (malignancy, tuberculosis, nephrotic syndrome, pancreatic ascites), however literature on the interpretation and value of a low SAAG ascites in patients with cirrhosis is very limited and its clinical significance is unclear. Our aim was to investigate patients with cirrhosis who had low SAAG ascites, the presence of a causative factor not related to portal hypertension and the value of repeating paracentesis for SAAG re-assessment.

METHODS:

We conducted a retrospective designed study in which we obtained a cohort of patients with low SAAG ascites defined as <1.1 g/dl, between the years of 2008 to 2017 in a single large tertiary community Hospital in Chicago, IL. Cirrhosis was defined by clinical, histopathological and radiological findings. Non-portal hypertension causes were reviewed including bacterial peritonitis, peritoneal carcinomatosis, nephrogenous ascites, tuberculous peritonitis, chylous ascites and pancreatic ascites. Receiver operating curve and multivariable logistic regression models using SAS software version 9.4 were performed.

RESULTS:

A total of 77 patients were evaluated, of whom 53 (69%) were patients with cirrhosis and 24 (31%) without cirrhosis. Patients with cirrhosis were more likely to be males, smokers, alcoholics (Table 1). 47 (89%) patients had a repeat paracentesis that allowed re-calculation of the SAAG. 13 (28%) patients had persistent low SAAG ascites: 3 cardiac, 2 tuberculosis, 1 pancreatic, 1 malignancy and 6 idiopathic. 7 (53%) out of the 13 had identifiable secondary etiology that explained the low SAAG and in 1 (7.7%) case, malignant ascites was diagnosed. Importantly, in 34 (72%) patients the SAAG changed to high SAAG. Of note, the repeat SAAG in those with low SAAG was not difference from the initial one (mean 0.71 vs. 0.84, P = NS).

CONCLUSION:

High SAAG >1.1 g/dl is specific for cirrhosis as shown in previous studies. However, in patients with known cirrhosis and a low SAAG <1.1 g/dl further evaluation with a repeat paracentesis is recommended; in patients with a persistent low SAAG value up to 53% a secondary etiology of the ascites was identified, including malignancy, in these cases we recommend further investigation to clarify the cause of the ascites.
2962 Pre-Operative Treatment of Hepatitis C Infection Decreases Post-Operative Complications in Patients Undergoing Knee and Hip Arthroplasty
Authors: Patel Harish , Abbas Hafsa , Baiomi Ahmed , Shehi Elona , Miranda Jeirym , Kirschenbaum Ira , Makker Jasbir , Meftah Morteza , Tariq Hassan , Bhandari Peter , Hanumanthu Siddarth , Balar Bhavna , Chilimuri Sridhar
Published: October 2019

INTRODUCTION:

Large joint surgeries, hip and knee arthroplasties, are often performed in individuals with hepatitis C infection. Hepatitis C has been identified as one of risk factors for the post-operative complications. There is scarcity of the data about the role of pre-operative hepatitis C treatment in decreasing the post-operative complications for patients undergoing hip and knee arthroplasties.

METHODS:

The retrospective review of the patient with hepatitis C infection who have undergone hip and knee arthroplasties from 2008 to 2015. Diagnosis of Hepatitis C was made based on the positive viral load. The study population is divided into two groups based on the sustained virologic response (SVR) after the hepatitis C treatment prior to the hip and knee arthroplasty surgery and those who did not have treatment prior to surgery. The baseline demographic data, laboratory parameters (Table 1) and post-operative course were reviewed from electronic medical records. AIM: To compare the post-operative outcomes for hip and knee arthroplasties, in patients with hepatitis C infection, based on prior hepatitis C treatment status (Table 2).

RESULTS:

There were 1187 hip and knee arthroplasties performed during study period. 11% of patients (n = 129) were positive for hepatitis C infection. In our study population hepatitis C infection is identified as the risk factor for post-operative infections. Among the patients with the hepatitis C infection 18.6% (n = 24) had received treatment with SVR prior to surgery. All patients were treated with the direct acting anti-viral agents (DAA). The mean age of the patients was 55 years and they were predominantly males (75%). The base line demographic and laboratory parameters were comparable between the two groups, except for serum albumin level, which was lower in patients with no prior hepatitis C treatment. The patients with liver cirrhosis were equally distributed in both groups. The patients with prior hepatitis C infection consistently demonstrated higher rates for post-operative complications including infection, bleeding and impaired would healing, whereas “zero” post-operative complications (infections, joint bleeding or wound dehiscence) were noted for the patients who had prior hepatitis C treatment with SVR.

CONCLUSION:

This retrospective review of patients with hepatitis C undergoing the hip and knee arthroplasties demonstrates a protective effect for post-operative complications in patients with prior hepatitis C treatment and SVR.
2965 Utilizing Fracture Risk Assessment Tool (FRAX) in Patients With Osteopenia Listed for Liver Transplant to Guide Treatment for Fracture Prophylaxis
Authors: Mushtaq Asim , Sood Gagan , Victor David W.
Published: October 2019

INTRODUCTION:

Low bone mineral density (BMD) is common in chronic liver disease and predisposes to fracture. FRAX score is a widely used web-based algorithm used to estimate fracture risk with or without dual-emission x-ray absorptiometry (DEXA). FRAX score has not been studied in patients listed for liver transplant. Aim of this study was to determine if FRAX score with DEXA is effective in patients with osteopenia listed for liver transplant to guide treatment for fracture prophylaxis.

METHODS:

104 consecutive patients who were actively listed for liver transplant at Baylor St. Luke's medical center were included. Clinical and demographic patient information was collected retrospectively. FRAX scores calculated with BMD data.

RESULTS:

104 patients (29 ALD, 26 HCV, 22 NASH, 27 others) were studied (mean age 56 ± 10, 59% male, 41% female, mean BMI 28 ± 5, mean MELD 17+8). All patients had bone mineral density assessed (13 [12%] were osteoporotic and 42 [40%] were osteopenic at the spine and/or hip. 4 [3.8%] had a previous osteoporotic fracture. Mean FRAX score for a 10-year probability of a hip fracture was 1.7% and a 10-year probability of a major osteoporosis-related fracture was 6.2% based on the US-adapted WHO algorithm. Among 40% osteopenic and 13% osteoporotic patients, only 3% and 8% of patients had significantly high FRAX score respectively.

CONCLUSION:

BMD FRAX score underestimated fracture risk in actively listed liver transplant patients. We believe this could be related to small sample size of the study and strict selection criteria for liver transplant listing. Majority of our study population was non-smoker, non-drinker and with a higher BMI. Therefore, future studies with bigger sample size would be helpful to utilize FRAX score to guide treatment in osteopenic patients for fracture prophylaxis.
2984 The Osteoarthritis of Celiac Disease: Incidence and Risk Factors of Osteoarthritis in Celiac Disease Cohort
Authors: Saleem Saad , Abu-Heija Ahmad , Then Eric O. , Weissman Simcha , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Osteoarthritis has been alluded to be an extra-intestinal manifestation of celiac disease, but definitive data about its association has been lacking. Therefore, we evaluated the association of primary osteoarthritis in celiac disease cohort and determined the risk factors for primary osteoarthritis.

METHODS:

A retrospective analysis was conducted using the de-identified data from the national health database, the Healthcare Cost and Utilization Project (HCUP). We identified the hospital encounters for “history of celiac disease” using international classification of Diseases (ICD-9) diagnostic codes from 2011 to 2014. We assessed the incidence of primary osteoarthritis in celiac disease population and independent predictors of by multivariate analysis. P-values less than 0.05 indicated a statistically significant association. The odds ratio and 95% confidence interval were also calculated. Data were analyzed using SPSS.

RESULTS:

A total of 29,446 history of celiac diease hospital visits were identified - 111 with primary diagnosis of primary osteoarthritis (case group) and 29,335 without osteoarthritis (control group). Comparing study group with control group, age - mean with standard deviation 64.15 + 11.04 yrs vs. 55.15 + 22.10 yrs (P < 0.001), sex - female 88 (79.3%) vs. 20846 (71.1%) (P = 0.057, Odds ratio [OR] = 1.56 (95% Confidence interval (CI) 0.98-2.5), race - Hispanic 7 (6.3%) vs. 1142 (3.9%) (P = 0.19, OR = 1.67, CI; 0.77-3.59), obesity 15 (13.5%) vs. 1454 (5%) (P < 0.0001, OR = 3.0, CI; 1.73-5.18), smoking 4 (3.6%) vs. 2829 (9.6%) (P < 0.03, OR = 0.35, CI; 0.13-0.95), nausea and vomiting 2 (1.8%) vs. 1219 (4.2%) (P = 0.214, OR = 0.42, CI; 0.104-1.716), diarrhea 0 vs. 1353 (4.6%), underweight 0 vs. 63 (0.2%), anemia 21 (19%) vs. 3293 (11.2%) (P = 0.01, OR = 1.85, CI; 1.15-3.0), constipation 11 (10%) vs. 1732 (5.9%) (P = 0.07, OR = 1.75, CI; 0.94-3.27). The odds of developing osteoarthritis among celiac diease population was significantly higher (adjusted odds ratio [aOR] = 1.59, CI; 1.18-2.13, P < 0.001) (shown in Figure 1).

CONCLUSION:

This study concluded up to 59% increased likelihood of primary osteoarthritis in the celiac diease patients. Older age, obesity and celiac diaese showed greater odds of developing primary osteoarthritis. Further studies are needed to determine the association between gluten free diet and its effect on osteoarthritis.
2992 Systematic Review of Gastrointestinal Angiomyolipoma
Authors: Zafar Yousaf , Gondi Keerthi , Muthukumar Varsha , Luke Alex
Published: October 2019

INTRODUCTION:

Angiomyolipoma (AML) is a rare tumor composed of adipose tissue, smooth muscle, and abnormal blood vessels. Although most commonly, occurring in the liver and kidney, it has been described to occur in the gastrointestinal tract (GI AML). A systematic review has not been performed to investigate its clinical characteristics.

METHODS:

We conducted a systematic review of the literature to identify all published cases of GI AML in the literature between 1980 and 2019. All available cases were analyzed for clinical characteristics and outcomes. Statistical analysis was mainly descriptive.

RESULTS:

16 cases of GI AML were identified. The majority of patients were male (81.3%) and of old age (mean = 61.3 years). GI AML most commonly occurred in the stomach (62.5%) followed by the colon (25%) and duodenum (12.5%). It commonly presented with gastrointestinal bleeding and fatigue. Computed tomography most commonly revealed a submucosal, well-circumscribed lesion with varying intensity in the mass. 100% of cases were benign, with only one case of recurrence following surgical resection.

CONCLUSION:

GI AML is a rare condition which commonly presents in the stomach and colon. Morbidity is minimal, and surgical resection is commonly curative with low recurrence. Future studies are necessary to characterize its etiology and association with other conditions.
3027 Lipase Stands Out: Is It Sufficient to Diagnose Acute Pancreatitis?
Authors: Neupane Sunita , Shrimanker Isha , Sapna Fnu , Bhandari Binita , Nookala Vinod
Published: October 2019

INTRODUCTION:

Acute pancreatitis is defined when two out of the three diagnostic criteria are present such as abdominal pain often radiating to the back, characteristic imaging findings, and amylase and/or lipase levels that are three times or more the upper limit of normal (ULN). We present the case of an elderly male with abdominal pain and isolated raised lipase concentrations treated as acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 96-year-old male with a history of dementia, coronary artery disease, hyperlipidemia, presented with sudden onset right-sided abdominal pain and six episodes of vomiting that started a few hours prior. He denied constipation, diarrhea, and fever. The patient does not drink alcohol or smoke. On arrival, he had a pulse of 77 beats/minute, blood pressure of 165/88 mm Hg, respiratory rate of 16 breaths/minute and oxygen saturation of 93% on room air. Physical exam revealed bilateral pedal edema along with significant tenderness in the right lower quadrant with mild tenderness in the right upper quadrant with negative Murphy's sign. Laboratory investigations revealed white blood cell count of 13 K/ul, sodium of 131 mmol/l, chloride of 95 mmol/l, calcium of 9.4 mg/dl, triglyceride levels of 60 mg/dl, aspartate aminotransferase of 65 U/l, alanine transaminase of 36 U/l, and alkaline phosphatase of 123 U/l, and lipase of 4450 U/l. Ultrasound of the gall bladder and computed tomography of the abdomen revealed diffuse gallbladder wall thickening with pericholecystic fluid without any significant pancreatic abnormality. A provisional diagnosis of acalculous cholecystitis was made and he was started on intravenous (IV) ceftriaxone one gm, once a day and IV metronidazole 500 mg, thrice a day with IV pantoprazole 40 mg, once a day. Magnetic resonance cholangiopancreatography done after two days revealed the absence of gall bladder wall thickening. Cholecystitis was thus ruled out and the patient was diagnosed with acute pancreatitis owing to the raised levels of lipase. A resolution of abdominal symptoms and a decreasing trend was seen in serum lipase levels on day four of hospitalization but the levels still remained above the ULN (Figure 1). The patient was discharged with surgical follow-up on an outpatient basis.

DISCUSSION:

The cut-off set for lipase levels in acute pancreatitis has a specificity of >99%. Clinicians should have a high suspicion of pancreatitis in patients with abdominal pain and isolated hyperlipasemia but be wary of alternative diagnosis too.
3036 Alcohol Consumption Increases Risk of Pancreatitis in Celiac Disease: A Case Report
Authors: Rashid Mamoon Ur , Khan Muzammil Muhammad , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Ur Rehman FNU Asad , Hurairah Abu
Published: October 2019

INTRODUCTION:

Celiac disease is an autoimmune disorder of small intestine that improves significantly with gluten free diet. It is reported that patients with celiac disease are associated with increased risk of hepatobiliary and pancreatic diseases. In patients with celiac disease, alcohol further increases the risk of pancreatitis.

CASE DESCRIPTION/METHODS:

35 year old female with history of celiac disease and alcohol abuse presented to us with abdominal pain, nausea and vomiting for 1 week. Pain was generalized, characterized as sharp and stabbing. She admitted drinking half a bottle of vodka daily for pevious few weeks and has been dealing with alcohol abuse for many years. Initial labs showed hyponatremia 125, Hypokalemia 2.4, Ethanol 280 and lipase 500. CT Abdomen was unremarkable. Patient IGA was elevated with Tissue transglutaminase IgA level more than 250. Patient was diagnosed with acute pancreatitis and was treated with supportive management. Patient previous pathology showed villous blunting and intraepithelial lymphocytes suspected for non-compliance with gluten free diet. Patient symptoms and labs improved significantly during hospitalization and was discharged home. Unfortunately, patient was admitted within a week with similar symptoms of abdominal pain with hyponatremia, hypokalemia, and elevated lipase but Ethanol level was less than 10. Patient was again treated conservatively for recurrent pancreatitis and discharged home with counselling for gluten free diet and alcohol cessation.

DISCUSSION:

Celiac disease is an autoimmune disease with abnormal response of the small intestine to the gluten, widely present in our diet. Patient may present with vomiting, abdominal pain, nausea, flatulence, weight loss or diarrhea. It has been reported that almost 20% of the patients with celiac disease are associated with pancreatitis and pancreatic inflammation. It is believed that impaired release of pancreatic stimulating hormones from the pancreas due to inflammed proximal small bowel may be responsible. However, it has also been reported that papillary stenosis may be responsible for the pancreatic inflammation present in the celiac disease. Alcoholic patients with celiac disease have several fold increased risk of development of pancreatitis and pancreatic inflammation and are counselled to avoid or reduce the alcohol intake.
3038 A Rare Case of Pancreatitis Due to Paraesophageal Hernia
Authors: Al Kateb Mohamad , Leibach John , Calestino Matthew , Bray Christopher
Published: October 2019

INTRODUCTION:

Pancreratitis due toWe present a rare case of acute pancreatitis due to a large paraesophageal hernia who presented to the emergency department with chief compliant of epigastric pain and dysphagia.

CASE DESCRIPTION/METHODS:

A 65-year- old female presented to our emergency department due to progressively worsening epigastric pain. The pain sharp, intermittent and moderate in severity and radiated to her back associated with nausea and vomiting. She denied fever, shortness of breath, or chest pain. A review of systems was otherwise negative. Physical examination including vital signs was unremarkable with the exception of mild epigastric tenderness on palpation. Seven years prior to admission, patient underwent laparoscopic cholecystectomy for gallstones pancreatitis. Laboratory data was unremarkable. Although her serum lipase was within normal limits (114 U/L), her history and physical were concerning for pancreatic pathology. Therefore, CT scan of the abdomen was obtained and demonstrated trace inflammatory fluid around the pancreatic uncinate process, consistent with mild pancreatitis. Additionally, a massive hiatal hernia was noted causing mild atelectasis in the lung bases. The patient was admitted to our facility and was treated for the presumptive diagnosis of recurrent pancreatitis. Of interest, five months prior to this admission, the patient had presented to the ED with similar symptoms. CT imaging at that time had also demonstrated large paraesophageal hernia. She was evaluated by our general surgery service and was deemed not to be a candidate for surgical intervention. Due to the recurrent nature of her symptoms, she subsequently underwent esophagogastroduodenoscopy during which the paraesophageal hernia was identified with a large amount of food and fluid within it. Thusly she was reevaluated by our general surgery team and ultimately underwent reduction of her stomach, paraesophageal hernia repair, and gastrostomy tube insertion. Patient did well post-operatively with no complication. Patient was discharged to rehab 7 days after surgery.

DISCUSSION:

We believe that the patient's recurrent symptoms were the result of progressive enlargement of the paraesophageal hernia that manifested as a gastric volvulus. There are few cases of pancreatitis due to paraesophageal hernia leading pancreatic herniation1. Serum lipase measurements that are below normal limits can indicate chronic pancreatitis2. Few cases of pancreatitis were reported with low lipase.2
3043 Not All Bumps Are Equal, Mucosal Schwann Cell Hamartoma a Rare Subtype
Authors: Altamimi Barakat Aburajab , Niyazi Fadi , Snow Anthony , El Sayed Amer
Published: October 2019

INTRODUCTION:

Benign mesenchymal polyps are an interesting group of colonic polyps. There has been a surge in the number of these polyps identified since legislation modified Medicare and began reimbursement for screening colonoscopy in patients at an average risk for colorectal carcinoma. It is important to differentiate between the different types of mesenchymal polyps given that some have correlation with hereditary diseases.

CASE DESCRIPTION/METHODS:

66 year old male patient with history of hypertension presents for routine colorectal cancer screening colonoscopy. He is asymptomatic and has no family history of cancer including colon cancer. During the colonoscopy a small 5 mm polyp was found in the rectosigmoid which was removed using cold forceps polypectomy. The pathology was read as a benign mesenchymal polyp. Further staining with S-100 and CD 68 was done which revealed that this polyp was in fact a Schwann cell hamartoma.

DISCUSSION:

There has been 10 reported cases of mucosal schwann cell hamartoma in literature. Using immunohistochemistry for S100 highlights tissue with neural differentiation expanding the lamina propria of the colonic biopsy and CD68 highlights muciphages. These polyps resemble spindle cell proliferation and other neuronal tumors and are usually limited to the mucosa of the colon with no submucosal extension. They are usually solitary and patients do not have symptoms though a couple of cases reported finding them in the process of workup for diarrhea. Gibson and Hornick supplied the necessary name in 2009 in an attempt to differentiate it from other Schwann cell proliferation which is seen in entities like neurofibroma and ganglioneuroma. The importance of this entity is its lack of association with hereditary cancer syndromes, specifically neurofibromatosis type 1 (NF1) and multiple endocrine neoplasia 2B (RET) which is seen with neurofibromas. Also ganglioneuromatous polyposis and diffuse ganglioneuromatosis are seen in Cowden syndrome, Juvenile polyposis syndrome, MEN2B and NF1 however solitiary ganglioneuroma are not associated with hereditary diseases. It is important to differentiate this entity from others to prevent unnecessary and aggressive testing and treatment. Pathologists should include this differential as part of S 100 positive spindle cell proliferative lesions and gastroenterologists should be aware of the benign nature of this pathology.
3047 A Tale of Two Tumors: Peritoneal Malignancies
Authors: Glover Matthew , Walker Ted , Kang Liang-I , Rood Richard P.
Published: October 2019

INTRODUCTION:

Pseudomyxoma peritonei (PMP) and malignant peritoneal mesothelioma (MPM) are rare malignancies of the peritoneum that present in similar fashion. We describe one case of each to illustrate the diagnostic and therapeutic challenges associated with these tumors.

CASE DESCRIPTION/METHODS:

Case 1: A 67 year old Ukrainian male presented with a chief compliant of 6 months abdominal pain and fever. Physical exam revealed abdominal distension. A CT scan showed infiltrative densities of the omentum and mesenteric fat suggesting an inflammatory process. CRP and ESR were elevated. Colonoscopy was unremarkable. His abdominal pain continued to worsen. A repeat CT showed progressive omental densities (Figure 2a). An initial percutaneous omental biopsy showed atypical mesothelia cells. Subsequent exploratory laparotomy with targeted biopsies revealed a diagnosis of MPM (Figure 3a). He was initiated on hyperthermic intraperitoneal chemotherapy (HIPEC) with possible future cytoreductive surgery (CRS). Case 2: A 75 year old Nepali male presented with a chief complaint of abdominal pain, distension and weight loss. An outpatient ultrasound several months prior had demonstrated septated ascites. Physical exam revealed a markedly distended abdomen. A CT scan showed diffuse peritoneal and omental thickening (Figure 2b). An Omental biopsy was performed and pathology revealed pseudomyxoma peritonei (PMP) (Figure 3b). A colonoscopy revealed mucinous material at the appendiceal orifice (Figure 1). Following laparoscopy, he was not deemed a candidate for CRS with HIPEC due to burden of disease.

DISCUSSION:

PMP and MPM are rare tumors of the peritoneum that typically present with non-specific signs and symptoms.1,2 As a result, diagnosis is often delayed and occurs late in the progression of disease. Both PMP and MPM defy typical TNM staging as spread is predominately expansive rather than infiltrative. This pattern of spread gives limited extra-abdominal metastatic potential. As a consequence, these tumors tend to remain confined to the abdominal cavity. First line therapy for both PMP and MPM is CRS and HIPEC.3,4 Candidacy is determined by the peritoneal cancer index (PCI), a scoring system based on extent of peritoneal tumor burden visualized on laparoscopy.5 Systemic chemotherapy is an option for patients ineligible for CRS and HIPEC. Ideal chemotherapy regimens remain unclear as no randomized controlled trials exist.1,2 Intraperitoneal mucolytics remain under investigation as a potential therapy unique to PMP.6
3074 In Colon Cancer: Superficial Thrombophlebitis Is a Road to PE
Authors: Vekaria Pratikkumar , Raiyani Chandrika , Robitshek Daniel , Raiyani Tejas
Published: October 2019

INTRODUCTION:

In general, all cancers associated with developing vascular thromboembolism (VTE). Colorectal cancer (CRC) can also cause VTE, but overall incidences of VTE related to CRC is underestimated. Superficial thrombophlebitis (STP) involves phlebitis and thrombosis of superficial vein of upper or lower extremity. It is broadly known as self-liming condition and requires conservative management. Nonetheless, few case reports suggest that superficial thrombophlebitis can progress into Pulmonary Embolism (PE), especially, with concomitant hypercoagulable state such as cancer, chemotherapy.

CASE DESCRIPTION/METHODS:

56-year-old-Caucasian-female with pertinent history of adenocarcinoma of colon s/p resection, on adjuvant chemotherapy presented to ED with right side chest pain and dyspnea. CT chest showed right upper and lower lobe PEs. Around 2 months prior to this, after her chemotherapy cycle, patient had developed right leg redness and pain along the ankle and lower inner leg. She had developed STP in right Great Saphenous Vein without any DVTs noted on Doppler. She was treated with conservative management with NSAIDs, with resolution of her symptoms in 2 days. However, after her next chemotherapy cycle, she had recurrence of STP and work up was again negative for DVT. Patient was started on low dose Aspirin then. On subsequent cycle, she developed PE as noted on presentation, which was treated successfully with Apixaban and she uneventfully completed her chemotherapy cycles.

DISCUSSION:

Cancer and chemotherapy are major risk factors for developing VTE, and it causes imbalance between coagulation and fibrinolytic system. Study shows that chances of getting CRC related VTE is more during first 6 months after diagnosis and then it falls subsequently. Our patient, developed PE in 4 months after diagnosis. No robust study has been done that shows prospects of developing VTE if CRC patient develops STP. Many factors can play role in such situation, like; age, sex, location (below or above-knee STP), health condition, chemotherapy, and coagulation profile. Few studies have reported that STP should be managed more rigorously when it is associated with cancer and starting anticoagulants (AC) prophylactically can help patient from getting PE. Therefore, from our and other case reports, we suggest that CRC patient on chemotherapy should be considered for prophylactic AC if they develop STP to minimize risk of developing VTE.
3090 Endoscopic Removal of Partially Migrated Gastric Banding
Authors: Boškoski Ivo , Bove Vincenzo , Tringali Andrea , Landi Rosario , Familiari Pietro , Perri Vincenzo , Costamagna Guido
Published: October 2019

INTRODUCTION:

Intragastric band migrations or dysfunctions are common long-term complications of laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment. In this video case we describe the endoscopic removal of partially eroded Lap-Bands.

CASE DESCRIPTION/METHODS:

We present the case of a 61 years-old female that underwent a Lap-Band in 2002 for morbid obesity (weight 150 Kg, BMI 55.1). In November 2017 she had abdominal pain and an EGD showed erosion of the gastric mucosa and partial intragastric migration of the Lap-Band (>50%). After surgical removal of the subcutaneous reservoir an endoscopic procedure was planned to remove the migrated gastric band. The procedure was performed under general anesthesia, with CO2 insufflation and using a therapeutic gastroscope (GIF-1T 160, Olympus, Japan). The ring was captured with a guidewire (Jagwire, Boston Scientific, Marlborough, MA) under endoscopic control and fluoroscopic control in a "loop shape". The endoscope was then removed, and a mechanical lithotripter (Endobair, London, UK) was placed over the 2 extremities of the wire and a biliary lithotripsy device was used to cut the migrated band. The band was pushed into the stomach, captured with a snare and pulled out. There were no procedure related complications.

DISCUSSION:

Endoscopic removal of intragastric migrated Lap-Band is safe, repeatable and procedure and is a valide alternative over surgery.

Watch the video: http://bit.ly/2LuYDJS