bluuebunny/crossref_metadata_2025 huggingface dataset:
A109 CELIAC DISEASE IS A RARE CAUSE OF BENIGN DUODENAL STRICTURE
Authors: Balubaid I , Khanna N
Published: February 2020

Background

Benign duodenal stricture is an uncommon problem encountered by gastroenterologists. The most common cause is peptic ulcer disease (PUD). With the diagnosis and eradication of H. Pylori, early diagnosis of PUD and the use of PPIs to treat upper gastrointestinal inflammation, the incidence of benign duodenal stricture has dramatically decreased. Patients with duodenal stricture may present with early satiety, nausea, vomiting and weight loss. We present the case of a man with a refractory web-like stricture in the second part of the duodenum (D2) caused by Celiac disease.

Aims

To describe a rare endoscopic finding in a patient with Celiac disease

Methods

Case report with literature review

Results

We present a case of a 64 year old male was referred for consideration of duodenal stenting of a refractory stricture in the second part of the duodenum D2. The patient had a 1 year history of abdominal pain, early satiety and weight loss (10 lbs). He also reported intermittent episodes of diarrhea. Investigations included a CT scan of the abdomen which showed a stricture at the level of proximal D2 described as a “duodenal band”. Previous attempts at balloon dilation had not resulted in prolonged symptomatic or endoscopic improvement. Testing for H. Pylori was negative and he did not use NSAIDs.

Upper endoscopy was performed to assess the stricture prior to consideration of stenting. This showed a tight web-like stricture in proximal D2. The stricture was balloon dilated up to 16.5 mm, enabling the endoscope to pass beyond it. The mucosa in D2 was atrophic with flattening of the folds and scalloping. There was no inflammation seen. Biopsies from D2 revealed moderate villous blunting and intraepithelial lymphocytosis. Celiac serology testing was abnormal, with an anti-tTG Ab level of 32 RU/ml which confirmed the diagnosis of Celiac disease. The balloon dilation and gluten-free diet resulted in resolution of his symptoms. Follow up endoscopy revealed normalization of his duodenal folds and biopsies. In addition, anti-tTG Ab level was normalized. Although stricture improved with prolonged patency, he still has mild recurrence of his stricture requiring balloon dilation on an annual basis.

Conclusions

This case describes a very uncommon complication of Celiac disease. The likely pathophysiology involves inflammation and potentially ulceration from Celiac disease, resulting in a benign stricture. There have been a few case reports describing duodenal strictures as a complication of Celiac disease. Treatment involves a gluten-free diet and endoscopic therapy. More severe cases of obstruction would likely require surgical intervention. In our case, the gluten-free diet and balloon dilation were successful and duodenal stenting was not necessary. Given the possibility of Celiac disease as a cause of duodenal stricture, it would be reasonable to biopsy D2 and check anti-tTG Ab in cases of duodenal stricture.

Funding Agencies

None
A112 ANGIOEDEMA,A RARE YET AN IMPORTANT CAUSE OF ABDOMINAL PAIN. A CASE STUDY AND LITERATURE REVIEW
Authors: Almalki F M , Cino M , Betschel S , Sasson A N
Published: February 2020

Background

Abdominal pain is a common gastroenterological symptom with an extensive deferential diagnoses. Angioedema is an important cause to remember after the more common causes have been excluded.It is caused by a deficiency in the inhibitor of the first component of classical complement pathway and is divided into hereditary or acquired.Acquired angioedema is associated with autoimmune or lymphoproliferative neoplasms.The clinical features of both include recurrent,self-limiting and circumscribed edema affecting the subcutaneous tissue of the upper respiratory airways and gastrointestinal tract.

Aims

We describe an interesting case of acquired angioedema presenting with recurrent abdominal pain. We also systematically review the current literature on this rare entity.

Methods

A search of electronic databases was performed inclusive to September 2019, for all studies and reviews of patients with acquired angioedema manifested as recurrent attacks of abdominal pain.

Results:

Case Report: 65 year old lady ho has an at least 2 year long history of abdominal pain and bloating associated on some occasions with nausea and vomiting.She presented to our emergency department in August,2018 with a day history of severe generalized abdominal pain and was found to have circumferential thickening,edema with mucosal hyperenhancement involving the distal segment of the small bowel.Splenomegaly was noted on that study.A double balloon enteroscopy was planned,but ultimately cancelled as her ileitis had resolved.The patient was discharged home as her pain resolved with conservative management which included intravenous fluid, pain medications and antiemetics.She then represented to the hospital on September 16, 2019 severe abdominal pain and throat tightness associated with shortness of breath. Again,noted was an extremely short segment of ileum with mucosal edema and hyperenhancement which resolved on a repeat CT scan done during that admission on September 18th, 2019.In light of the patient’s symptoms,CT scan findings,progressive anemia, thrombocytopenia and splenomegaly. It was thought that her abdominal pain is related to secondary to angioedema driven by a lymphoproliferative process as evident by the splenomegaly and worsening cytopenia. A bone marrow was done which revealed clonal B, so the diagnosis of lymphoma was made. The patient’s C1 esterase was 0.2 with reduced functional activity.CH50 less 10 perecent. A diagnosis of acquired angioedema was made and the patient was started on BERINERT 3000 IU SQ every three days with 1500 IU for break through with significant improvement in the frequency and severity of abdominal pain episodes.

Conclusions

Acquired angioedema is to be considered as a cause of recurrent abdominal pain in a patient with a lymphoproliferative malignancy after common causes and etiologies have been ruled out.

Funding Agencies

None
A114 AMEBIC COLITIS AS A RARE CAUSE OF PSEUDOMEMBRANOUS COLITIS
Authors: Tsoukas S E , Szilagyi A
Published: February 2020

Background

Globally, Entamoeba histolytica results in nearly 40 million cases of amebic colitis and 50 000 deaths annually. The disease is common in Africa, Asia, and Central and South America but infection remains rare in North America, limited to travelers, immigrants, and immunocompromised hosts. The disease ranges from asymptomatic chronic colonization to dysentery and fulminant colitis. Endoscopically, the ulcerations may demonstrate the non-specific pattern of pseudomembranous colitis that is classically seen with Clostridoides difficile infection.

Aims

To discuss an unusual case of pseudomembranous colitis caused by Entamoeba histolytica.

Methods

The patient records were reviewed and a review of the literature was performed.

Results

A 54-year-old male with a remote history of peptic ulcer disease visiting from Guinea presented with a 3-day history of right sided abdominal cramping and intermittent bloody diarrhea. The pain was gradual in onset with moderate severity. He reported >5 episodes of blood intermixed with brown stools. He was incidentally diagnosed with hypertension and started on treatment two weeks prior. He denied recent antibiotic use and family history was unremarkable for inflammatory bowel disease (IBD) or other forms of colitis. There was no abdominal tenderness or bleeding on rectal examination. He had a stable normocytic anemia (Hgb 114), leukocytosis (13.4) with neutrophilia, and elevated C-reactive protein (43.4 mg/L). He was discharged with presumed resolving ischemic colitis. Colonoscopy showed diffuse colonic involvement with areas of patchy yellow plaques and a mix of shallow and deep non-bleeding ulcers suggestive of pseudomembranous colitis. He was discharged with empiric oral vancomycin, later discontinued following negative C. difficile toxin testing. Stool cultures and microscopy detected Entamoeba histolytica. Limited biopsies of the nodular ulcers failed to show any pathologic alterations or trophozoites. The patient was treated for luminal amebiasis with oral metronidazole and paromomycin but was lost to follow up on return to his native country.

Conclusions

Amebic colitis remains a rare entity in the developed world and is limited to travelers or recent immigrants from endemic areas. Diagnosis is typically difficult and may require endoscopy as its clinical course may resemble IBD or infectious colitis. Limited cases exist of fulminant amebic colitis causing pseudomembranous colitis, with even fewer cases of mild dysentery having this appearance. Despite pseudomembranous colitis being commonly associated with C. difficile infection, this pattern of mucosal injury may be seen with other enteric bacterial and protozoan infections, inflammatory conditions, or use of certain medications. In the appropriate clinical context, on exclusion of C. difficile, secondary causes such as active amebiasis should be considered.

Funding Agencies

None
A116 ASSESSING THE EFFECTIVENESS OF THE NURSE NAVIGATOR ROLE IN AN IBD MEDICAL HOME: A RETROSPECTIVE COHORT STUDY
Authors: Gawdat K , Heisler C , Nazer N , Stewart M , Currie B , Phalen-Kelly K , Jones J
Published: February 2020

Background

Patients living with chronic illnesses require long-term and often repeated interactions with the healthcare system. Inflammatory Bowel Disease (IBD) is an incurable, chronic gastrointestinal disease which frequently flares and remits. The nurse navigator (NN) serves as the point of first contact for IBD connecting patients with their multidisciplinary care team in order facilitate and expedite assessment, treatment and navigation through the healthcare system with the goal of improving disease-related outcomes while reducing healthcare system burden.

Aims

The aim of this study was to assess the impact of implementation of an IBD NN role within a multidisciplinary IBD Medical home on access to care, disease related outcomes, patient satisfaction with care, and healthcare resource use.

Methods

This was a retrospective cohort study comparing an IBD patient population that had access to a 24/7 NN-led helpline to a reference population who did not have access to such a service. Data between August 2017 and October 2019 were extracted from patient charts. Distribution of number of flares and time to clinical assessment between the NN exposed cohort and a non-NN exposed cohort are planned using multivariate analysis. This is a preliminary description of the NN-exposed cohort only.

Results

Preliminary results identified a total of 643 patients in the NN-exposed cohort. The majority of our NN-exposed population were female (64.3%). The mean age was 46.42 ± 16.86 years. Sixty-five percent of patients had CD, 33% UC and 2% IBDU. Of the 729 calls extracted, care coordination (39%) was the most frequent indication for calls followed by flare (25%), and medication education (16%). Patients made the majority (52.8%) of calls compared to NN initiated calls (47.2%). The mean number of calls per patient was 2.64 ± 2.51 (range 1–18) during the study period. Time to clinic assessment post flare call was on average 10.22 ± 8.51 days.

Conclusions

These results are descriptive of the NN-exposed cohort. Data comparing outcomes amongst the NN-exposed cohort to the non-exposed cohort will be presented at CDDW.

Funding Agencies

None
A121 SILENCING ENTERIC SENSORY NEURONS ABOLISHES THE EXCITATORY EFFECT OF SERTRALINE ON VAGAL AFFERENTS
Authors: West C , Stanisz A , Bienenstock J , Kunze W A
Published: February 2020

Background

Two thirds of vagal afferents supplying the small intestine terminate on intrinsic primary afferent neurons (IPANs) of the enteric nervous system via intraganglionic laminar endings (IGLEs) rather than the luminal epithelium (FASEB J, 28, 3064–3074, 2014). The IPAN to IGLE connection forms a functional intramural sensory synapse within the myenteric plexus. We have recently shown (Sci Rep, 9, 14290, 2019) that the antidepressant behavioural effects of selective serotonin reuptake inhibitors (SSRIs) are dependent on the vagus nerve and that intraluminal application of the SSRIs fluoxetine and sertraline increase vagal afferent firing rate in vitro.

Aims

We hypothesize that the vagal afferent response to intraluminal sertraline is mediated by IPAN to IGLE sensory signaling.

Methods

Mesenteric nerve recordings were performed using 2–3 cm jejunal segments and attached mesentery from 6–8 weeks old male Balb/c mice. Jejunal tissue was pinned out and dissected in a petri dish of Krebs to remove excess mesentery to isolate the mesenteric nerve bundle. Multi-unit electrical activity was recorded by patch-clamp electrode using an amplifier and signal converter by sucking onto the mesenteric nerve bundle with a glass micropipette. Baseline firing was recorded for 30 mins during luminal Krebs perfusion. The vagal afferent firing response to sertraline (10 µM) was measured in the absence or presence of 5 µM of the intermediate conductance calcium-dependent (IKCa) channel opener 5,6-dichloro-1-ethyl-1,3-dihydro-2H-benzimidazole-2-one (DCEBIO) to the serosa to selectively silence IPANs. Dataview software (J Neuroscience Methods, 185, 151, 2009) was used to isolate single unit firing post-hoc. Vagal fibre action potentials were identified by response to CCK.

Results

Intraluminal sertraline decreased the mean vagal interspike interval (increased vagal firing frequency) by 29% (p = 0.008) compared to Krebs control (N = 15 fibres). In contrast, addition of luminal sertraline in the presence of DCEBIO increased mean vagal interspike interval by 48% (p = 0.0103) compared to Krebs control (N = 12 fibres). Serosal addition of the N-type Ca2+ channel blocker w-Conotoxin GVIA simultaneously with luminal sertraline increased the mean vagal interspike interval by 12% (p = 0.0282) compared to Krebs control (N = 7 fibres).

Conclusions

Silencing of myenteric IPANs to vagus neurotransmission blocked excitatory response of vagal afferent fibres to intraluminal sertraline. Blocking myenteric neurotransmission reduced the vagus excitatory response to sertraline by more than 50%. These results suggest that the therapeutically necessary vagus nerve stimulation by sertraline involves activation of the myenteric intramural sensory synapse.

Funding Agencies

NSERC, OGS
A126 RETROGRADE LABELLING OF NODOSE GANGLIA IN VIVO BY FLUORESCENT TRACERS
Authors: Tashtush A A , Lomax A E
Published: February 2020

Background

The gut-brain axis is a bidirectional connection between the gastrointestinal tract (GI)and the central nervous system. The vagus nerve has been recognized as a principal component of this axis. Vagus nerve plays important role in maintaining homeostasis and normal GI functions, its afferent fibers can detect microbiota metabolites also. Many studies have demonstrated that the upper GI tract receives dense vagal innervation, which decreases distally throughout the tract. However, the distal colon sensory innervation of the vagus nerve remains controversial.

Aims

To illuminate the extent to which the vagus nerve innervates the colon, to determine whether anatomical evidence exists for double-labeled vagal afferents supplying the proximal and distal colon in the nodose ganglia.

Methods

C57Bl/6 mice (n=8) were injected in the proximal and distal colon with alternating solutions of retrograde tracers 1.7% Fast blue (FB) and 5% of lipophilic tracer DiI. Animals were left to recover for 10–13 days then underwent cardiac perfusion. Nodose ganglia were collected and fixed in 4% paraformaldehyde. 12 um tissue sections were then analyzed under a fluorescent microscope at 350nm and 555nm wavelength.

Results

In total, 27% of nodose cell bodies were labeled from the entire colon. Following proximal DiI injections, the percentage of labeled cell bodies in the nodose ganglia were 24.3± 3.9%. However, we observed a lower percentage of labeled neurons from the distal colon, with 9.3± 1.4% after DiI injections. FB labelling from the distal colon was three times less than that observed for DiI. Within the nodose ganglia, 40% of all distally labelled neurons were labelled with both tracers.

Conclusions

These findings indicate that in mice, both distal and proximal colon receives visceral sensory innervation from the vagus nerve. Thus, providing evidence for a sensory anatomical connection of the vagus nerve between these two parts of the colon.

Funding Agencies

CCC, CIHR
A130 RETROGRADE TRACING ANALYSIS OF THE SENSORY INNERVATION OF THE MOUSE COLON
Authors: Osman S , Lomax A E
Published: February 2020

Background

Visceral pain is a primary symptom of many gastrointestinal diseases. One feature of visceral pain is its vague localization. We hypothesized that overlap in the receptive fields of spinal primary afferent neurons that innervate the gut may contribute to this vague localization. Many studies have confirmed that the proximal and distal colon are mainly innervated by spinal afferent neurons with cell bodies in thoraco-lumbar and lumbo-sacral dorsal root ganglia (DRG), respectively. However, no murine studies have examined whether individual DRG neurons simultaneously innervate both proximal and distal colon.

Aims

To determine the extent of overlap in receptive fields of colon-projecting DRG neurons.

Methods

C57BL/6 mice (n=8) were anesthetized, and two retrograde neuronal tracers with distinct fluorescence emission spectra (Fast blue and DiI) were injected separately into the smooth muscle layers of proximal and distal colon. Mice were left for 10–13 days for dye transport, before being euthanized. Thoraco, lumbar and lumbo-sacral DRGs (T8-13, L1-4, L5-S2) were dissected and fixed in 4% paraformaldehyde overnight. 12μm cryostat sections were obtained and analyzed using a fluorescent microscope equipped with filter cubes that detect Fast blue and DiI.

Results

When DiI was injected into the proximal colon, we observed labelling to be highest in T8-13 DRG with 12.6 +/- 4.5% of cell bodies labelled, followed by L1-4 was (8.2 +/- 1.4%) and in L5-S2 (6.5 +/- 0.8%). DiI injections into the distal colon resulted in labelling of similar numbers of neurons labelled in T8-13 and L1-4 ganglia, whereas half as many neurons were labelled in L5-S2 ganglia. This data shows that the majority of spinal afferent innervation of the colon originates in thoracolumbar DRG. Most importantly, 26.4% and 17.6% of thoracolumbar and lumbo-sacral DRG neurons labelled by Fast blue injection into the proximal colon were also double-labelled by DiI injected into the distal colon. Similarly, 16.6% and 13.8% of neurons in thoracolumbar and lumbosacral DRG labelled by Fast blue injection into the distal colon were double-labelled by DiI injected into the proximal colon.

Conclusions

These data reveal a surprisingly large number of DRG neurons that innervate the colon have receptive fields that cover both the proximal and distal colon, which may contribute to the poor spatial localization of pain emanating from the colon.

Funding Agencies

CCC, CIHR
A133 DEVELOPMENT OF TYPE 3 ACHALASIA WITH DISTANT PANCREATIC MALIGNANCY
Authors: Leung K , Habal F , Alrukaibi M , Liu L W
Published: February 2020

Background

Pseudoachalasia is often caused by malignant involvement at the gastroesophageal junction (GEJ) leading to dysphagia.

Aims

We describe a case of type 3 achalasia presenting in a woman with metastatic pancreatic cancer with no direct involvement at the GEJ, fundus or cardia.

Methods

A case report and literature review were performed.

Results

A 53-year-old woman presented with a 2-month-history of progressive abdominal pain, nausea and vomiting with a 30-pound weight loss. She had a remote history of breast cancer in remission after surgery and chemoradiation. On presentation, she denied chest pain, reflux, dysphagia or odynophagia. Abdominal exam revealed focal epigastric tenderness and jaundice. Abdominal CT showed a 6.7 x 5.8 cm conglomerate mass involving the hepatic hilum, pancreatic head, duodenum, common bile duct, and portal vein with gastric outlet and biliary obstruction. This mass was confirmed to be a pancreatic adenocarcinoma on pathology. She then underwent nasogastric tube decompression. Initial esophagogastroduodenoscopy (EGD) confirmed a stenotic area at the distal duodenal cap. A duodenal stent and common bile duct stent were placed during a second EGD. The esophagus and GEJ were unremarkable on both endoscopic exams. She was started on chemotherapy with gemcitabine and abraxane. Two weeks after her stent placement, she rapidly developed severe retrosternal squeezing discomfort and choking occurring with swallowing. CT chest and abdomen were negative for any intrathoracic and diaphragmatic involvement with stability of the mass. A barium swallow study demonstrated tertiary contractions in the thoracic esophagus with marshmallow hold-up in the distal esophagus. She then underwent a high-resolution esophageal manometry study that demonstrated an elevation of integrated residual pressure (IRP) of the lower esophageal sphincter (LES) and absence of peristalsis, with the distal 2/3rds of the esophagus showing a simultaneous and prolonged pressure front consistent with type 3 achalasia, Chicago classification v3.0 [Figure 1]. All contractions had a distal contractile integral (DCI) of >8000 mmHg-cm-s. She experienced significant symptom improvement with pinaverium bromide, a gut-specific calcium channel antagonist.

A review of the literature revealed that there have been 4 English-language cases published on pseudoachalasia associated with pancreatic cancer, with all cases describing direct infiltration of pancreatic cancer in the GEJ, cardia or fundus with manometric features of type I achalasia.

Conclusions

We report the first case of type 3 achalasia with no evidence of direct malignant infiltration at the GEJ on radiographic and endoscopic evaluations. Possible mechanisms to explain this phenomenon include paraneoplastic antibody-mediated impairment of enteric neurons that decrease nitric oxide availability, or microscopic disease involvement at the GEJ.

Funding Agencies

None
A154 ASSESSING COLON SCREENING PROGRAM COLONOSCOPIES IN A NON-HOSPITAL ENDOSCOPY CLINIC
Authors: Gillies A N , Chow R , Galorport C , Macdonnell C A , Yonge J , Telford J J , Rosenfeld G , Bressler B , Whittaker S , Lam E , Ramji A , Enns R A
Published: February 2020

Background

Colorectal cancer is the most commonly diagnosed cancer in British Columbia, affecting 1 in 6 persons. The BC Colon Screening Program (CSP) screens individuals 50–74 years of age with biennial FIT (cut-off 10 mcg/g) with follow-up colonoscopy for positive results. In Vancouver, colonoscopies are performed in a hospital environment; however non-hospital endoscopy clinics have been used in other jurisdictions.

Aims

To investigate the quality of procedure, rate of complications and need to repeat procedures in a hospital setting for colonoscopies performed on CSP patients in a non-hospital setting.

Methods

A retrospective chart review for all CSP colonoscopies performed from 04/19 to 07/19 in a non-hospital endoscopy clinic. Data was collected from an electronic medical record system and included adenoma detection rates; any repeat procedures required in a hospital setting and adverse event rates. Criteria for a repeat in hospital colonoscopy were inadequate bowel preparation, body mass index exceeding the allowable threshold for a non-hospital colonoscopy and identification of a difficult to remove polyp such as a polyp > 20 mm or in a difficult location.

Results

801 FIT positive patients (ages 50–74) underwent colonoscopy in the non-hospital endoscopy clinic. The mean age was 60 years (51% female). The mean time between referral date and procedure date was 192 days. The neoplasia detection rate was 60.2%, there was one (0.1%) adverse event (post-polypectomy bleed) and 21 (2.6%) patients required a repeat colonoscopy in a hospital setting.

Conclusions

Colonoscopy to follow-up a positive FIT in an non-hospital endoscopy clinic was safe and effective with a low number of repeat, in hospital colonoscopies required.

Funding Agencies

None
A159 ARE MOBILE HEALTH TECHNOLOGIES SUPPORTING COLONOSCOPY PREPARATION ASSOCIATED WITH BETTER PATIENT OUTCOMES: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS
Authors: El Sheikh M , Lee G , El Bizri M , Sewitch M J
Published: February 2020

Background

Mobile health technologies are innovative solutions for delivering instructions to patients preparing for their colonoscopy appointments.

Aims

To systematically review the literature of the effect of smartphone-based technologies supporting colonoscopy appointment preparation on patient outcomes.

Methods

With the assistance of a librarian, one author searched MEDLINE, EMBASE, CINAHL and CENTRAL for randomized controlled trials (RCTs) that evaluated the effect of smartphone-based technologies for colonoscopy preparation on bowel cleanliness and user satisfaction. Two independent reviewers extracted data on patient and intervention characteristics and study outcomes, and appraised study quality using the Cochrane Risk-of-Bias tool. Summary statistics were generated using random effects models for the trials that used either the Boston Bowel Preparation Scale (BPPS) or the Ottawa Bowel Preparation Scale (OBPS). Statistical heterogeneity was assessed using I2.

Results

Ten RCTs met our inclusion criteria. Smartphone-based interventions included apps, SMS text messages, video clips, camera apps, and social media apps. Most studies showed smartphone-based interventions were associated with better quality bowel cleanliness scores and higher user satisfaction compared to usual care. Standardized mean differences for the BBPS and OBPS differed between the intervention and control groups [SMD 0.57, 95%CI 0.18, 0.95] and [SMD -0.39, 95%CI -0.59, -0.19], respectively. Statistically significant statistical heterogeneity was found for the meta-analyses for the trials employing the BBPS (I2=80%, p=0.03) but not for the trials using the OBPS (I2=45%, p=0.16). All RCTs were at high risk of bias from non-blinded participants, and most studies were at high or unclear risk of bias due to lack of allocation concealment. Funnel plots to evaluate publication bias were not generated as there were too few studies with sufficient data to analyze.

Conclusions

This systematic review found that smartphone-based technology users had better bowel cleanliness quality scores and higher satisfaction with the method of delivering instructions compared to patients given usual care. Given that all RCTs were at high risk of bias, high-quality RCTs that blind participants and conceal study group allocation are needed.

Funding Agencies

CIHRDepartment of Medicine, McGill University and the Research Institute of the McGill University Health Centre
A162 THE UTILITY OF FECAL CALPROTECTIN IN PREDICTING SEVERITY OF CLOSTRIDIUM DIFFICILE INFECTION: A SYSTEMATIC REVIEW
Authors: Yusuf A , Tandon P , Huang V
Published: February 2020

Background

Clostridium difficile is an anaerobic, spore-forming, gram-positive bacillus, and a leading cause of infectious diarrhea in hospitalized patients. It is associated with high mortality and morbidity, and places an enormous burden on the healthcare system. Symptoms and severity of CDI vary widely, from illness that resolves with antibiotics, to toxic megacolon, colectomy, and death. The ability to risk-stratify patients to predict severe versus non-severe outcomes at baseline would be clinically useful. The role of fecal calprotectin in predicting severity of CDI has not been well established.

Aims

To perform a systematic review of the literature on the ability of fecal calprotectin to predict disease severity in patients with CDI.

Methods

PubMed, OVID (EMBASE/MedLine) and Cochrane Library databases were searched up until October 2, 2019. Publications of pediatric populations, Inflammatory Bowel diseases, and those only published as abstracts were excluded.

Results

130 non-duplicate citations were screened; after title/abstract screening, and full-text review, 7 articles were included for analysis. Articles were from 2014 onwards, and varied from 29 to 232 patients/samples analyzed; 832 patients in total were analyzed. Three studies were conducted in the USA, two in Europe, one in Israel and in South Korea. Four studies were prospective, and the remaining three were retrospective cohort studies. There was significant heterogeneity between studies with respect to population size, age (when reported), fecal calprotectin assay and cutoff used, method of diagnosis of CDI, and criteria for defining disease severity. There was wide variation in median fecal calprotectin levels between studies. Four studies demonstrated a statistically significant difference of fecal calprotectin according to disease severity, and three did not, of which two of these demonstrated an overall predictive trend with fecal calprotectin.

Conclusions

It is unclear whether fecal calprotectin is predictive of severity of CDI in adult patients without IBD. In the existing literature, there seems to be a statistically significant association or trend towards association in most studies, but due to heterogeneity of methods, assays, cutoffs and populations, the data within these studies cannot be pooled in meta-analysis. Further high-powered, well-designed studies are required to clarify this important clinical question.

Funding Agencies

None
A165 ASSESSING ATTENDANCE OF SUBSTANCE USER ENDOSCOPIES (A.S.U.R.E)
Authors: Chow R , Gillies A , Enns R A , Telford J J , Galorport C
Published: February 2020

Background

In Canada, British Columbia (BC) is the leading province in opioid deaths with 30.6 per 100,000 population. Since substance users are stigmatized in health care, patient care requires specific, individualized management strategies, which often creates a gap between the patient and health care service. Diagnostic studies remain a challenge due to lack of funding and the unique requirements necessary to treat this patient population efficiently. Thus, new methods of prevention must be cultivated to ensure ideal patient care.

Aims

To investigate the proportion of patients on restricted narcotics that failed to attend scheduled gastroenterology and hepatology appointments at our center.

Methods

A retrospective chart review from 01/05 – 07/19 and data analysis of patients (≥ 19 yrs.) referred to a Downtown Gastroenterology office was performed. Data was collected from an electronic medical record system and filtered through a keyword search for ‘Methadone’, ‘Suboxone’, ‘Dilaudid’, and ‘Morphine’ to create a sample size of patients with recent/ongoing use of narcotic agents. Patients with chronic pain, or terminal illness prescribed these drugs were not included. Demographic information, type of appointment scheduled and failure to attend were recorded.

Results

Acquired data yielded 2630 patients of which 350 patient were included. Mean age was 47 years (61% male). 35% of the patients were current narcotics users, the rest being previous users of these agents. Scheduled appointments and non-attendance are shown in Tables 2 and 3. Most patients (70%) were referred for various general GI complaints with HCV accounting for 23% of the consults. Despite the use of confirmation lines, 20% of HCV referred patients and 29% of non-HCV referred patients did not attend their first appointment.

Conclusions

Current and prior narcotic users failed to attend more than one quarter of scheduled gastroenterology/hepatology appointments. Ideal management of care for GI disease can’t be obtained without contact with those that provide the service. Creative, innovative management strategies are required to ensure ideal care for this unique group of patients.

Funding Agencies

None
A171 MAGNETIC RESONANCE IMAGING IN CHILDREN WITH EARLY ONSET INFLAMMATORY BOWEL DISEASE- A RETROSPECTIVE COHORT STUDY
Authors: Eindor A , Meleady L , Lakhani A , Lawrence S , Krikler G , Hamilton Z , Jacobson K
Published: February 2020

Background

Magnetic Resonance (MR) Imaging is the preferred imaging method in Inflammatory Bowel Disease (IBD) patients to investigate for small bowel disease. There are challenges in performing MR imaging in Early Onset IBD (EO-IBD) patients, and in particular in children with Very Early Onset IBD (VEO-IBD). These children often need a general anaesthetic which exposes them to adverse effects and preclude conventional luminal distention influencing the quality of the test. Therefore, the utility of MR imaging in this age group is questionable.

Aims

To assess the quality of MRI studies in VEO-IBD and EO-IBD patients and to compare the utility of this test between the two groups.

Methods

We retrospectively identified and reviewed IBD patients diagnosed under 10 years of age, between January 1999 and December 2011, from the British Columbia Children’s Hospital (BCCH) GI Division IBD database. Patients’ first diagnostic MRI results were recorded. Disease location and severity were documented according to the Paris classification.

Results

124 patients were included in the cohort, 54 VEO-IBD and 70 EO-IBD patients (See Table 1). Median age at diagnosis was 6.46 (IQR 3.94–8.71), 65.32% males and 43.54% were diagnosed with Crohn’s disease. Overall, 52 patients underwent MRI, 17 (31.48%) in the VEO-IBD group and 35 (50%) in the EO-IBD group; median time from diagnosis to MRI was 3.02 years (IQR 1.08–5.83) for VEO-IBD and 0.44 years (IQR 0.07–1.58) for EO-IBD (p<0.001). In the EO-IBD group there was a significantly higher percentage of patients with MRI findings than in the VEO-IBD group, 23 (67.31%) and 5 (29.41%) respectively (p=0.014). Only one patient in the VEO-IBD group had a disease characteristic identified by MR imaging that could not be diagnosed by endoscopy (small bowel disease).

Conclusions

The diagnostic yield of MRI in children with VEO-IBD appears to be quite limited but requires further study.

Funding Agencies

None
A180 SENSITIVITY AND SPECIFICITY OF LOWER GASTROINTESTINAL BLEEDING SCORES TO PREDICT ADVERSE OUTCOMES: SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Almaghrabi M M , Gandhi M , Iansavitchene A , Jairath V , Sey M
Published: February 2020

Background

Acute lower gastrointestinal bleeding (LGIB) is a common reason for emergency hospitalization. In most patients bleeding resolves spontaneously, although some presentations result in adverse outcome such as transfusion, therapeutic intervention, rebleeding and mortality. Risk prediction scores are important to stratify patients at presentation with LGIB.

Aims

To perform a systematic review and meta-analysis comparing LGIB risk prediction scores. We provide a summary effect measure of their predictive values for 30-day mortality, safe discharge, rebleeding, need for blood transfusion, and need for endoscopic therapy/IR/surgery.

Methods

Electronic search for relevant publications after 1990 was conducted in PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, NIH ClinicalTrials.gov, and Cochrane Database of Systematic Reviews. We also searched relevant published conference abstracts over the past 5 years. Studies with a primary goal of deriving or validating a LGIB risk score were included. Title and abstracts were reviewed by two independent reviewers and then full text review was done by both reviewers.

Results

Our search identified 1,832 citations for review. After title and abstract review, 68 publications were selected for full text review. So far, a total of 16 citations were excluded since we started full text review including: insufficient information (n=14), review article (n=2). Thus far, we identified 14 risk scores and algorithms from 9 studies. Two of the risk scores are UGIB risk scores that were assessed for LGIB. Of these studies, 3 were validation studies, one derivation study and five for both validation and derivation. The scores assessed safety of discharge (n=3), mortality (n=4), need for therapy (n=8), severe bleeding (n=8) and requirement for blood transfusion (n=1). A meta-analysis will follow.

Conclusions

We conducted a systematic review of LGIB risk scores, with a meta-analysis to follow if appropriate, for use to predict 30-day mortality, safe discharge, rebleeding, required blood transfusion, endoscopic therapy/IR/surgery.

Funding Agencies

None
A185 ABDOMINAL WALL VARICES: A CASE REPORT
Authors: Aruljothy A , Russell L , Nair S , Albashir S
Published: February 2020

Background

Portal hypertension in cirrhosis results in variable and numerous portosystemic collateral circulations. Computed tomography (CT) and Doppler ultrasound (US) can identify these collateral vessels, especially abdominal wall varices, which can be encountered during a bedside paracentesis.

Aims

Describe a case of traumatic abdominal wall variceal bleed.

Methods

Case report.

Results

A 53 year-old Caucasian male presented to the emergency department (ED) with 4-days of abdominal pain and 2-months of increased abdominal girth. His medical history included Child Pugh Class B alcoholic liver cirrhosis diagnosed 1 year ago. No prior history of ascites, esophageal variceal bleed or hepatic encephalopathy. In the ED, his US showed moderate ascites with right portal vein flow reversal. A diagnostic RLQ paracentesis showed yellow ascitic fluid, no spontaneous bacterial peritonitis (SBP), and he was discharged home with diuretics.

He returned to the ED the next day for increased abdominal girth with a Hb of 103 g/L. A diagnostic RLQ paracentesis showed orange-red ascitic fluid and no SBP. The following day, a therapeutic US-guided paracentesis was attempted in the RLQ and left-lower quadrant LLQ; however, ascitic fluid aspirate was grossly bloody. The procedure was aborted. Hb was 82 g/L and progressively decreased. CT angiogram was performed and showed a 10.7 x 4.7 x 8.0 cm hyperdense fluid in the right paracolic gutter near the paracentesis site, consistent with intraperitoneal hemorrhage (Figure A). The insertion site was seen as abdominal wall musculature focal thickening around abdominal wall varices and no contrast extravasation was seen. Gastroesophageal, splenic hilar and omental varices were seen. Doppler US showed no sonographic signs of active extravasation. Interventional Radiology performed a US-guided paracentesis and aspirated 3650 mL of hemorrhagic fluid. Color Doppler US showed small varices within the subcutaneous soft tissues (Figure A).

The patient later developed hematemesis with an EGD showing a large high-risk esophageal varix actively bleeding that was banded. Given the refractory variceal bleeding, a Minnesota tube was inserted 4 days later and a transjugular intrahepatic portosystemic shunt was inserted the following day. Unfortunately, the patient developed progressive worsening hepatic encephalopy, multi-organ failure and expired 7-days later.

Conclusions

Adjunct imaging modalities such as color flow Doppler US or CT can be used as a screening tool to identify abdominal wall varices and reduce paracentesis bleeding complications.

Funding Agencies

None
A190 POST-PARTUM PRIMARY BILIARY CHOLANGITIS (PBC) AFTER RESOLUTION OF INTRAHEPATIC CHOLESTASIS OF PREGNANCY (ICP) IN FIRST NATION’S PATIENTS OF BC: A CASE SERIES
Authors: Chahal D , Yoshida E M , Arbour L , Wallach J
Published: February 2020

Background

PBC is a progressive cholestatic disease characterized by destruction of intrahepatic bile ducts, peri-portal inflammation and fibrosis. PBC is the leading indication for liver transplantation in First Nations of British Columbia. Diagnosis of PBC during pregnancy is difficult due to clinical overlap with ICP and pregnancy induced immune tolerance (4–6). We present 3 cases of clinically diagnosed ICP in First Nations women who were later diagnosed with PBC post-partum.

Aims

To investigate the potential relationship between ICP and PBC in the First Nations community of BC.

Methods

Retrospective review of relevant cases.

Results

Case 1: A 27-year-old woman with history of ICP at 31 weeks during her 3rd pregnancy and family history of PBC presented with ursodiol and cholestyramine responsive pruritis and jaundice 20 weeks into her 4th pregnancy. Bilirubin was 103 µmol/L, ALP 371 IU/L, ANA and AMA negative. Symptoms and biochemistry remained in remission after delivery at 33 weeks. Discontinuation of medications led to recurrent pruritis 4 months later. Bilirubin was 6 µmol/L, ALP 272 IU/L, GGT 153 IU/L and ALT 204 IU/L. Liver biopsy was consistent with PBC, F1. Pruritis has now been refractory to ursodiol, cholestyramine and rifampin.

Case 2: A 30-year-old woman with history of ICP at 20 weeks during 2 prior pregnancies presented with ursodiol responsive pruritis 20 weeks into her 3rd pregnancy. Symptoms and biochemistry remained in remission after delivery at 35 weeks. Post-partum discontinuation of ursodiol led to recurrent pruritis 2 months later. ALP was 876 and AMA >1:640. Re-initiation of ursodiol improved symptoms and biochemical abnormalities.

Case 3: A 30-year-old woman with family history of PBC (mother) presented with ursodiol responsive pruritis and jaundice 20 weeks into her 4th pregnancy. Symptoms and biochemistry remained in remission after delivery at 37 weeks. Post-partum discontinuation of ursodiol led to recurrence jaundice 4 months later. Bilirubin was 68, ALP 1279, total cholesterol 7.72, IgM 18.98, ANA >1:640 and AMA 1:320. Jaundice and biochemical abnormalities persisted despite re-initiation of ursodiol. Obeticholic acid has been initiated.

Conclusions

First Nations communities of BC are disproportionately affected by PBC, due to both genetic and epigenetic phenomena. We present 3 patients who were diagnosed with ICP that resolved post-partum but with the subsequent development of PBC. The intrapartum cholestasis did not have clinical features of PBC during pregnancy. Although not previously reported, ICP may predispose to PBC in this specific community. It remains to be seen if there is a genetic association. Clinicians must remain suspicious of PBC during pregnancy in this population and ongoing monitoring in the post-partum period is paramount.

Funding Agencies

None
A198 EOSINOPHILIC ESOPHAGITIS WITH STRICTURE PRESENTING SHORTING AFTER INITIATION OF ORAL PEANUT IMMUNOTHERAPY
Authors: Al Yaarubi Z , Foster A , Avinashi V , Lam G , Soller L , Chan E
Published: February 2020

Background

Oral immunotherapy (OIT) is increasingly practiced outside of research settings with reasonable success (Soller 2019).

With OIT, a patient eats their food allergen daily, gradually increasing the dose, with the goal to prevent or reduce the severity of an anaphylactic reaction.

One of the described adverse events of OIT is a risk of developing Eosinophilic Esophagitis (EoE), with cited frequency of 2.7% (Lucendo 2014). In addition, OIT is typically contraindicated in patients with known EoE but patients are not routinely screened for EoE prior to initiation of OIT.

Aims

To present a case of a 12 year old boy with peanut anaphylaxis who developed eosinophilic esophagitis and an esophageal stricture shortly after starting peanut immunotherapy

Methods

Patient chart review was conducted. A literature review was done using the words “eosinophilic esophagitis” and “immunotherapy”.

Results

A12 year old boy with asthma, allergic rhinitis and multiple anaphylactic food allergies, started peanut OIT with an allergist. Prior to OIT, the patient had no symptoms suggestive of EoE such as dysphagia, heartburn, chest pain or washing of food. Approximately 3.5 weeks into treatment, the patient developed daily vomiting. The patient was advised to stop the peanut OIT three days after symptom onset, but the vomiting continued for another 8 days. By the time of endoscopy (16 days after onset of vomiting), the vomiting had completely subsided for the previous five days.

The upper GI endoscopy demonstrated signs of EoE throughout the length of the esophagus. In the mid esophagus there was resistance where the 9.8 mm gastroscope was unable to pass. A smaller gastroscope with a 5.9 mm width was easily able to pass through the stricture. Histology showed marked eosinophilia throughout the esophagus with basal cell hyperplasia, spongiosis, superficial microabscesses and stromal fibrosis consistent with EoE. The patient continued to be ‘asymptomatic’ at the time of endoscopy and after despite the presence of a stricture. After discussion, the patient was started on oral viscous budesonide (OVB) 1mg PO BID.

The patient was re-scoped 4 weeks into OVB therapy with complete resolution of the stricture with neither macroscopic nor histologic findings of EoE. Patient is now off OVB for over a month, remains asymptomatic, and will undergo repeat endoscopy in the upcoming month to ensure normal histology

Conclusions

This is the first case describing EoE with an esophageal stricture shortly after initiation of OIT. Pediatric Gastroenterologists need to be increasingly aware that patients undergoing OIT are at an increasing risk of ‘developing’ or at least ‘unmasking’ EoE. More research is required to evaluate whether EoE screening, by symptom questionnaire or endoscopy is warranted prior to beginning OIT, and whether OIT is truly needed.

Upper GI endoscopy showing signs of EoE and an esophageal stricture

Funding Agencies

CAG