bluuebunny/crossref_metadata_2025 huggingface dataset:
380 High Resolution Manometry Findings in Patients With Absent Contractility
Authors: Fan Xiaowen , Paik Il J. , Zhang Xiaocen , Kassim Gassan , Hershman Melissa , Verheyen Elijah , Abed Jean , Smith Michael S.
Published: October 2019

INTRODUCTION:

High resolution manometry (HRM) is a widely utilized diagnostic tool for identifying esophageal motility disorders. The Chicago Classification V3.0 (CC3) applies a hierarchical stepwise approach to the analysis of HRM parameters, allowing for characterization and diagnosis of different disorders. While upper esophageal sphincter (UES) parameters are not utilized in CC3, studies have shown that these values could potentially help in differentiating between different disorders. The aim of this study was to evaluate for trends in esophageal sphincter parameters in patients with absent contractility (AC).

METHODS:

Reports for esophageal HRM performed at a single referral-based motility center between 2013 and 2018 were retrospectively analyzed. We selected patients diagnosed with either AC (study group) or no CC3 abnormality (control group), and divided them by age group. The primary outcome included differences in parameters related to both the lower esophageal sphincter (LES) and UES. Multivariate regression analysis was used to adjust for age group and sex.

RESULTS:

A total of 455 patients were included in the study (Figure 1), 52 with AC (mean age 51.4, 50.0% female) and 403 without CC3 abnormality (mean age 52.8, 69.5% female). The primary indication for HRM was more likely to be dysphagia in AC patients (73.1% vs 30.5%, P < 0.01), whereas GERD was more likely to be reported in controls (67.2% vs 25.0%, P < 0.01). AC diagnosis was associated with a lower LES mean basal pressure (14.9 vs 27.0 mmHg, P < 0.01) and LES mean residual pressure (5.9 vs 7.9 mmHg, P < 0.01). However, UES mean residual pressure (2.1 vs 0.1 mmHg, P = 0.02) and UES mean relaxation time to nadir (296.4 vs 228.5 ms, P = 0.04) were significantly higher compared to control. No significant difference in UES mean basal pressure was identified between the study group and control.

CONCLUSION:

AC affects both the LES and UES, causing decreased LES basal and residual pressures, along with increased UES residual pressures and UES relaxation time to nadir. Our data suggest that AC affects smooth muscle in both the esophageal body and LES, where it causes decreased LES tone. The increased UES residual pressures and relaxation time to nadir might be compensatory adaptation to poor esophageal bolus clearance to prevent esophago-pharyngeal reflux. Utilization of UES parameters in future versions of the Chicago Classification may help users better diagnose and manage AC and related disorders.
389 Are Proton Pump Inhibitors Associated With an Increased Risk in Developing Ischemic Heart Disease in Non-Cardiac Chest Pain Patients?
Authors: Kim Yeseong , Fass Ronnie
Published: October 2019

INTRODUCTION:

Non-cardiac chest pain (NCCP) is defined as chest pain that persists after cardiac etiologies have been excluded. Treatment of NCCP is targeted towards the underlying cause, most often GERD, which is commonly treated with proton pump inhibitors (PPI). It has been reported that long term PPI use is associated with increased risk for developing ischemic heart disease (IHD). We aim to determine whether PPI use is associated with an increased risk for IHD in NCCP patients, and thus alter the otherwise benign course of the disease.

METHODS:

Cohort analysis was performed using the multi-institutional database IBM Explorys. NCCP patients started on a PPI at least 1 day after diagnosis, and who developed IHD at least 30 days following PPI initiation were included. Identical parameters were used to acquire data on patients prescribed histamine H2 receptor antagonists (H2RA). Data analysis was controlled for 6 known confounding factors for IHD including hyperlipidemia, hypertension, obesity, smoking status, male gender, and diabetes mellitus.

RESULTS:

A total of 13,250 NCCP patients without preexisting IHD received PPI; 1,280 (9.66%) developed new IHD. Of these patients, 740 (57.8%) had ST-elevation MI (STEMI), 340 (26.5%) non-ST elevation MI (NSTEMI), and 200 (15.6%) ischemic cardiomyopathy (ICM). A total of 22,260 NCCP patients without preexisting IHD were never prescribed a PPI; 870 (3.91%) developed new IHD. Of these patients, 490 (56.3%) had STEMI, 210 (24.1%) NSTEMI, and 170 (19.5%) ICM. The unadjusted and adjusted odds ratios of developing IHD in NCCP patients while on PPI compared to not on PPI were 2.63 (95% CI 2.41-2.87), and 1.14 (95% CI 1.03-1.25, P-value 0.0093), respectively. A total of 3,050 NCCP patients without preexisting IHD received H2RA; 250 (8.19%) developed new IHD. Of these patients, 160 (64%) had STEMI, 70 (28%) NSTEMI, and 20 (8%) ICM. Overall, 22,070 NCCP patients without preexisting IHD received H2RA; 1,320 (5.98%) developed new IHD. Of these patients, 790 (59.8%) had STEMI, 350 (26.5%) NSTEMI, and 180 (13.6%) ICM. The unadjusted and adjusted odds ratios of developing IHD while on H2RA compared to not on H2RA were 1.40 (95% CI 1.22-1.62) and 0.90 (95% CI 0.77-1.06, P-value 0.2049), respectively.

CONCLUSION:

PPI use appears to confer a statistically significant, but marginally increased odds in developing IHD in NCCP patients. Thus, PPI use in NCCP only minimally alters the course of the disease. H2RA use does not statistically increase the risk for IHD in NCCP patients.
391 How Useful Is Prolonged 96 Hr versus 48 Hr Wireless pH Monitoring in PPI Refractory GERD?
Authors: Rassameehiran Supannee , Tetangco Eula Geralyn , Lee Jai Eun , Sharma Amol , Rao Satish
Published: October 2019

INTRODUCTION:

Gastroesophageal reflux disease (GERD) is a common problem. Ambulatory pH monitoring has been used to identify pathological esophageal acid exposure and reflux-symptoms association in GERD, especially when endoscopy is normal, but the utility of prolonged 96 hr monitoring and if PPI therapy during study facilitates better management is unclear. The purpose of the study is to evaluate the clinical utility of prolonged 96 hr wireless pH monitoring, before and after PPI therapy.

METHODS:

We conducted a retrospective study of adult patients presenting to our center between January 2015 and June 2018 with suspected diagnosis of GERD and refractory to PPI therapy. Consecutive patients who underwent 96 hr wireless pH monitoring (Bravo®, Medtronics, Minneapolis, MN) placed endoscopically, 6 cm above LES zone were enrolled. Patients were instructed to stop PPI therapy 7 days prior to the study and to resume their usual PPI therapy on day 3 and day 4 of study. The percent time of esophageal acid exposure (pH < 4) for each day during supine and upright positions and GI symptoms were analyzed using (SPSS™) version 22. Patients were excluded if the entire 96 hr study was not recorded either from battery malfunction or capsule detachment. Data compared between those with normal and abnormal pH study, and between first 48 hrs and next 48 hrs.

RESULTS:

64 patients met inclusion criteria (Table 1). 42 (65%) patients had elevated >4.5%. Total 24 hr acid exposure time; 38% on either D1 or D2 and 62 % on both days and 22 (35 %) had normal acid reflux study (Figure 1, Table 2). Of patients with abnormal study, 23/42 (54.7%) had persistent increase in % acid exposure time on D3 and 17/42 (40.4%) patients on D4 following PPI therapy.

CONCLUSION:

Our study demonstrates that prolonged 96 hr pH monitoring is feasible and clinically useful. We confirmed abnormal acid reflux in 65% of patients and normal acid reflux in 35%. Also, the abnormal reflux profile normalized in 36% of patients on their usual PPI whereas 64% had persistent abnormal acid reflux, despite their usual PPI therapy. Thus 96 hr testing allows improved diagnosis of day time or supine acid reflux symptoms, and identifies patients who are either refractory or responsive to current PPI therapy. This test could improve management of patients with PPI refractory GERD.
392 Baseline Characterization of Patients With Eosinophilic Esophagitis (EoE) Using the EoE Histology Scoring System and Correlations With Endoscopic and Symptom Outcomes: Analyses From a Randomized, Placebo-Controlled Trial
Authors: Collins Margaret H. , Dellon Evan S. , Hirano Ikuo , Katzka David A. , Williams James , Lan Lan , Desai Nirav K.
Published: October 2019

INTRODUCTION:

It is becoming clear that eosinophilic esophagitis (EoE) activity cannot be measured by eosinophils alone, and that a more complete assessment is needed. The EoE Histology Scoring System (EoE HSS) measures the severity (grade) and extent (stage) of 8 histopathologic features in EoE: eosinophilic inflammation (EI); basal zone hyperplasia (BZH); eosinophilic abscess (EA); eosinophilic surface layering (SL); dilated intercellular spaces (DIS); surface epithelial alteration (SEA); dyskeratotic epithelial cells (DEC); and lamina propria fibrosis (LPF). We aimed to assess EoE histology at baseline using the EoE HSS, and to compare correlations between this and endoscopic and symptom outcomes.

METHODS:

This study analyzed baseline data from a 12-week, phase 2, randomized, placebo-controlled trial of budesonide oral suspension in patients with EoE (MPI 101-06; NCT01642212). Patients were eligible for inclusion if they were aged 11–40 years and had EoE with dysphagia. Esophageal biopsies from patients were examined, and mean EoE HSS total score ratios and mean individual feature scores were calculated at baseline for all patients (irrespective of treatment allocation). A correlation analysis was then performed to compare these scores with Dysphagia Symptom Questionnaire (DSQ) scores and those from the EoE Endoscopic Reference Score (EREFS) system at baseline.

RESULTS:

In total, 87 patients were included for analysis. At baseline, mean (standard deviation) EoE HSS grade and stage total score ratios for all patients were 0.5 (0.2) and 0.4 (0.1), respectively. For individual EoE HSS features, a summary of mean grade and stage scores at baseline is shown in Table 1; the most severe features for grade and stage were EI, BZH, DIS and LPF. At baseline, mean EoE HSS grade and stage total score ratios did not correlate with mean DSQ score, but did correlate significantly with mean EREFS score (grade: R = 0.3166; P = 0.0028; stage: R = 0.3344; P = 0.0015; Table 2). Similarly, mean scores for individual EoE HSS features did not correlate with mean DSQ score at baseline, but did correlate with mean EREFS score for 4 and 3 of the 8 features for grade and stage scores, respectively (Table 2).

CONCLUSION:

The most severe EoE HSS features at baseline for grade and stage were EI, BZH, DIS and LPF. At baseline, there were significant correlations between the EoE HSS and endoscopic severity, but not dysphagia. This suggests that the EoE HSS could become an essential and independent tool to measure EoE activity.
402 Shared Decision Making in Eosinophilic Esophagitis Is Associated With Treatment Satisfaction but Is Inadequately Practiced
Authors: Chang Joy W. , Rubenstein Joel , Mellinger Jessica , Kodroff Ellyn R. , Strobel Mary Jo , Scott Melissa M. , Mack Denise , Book Wendy , Sable Kathleen L. , Kyle Scholeigh (Shay) M. , Paliana Ally , Dellon Evan S.
Published: October 2019

INTRODUCTION:

Given the similar effectiveness but differing philosophies of treatments for eosinophilic esophagitis (EoE), shared decision making (SDM) between patients and providers is important for improving treatment and adherence. Because little is known about this area, we aimed to describe patient-reported SDM and satisfaction in EoE care.

METHODS:

We developed and administered a web-based survey about SDM and satisfaction around EoE treatment based on a validated 9-item SDM questionnaire (composite range 9 – 54, low SDM defined as < 32). Adults and caregivers of pediatric patients were recruited via patient advocacy groups and at two tertiary care centers. Regular care was defined by seeing the specialty provider at least annually. Multivariable linear and logistic regression was performed to identify predictors of SDM and satisfaction with treatment.

RESULTS:

A total of 243 (47%) adults (mean age 38.7 years, SD 12.1) and 270 (53%) caregivers of pediatric patients (mean age 9.5 years, SD 4.5) completed the survey. A majority (90%) had a diagnosis of EoE alone. Among adults, 31% had regular care with both gastroenterology (GI) and allergy, 30% only with GI, 7% only with allergy, and 32% without specialty care. In contrast, a large majority of the pediatric cohort (70%) had regular follow-up with both GI and allergy, 25% only with GI, 3% only with allergy, and 2% with neither subspecialist. Patients followed by GI providers were more likely to experience greater SDM compared to non-specialists (adjusted β = 6.85; 95% CI 3.31-10.4) (Figure 1, Table 1). Despite this, nearly half of adults (44%) and children (40%) experienced low SDM for EoE management. SDM with allergists alone was similar to non-specialists. There was no difference between adults and children for the effects of provider type. More SDM occurred when patients perceived providers as comfortable with choosing a therapy outside of their recommendation (Table 1). Those receiving more SDM were more satisfied with current treatment, regardless of provider or treatment type (OR 2.77, 95% CI 1.86-4.11; Table 2).

CONCLUSION:

SDM around EoE care is practiced most by gastroenterologists and when patients perceived provider comfort with various options, however many patients still do not experience joint decision making. Because patients are more likely to be satisfied with any treatment when SDM is practiced, it is important to improve patient-centered communication and engagement in managing EoE.
403 Elucidation of Patient Motivators and Barriers to Pursuing Treatments for Eosinophilic Esophagitis
Authors: Chang Joy W. , Rubenstein Joel , Mellinger Jessica , Strobel Mary Jo , Kodroff Ellyn R. , Scott Melissa M. , Mack Denise , Book Wendy , Sable Kathleen L. , Kyle Scholeigh (Shay) M. , Paliana Ally , Dellon Evan S.
Published: October 2019

INTRODUCTION:

Because comparative effectiveness trials of eosinophilic esophagitis (EoE) treatments are lacking, patient preferences are often incorporated to select the ideal therapy plan. However, treatment uptake and adherence are often complicated by minimized symptoms, financial cost, convenience, perceived risk and knowledge. We aimed to explore motivators for treating EoE and barriers to using common therapies.

METHODS:

We developed and administered a web-based survey on factors which affect EoE treatment choices. Adult patients and caregivers of pediatric patients were recruited via patient advocacy groups and at two tertiary care centers. Descriptive statistics of multiple response questions were performed.

RESULTS:

Of 513 respondents, 47.4% were adults and 52.6% caregivers of pediatric patients (Table 1). The most common motivator to treat EoE was a desire to prevent complications or worsening disease (88.2% adults, 94.2% peds) (Figure 1). However, only half of adults felt that EoE could be a serious disease (54.1%) and 44.4% had trust that medications or diet could control it. The greatest barriers to topical steroids were potential side effects (58.2% adults, 63.4% peds), financial cost (34.1% adults, 19.3% peds), and preference for a medication-free approach (24.8% adults, 25.9% peds) (Figure 2). Inconveniences of a restrictive diet (36.3% adults, 27.6% peds), multiple endoscopies (30.4% adults, 26.8% peds), poor quality of life and socialization (23.7% adults, 27.6% peds), and inadequate nutrition (28.4% peds) were common barriers to diet therapy. Participants reported avoiding dilation because of belief that it is a high risk procedure (30.7% adults, 36.6% peds), discomfort (30.4% adults, 27.6% peds), and financial cost (31.1% adults, 20.6% peds). Additionally, 24.4% adults felt that they would avoid dilation because of inconveniences around having a procedure.

CONCLUSION:

Although only half of patients trusted that therapy could control EoE, preventing complications and worsening disease were the most important factors in pursuing treatment. Common barriers were inconvenience and financial costs. Side effects of steroids, quality of life and nutrition management for diet therapy, and discomfort from dilation were treatment specific barriers. To improve management of EoE and patient engagement, providers need to recognize challenges of both the disease and treatments, elicit patient preferences, and tailor therapy plans to individual attitudes and values.
425 Is the Use of Proton Pump Inhibitors Associated With Increased Risk of Ischemic Stroke: A Systematic Review and Meta-Analysis
Authors: Laique Sobia N. , Riaz Haris , Carey William , Deshpande Abhishek
Published: October 2019

INTRODUCTION:

The use of proton-pump inhibitors (PPIs) has been associated with various adverse effects including increased risk of major adverse cardiovascular events, community acquired clostridium difficile infection, chronic kidney disease and dementia. Some studies over the past decade have suggested an association between PPIs use and ischemic stroke.

METHODS:

We pooled the data after comprehensive literature search from the PubMed, Embase, Cochrane Library and Scopus databases using ‘proton pump inhibitors’ AND ‘stroke’ as the keywords. RevMan was used for the entry and analysis of data. A random effects model was created given the significant heterogeneity of the included studies and a funnel plot was made to assess the publication bias. Our primary objective was to study whether all-comers patients on PPIs are at an increased risk of stroke. Sub-group analysis was also done to investigate the association between patients on dual anti-platelet therapy [DAPT] (aspirin and clopidogrel) with or without PPIs and stroke.

RESULTS:

After searching 774 titles, 25 titles were selected to be included in the systematic review and 15 articles for the meta-analysis. Our pooled analysis of 155,406 patients (46,652 patients on PPI and 101,892 patients without PPI found a positive association between the use of PPI and stroke (odds ratio = 1.28, 95% confidence interval = 1.12, 1.48, P = 0.001) [Figure 1]. Given the significant heterogeneity of the studies (I2= 60%) a sub-group analysis was done which also suggested an increased risk of stroke associated with PPI use among patients on dual antiplatelet therapy (OR: 1.43, 95% CI: 1.26, 1.66, p< 0.001, I2= 11%) [Figure 2]. Analysis of the included randomized controlled trials revealed an OR: 1.47, 95% CI: 0.66, 3.25 but the results were not statistically significant (p< 0.81) [Figure 3].

CONCLUSION:

In a pooled analysis of over 155,000 patients we found a positive association between the use of PPIs and stroke. Our results are limited by significant heterogeneity and retrospective study design of the observational studies. Rigorous clinical trials are needed to establish the safety of PPIs in relation to stroke, especially among patients on DAPT. Until definitive data emerges, patients on DAPT are probably best served by being off PPIs or being on alternative acid suppression regimen, unless there is a compelling indication for PPI use.
428 Esophageal Food Bolus Impactions: Predictors of Persistent Impaction at Endoscopy and Strategies for Disimpaction
Authors: Keyes Erin , Kouanda Abdul , Kathpalia Priya
Published: October 2019

INTRODUCTION:

Esophageal food bolus impaction is a true gastrointestinal emergency. While most cases resolve spontaneously, up to 20% require emergent upper endoscopy (EGD). No prior studies have been done in the United States to explore how patient symptoms may predict persistent obstruction at the time of endoscopy. Our aim was to determine symptoms that reliably predict complete impaction in efforts to quickly recognize those who need emergent EGD at time of presentation.

METHODS:

This is a retrospective cohort study of 83 patients who presented to the emergency room with suspected food bolus impaction between 1/2013 and 5/2018 at a tertiary care academic medical center. Electronic health records were reviewed to determine presenting symptoms and initial treatment course. Exclusion criteria were age < 18, history of esophageal malignancy, or presence of an esophageal stent. Descriptive statistics, univariate and multivariate analysis were performed.

RESULTS:

During the study period 52 of 83 (63%) patients underwent an EGD for suspected food bolus impaction. Patients who underwent EGD were more likely to have received glucagon (P = 0.004) and to have presented with sialorrhea (P = 0.001), as compared to patients who did not undergo EGD. 42 of 52 (81%) patients who underwent EGD had an overt food bolus impaction identified. Predictors of overt impaction at EGD were glucagon administration (P = 0.02), underlying esophageal pathology (P = 0.01), and sialorrhea on presentation (P = 0.01). 30 of 42 (71%) patients with overt food impaction were found to have complete obstruction. These patients were more likely to have received glucagon (P = 0.04), have an earlier EGD (P = 0.04), and have symptoms of odynophagia (P = 0.003), sialorrhea (P = 0.001), and regurgitation (P = 0.006), as compared to patients with partial obstruction. On multivariate analysis, sialorrhea (P = 0.001) and odynophagia (P = 0.023) were symptoms predictive of EGD, and only sialorrhea (P = 0.01) was predictive of persistent food impaction at EGD.

CONCLUSION:

Sialorrhea and glucagon administration were independently associated with the need for EGD during admission. Sialorrhea was the only symptom predictive of persistent impaction found on EGD. Sialorrhea along with odynophagia were most predictive of complete obstruction as compared to partial. These symptoms on presentation may help triage patients in need of more emergent EGD.
441 Combination of Dysphagia and Exophytic Esophageal Carcinoma Strongly Correlates With Advanced Disease Based on EUS: A Possible Clinical Shortcut?
Authors: Simmelink Andrew , Lewis Jason
Published: October 2019

INTRODUCTION:

Since the 1960’s, the incidence of esophageal cancer has increased steadily by 8% annually in the U.S, and has an overall 5-year survival for early stage adenocarcinoma < 15%. Combined modality of endoscopy, CT and/or CT/PET imaging, and endoscopic ultrasound (EUS) are often utilized to diagnose and stage according TNM classification. If no distant metastases are found, EUS can be used to stage regional lymph nodes and tumor depth. Historically, esophagectomy was the therapeutic mainstay, but is associated with 10% mortality and > 50% morbidity. Endoscopic therapy is now utilized in patients with Tis or T1a tumors with improved survival. We examined the likelihood of clinical symptomatology predicting esophageal carcinoma TNM stage at the time of EUS.

METHODS:

Our IRB approved retrospective study from January 2007 to July 2017 included 300 medical records of patients over 18 years old obtained through ICD 9&10 codes. 100 patients were randomly chosen for analysis. Patients were excluded for the following: insufficient records, caustic or hazardous exposures, acute trauma, perforation, or surgery, radiation or chemotherapy, HIV, eosinophilic esophagitis, or those undergoing Barret’s esophagus surveillance screening. Data analysis included student t-test to determine significance.

RESULTS:

Mean age at time of diagnosis was 64, with 77% male. Eighty-one percent of lesions were in the distal third of the esophagus. Adenocarcinoma was the predominant tumor at 81% followed by squamous cell carcinoma. Of these cancer diagnoses, 78 patients experienced either solid food or progressive dysphagia prior to endoscopy. 83% of dysphagia patients were T3 or greater by EUS [Figure 1]. There was no correlation between dysphagia symptoms and lymphadenopathy on either CT (P = 0.21) or EUS (P = 0.34).

CONCLUSION:

Our results show a strong association of dysphagia as a presenting symptom with advanced TNM stage at the time of EUS (P = 0.03). CT imaging techniques alone may be sufficient in individuals with dysphagia and exophytic lesion by ruling out distant metastasis. Evidence gained by EUS and the associated added costs may not add clinical information to assist in management decisions with neoadjunvant therapy or esophagectomy candidacy. Further prospective study is needed to determine if EUS is warranted in individuals with dysphagia and an exophytic mass at the time of EGD, who have undergone CT staging to rule out distant metastasis.
446 Do GI Patients Care About Adverse Effects of Proton Pump Inhibitors?
Authors: Patel Ami , Munis Assad , Shah Natasha , Khan Mohsen , Ehrenpreis Eli
Published: October 2019

INTRODUCTION:

Proton Pump Inhibitors (PPIs) are generally considered to be safe. Recently, several observational studies have associated PPI use with potential adverse drug reactions (ADRs) including chronic kidney disease (CKD), dementia, and cardiovascular disease. Other potential ADRs such as osteoporotic fractures and increased risk of community acquired pneumonias and Clostridium difficile infection have been known for a longer period of time. Patient awareness of potential ADRs and its effect on continued use of PPIs have received little attention in the medical literature.

AIM:

To survey patients at a single community-setting outpatient endoscopy center to assess and understand gastrointestinal (GI) patient opinions about ADRs from PPI use.

METHODS:

An anonymous survey with 15 multiple choice questions regarding PPI use (two questions allowing for more than one answer) was distributed to all adult outpatient endoscopy patients at Advocate Lutheran General Hospital from January to March 2019. The survey questioned indication and duration of PPI use, awareness of PPI ADRs, level of concern for ADRs, and drug discontinuation.

RESULTS:

Of 2,288 patients surveyed, 1,689 (74%) returned the survey. Of these, 342 patients (20%) were current PPI users and were the subject of this analysis. The most common indications (multiple could be selected) for PPI usage were heartburn (n = 162), GERD (n = 155), and stomach/abdominal pain (n = 78) (Table 1). The most commonly identified ADRs related to PPI use were osteoporosis (n = 43) and CKD (n = 35) (Figure 1). However, 181 (53%) patients reported that they were not aware of any ADRs from PPIs. Of 218 (64%) patients who expressed concern regarding ADRs, 47 (14%) selected extreme concern, 57 (17%) with moderate concern, 88 (26%) somewhat concerned, and 26 (7%) hardly concerned (Figure 2). No concern was selected by 48 (14%), and 76 (22%) felt there were no ADRs from PPIs. There were 91 (27%) patients who attempted to stop their PPI treatment, but only 17 (5%) stopped because of concerns about ADRs.

CONCLUSION:

The majority of GI patients consuming PPIs are unaware of PPI-associated ADRs. However, when patients are alerted to these side effects, only approximately 60% of these patients express some degree of concern. More importantly, concern and awareness of these side effects does not appear to be a common cause for discontinuation for PPI therapy amongst GI patients.
453 Characterizing Esophageal Dysmotility in Patients With Post-Fundoplication Dysphagia
Authors: Wang Allison , Clayton Steven
Published: October 2019

INTRODUCTION:

Studies show that up to 90% of patients who undergo a fundoplication experience dysphagia post-operatively, and at least 10% of these patients' dysphagia will persist past 1 year. Little is known about possible causative etiologies. This project aims to manometrically characterize post-fundoplication dysphagia present in patients at least 1 year after surgery versus dysphagia controls with no prior history of gastric surgeries.

METHODS:

This is a single-center, retrospective chart review of patients who received a Nissen fundoplication for refractory GERD and were seen between January 2011 and February 2019 for post-fundoplication dysphagia lasting longer than 1 year before undergoing high resolution manometry (HRM). The 25 research subjects were matched to corresponding age, gender, and race-matched controls who were seen at the center for dysphagia during the same time period. The data collected includes demographics, symptoms, and findings from HRM, endoscopy, gastric emptying studies, pH impedance studies, and barium esophagrams.

RESULTS:

The mean lower esophageal sphincter respiratory basal pressure (LES RBP) was significantly lower in patients with fundoplication as compared to controls (P = 0.028). Patients with fundoplication had a significantly decreased distal contractile integral (DCI) as compared to controls (P = 0.0089). The ranges of DCI values between the two groups were notably different (subjects: 643-1500 mm Hg-cm-s; controls: 1654-3590 mm Hg-cm-s). Patients with post-fundoplication dysphagia were more likely to have a hypotensive LES (P = 0.096) and less likely to have a hypertensive LES (P = 0.023) compared to the dysphagia controls with no prior history of gastric surgery. Furthermore, they were more likely to have an esophageal dysmotility disorder—ineffective esophageal motility (43%), failed peristalsis (21%), fragmented peristalsis (7%), or diffuse esophageal spasm (29%) (P = 0.038). There were no significant differences between subjects and controls found in patient-reported symptoms, gastric emptying studies, pH impedance studies, barium esophagrams, and endoscopy reports.

CONCLUSION:

Many believe that esophageal hypomotility will improve in patients undergoing fundoplication for GERD. Our study demonstrates that post-fundoplication dysphagia is associated with higher rates of esophageal motor abnormalities, specifically esophageal hypomotility, when compared to dysphagia controls with no prior gastric surgical history.
457 Predictor Factors for Dilation Treatment in Stricture Due to Eosinophilic Esophagitis
Authors: Ansstas Michael , Lew Daniel , Early Dayna
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EOE) is one of the most common causes of dysphagia and food impaction in the last two decades. Medical therapy including proton pump inhibitors (PPI), topical steroids, and diet can help, but if an esophageal stricture is present, then dilation may be necessary. The safety and efficacy of stricture dilation in EOE have been shown, but there is limited data on factors that can predict if patients will require multiple dilations. The objectives of this study were to determine the frequency and predictors of requiring multiple dilations in patients with EOE.

METHODS:

A retrospective study from 2003-2018 was performed at a tertiary care center. Patients included in this study required a pathologic diagnosis of EOE (>15 eosinophils per high power field), and required an esophageal stricture. The response was defined as the absence of symptoms. Adverse events included perforation.

RESULTS:

A total of 34 patients (21 men, 13 women) were included in the study. The median age was 43 years (range, 18-65). Follow-up time was 5.8 years. All patients underwent either a Savary dilation or pressure balloon dilation. Table 1 lists the characteristics of the strictures and balloon dilations. 8 patients required only one dilation session with 100% response rate, which defined. All patients were on PPI. 9 patients did not have adjunctive therapy, while 21 patients used topical steroids, 3 patients used 6-food elimination diet, and 1 patient used both topical steroids and 6-food elimination diet. 5 patients had an 8 mm stricture that was not able to be traversed with the endoscope, requiring a median of 2 sessions (range 2, 3) of dilation. Table 2 shows the characteristics of the strictures stratified by the number of sessions. Table 3 shows the number of sessions stratified by the length of the stricture. There were no perforations.

CONCLUSION:

Esophageal dilation has a definitive role in the management of EoE. It is indicated if the patients do not respond to pharmacological or dietary therapy. In this study, it seems the major predictor factor for frequent esophageal dilation is the length of the stricture. The treatment including corticosteroid inhaler or 6-food elimination is not helpful when the length of stricture more than 1 cm.
469 Efficacy of Biofeedback Therapy for Dyssynergic Constipation Among Elderly Patients
Authors: Spilman Samantha , Gupta Roopali , Kunkel David
Published: October 2019

INTRODUCTION:

The prevalence of constipation among older adults is estimated to be as high as 40% (Melton et al, 1996). Dyssynergic defecation (DD) is an important cause of constipation for a large proportion of these patients. While biofeedback (BFB) therapy has been shown to be highly effective in correcting DD, it involves operant conditioning which requires learning new techniques and few studies have looked at how older adults respond to BFB.

METHODS:

This is a retrospective analysis of age 65+ patients enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. For patients that had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each BFB visit. 58 patients met criteria. ARM is utilized with sensors in the rectum and anal canal. Stool retention simulation is performed involving inflation of a rectal balloon during the BFB sessions.

RESULTS:

Patients described improvement in several meaningful clinical outcomes. The overall median education level was completed high school and some college. Mean global bowel satisfaction on a scale of 1 (very dissatisfied) to 10 (very satisfied) showed a statistically significant increase, 2.77 to 5.01 with BFB (P ≤ 0.0001). In addition, the important symptom of a feeling of incomplete evacuation after stooling decreased from 95% down to 24% (P = 0.0025). Most significantly, 79% of the age 65+ patients showed resolution of their dysyynergia on HR-ARM at their final session (P = 0.0006). The defecation index (DI), intrarectal pressure divided by intra-anal pressure during simulated defecation, also trended towards improvement (0.564 to 0.681, P = 0.12). In terms of types of dyssynergia (1 through 4), subjects with defects in both propulsion and paradoxical contraction of sphincter muscles during defecation, i.e. type 2 dyssynergia, showed the most substantial objective gains in defecation index, with an average increase of 0.486, P-value 0.01 (2 vs 1) and 0.02 (2 vs 3).

CONCLUSION:

Biofeedback for DD shows meaningful improvement in both patient reported outcomes and objective manometric parameters in older adults. This is an important finding because our data supports the efficacy of BFB among older adults, across all levels of education. Given the profound burden of constipation with DD in older adults, we propose biofeedback therapy continue to be given strong consideration as first line therapy for this population.
480 High Resolution Transrectal Ultrasound Findings Predict Manometric Responders to Biofeedback Therapy for Anal Incontinence
Authors: Greenwald Holly , Zifan Ali , Tuttle Lori , Kunkel David
Published: October 2019

INTRODUCTION:

In the United States, over 8% of adults are affected by anal incontinence (AI), and a large percentage of these patients have a history of damage to their pelvic floor. High resolution three-dimensional transrectal ultrasound (TRUS) can be used to assess for microstructural damage to the pelvic floor muscles. Biofeedback (BFB) therapy is a key intervention for AI in addition to anti-diarrheal medications or fiber supplements but it relies on strengthening and improving coordination of existing pelvic floor structures. TRUS is a promising tool to predict meaningful improvement with BFB.

METHODS:

This is a retrospective analysis of patients enrolled in BFB for AI between 2015 and 2018 at a tertiary referral motility program. Survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each AI BFB visit. Of the 36 patients who met criteria, 9 had TRUS as part of their care. TRUS images were obtained using a high frequency (7-15MHz) ultrasound probe. Fisher's exact test and t-test were used for statistical analysis. Improvement in maximum squeeze pressure on HR-ARM was defined as increase by greater than 30% or ≥29 mmHg from baseline to final session.

RESULTS:

Patients were on average 62 years old (SD 10 years), one was male, and the mean BMI was 28.0 (SD 6.7). Five of the 8 women had a suspected obstetric etiology to their AI, while two patients attributed symptoms to surgery, one to radiation therapy, and one to neurologic injury. TRUS revealed microstructural defects in the external anal sphincter (66.7%), internal anal sphincter (77.8%), puborectalis muscle (55.6%), and perineal body (66.7%) as shown in Table 1 Three patients had damage to all 4 structures and this was significantly associated with lack of improvement in squeeze on ARM (P = 0.047). Absence of an external anal sphincter defect trended towards correlation with improvement in squeeze (P = 0.07). Baseline levator hiatus abnormalities did not predict lack of improvement in manometric characteristics (P = 0.17).

CONCLUSION:

TRUS is an emerging tool to identify microdamage to structures of the pelvic floor including internal and external anal sphincter complexes and other key support structures. As BFB for patient with AI aims to retrain muscle coordination, absence of multiple deficits identified on TRUS may predict positive responders to BFB therapy.
483 Phenotype and Antibiotic Response in Patients With Elevated Baseline Hydrogen Breath Test Results: A Large Scale Database Analysis
Authors: Lakhoo Krutika , Lenz Greg , Lin Eugenia , Chang Bianca , Pimental Mark , Pichetshote Nipaporn , Rezaie Ali
Published: October 2019

INTRODUCTION:

Breath testing (BT) is a non-invasive method used for diagnosis of small intestinal bacterial overgrowth (SIBO). Elevated baseline hydrogen breath test results, defined as no excessive methane and elevated hydrogen production >20 part per million (ppm), is an uncommon but important pattern in breath testing. This result has been difficult to understand in clinical settings. Multiple interpretations are used including an abnormal result suggesting SIBO or attributing to poor compliance with the diet for the test. Large-scale studies are lacking to explore the clinical characteristics of these patients and potential response to treatment regimens.

METHODS:

We reviewed a database of 14,847 consecutive lactulose breath tests performed between November 2005 and October 2013 at a single institution. All subjects underwent a low fermentation diet on the day prior to the test and fasted for at least 8 hours overnight. Compliance to diet and fasting was confirmed prior to testing. Breath tests with an elevated baseline hydrogen result (>20 ppm) were identified. A retrospective chart review was performed to retrieve patient characteristics including age, gender, BMI, symptoms, and medications. Furthermore, the response to and type of antibiotic treatment was assessed.

RESULTS:

A cohort of 107 patients with elevated baseline hydrogen BT was identified. Basic demographics showed females comprising 72%, mean age 40.3 (std dev 19.3) and mean BMI = 24.2 kg/m2 (std dev 5.7). The most common symptoms experienced included abdominal pain (84%), bloating/distention (87%), fecal urgency (82%) and flatulence (80%) (Table 1). Regarding medications relevant to SIBO, patients used PPI (31%), chronic narcotics (21%), probiotics (5%) and antidiarrheals (10%). In patients who were treated with antibiotics after an elevated baseline hydrogen result (n = 22), 55% responded to antibiotics. Response rates in the rifaximin alone group (n = 11) and rifaximin plus neomycin group (n = 4) were 73% and 25% respectively (P < 0.01)

CONCLUSION:

In the largest cohort of patients with elevated baseline hydrogen breath tests analyzed to date, the most common gastrointestinal symptoms were abdominal bloating, pain, and urgency. Response to rifaximin alone appeared better than rifaximin/neomycin however small sample sizes were analyzed. An elevated baseline hydrogen breath test can occur despite full compliance with diet and fasting prior to the test. Further prospective controlled studies are needed to validate these findings
487 Use of Central Neuromodulators by Gastroenterologists in the Treatment of IBS: A Pilot Survey
Authors: Nulsen Benjamin , Drossman Douglas , Videlock Elizabeth , Chang Lin
Published: October 2019

INTRODUCTION:

Central neuromodulators (CN) include antidepressants and other CNS-targeted medications. They are effective in providing symptom relief in Irritable Bowel Syndrome (IBS) and other chronic abdominal pain disorders. However, little is known about gastroenterologists' practices, attitudes and knowledge regarding the use of these medications.

METHODS:

A 44-question survey designed by two national experts in functional gastrointestinal disorders (FGID) and a GI fellow was distributed via email to 7 experts in FGID and the GI faculty and alumni at UC-Los Angeles. Responses were reported using simple proportions and descriptive statistics.

RESULTS:

Characteristics of the 46 GIs that participated in the survey (response rate = 19.2%) are described in Table 1. 64.4% considered the use of CN extremely or very important in their management of IBS patients (Table 2) and 46.7% believed that CN were effective in at least half of their patients (Table 3). However, 37.9% prescribed CN to ≤20% of their IBS patients. 42.2% rated their competency in prescribing CN as ≥4 on a 5-point scale (5 = most competent). 97.8% of respondents used TCA, 63.6% used SSRI and 53.3% used SNRI. Respondents were more comfortable prescribing TCA than SSRI (100% vs. 59.5%; P < 0.01) and SNRI (100% vs. 60.0%; P < 0.01), however, their knowledge about the side effects of TCA (68.9%), SSRI (68.9%) and SNRI (64.4%) was similar (P = 0.87). The most common reasons GIs provided for not prescribing CN was concern about side effects (65.9%). 57.7% of respondents estimated that >20% of their patients refused treatment with a CN, most commonly due to psychiatric stigma (80.0%) and potential side effects (57.8%). FGID experts had higher mean scores for self-assessed confidence (4.3 vs. 2.3; P < 0.01) and competence (4.6 vs. 3.2; P < 0.01) in prescribing CN when compared to non-experts. While experts were more likely than non-experts to feel comfortable prescribing CN for IBS patients' psychiatric symptoms (P < 0.01), there was no difference in their comfort prescribing CN for patients' IBS symptoms (P = 0.32).

CONCLUSION:

Many surveyed gastroenterologists infrequently prescribe CN to their patients with IBS even though most consider them important in managing these patients. Perceived lack of competence and concern about CN side effects may be significant barriers to prescribing these medications. In particular, non-TCA CN such as SSRI and SNRI may be underutilized. These results warrant further study in a larger population of gastroenterologists.
497 MD-7246, a Delayed-Release Formulation of Linaclotide Targeting Visceral Pain Associated With IBS-D, Does Not Impact Bowel Frequency or Stool Consistency in Healthy Volunteers: Results From Phase I Trial
Authors: Kuo Braden , Bartolini Wilmin , Tripp Kenneth , Boinpally Ramesh , Borgstein Niels
Published: October 2019

INTRODUCTION:

MD-7246 is a delayed-release formulation of linaclotide (LIN), releasing drug in the distal ileum, under development for treating visceral pain with limited pro-secretory effects. LIN, a GC-C agonist, is approved as an immediate-release (IR) formulation, releasing in the stomach, for treating irritable bowel syndrome with constipation and chronic idiopathic constipation. This study assessed the safety, tolerability, and pharmacokinetics of MD-7246 and explored select pharmacodynamic (PD) parameters.

METHODS:

This double-blind, placebo-controlled study randomized healthy adult volunteers to placebo or 1 of 3 daily doses of MD-7246 for 7 days. Safety and tolerability were assessed at each dose prior to dose escalation. PD assessments for spontaneous bowel movement [SBM]/week and stool consistency (Bristol stool form scale [BSFS]) were recorded in a diary.

RESULTS:

Placebo, low, mid, or high doses of MD-7246 were received by 6 subjects each. Neither LIN nor its active metabolite were detected in plasma after 7 days of oral administration and no intact tablets were discovered in any subject's stool. The median and interquartile range (IQR) for change from baseline (CFB) in SBM and BSFS were similar and overlapping for placebo and all 3 MD-7246 dose groups (median (IQR) CFB: SBM: -2.6 (-4.6, 2.9), -1.9 (-4.4, -1.4), -1.3 (-2.0, 0.0), and 0.0 (-7.7, 0.9); BSFS: 0.4 (-0.2, 1.0), 0.2 (-1.0, 0.9), 0.2 (-0.4, 1.0) and 0.4 (-0.3, 1.8) in placebo and low, mid, and high MD-7246 doses, respectively). MD-7246 was well tolerated and there were no adverse events of diarrhea reported in any subject (placebo or MD-7246). For comparison, the PD effects of LIN (290 µg) IR formulation was evaluated in a previous food effect study in healthy volunteers (n = 18). SBM frequency and BSFS showed an increase from baseline (median (IQR) CFB: SBM: 3.5 (3.0, 8.0) and 1.0 (0.0, 4.0); BSFS: 2.3 (2.1, 2.8) and 1.6 (1.3, 2.4) in fed and fasted state, respectively) with a greater mean CFB in the fed state vs. the fasted (P < 0.01). Diarrhea was reported in those who received IR LIN 290 µg.

CONCLUSION:

MD-7246, a delayed-release formulation of LIN, was safe and well tolerated for 7 days at all 3 doses. MD-7246 appears to have distinct clinical properties from the approved LIN 290 µg IR formulation and showed no effect on SBM frequency or stool consistency. In comparison, SBM frequency increased and stool consistency shifted to looser stools in healthy volunteers following LIN 290 µg IR QD for 7 days.