bluuebunny/crossref_metadata_2025 huggingface dataset:
1124 Identifying Predictors of Weight Loss for Patients Enrolled in an Intensive Medical Weight Management Program
Authors: Bodiwala Vimal , Gardiner Catherine , Pothraj Sonia , Marshall Timothy , Clifford Shannon , Schwartz Mark , Hunt Rameck
Published: October 2019

INTRODUCTION:

Identifying predictors of weight loss are of paramount importance for patients and clinicians involved in obesity management. The aim of this study was to identify predictors of weight loss for patients enrolled in an intensive medical weight management program (IMWMP).

METHODS:

Our IMWMP involved visits every two to four weeks with medical providers, a recommended low carbohydrate diet with the goal carbohydrates individualized and often fewer than 100 g per day, encouraging physical activity, pharmacotherapy for some patients and surveillance every three months with bioimpedance plethysmography analysis (BIA). A binomial logistic regression was performed to ascertain the effects of gender, number of visits, number of daily steps, waist circumference, starting weight, starting fat mass measured by BIA, body mass index, HgbA1C, carbohydrate intake and pharmacologic medications to identify predictors of 10% weight loss from the time of enrollment to most recent office visit over a three year period.

RESULTS:

160 consecutive patients enrolled in our IMWMP who had at least three or more follow-up visits were analyzed. The mean weight at the time of joining IMWMP and most recent office visit were 238.8 lbs and 214.6 lbs, respectively, for a mean weight loss of 24.2 lbs (-10.1%; P = 0.01). Ten or more visits to our IMWMP was identified a predictor of 10% weight loss (P = .012; eB: 9.6 [CI (1.63-55.5)]; see Table 1). Female gender (P = .139; eB: 3.1 [CI (.69-14.0)]) and starting fat mass less than the mean of 106 kg on BIA (P = .054; eB: 6.37 [CI (0.97-41.7)]) showed trends towards significance. Interestingly, a starting weight under the mean of 242 pounds was associated with a reduction in the likelihood of losing 10% body weight (P = .113; eB: 0.213[CI (0.031-1.45)]. Other predictors of 10% weight loss that had a positive estimate of odds ratio (eB) but did not achieve or show trends towards significance included starting waist circumference below mean of 45 inches, daily carbohydrate intake less than 65 grams, daily steps greater than 5000 and use of pharmacologic therapy intended for weight loss.

CONCLUSION:

10 or more visits to our IMWMP are identified as a predictor of 10% weight loss. These results provide insights into predictors of weight loss in obesity management. Further studies are needed to establish the current trends and to identify additional modifiable factors.
1151 Linaclotide Safety and Efficacy in Children Aged 6 to 17 Years With Functional Constipation
Authors: Di Lorenzo Carlo , Nurko Samuel , Hyams Jeffrey S. , Weissman Taryn , Borgstein Niels , Mallick Madhuja , Muslin Anna , Saps Miguel , Simon Michael
Published: October 2019

INTRODUCTION:

Functional constipation (FC), also known as chronic idiopathic constipation, is a common problem in children that may severely impact quality of life and persist into adulthood. Currently there are no approved therapies for children and more effective treatments are needed to provide symptomatic relief. This study evaluated the safety and efficacy of a range of linaclotide (LIN) doses for treatment of FC in children aged 6–17 years.

METHODS:

This multicenter, randomized, double-blind, placebo (PBO)-controlled, parallel-group safety and efficacy study of a range of LIN doses compared to PBO randomized participants aged 6–11 years to once-daily PBO or LIN doses A, B, or C based on weight and those aged 12–17 years to once-daily PBO or LIN doses A, B, C, or 145 μg (Table 1) for 4 weeks. Primary efficacy endpoint was change from baseline (CFB) in 4-week overall spontaneous bowel movement (SBM) frequency rate. Secondary efficacy endpoints included CFB in 4-week daytime abdominal pain and bloating, stool consistency, straining severity, overall complete SBMs frequency rate, and daytime fecal incontinence. Safety assessments included adverse events (AEs), specifically AEs of special interest, treatment-emergent AEs (TEAEs), causality, severity, and serious AEs (SAEs).

RESULTS:

173 participants were randomized; 90 (52%) aged 6–11 years and 83 (48%) aged 12–17 years. For the primary endpoint, or the secondary efficacy endpoints, none of the LIN doses (A, B, C) led to a clear improvement over PBO (P ≥ 0.1502) in the ITT population. A trend toward improved efficacy at the high LIN dose vs. PBO was observed for the primary endpoint, stool consistency, and straining severity (Table 2). Similar results were observed in each age group. TEAEs were reported in 16.7% (LIN A), 29.3% (LIN B), 38.5% (LIN C), 22.0% (PBO), and 25% in the LIN 145 μg group (Table 3). The most commonly reported TEAE was diarrhea; the majority of cases were mild, and none were severe. No SAEs or AEs leading to discontinuation were reported in participants aged 6–11 years. Two SAEs were reported in participants aged 12–17 years (suicidal ideation and vomiting; 1 each); neither were considered related to study treatment.

CONCLUSION:

In children with FC, no clear improvement over PBO was observed for LIN; however, a trend for improved efficacy was observed at higher doses. LIN was well tolerated with a safety profile consistent with studies in adults with chronic idiopathic constipation.
1158 Increasing Gastroenterology Related Scholarly Output in Internal Medicine Residents Using a Novel Individualized Curriculum
Authors: Bilal Mohammad , Hernandez-Barco Yasmin G. , Parupudi Sreeram , Sonstein Lindsay , Powell Don , Buck Era , Szauter Karen
Published: October 2019

INTRODUCTION:

Scholarly work in residency can be challenging due to a busy clinical schedule, lack of prior research and biostatistical experience, and absence of a formal curriculum. Scholarly work is a mandatory requirement from the Accreditation Council for Graduate Medical Education (ACGME) for residents. Therefore, we designed and implemented a formal individualized research curriculum to enhance gastroenterology-related scholarly output in internal medicine residents.

METHODS:

We developed and instituted a research curriculum to enhance and increase scholarly activity and culture amongst internal medicine residents. The components of the curriculum were: i) Learner assessment, ii) identify needs of learner, iii) selection of the correct type of scholarly work, iv) Learner education [Referencing software (writing skills), IRB training, Institute for Healthcare Improvement modules (quality improvement projects), writing templates, statistical help / learning], finding mentorship, and dissemination of work. Our objectives were: i) foster and develop an interest in research and academic career paths, ii) meet ACGME requirements for research in residency, and iii) to increase knowledge regarding various types of scholarly work.

RESULTS:

This curriculum was applied to a total of 16 internal medicine residents and 7 medical students over a period of 30 months. A total of 30 peer-reviewed publications in PubMed indexed journals, and 50 presentations/abstracts at national meetings were presented as a result of this curriculum. In addition, a total of 7 national research awards including Presidential Poster Abstract Awards at the American College of Gastroenterology annual meeting, national American College of Physicians meeting presentation awards, and best Poster Presenter Awards were attained by these learners in recognition of their scholarly work. Also, 9 research awards were won at local/regional research meetings by the learners participating in the curriculum.

CONCLUSION:

In conclusion, a formal, systematic and individualized curriculum improved gastroenterology related scholarly output in internal medicine residents at our institution. The success of the program was largely due to the presence of identified mentors in the division who were interested in guiding enthusiastic learners. Further outcomes from the implementation of this curriculum by other departments and institutions are needed to validate the transferability and overall success of the curriculum.
1164 Breaking the Academic Ceiling: Gender Disparities and Bias in Authorship in Leading Gastroenterological Journals
Authors: Ou Amy , Lin Elissa , Pavri Tanya , Williams Renee L. , Thompson Christopher , Popov Violeta
Published: October 2019

INTRODUCTION:

The number of women entering gastroenterology in the US has steadily increased over the last quarter century. Women made up 28% of gastroenterology trainees on average during this period and are 33.6% now. When it comes to academics, however, women lag behind in all major leadership roles; for example, only 7% of gastroenterology division chiefs were women in 2015. Gender inequality has become a prominent area of concern, with many institutions taking steps to increase equality; one aspect affecting academic appointments is publication of articles as senior or first author. The objective of this study is to evaluate if these efforts have decreased gender disparities in female authorship.

METHODS:

We evaluated all original research papers and invited reviews published in 2017 and 2018 in leading gastroenterology journals: Hepatology, Gastroenterology, American Journal of Gastroenterology (AJG), Gastrointestinal Endoscopy (GIE), and Clinical Gastroenterology and Hepatology (CGH). Our primary outcome was the rate of female senior authors. Our secondary outcome was the rate of female first authors. We also assessed whether single versus double-blinded peer review has an impact on women’s authorship. We included the journal Endoscopy as a comparator to GIE, as well as New England Journal of Medicine (NEJM) as a non-gastroenterology journal.

RESULTS:

The gender was determined for 97% of authors of 3100 included articles. Female authorship is presented in Table 1 and Figure 1 along with historical data. Hepatology had the highest female senior authorship rate of 24% while GIE had the lowest: 12%. When comparing single-blinded vs. double-blinded review process in two journals with similar impact factors and scope (GIE and Endoscopy), the journal with a double-blinded review had a higher rate of senior female authors (P = 0.3), but had lower first female authorship (P = 0.001).

CONCLUSION:

Female authorship continues to lag behind the rate of women entering the field. There were fewer senior female authors than first authors across all journals. First authorship by women appears to have plateaued in several journals. Although senior authorship appears to be growing, the rate of growth in the last 10 years lags behind the growth in first authorship and number of female gastroenterologists. Overall, female authorship has gradually increased over the years but the rate of increase appears to be slowing or stalling altogether. Gender equality in authorship remains a goal to strive for.
1172 Low Diagnostic Yield of Dudodenal Biopsy of Celiac Disease in Patients With Iron Deficiency Anemia and Malabsorption Symptoms
Authors: Kwon Alvin Guyun , Yoo Heesoo , Nam Myungwoo , Nguyen Nghia , Barsky Maria , Kalmaz Denise
Published: October 2019

INTRODUCTION:

Iron deficiency anemia (IDA) is the most common form of anemia worldwide and can present with malabsorption symptoms. Current guidelines recommend performing both upper and lower endoscopies with biopsies for patients with iron deficiency anemia. Studies show that for celiac disease pooled diagnostic yield of duodenal biopsies in IDA is around 1.15%. The primary aim of this study is to determine the diagnostic yield of routine duodenal biopsies for celiac disease in patients with IDA and malabsorprtion symptoms.

METHODS:

A retrospective chart review was performed of patients undergoing EGD with duodenal biopsy as work up of IDA. All duodenal biopsies were performed from 1/1/2011-4/26/2019 at an academic tertiary referral center. Inclusion criteria was ferritin < / = 45ng/mL within 1 year prior to EGD. If ferritin data was unavailable, physician records were reviewed for diagnosis of iron deficiency anemia in patients who had proven serum MCV < 80 um3 within 1 year prior to EGD. Charts were then reviewed for reported malabsorption symptoms, n = 166. Malabsorption symptoms included abdominal pain and bloating. Patients with rectal bleeding, history of Crohn’s disease, Ulcerative colitis, gastrointestinal cancer, lymphoma or abdominal surgery leading to malabsorption were excluded. A diagnosis of celiac disease was defined as a Marsh type 2 or greater on tissue biopsy. Data on patients that had tissue transglutaminase IgA was (TTG-IGA) was also collected. Diagnostic yield for celiac disease was determined for patients who reported malabsorption symptoms.

RESULTS:

The median age of patients was 57.5 ± 16.8, of whom 25% were female. Symptoms included abdominal pain (22%), bloating (6%), diarrhea (11%) or weight loss (13%). 54% of the sample was white, 20% were Hispanic and 13% were black. Average Hgb was 9.3 ± 2.1, MCV was 76.1 ± 8.5 and ferritin was 22.9 ± 45.9. 31% of the sample had DM2, 10% had CAD, 11% had CKD, 8% had atrial fibrillation and 5% had cirrhosis. The diagnostic yield of duodenal biopsy in respect to celiac disease was 4.2%. The overall diagnostic yield in symptomatic patients with positive TTG IGA was 17%.

CONCLUSION:

Diagnostic yield of routine duodenal biopsies for identifying patients with celiac disease in setting of IDA is low. In patients with malabsorption symptoms, the diagnostic yield of routine duodenal biopsies remains less than 5%. These results suggest that alternative diagnoses should be considered in these patients.
1175 Ileal Carcinoid Tumors Detected During Screening versus Diagnostic Colonoscopy: Comparison of Tumor Characteristics
Authors: Narayani Raj I. , Narayani Kaden R.
Published: October 2019

INTRODUCTION:

Small intestinal carcinoid tumors are the most common type of small bowel malignancy observed. Most are indolent and incidentally found in asymptomatic patients undergoing ileal intubation during routine colonoscopy. Our aim was to survey all patients diagnosed with ileal carcinoid and to compare tumor characteristics for those discovered during screening or diagnostic colonoscopy.

METHODS:

We reviewed all ileal carcinoid tumor cases from 2005-2018. For each case, we recorded patient age, colonoscopy indication at diagnosis, timing of prior colonoscopy (if ever performed), coexistence of adenomatous polyps in the colon, carcinoid tumor size and stage after resection, and disease-free survival.

RESULTS:

Twenty-nine (29) cases of ileal carcinoid tumor were identified. Mean patient age at diagnosis was 64. In 5 cases, the tumor was initially identified during urgent surgical evaluation of obstructive symptoms and not during colonoscopy. In the remaining 24 cases, tumors were initially detected during colonoscopy with ileal intubation. Of these, 13 were having initial screening or surveillance. The remaining 11 were having diagnostic evaluation of symptoms, abnormal findings on CT imaging, or both. Table 1 compares carcinoid features for cases detected during screening versus diagnostic colonoscopy. A prior colonoscopy was performed within the preceding 10-year period in 11 cases, and of these, only 3 included terminal ileum intubation. Adenomatous colon polyps were found in 11 of 24 patients, with advanced adenomas identified in 3. Tumor size ranged from 0.5 to 3.7 cm (mean 1.8 cm). Lymph nodes were involved in 21 of 24 patients. In the 3 patients without lymph node involvement, tumors were small (0.5, 0.5, 0.6 cm). At diagnosis, only 1 patient had distant metastases and eventually died from tumor complications 42 months later. Another patient died from an unrelated cause at 99 months after diagnosis. Mean survival-to-date for the remaining 22 patients is 57 months with a range of 2-172 months.

CONCLUSION:

In our series, most patients with ileal carcinoid tumors were initially diagnosed during colonoscopy rather than during urgent surgery. Nearly all carcinoids discovered during colonoscopy were associated with lymph node involvement at the time of diagnosis. Most, however, did not have or develop distant metastases and have enjoyed prolonged survival. No significant differences in carcinoid tumor size or stage were observed between patients having screening versus diagnostic colonoscopy.
1176 A Sex-Based Comparison of Initial Presentation and Disease Severity of Celiac Disease
Authors: Cao Christopher , Block Peter , Russell Madeline , Parikh Devayu , Robbins Justin , Kumar Priyanka , David Allison , DiMarino Anthony J. , Moleski Stephanie
Published: October 2019

INTRODUCTION:

The presenting symptoms of Celiac Disease (CD) in females were initially described as more severe and rapid in comparison to males1. However, a recent study implied these differences may not be as significant as once believed2. The primary objective of this study is to assess for sex differences in CD.

METHODS:

This study is a single center retrospective chart review of adult patients diagnosed with CD at an urban, tertiary hospital. Patients without clear documentation of initial presentation were excluded. Outcomes included age at diagnosis, demographic data, presenting symptoms, relevant clinical values, mode of diagnosis, and adherence to diet.

RESULTS:

We included 194 patients (77% females, n = 150) diagnosed between 1999 – 2017. Ethnicity was similar between sexes. Female patients had a lower mean age (38.7 yr in females; 42.0 yr in males) and lower hemoglobin at presentation (13.5 in females; 14.3 in males; P = 0.0019). Female patients on presentation had similar BMI but higher total cholesterol. Both sexes had similar presentation at time of diagnosis, most commonly GI symptoms and neurologic symptoms. More females presented with symptoms of anemia (9.3% of females; 2.3% of males). The majority of patients in each group were diagnosed by both biopsy and serology. Both sexes presented with a similar distribution of Marsh Classification and were similarly adherent to a gluten free diet.

CONCLUSION:

This study compared the presentation of CD between sexes. In support of recent literature, our study found that male and female patients have similar clinical presentations of CD. However, a few notable differences were noted. Namely, females presented at a younger age and more frequently presented with symptomatic anemia. Both sexes had similar marsh classification on initial diagnosis and had similar adherence to a gluten free diet. While more females carry the diagnosis of CD, clinicians should have a high index of suspicion for CD in both male and female populations.
1191 Use of Artificial Intelligence for Identification of Celiac and Vascular Lesions on Capsule Endoscopy
Authors: Sethi Sajiv , Singh Arush , Morera Hunter H. , Edwards Jade , Goldgof Dmitry , Vidyarthi Gitanjali
Published: October 2019

INTRODUCTION:

Capsule endoscopy is an important tool for noninvasive identification of gastrointestinal pathology. It requires a physician to review images which can be tedious and time consuming. The use of artificial intelligence has increased in popularity for colonoscopy for identification of polyps and vascular lesions. We aim to use computer-assisted image analysis using convolutional neural networks (CNNs) for the identification of inflammatory and vascular lesions on capsule endoscopy.

METHODS:

We examined a total of 2371 publicly available wireless capsule endoscopy (WCE) images obtained using MiroCam® (IntroMedic Co, Seoul, Korea) capsule endoscopes. The capsule images illustrated normal and assorted small bowel findings including polypoid, vascular and, inflammatory lesions and were notated with each finding. Images were divided into “normal” (725 images), “inflammatory” (225 images), and “vascular” (300 images) for the purposes of this analysis. Pre-processing was performed on these images. Augmentation of the image was performed by flipping and rotating the image to obtain multiple views of pathologic and normal images. The machine learning algorithm was trained on the original and augmented images, testing was only performed on original images.

RESULTS:

Using this machine learning architecture, a total testing accuracy of 73.7% was able to be achieved for the differentiation of normal versus inflammatory and a total testing accuracy of 70.2% was able to be achieved for the differentiation of normal versus vascular capsule endoscopy images. In a set of 2371 capsule endoscopy images, the CNN identified both vascular and inflammatory images using a 5-Fold Cross validation with an accuracy of 73.7% for normal compared to inflammatory images (Figure 1) and 70.20% for normal versus vascular images. The area under the receiver operating characteristic curve (ROC) for identification of inflammatory images was 0.70 (95% CI 0.664-0.736) compared to 0.68 (95% CI 0.646-0.714) for vascular lesions.

CONCLUSION:

This system demonstrates that AI can be used to find more subtle inflammatory and vascular lesions. The CNN system detected and localized polyps well within real-time constraints using an ordinary desktop machine with a contemporary graphics-processing unit. It can increase the findings of pathology and decrease time needed to review capsule endoscopy studies, but requires further validation in large multicenter trials.
1192 The Safety, Efficacy, and Outcomes for the Endoscopic Resection of Large Non-Ampullary Duodenal Polyps in Familial Adenomatous Polyposis (FAP)
Authors: Mehta Neal , Shah Ravi , Yoon Ji Yoon , O'Malley Margaret , LaGuardia Lisa , Mankaney Gautam , Cruise Michael , Kalady Matthew F. , Church James M. , Walsh R. Matthew , Burke Carol A. , Bhatt Amit
Published: October 2019

INTRODUCTION:

Nearly all patients with FAP will develop duodenal adenomas. Duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging (SS) system. Endoscopic resection (ER) of larger duodenal polyps is technically challenging because of the duodenum’s thin wall, narrow lumen, multiple folds, and increased vascularity. However, successful removal of these large duodenal lesions can potentially avoid foregut surgery by downstaging the SS. We evaluated the safety, feasibility, and outcomes, including the effect on SS, for the ER of large duodenal polyps in FAP.

METHODS:

This is a single-center retrospective cohort study including consecutive FAP patients who underwent ER of large (defined as >1.5 cm) duodenal polyps between 4/2016-2/2019. Resection techniques used included injection-assisted endoscopic mucosal resection (EMR) and hybrid EMR-Endoscopic submucosal dissection (ESD) by an advanced endoscopist specialized in endoscopic resection. Primary aim was to determine safety of the technique, particularly perforation, immediate (>2-gram hemoglobin drop < 48 hrs after procedure) and delayed (active bleeding from a post-resection ulcer diagnosed by emergency or planned follow-up endoscopy) bleeding. SS before and after resection was calculated.

RESULTS:

35 unique FAP patients (48.6% male; age 47.7 years) with 55 large duodenal polyps were identified. All 35 underwent endoscopic resection (54 EMR, 1 ESD/EMR hybrid) of at least one large duodenal polyp [Table 1]. 7 polyps were resected from the duodenal bulb, 33 in D2, 10 in D3/D4, and 2 in the neoduodenum. Median lesion size is 2.4 cm [25-75 IQR:1.65-3], median procedure time 49 min[30-60], and median resection speed 0.16 cm2/min [0.073-0.208]. No duodenal perforations or delayed bleeding occurred. 1 case of immediate bleeding was managed endoscopically. 53/55 polyps were completely resected endoscopically. The 2 incomplete resections were poorly-lifting lesions, preventing safe resection. Of the 35 patients included, 25 had adequate endoscopic surveillance over the study period. 11/25 started at SS IV and 8 were downstaged to SS III (73%) with endoscopic resection, avoiding surgery (Figures 1 and 2).

CONCLUSION:

Endoscopic resection of large duodenal polyps in FAP is safe when performed with adequate expertise. Endoscopic resection of large polyps allows downstaging of advanced SS in many of these patients. Long-term benefit of downstaging needs to be further evaluated.
1201 Clinical and Pathologic Risk Factors for Lymph Node Metastases in Gastric Neuroendocrine Tumors
Authors: Ragheb Jonathan , Bahdi Firas , Mehta Neal , Butler Robert , Chahal Prabhleen , Stevens Tyler , Cruise Michael , Augustin Toms , McNamara Michael , Walsh R. Matthew , Bhatt Amit
Published: October 2019

INTRODUCTION:

Among gastric neuroendocrine tumors (GNETs), type III is believed to have higher risk of lymph node (LN) metastases than type I or II; however, few studies have explored the clinical history and pathologic attributes correlating with LN metastases. With advances in endoscopic resection techniques like endoscopic submucosal dissection and endoscopic full thickness resection allowing endoscopic removal of these tumors, it is important to understand which lesions are at risk of LN metastases and not candidates for endoscopic resection. Our study aims to determine clinical and pathologic risk factors associated with GNET LN metastases in the US.

METHODS:

This single center retrospective study evaluated consecutive patients at a large tertiary referral center undergoing surgical resection of biopsy proven GNET from April 1988 to January 2019. Demographics, past medical history, and serum studies (gastrin, B12, chromogranin) were included as available. Endoscopic and pathologic tumor features, such as size, number of lesions, depth of invasion, and lymphovascular invasion were studied. Tumor grading was characterized as high (poorly differentiated/WHO 3) or low (well differentiated/WHO 1 & 2) as some patients preceded WHO classification. If unreported, GNET type was based on presence of atrophic gastritis and/or gastrin levels. LN metastases were defined by positive nodes on surgical resection.

RESULTS:

Thirty patients underwent gastric surgical resection for GNET. There were 14 type 1, 8 type 3, and 8 unclassified GNETs (insufficient serum and/or pathology description for classification); no type 2 GNETs were identified based on documented history (Table 1). Of the 37.9% of patients who underwent LN dissection, 3 patients (27%) had positive LN on pathology. No patients that did not have LN dissection developed evidence of LN metastasis on surveillance imaging. Of the endoscopic and pathologic factors in Table 2, high tumor grade (P = 0.093) and deep invasion (P = 0.058) were statistically associated with LN metastasis, as with 1 high grade type 3 GNET invading the subserosa.

CONCLUSION:

High grade or deeply invading GNETs are associated with LN metastases; endoscopic resection should be avoided in these patients. In our case series, low grade type 3 GNETs were not associated with LN metastasis. Endoscopic resection with close surveillance may be considered in small, low grade type 3 GNET, especially if patients are poor surgical candidates. Further studies are needed to confirm these findings.
1209 Effect of Secretin on Gastric Accommodation, Emptying, and Symptoms in Functional Dyspepsia and Health: A Randomized, Controlled, Cross-Over Trial
Authors: Brandler Justin , Miller Laurence J. , Wang Xiao Jing , Vijayvargiya Priya , Arndt Kayla , Busciglio Irene , Burton Duane , Harmsen William S. , Acosta Andres , Camilleri Michael
Published: October 2019

INTRODUCTION:

Reduced gastric accommodation (GA) or accelerated or delayed gastric emptying (GE) contributes to pathophysiology in functional dyspepsia (FD). Secretin is an endogenous hormone secreted postprandially from the duodenal mucosa. Our objective was to determine the effects of secretin in human gastric motor functions and satiation in health and FD.

METHODS:

We conducted a double-blind, randomized, placebo-controlled, cross-over trial in 10 healthy participants and 10 patients with FD by Rome IV criteria. Subjects were randomized to IV secretin or normal saline with a 1-4 week washout period. We measured GA using validated 99mTc-single photon emission computed tomography with a standardized 300 mL meal of 111In radiolabeled Ensure®. We measured GE using scintigraphy of the same meal and symptoms 30 minutes post meal based on 100 mm visualized analog scale (VAS). To measure volume to fullness (VTF) and maximum tolerated volume (MTV), we performed Ensure® nutrient drink test (NDT) and recorded symptoms 30 min post-MTV. Wilcoxon Signed-Rank Test was used for comparison within healthy and FD groups and ANCOVA modeling was used for intention to treat comparison between groups, adjusting for age, sex, and treatment arm (secretin vs. placebo). Study drug was provided by ChiroClin, Inc.

RESULTS:

The median age for healthy volunteers (HV) was 45.0 years [IQR: 38.0, 49.0 (80% female)] and for FD was 50.5 years [42.0, 55.0 (70% female)]. There was no statistical difference in either group for secretin vs. placebo for GA. Secretin delayed GE in both HV and FD (Table 1). There was decrease in GE for secretin vs. placebo in HV at 20 minutes [-10% (-13, -7), P = 0.008] and 30 minutes [-11% (-16, -4), P = 0.004]. This finding was also seen in the FD group for GE at 25 minutes [-5% (-9, 0), P = 0.047] and 30 minutes [-8% (-9, 0), P = 0.03]. There were no statistically significant differences between treatment arms for VTF or MTV in either HV or FD. On ANCOVA analysis, there were statistically significant increases in nausea at 30 minutes (P = 0.0016) and fullness at 30 minutes (P = 0.0002) for secretin vs. placebo in FD compared to HV.

CONCLUSION:

Secretin delayed GE in both healthy volunteers and FD without significantly altering GA, VTF, or MTV. Secretin receptor stimulation deserves further study in FD patients with accelerated GE.
1220 Clinical Epidemiology of Gastric Signet Ring Cell Carcinoma in a Safety Net County Setting
Authors: Fung Brian M. , Patel Mital , Patel Neha , Brown Arleen F. , Ostrzega Nora L. , Miller Jeffrey M. , Tabibian James H.
Published: October 2019

INTRODUCTION:

Signet ring cell carcinoma is a rare but increasingly incident histotype of gastric cancer. Historically, this histotype (GSRC) has been known for its dismal prognosis; however, studies evaluating the clinical features and natural history of GSRC, particularly in the United States (US) and in minority populations, have been lacking. Thus, we examined the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmarked them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.

METHODS:

We identified all biopsy-proven GSRC cases at our Los Angeles County hospital (Olive View-UCLA Medical Center) between 2004-2017 through a retrospective histopathology database and prospective endoscopic repository. Pertinent data were collected from medical records with a standardized abstraction sheet and examined using descriptive statistics. Survival (measured as time to death or initiation of hospice) was calculated using the Kaplan-Meier method and compared with the log-rank test. Where applicable, cohort data were compared to SEER data.

RESULTS:

A total of 63 patients with GSRC were identified, of which 81% were Hispanic. Compared with SEER data, patients in this cohort were younger (mean age at diagnosis 52.6 vs 63.5 years), majority female (57% vs 45%), had higher T staging (T3 and T4 stage in 76.7% vs 60.7%), and more frequent lymph node involvement (89.2% vs 48.5%). Longer survival was seen in patients with lower tumor stage (P = 0.001), H. pylori infection (P = 0.017), and surgical intervention (P < 0.001). Overall median survival was slightly longer in this cohort compared to SEER (12.6 vs 10.0 months).

CONCLUSION:

Patients with GSRC in this safety net hospital cohort have different clinical characteristics compared to what has been reported in SEER. Patients in our cohort were younger and more often female, and despite having more advanced disease, did not have shorter survival. Further study is needed and underway to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.
1223 7 Years' Retrospective Study of Helicobacter pylori Therapy Prescription Patterns in an Urban Academic Medical Center in the United States
Authors: Lin Christina , Lee Salina
Published: October 2019

INTRODUCTION:

H. pylori is a significant cause of gastrointestinal (GI) morbidity and highly associated with gastric cancer. Combined with rising antibiotic resistance rates, prescribing effective treatment is important. Infection is not only managed by gastroenterologists, so discrepancies in prescribing patterns between GI and non-GI practitioners would be expected. Despite new ACG guidelines recommending that clarithromycin triple therapy (Tx) is no longer first line, non-GI providers may still be prescribing it over more effective therapies.

METHODS:

The data of 808 H. pylori positive adult patients, treated a variety of regimens in an urban academic medical center in the United States from 2011 to 2017 was collected and stratified by year. Positivity was determined by urea breath test, serology, stool antigen testing, or pathology. Therapies were categorized by departments, either GI (GI, pediatrics GI, hepatology, or digestive diseases) or non-GI related. Microsoft Excel was used for statistical analysis. T-tests significance level was set to α = 0.05.

RESULTS:

GI providers (68.4%) prescribed 660 therapies (315 triple, 208 quadruple, 33 sequential, 52 concomitant, & 52 hybrid). Non-GI providers (31.6%) prescribed 286 therapies (226 triple, 39 quadruple, 5 sequential, 4 concomitant, & 12 hybrid). Overall, significant differences were seen in triple (-31.3%), quadruple (17.9%), sequential (3.3%), concomitant (6.5%), and hybrid (3.7%) Tx between the groups. Significant differences between them in triple and quadruple Tx were seen in 2012-2017 and 2012 & 2014-2017, respectively. Differences in sequential, concomitant, and hybrid Tx were significant in 2015 & 2017, 2016-2017, and 2011 & 2013 & 2015, respectively. Amongst GI prescribers, a significant increase (27.9%) in concomitant Tx from 2016 to 2017 and decrease in triple Tx (15.1%) from 2015 to 2016 was observed. After 2016, triple Tx was exceeded by quadruple and concomitant Tx in the GI group, but remained the most prescribed in non-GI group.

CONCLUSION:

Triple therapy most likely decreased due to new guidelines, but it remains most prescribed by non-GI practitioners, suggesting more resources should be invested in outreach. Consistent decrease of triple therapy in the GI group, juxtaposed to the non-GI group, strongly reinforces the guideline's impact on prescription patterns. Thus, further studies to determine changes in non-GI prescribing patterns would be warranted.
1237 Efficacy and Safety of Nitazoxanide-Based Regimen for the Eradication of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis
Authors: Iqbal Umair , Khara Harshit S. , Khan Muhammad Ali , Haq Khwaja F. , Hu Yirui , Siddiqui Hafiz U. , Bergenstock Marika , Howden Colin W. , Shellenberger Mathew
Published: October 2019

INTRODUCTION:

Helicobacter pylori (HP) is the most common cause of gastritis worldwide. Clarithromycin-based triple therapy and bismuth-based quadruple therapy are among recommended first-line treatment regimens, but may fail in around 30% of patients. Resistance of HP to clarithromycin and metronidazole is also a growing concern. Therefore, there is a need for newer, reliable eradication regimens for HP. Nitazoxanide (NTZX), a bactericidal thiazolide antibiotic, has been effective in HP infection. We conducted a systematic review and meta-analysis to evaluate the efficacy of NTZX-based regimens for the eradication of HP.

METHODS:

We searched several databases from inception to April 2019 to identify studies that used nitazoxanide as part of an HP treatment regimen. We only included patients who completed the full length of therapy and were tested for eradication on follow up. Our primary outcome was the pooled HP eradication rate. We also performed a subgroup analysis to evaluate NTZX-based regimens in patients who had failed prior treatment. Pooled eradication rates and 95% confidence intervals (CIs) were initially calculated as per protocol analysis from the included studies. Publication bias was evaluated by Egger's test.

RESULTS:

Twelve studies including 978 patients met our inclusion criteria and were included in the meta-analysis. There were 4 randomized controlled trials, 7 prospective cohort studies and 1 retrospective cohort study. 7 studies were of good quality and 5 studies were of fair quality. HP eradication was successful in 826; (pooled eradication rate = 83%; 95% CI 76-90%) without significant heterogeneity (P = 0.17). In a subgroup analysis including 230 patients who had failed other prior regimens, the pooled eradication rate was 80% (95% CI 66-94%) without significant heterogeneity (P = 0.39). No serious adverse events were reported. In a subgroup analysis, the highest eradication rates were with levofloxacin, doxycycline, NTZX and a proton pump inhibitor; pooled eradication rate = 92% (81 -100%). There was no publication bias as evaluated by Egger's test [P = 0.94].

CONCLUSION:

NTZX-based regimens appear safe and effective first-line for HP eradication and are also successful as salvage therapy in patients who had failed prior treatments. Larger randomized controlled trials are required to determine the most effective NTZX-based regimen and the optimum duration of therapy for this increasingly multi drug-resistant infection.
1274 An Unusual Case of Sarcoidosis Involving the Pancreas
Authors: Sannapaneni Shilpa , Desai Amit P. , Feldman Mark
Published: October 2019

INTRODUCTION:

Sarcoidosis is a multisystem disease primarily involving the lung. Skin, eyes, lymph nodes, spleen, liver, bones, exocrine glands, heart, kidneys, and central nervous system are the most common extrapulmonary sites involved. Clinically apparent gastrointestinal (GI) sarcoidosis is rare involving 0.1 to 0.9 percent of patients with sarcoidosis. The most commonly involved portion of the GI tract is the stomach, although sarcoidosis of the esophagus, appendix, colon, rectum, and pancreas have been reported in the literature.

CASE DESCRIPTION/METHODS:

A 73-year-old African American male was found to have pancreatic duct dilation on a computed tomography scan of abdomen done for investigation of mild epigastric abdominal pain that started a few months prior to presentation. He described the pain as dull, non-radiating, aggravated when hungry, subsided with food intake and associated with bloating. He had a past medical history of hypertension, hypothyroidism, and sarcoidosis involving lymph nodes and liver (not on treatment). He had no family history of GI cancer. He was a non-smoker and non-alcoholic. On presentation, his vital signs were normal; his abdomen was soft and non-tender, with normoactive bowel sounds and no masses or organomegaly. He had a normal calcium level of 9.7 mg/dL and his liver panel was significant for slightly elevated serum alkaline phosphatase, AST, ALT levels, with normal serum bilirubin. Magnetic resonance imaging showed 1.2 cm mass in the body of the pancreas obstructing the pancreatic duct and another 1.1 cm mass in the head of the pancreas concerning for malignancy. He underwent endoscopic ultrasonography with fine needle aspiration cytology of both pancreatic masses which showed numerous non-caseating granulomas consistent with sarcoidosis. Special stains for fungi and tuberculosis were negative.

DISCUSSION:

Less than 30 cases of biopsy-proven pancreatic sarcoidosis have been reported in the literature. Patients can have direct involvement of pancreas with sarcoidosis or 1, 25-dihydroxy vitamin D3 mediated hypercalcemia causing hypercalcemic pancreatitis. About three fourths of patients with pancreatic sarcoidosis have bilateral hilar adenopathy on chest radiography. On imaging, these patients demonstrate either a pancreatic mass (or masses) or a diffuse nodular pancreas. A biopsy is essential to distinguish between sarcoidosis, mycobacterial or fungal infection, and cancer. Treatment is usually conservative or with glucocorticoids.
1278 Often a Favorable Prognostic Factor: Unusually Elevated Alpha-Fetoprotein (AFP) in a Case of Hepatitis B Virus (HBV) Associated Intrahepatic Cholangiocarcinoma (ICC)
Authors: Yuridullah Ruhin , Estifan Elias , Vora Aarohi , Kumar Vinod , Michael Patrick , Maroules Michael
Published: October 2019

INTRODUCTION:

Intrahepatic cholangiocarcinoma (ICC), often an incidental finding is a rare tumor of the epithelial cells of the biliary ducts that originate in the liver and extrahepatic bile ducts. Serum alpha-fetoprotein (AFP), as a tumor marker of hepatocellular carcinoma (HCC), and carbohydrate antigen 19-9 (CA 19-9), as a tumor marker of ICC, have been widely used in clinical practice. Although, a subset of patient with ICC (20-25%) present with elevated AFP levels, usually >100 ng/mL and very rarely >1000 ng/mL, its role remains significant in prognosis of ICC. Herein, we discuss a case of Hepatitis B virus (HBV) associated ICC in a young individual with exceptionally high serum AFP levels.

CASE DESCRIPTION/METHODS:

A 45-year-old male with no apparent past medical history was seen for complaints of fatigue, nausea, anorexia, and associated 34-lb weight loss of 6-weeks duration. Initial labs revealed a chronic HBV infection and an obstructive pattern on liver function tests. Computerized tomography (CT) scan of the abdomen showed a large heterogeneous mass originating from porta hepatis and invading the left lobe of the liver with multiple liver metastases and metastatic lymphadenopathy of the porta hepatis. CT also revealed a mass in the gallbladder along with thrombosed portal vein and intrahepatic biliary dilation (Figures 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) confirmed initial CT findings. Labs revealed an AFP level of 9,715 ng/mL and CA 19-9 level of 554 units/mL. Percutaneous transhepatic cholangiography (PTC) and tissue biopsy revealed liver parenchymal poorly differentiated adenocarcinoma. Attempted internalization of a biliary stent by interventional radiology (IR) was unsuccessful. Management options were discussed with the patient and family who opted for a palliative approach without chemotherapy.

DISCUSSION:

Intrahepatic cholangiocarcinoma (ICC) is a rare tumor of the epithelial cells of the biliary ducts originating in the liver and extrahepatic bile ducts. ICC tends to be aggressive due to lymph node involvement at diagnosis with intrahepatic, and peritoneal dissemination. Several factors have been implicated in the pathogenesis of ICC including hepatitis B and C viral infections. Role of AFP, often a marker of HCC, is a significant one in prognostication of ICC. Elevated AFP levels, especially with HBV-associated ICC carries a favorable prognosis. Unfortunately, in the case of our patient, due to the advanced nature of his condition, his prognosis remained poor.
1284 Epstein Barr Virus (EBV)-Associated Acute Pancreatitis: Case Report
Authors: Hammami Muhammad B. , Aboushaar Reem , Musmar Ahmad , Azhar Mishah , Miller Stephen M. , Salomon Peter
Published: October 2019

INTRODUCTION:

EBV infection is mostly subclinical and resolves spontaneously without complications. GI involvement manifests mainly with asymptomatic liver enzyme elevation. We report a case of acute pancreatitis complicating EBV infection.

CASE DESCRIPTION/METHODS:

An 18-year-old woman presented with 12 day history of moderate unremitting upper abdominal pain, nausea, and anorexia. She had a temperature of 36.8°C, bilateral non-tender cervical lymphadenopathy, mild pharyngeal injection, and moderate epigastric tenderness, but no splenomegaly or jaundice. She didn't take any medications and denied alcohol/illicit drug use. Leukocyte count was 14.5 cells/μL (15% neutrophils, 9% monocytes, 44% reactive lymphocytes), hemoglobin 12.7 g/dL, amylase 327 IU/L, lipase 2016 U/L, alkaline phosphatase 246 IU/L, aspartate aminotransferase 210 IU/L, alanine aminotransferase 283 IU/L, total/direct bilirubin 2/1.6 mg/dL. Calcium, blood glucose, and triglycerides were normal. Ultrasound showed mildly enlarged liver with coarse echotexture, contracted gallbladder, normal common bile duct, and mildly enlarged right upper quadrant lymph nodes, but no intrahepatic biliary ductal dilation. Computed tomography showed acute pancreatitis and mild splenomegaly. Anti-HAV IgM; HBsAg and anti-HBV core IgM; anti-HCV; HIV1 p24 antigen; anti-HIV1 and anti-HIV2 antibodies (AB); and CMV (quantitative PCR) were negative. EBV heterophile AB was positive, EBV IgG viral capsid AB 78.6 U/mL, EBV IgM viral capsid AB >160 U/mL, and EBV IgG early disease AB 70 U/mL. She was treated conservatively and discharged on the fourth day of hospitalization.

DISCUSSION:

Clinical pancreatitis is rarely associated with EBV infection; only 17 cases have been previously reported. As in our case, most patients were adolescent/young adults, have clear EBV infection picture, and have mild to moderate pancreatitis course with spontaneous recovery. Although acyclovir was tried, it isn't clear if it's required. Our patient was unique in that her hospital stay was 4 days in comparison to a mean of 10 days in other reported cases. EBV infection should be considered in the differential diagnosis of mild to moderate pancreatitis. It is not clear if subclinical pancreatitis in the setting of EBV infection is more common and why only few patients develop clinical pancreatitis.