bluuebunny/crossref_metadata_2025 huggingface dataset:
2763 A Case of Intermittent Organo-axial Gastric Volvulus
Authors: Gurala Dhineshreddy , Fady Haddad , Deeb Liliane
Published: October 2019

INTRODUCTION:

Gastric volvulus is a rare clinical entity defined as twisting of the stomach along its long or short axis leading to gastric outlet obstruction (GOO). Commonly symptoms are acute and include retching, abdominal pain, and vomiting. Chronic intermittent manifestations of this entity constitute a diagnostic challenge as conclusive findings in imaging are only present during symptomatic periods and due to the intermittent nature of the disorder, a volvulus may spontaneously resolve before imaging studies are performed. Herein we illustrate a rare case of an intermittent organo-axial gastric volvulus that responded to conservative measures.

CASE DESCRIPTION/METHODS:

A 92-year-old female presented with intermittent epigastric pain and food intolerance of a few weeks duration. She reported dysphagia one year prior to presentation. Upper gastrointestinal (UGI) series showed gastric organo-axial rotation with no obstruction. Symptoms resolved at that time without any intervention. Physical examination revealed epigastric tenderness. Vitals and laboratory tests were unremarkable. UGI series showed a large para-esophageal hernia, an intrathoracic stomach with a gastric organo-axial rotation and partial obstruction at the level of gastroduodenal junction [Figures 1 and 2]. A contrast computed tomography (CT) scan of abdomen confirmed the same findings [Figure 3]. Endoscopic as well as surgical gastropexy were offered but the patient refused any intervention in view of her poor functional status. She was managed conservatively with intravenous fluids and bowel rest and was discharged 5 days later.

DISCUSSION:

Gastric volvulus was first described in 1866 as a torsion of the stomach around its short or long axis. Based on the axis of rotation, it was classified into organo-axial, mesentero-axial or combined. Organo-axial volvulus is common in adults, constitutes about 59% of cases and peaks after the 5th decade of life. It is mainly seen in the context of diaphragmatic abnormalities such as para-esophageal Hiatal hernias and diaphragmatic eventration. Diagnosis is challenging due to non-specific presenting symptoms. Contrast CT of abdomen and UGI series are gold standard diagnostic modalities. Endoscopic and surgical gastropexy is the mainstay of therapy. Heightened awareness is warranted in patients presenting with GOO in the setting of UGI tract anatomical abnormalities, since delayed diagnosis and management may lead to life-threatening complications and mortality rates up to 50%.
2764 An Unusual Presentation of Gastric Kaposi's Sarcoma
Authors: Akhavan Shahrzad Anita , Koya Nisha , Oak Rachana , Chum Christopher , Trillo John
Published: October 2019

INTRODUCTION:

Kaposi sarcoma (KS) is a low grade angioproliferative tumor. AIDS-related KS is the most common and aggressive form of KS. The prevalence of AIDS-related KS is up to 30%. Skin is the most commonly affected organ in 78% of cases, The gastrointestinal (GI) tract is the most commonly affected extracutaneous site, and often asymptomatic. In advanced cases, patients may present with GI bleeding, diarrhea, protein-losing enteropathy, intussusception, or perforation. Although only 20% of KS patients experience GI symptoms, some studies have found that up to 80% of KS patients have GI lesions at autopsy. With the advent availability of HARRT therapy, the incidence of Kaposi sarcoma has decreased dramatically. Our objective is to present an unusual presentation of Kaposi sarcoma and its endoscopic findings leading to the diagnosis of KS, to share how endoscopy can be used as a tool for diagnosing and assessing the GI involvement in KS.

CASE DESCRIPTION/METHODS:

A 35-year-old African American male with HIV, syphilis, and hepatitis B complains of swelling of his legs and scrotum for 2 months. Physical examination revealed abdominal distension, bilateral lower extremity edema, and one skin nodule on his right foot. Laboratory studies revealed Hgb 8.7 g/dL, MCV 95.3 fL/cell, WBC 7500/cmm, CD4 count < 80 cells/uL, and albumin 1.4 g/dL. CT imaging revealed significant abdominal ascites (Figure 1). The patient underwent paracentesis removing 3.5 L of milky fluid. Fluid culture, gram stain and cytology were negative. Given the ascites and hepatitis history, an esophagogastroduodenoscopy (EGD) was completed in evaluating for possible esophageal varices. EGD revealed a nodular fungating lesion that extends diffusely from the gastric body into the duodenal bulb and sweep (Figures 2 and 3). Biopsy revealed cylindrical cells positive for HHV-8, confirming the diagnosis of gastric Kaposi's sarcoma (KS). Immunohistochemical analysis of the skin nodule biopsy confirmed KS. Computed tomography scan of the chest was consistent with pulmonary metastases. Patient is being treated with HAART and will be started on chemotherapy.

DISCUSSION:

KS is a rare neoplasm, and an AIDS-defining illness in HIV patients. About 40-51% of HIV patients with cutaneous KS will develop gastrointestinal KS, which is typically asymptomatic until growth is extensive enough to cause abdominal pain. This case illustrates the importance of endoscopic evaluation in HIV patients for early detection of gastrointestinal involvement of KS.
2766 An Atypical Case of Metastatic Lung Cancer Presenting as Abdominal Pain and Anemia
Authors: McDonald Emmanuel , Pinglo Monica , Panicker Linoj , Frontela Odayls , Avila Mark , Sobrado Javier
Published: October 2019

INTRODUCTION:

Lung cancer is the second most common cancer in both men and women. In 2019, the United States estimate number of lung cancer cases are 228,150 resulting in 142,670 deaths. The most frequent sites of metastasis include liver, adrenal glands, bone, and brain. The majority of patients have advanced disease at clinical presentation. There are very few reported cases of lung cancer metastasis to stomach and duodenum. Gastric metastasis account for only 4.5% and metastasis to the small intestine account for only 5.8%. There are very few reported cases of lung cancer metastasis to stomach and duodenum. In these previously described cases, lung cancer diagnosis was already known prior to the presentation of abdominal pathology.

CASE DESCRIPTION/METHODS:

In this case, 59 year old female with no significant past medical history presented to the gastroenterologists’ office for abdominal pain. On laboratory examination, patient was found to have iron deficiency anemia which led to full gastroenterologic work-up. EGD was performed that showed a gastric lesion. Biopsies were taken resulting in the diagnosis of poorly differentiated carcinoma. The patient returned for biopsy and lab results, and was found to be weak and fatigued with a hemoglobin of 6. Patient was sent to the emergency room where imaging revealed a 2.4 cm endobronchial and intraparenchymal mass in the right upper lobe with distant metastases, in the left adrenal gland. There was also a 5.5 cm left cerebellar mass. An endobronchial biopsy of the right upper lobe mass, disclosed the diagnosis of non-small cell carcinoma. The gastric and lung biopsies were compared and confirmed to be similar in histology.

DISCUSSION:

Previously reported cases of primary lung carcinoma metastasizing to the abdomen included symptoms such as melena, dysphagia, obstructive jaundice, or perforation in patients with known diagnosis of primary lung cancer. This case is unique from prior published cases because the patient was not aware of primary lung carcinoma and the only presenting symptom was generalized abdominal pain followed by anemia. Through this case we want to emphasize the atypical presentation of metastatic lung cancer. We would also like to highlight thorough endoscopic and laboratory work up of any patient with anemia and abdominal pain. All age related screening test should be performed to exclude all differential diagnoses.
2767 Acute Gastric Volvulus - A Rare Complication of a Paraesophageal Hernia
Authors: Baruwa Etti Abisola G.
Published: October 2019

INTRODUCTION:

Gastric volvulus is a rare clinical entity that involves rotation of the stomach along its long axis (organoaxial) or short axis (mesenteroaxial) through a perpendicular line connecting the greater and lesser curvatures. The most commonly observed association in adults is with a paraesophageal hernia.

CASE DESCRIPTION/METHODS:

60 year old female with a known paraesophageal hernia that was expectantly managed. She presented to the ED with a 10 hour history of intractable vomiting, dry heaves, epigastric discomfort and pleuritic chest pain. She denied constipation, fevers or chills. Vital signs were notable for tachycardia, tachypnea, hypoxia requiring 2 L of supplemental oxygen via nasal cannula. She was in obvious painful distress. Lung auscultation revealed decreased breath sounds throughout all lung fields. Her abdomen was not distended but was tender in the right upper quadrant region without guarding or rebound tenderness. Initial work up included cardiac evaluation for acute coronary syndromes which was negative. Liver enzyme and lipase levels did not support a diagnosis of hepatitis or pancreatitis as the etiology of her presentation. Chest X-ray demonstrated a massive hiatal hernia. CT Angiogram of her chest revealed a very large hernia occupying much of the mid thorax, which was significantly increased compared to the prior study. Her hospital course was complicated by persistent epigastric discomfort, nausea, and inability to tolerate oral intake. Upper GI series was obtained to further evaluate the paraesophageal hernia, and it demonstrated findings consistent with an organoaxial gastric volvulus with evidence of gastric outlet obstruction. She underwent laparoscopic paraesophageal hernia repair, gastropexy with gastrostomy tube insertion. Post operatively, she was able to tolerate a regular diet and discharged successfully.

DISCUSSION:

An acute gastric volvulus is a potentially life-threatening condition that requires a high index of clinical suspicion. Its intermittent nature, vague symptoms, and rarity of the disease may make diagnosis difficult. Gastric volvulus is seldom considered when a patient presents with abdominal or chest pain, associated with nausea and vomiting. A prompt and correct diagnosis followed by immediate surgery remains a key factor in reducing the associated morbidity and mortality. Keeping this diagnosis in mind may help to avoid the many potential adverse outcomes associated with this uncommon disease.
2768 Helicobacter pylori Infection: An Important Consideration in Patients With Suspected Cannabinoid Hyperemesis Syndrome
Authors: Kline Kevin , Bilal Mohammad , Parupudi Sreeram
Published: October 2019

INTRODUCTION:

Cannabinoid Hyperemesis Syndrome (CHS) is a clinical diagnosis made by the combination of chronic marijuana use, episodes of cyclic nausea and vomiting, and concurrent stereotypical behavior including use of hot showers for symptom relief during these episodes. CHS represents an emerging problem in part due to the legalization of marijuana in parts of the United States. Despite its recognition, other more common etiologies of chronic, episodic nausea and vomiting should be considered within the correct clinical context. We performed a single center analysis to understand the burden of H. pylori infection in patients diagnosed with CHS.

CASE DESCRIPTION/METHODS:

We used our electronic medical record to identify all patients 18 years or older with an active diagnosis of CHS from May 2017 to May 2019. Patient charts were reviewed and the presence of H. pylori infection (defined as positive urea breath test, stool antigen, tissue stain or culture) was verified. 30 patients with CHS were identified, and 19 (63%) of these were tested for H. pylori. 6 (32%) of those patients were diagnosed with active infection. All six patients were prescribed standard triple or quadruple therapy, but only one was documented to have completed the therapy in whole. The treated patient was a 52 year-old male who had a longstanding history of episodic nausea and vomiting. Prior upper endoscopy at an outside facility showed duodenal ulcers. He was admitted to the hospital for intractable nausea and vomiting in setting of marijuana abuse. H pylori stool antigen resulted positive during admission. The patient followed-up in outpatient clinic after completing triple therapy and reported complete resolution of nausea and vomiting despite ongoing daily marijuana use.

DISCUSSION:

This is the first report of the rates of concurrent infection of H. pylori in individuals diagnosed with CHS. The reported prevalence of H pylori in the United States varies widely, with the largest analysis of gastric biopsies revealing a rate of 7.5% with general trends higher in African Americans and populations close to the United States-Mexico border. In CHS patients with H. pylori, compliance issues may contribute to persistent and untreated infection. Our single center analysis suggests that H. pylori rates may be higher than the general population in patients with CHS, but larger patient databases will be needed ascertain true treatment rates, and response to therapy.
2769 Large Gastric Gastrointestinal Stromal Tumor With Spontaneous Rupture of Necrotic Fluid Collection
Authors: Marple Eric J. , Magulick John , Cho Ryan
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. Fluid collection within GISTs is very rare with only several case reports documented. We present the first case of spontaneous rupture from a large gastric GIST with necrotic fluid collection which has been documented on endoscopic exam.

CASE DESCRIPTION/METHODS:

A 91 year-old Caucasian female with a 3 month history of weight loss and progressive dysphagia to solids presented for evaluation. She was afebrile and hemodynamically stable with mild tachycardia. Initial labs revealed mild leukocytosis and low protein/albumin. Computer tomography demonstrated large 12 × 11 cm gastric mass with air-fluid level. Follow-up diagnostic esophagogastroduodenoscopy (EGD) showed a large fundic mass with two large cratered ulcerations with bridging mass in the proximal stomach with unremarkable histology on biopsy. Follow-up EGD with endoscopic ultrasound (EUS) demonstrated similar visualization with now small collection of purulent fluid though no fistula was appreciated. On EUS there was a larger heterogeneous hypoechoic mass bridging across all echo layers and a fluid echogenicity without doppler flow contained within the mass. Fine needle aspiration showed spindle cell neoplasm (CD117 +, DOG1 +) compatible with GIST. Given comorbidity and advanced age, she was not considered a surgical candidate. After starting Imatinib, she was offered therapeutic EGD was for possible decompression of the fluid collection within the tumor, to relieve mass effect for palliation. On visual exam there was again evidence of more purulent material that was extruding from a small opening in the center of the mass. The endoscope was advanced into the small opening and revealed a large fluid filled cavity within the mass. After copious irrigation with suction the majority of the cystic fluid was removed and two plastic double pigtail stents were placed to allow full decompression of the cystic cavity. On follow-up exam, she reported improvement of her pain.

DISCUSSION:

GIST are most often found in the stomach but overall account for 3% of all gastric malignancies. The initial presentation is often asymptomatic but there are many cases of highly variable symptomatic presentations of larger GIST. GIST with cystic changes are considered rare, with only 11 cases reported to date. This case is the first documentation of a cystic GIST that spontaneously ruptured, forming a fistulous tract between the cavity and the stomach.
2782 Disguised as IBD: A Rare Presentation of Diffuse Large B Cell Lymphoma in a Young Male
Authors: Biglin Mary , Oikonomou Ioannis
Published: October 2019

INTRODUCTION:

About 1-4% of all gastrointestinal malignancies are primary non-Hodgkin Lymphoma (NHL) and the most common pathologic subtype is diffuse large B-cell lymphoma (DLBCL). Risk factors include environmental exposure, Epstein Barr Virus (EBV), immunosuppression, Helicobacter Pylori (H.Pylori), and human T-cell leukemia virus type 1. The majority of patients are males over the age of 40. Patients can present with vague abdominal pain, dyspepsia, vomiting, weight loss, and bleeding. Endoscopic findings vary and include ulcers, erosions, nodules, mass, erythema, and gastric fold thickening. With appropriate therapy, the 5 year survival can be up to 90%. This case illustrates a rare presentation of gastric DLBCL, emphasizes the importance of both a broad differential diagnosis in the immunocompromised and prompt endoscopy in those with alarm symptoms.

CASE DESCRIPTION/METHODS:

An 18 year old male with selective IgA deficiency and a family history of Crohn’s in his father presented with 3 months of cramping abdominal pain, diarrhea with small amounts of blood and tenesmus. He also reported night sweats and a 10 pound weight loss. History was negative for fevers, localizing infectious symptoms, arthralgias, skin or visual manifestations of IBD. Laboratory evaluation revealed normal WBCs at 7.2 × 109/L with relative lymphocytosis [lymphocytes: 68% (Norm 18-52%), Neutrophils: 22% (Norm 18-52%)]. The rest of labs including Hbg, liver enzymes, albumin and CRP were normal. Given concern for Crohn’s, EGD and colonoscopy were performed. Colonoscopy to the terminal ileum with ileal and colonic biopsies was normal. EGD revealed a 1 cm non-bleeding cratered gastric ulcer with elevated edges and mild erythema in the gastric body. Biopsy of the ulcer demonstrated atypical dense lymphoid cell infiltrate with morphology and immunohistochemical features consistent with EBV + DLBCL. Duodenal biopsies were negative for Celiac disease. Gastric biopsies were negative for H. Pylori. He completed chemotherapy with R-CHOP and is in remission.

DISCUSSION:

This case illustrates a rare presentation of primary gastric DLBCL, given his young age and presentation with bleeding (occurring in ∼10% of cases). Even though this patient had a seemingly classic presentation for Crohn’s Disease, it is critical to maintain a broad differential diagnosis in immunocompromised patients and prioritize endoscopy in those with type B symptoms (weight loss, night sweats) in order to lead to prompt diagnosis and treatment.
2785 Vanek's Tumor: A Rare Presentation of Abdominal Pain and Reflux Disease
Authors: Mertz Andrew , Junga Zachary , Damiano Mark
Published: October 2019

INTRODUCTION:

Inflammatory fibroid polyps (IFPs), or Vanek’s tumors, are benign subepithelial tumors most commonly found in the stomach and small intestine. Histologically, they classically demonstrate spindle cell onion skinning with an abundance of eosinophilic infiltration. IFPs are most commonly found incidentally upon endoscopic evaluation, but may drive certain symptoms such as early satiety or epigastric pain depending on position. We describe a case of IFP successfully removed from the gastric antrum of a patient presenting with reflux and pain with resolution of symptoms after polypectomy.

CASE DESCRIPTION/METHODS:

A 47-year-old female with a history of gastroesophageal reflux with poor symptom control despite high dose twice daily proton pump inhibitor (PPI) therapy presented to the clinic for evaluation of worsening reflux. She also endorsed epigastric discomfort, chronic cough, and laryngitis. Her last upper endoscopy in 2015 was normal. Upper endoscopy was completed, which revealed the presence of a single pedunculated polyp measuring 1.2 cm in the gastric antrum near the pylorus. Polyp was removed with hot snare cautery and the residual defect was closed with clips. Given the endoscopic appearance, the lesion was initially thought to be hyperplastic. On pathologic review, the architecture and immunohistochemical profile was most consistent with an IFP. On follow-up several weeks later, the patient had improved reflux and abdominal pain symptoms and was then weaned off of her PPI without return of symptoms after several months.

DISCUSSION:

Although IFPs were initially postulated to be robust host responses to local injury with resultant inflammation, recent evidence has shown that IFP proliferation is driven by an activating mutation in the platelet derived growth factor receptor alpha (PDGFRA), which is suggestive of a neoplastic and possibly insidious etiology. While most are found incidentally and there are no guidelines on surveillance of these lesions, any large polyp in the stomach should be removed to reduce the risk of progression to malignancy. Furthermore, polyp removal may result in symptom improvement. Whether our patient’s symptom resolution was placebo-driven or actually a result of the IFP removal, our patient demonstrated a remarkable improvement exclusively with IFP polypectomy.
2786 Abdominal Pain in a Patient With Anorexia Nervosa
Authors: Lal Kailash , Slaby Isabella , Chiesa Drew
Published: October 2019

INTRODUCTION:

Gastric ischemia is a rare cause of abdominal pain due to the rich blood supply to the stomach. The etiology for gastric ischemia is generally due to systemic hypotension, gastric volvulus, vasculitis or thromboembolism. Acute gastric ischemia can rapidly lead to morbidity and mortality due to the formation of large hemorrhagic and necrotic ulcers unless recognized early. We present a case of gastric ischemia in a patient with a psychiatric history.

CASE DESCRIPTION/METHODS:

A 60 year old female presented to the ER with acute epigastric pain and nausea. She denied any history of alcohol, aspirin or NSAID use. She had a history of anorexia nervosa and had a recent inpatient psychiatric admission after she was found eating garbage by her family. A few days after her discharge, she reported that she had eaten a large meal and felt that the food was “stuck” in her abdomen. The patient appeared uncomfortable, yet did not seem to be in severe distress. Her exam was only notable for mild abdominal tenderness without rebound or guarding. On computed tomography of the abdomen and pelvis, the patient was found to have a severely distended stomach, gastric wall pneumatosis, perigastric intravenous gas and portal venous gas. She was treated with nasogastric tube decompression, proton pump inhibitor therapy and intravenous antibiotics. A repeat CT scan done 24 hours later showed resolution of ischemic changes and gastric distention. An EGD performed on hospital day 3 noted erosions and large clean based ulcerations in the gastric fundus. Biopsies were negative for Helicobacter pylori infection.

DISCUSSION:

Due to this patient’s psychiatric history, as well as her benign clinical appearance and abdominal exam, appropriate treatment was initially delayed. Early identification and treatment of acute gastric ischemia, even in patients without typical risk factors for ischemia is vitally important. In patients with anorexia nervosa with binging behaviors, the clinical presentation of gastric dilation and ischemia may not correlate with radiologic findings. Severe gastric distension from binge eating may lead to gastric ischemia and ischemic gastroparesis.
2791 Metastatic Lesions to the Pancreas: A Tertiary EUS Center Experience
Authors: Xie Chencheng , Abdallah Mohamed , Patel Bhaveshkumar , Bohy Kimberlee , Aloreidi Khalil , Abdullah Hafez Mohammad A. , Sudhagoni Ramu , Kiani Rabia , Atiq Muslim
Published: October 2019

INTRODUCTION:

Metastatic lesions of the pancreas present with varying clinical features and biological behaviors. They account for approximately 2% of all pancreatic lesions. This study was conducted to investigate metastatic pancreatic lesions distinctive clinical and EUS features compared to primary solid pancreatic neoplasms.

METHODS:

Patients who underwent EUS-FNA at a tertiary referral center between July 15th, 2011 and November 30th, 2017 for a solid pancreatic neoplasm were identified. Data on clinical features, cross-sectional imaging findings, EUS findings, and cytology results were collected. The clinical and EUS features in patients with metastatic pancreatic lesions were compared with those with intrinsic solid pancreatic tumors (adenocarcinoma and neuroendocrine tumors).

RESULTS:

8 patients who underwent 9 EUS-FNA procedures were diagnosed with a metastatic pancreatic lesion while 184 cases of solid primary pancreatic neoplasms (157 adenocarcinomas and 27 neuroendocrine tumors) were found. 5 of 8 metastatic pancreatic lesions were renal cell carcinoma (62.5%). Patients in the metastatic pancreatic lesions group were less likely to present with abdominal pain (33.3% vs. 71.7%, P = 0.014). Patients with metastatic pancreatic lesions also had lower CA 19-9 values (mean value: 82.50 U/mL vs. 4374 U/mL) and more frequently manifested as having multiple pancreatic locations involvement (55.6% vs. 4.9%).

CONCLUSION:

The most common metastatic pancreatic lesion is renal cell carcinoma. The clinical manifestation of metastatic pancreatic lesion patients is more insidious and is mostly identified by using surveillance imaging to identify the primary malignancy. A high index of clinical suspicion is needed for diagnosing these cases.
2799 The Association of Pancreato-Biliary Cancer With Lactose Intolerance
Authors: Asfari Mohammad Maysara , Sarmini Muhammad Talal , Sharjeel Arshad Hafiz Muhammad , Uy Pearl Princess , Kendrick Katherine , Hudgi Amit , Sifuentes Humberto , Sridhar Subbaramiah
Published: October 2019

INTRODUCTION:

The association of lactose intolerance (LI) with different malignancies including ovarian, prostate and colon cancers are reported in the literature with different hypotheses. Many components of dairy foods have been shown experimentally to carry protective effects against colon cancer. On the other hand, the hydrolyzing product of the milk sugar lactose has been suggested to be a risk factor for ovarian carcinoma. We aimed in our study to investigate the association of LI with pancreatic cancer (PC) and cholangiocarcinoma (ChC) using a large database.

METHODS:

We performed a cross sectional study using the National Inpatient Sample (NIS) database between 2004 and 2014. We identified adult patients (18-90 years) who were diagnosed with LI (study group) using appropriate ICD-9 codes. The control group was the patients who did not have a diagnosis of LI. We identified the diagnosis of PC and ChC in both study and control groups using the ICD-9 codes. Univariable and multivariable logistic regression analysis were performed to assess the association between LI, PC and ChC.

RESULTS:

The total population was comprised of 71,360,501 patients, of which 57,909 (0.08%) were diagnosed with LI. LI patients were older (62 vs 51) with more females (61.5% vs 60.1%) and less African American patients (11.8% vs 14.8%) (P < 0.0001 for all). In addition, LI patients had more smoking (12.4% vs 12%), obesity (15% vs 8.9%) and inflammatory bowel disease (2.2% vs 0.8%) (P < 0.002). On the other hand, LI had less alcohol use (4.2% vs 3.8%) and diabetes mellitus (DM) (1.6% vs 4%) (P < 0.0001 for all). After adjusting for the age, gender, race, smoking, alcohol, obesity and inflammatory bowel disease the association between LI and PC were not statically significant (OR: 1.068, 95% CI, 0.909-1.048, P = 0.486). The same results were found for the association of LI and ChC (OR:0.855, 95% CI, 0.558-1.312, P = 0.474).

CONCLUSION:

There is no statically significant association between lactose intolerance, pancreatic cancer or cholangiocarcinoma.
2803 Obesity Among Pancreatic Cancer Patients: A Trend Analysis of 15 Years
Authors: Twohig Patrick , Butt Muhammad , Gardner Timothy , Sandhu Sonia , Sandhu Dalbir S.
Published: October 2019

INTRODUCTION:

Global rates of obesity are increasing exponentially. The risk of developing pancreatic cancer has been shown to be significantly higher in obese patients. Additionally, the progression and outcome of malignancy has been shown to be worse in obese patients. Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide, with a 5-year survival rate of only 9%. Limited data exists on the demographic trends of obesity in pancreatic cancer patients. Our aim is to characterize trends in obesity among pancreatic cancer patients over the last 15 years.

METHODS:

We performed a retrospective analysis of patients in the IBM Explorys database (1999-2018), a pooled, de-identified clinical database of unique patient records from 26 health care networks and 300 hospitals across the United States. At the time of analysis there were 63,744,040 patients, of which 9,620 were adults ( >18 years old) with both pancreatic cancer and obesity (BMI > 30). Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing was performed to analyze trends in obesity among pancreatic cancer patients between 2004-2018. Subgroup analysis for insurance status and mortality rate were assessed.

RESULTS:

The percentage of obese patients with pancreatic cancer increased over the 15-year period (2.5% to 8.5%; P < 0.0001). Mortality rates in obese patients increased (2.4% to 7.4%; P = 0.00007). Rates of obesity among pancreatic cancer patients increased among all types of insurance, but most significantly in those with private insurance (P = 0.00008) and Medicare (P = 0.0001).

CONCLUSION:

This is the first study to assess trends in obesity among pancreatic cancer patients over the last 15 years. Obesity increases pancreatic cancer risk by increasing inflammation, intestinal bacterial overgrowth, and hormonal imbalance. Trials have demonstrated that inhibiting inflammation may delay tumor onset and decrease tumor size, providing an important future therapeutic target. Bariatric surgery can create up to a 60% reduction in pancreatic cancer incidence over a 10-year period, suggesting that weight loss could also be an effective preventative measure in these patients. Public health and epidemiologic data suggest that obesity will continue to significantly increase the incidence of pancreatic cancer. Developing methods to combat obesity and increase public awareness of the risks of obesity and cancer are of utmost importance.
2804 Outcomes in Intra-Ductal Papillary Mucinous Neoplasms in the New York Harbor Veteran Population: An Update
Authors: Hossain Naseem , Horowitz Judah , Grunwald Matthew , Martinez Manuel , Frank David M.
Published: October 2019

INTRODUCTION:

Over the last few years there has been an increase in the frequency of findings of intra-ductal papillary mucinous neoplasms (IPMNs). This is likely due to the increased use of advanced abdominal imaging as well as in increase in the quality of these images. In most cases, decisions are based on consensus rather than evidence based as to how to proceed with regard to follow up imaging, biopsy, or even surgical resection. At ACG 2017, we presented the outcomes of and natural history of patients with IPMNs in the Brooklyn VA. Since that presentation, we have an update regarding further data points as well as in increase in the number of patients we analyzed.

METHODS:

Retrospective chart review was performed on patients with diagnosis, based on coding) of pancreatic cyst, pancreatic lesion, and intra-ductal pancreatic mucinous neoplasm from the New York Harbor Veterans Affairs Hospital from 2000 to 2015. 767 patients were initially flagged, and based on either radiology reports or clinic notes 104 were determined to actually have an IPMN. We looked at basic demographics, risk factors and survival data.

RESULTS:

Baseline characteristics are outlined in Table 1 of the 104 patients formally diagnosed with an IPMN. In summary, 101 are male. The average age at the time of initial diagnosis was 71.5 years old, the median age was 72 years old. The average Body Mass index was 27.3. The subjects in this study were overwhelmingly African American (40.6%) and White (42.6%). There was a small Hispanic component (14.6%). There were no Asian patients in the study. Nine patients underwent surgical resection. 33 patients died and the median time to survival was not able to be calculated at this time. The average age at the time of death was 78.9 years old. In the 33 patients that died only 6 Patients (5.7% of total patients diagnosed) died from pancreatic causes.

CONCLUSION:

The management of IPMNs presents a clinical challenge for gastroenterologists today. To date, the levels of evidence in which the current guidelines are based on is poor. Our study is limited by factors such as advanced age, gender and multiple comorbidities preventing further invasive interventions. It is due to these factors, that our study is not applicable to the general population. Therefore, we recommend further larger multicenter trials with a diverse cohort to establish the risk of IPMN’s and their effect on mortality from pancreatic cancer.
2807 Endoscopic Management of Tumors of Minor Ampulla: A Multicenter Case Series
Authors: Aslam Rida , Ahsan Nayab , Ayub Kamran
Published: October 2019

INTRODUCTION:

Ampullary and duodenal carcinoma are aggressive cancers with poor 5 year survival rates. Like colorectal cancer, ampullary and duodenal carcinomas are also thought to follow the adenoma-carcinoma sequence. Ampullectomy is a well-established treatment for early stage carcinoma of major ampulla. Several studies have established its safety and efficacy in the management of major ampullary tumor. However, tumors arising in the minor ampulla are relatively rare and there are no good case series on endoscopic management of these tumors. We report a multicenter case series of endoscopic ampullectomy in the management of minor ampullary tumors.

METHODS:

To establish the safety and efficacy of endoscopic ampullectomy in the management of minor ampullary tumors. Consecutive patients undergoing ampullectomy for minor ampullary tumor at four hospitals were included in this study over a period of 5 years. A total of 6 patients were included in the study and all six patients underwent ERCP for purpose of minor ampullectomy. MRCP and EUS was performed on all patients prior to ERCP to rule out invasion. Pancreatic stents were placed after ampullectomy in 5 patients.

RESULTS:

Ampullectomy was technically successful in all 6 patients. One patient required two ERCPs for complete ampullectomy. The tumors varied in size from 1 cm to 3 cm. Pathology revealed adenoma in three patients, adenoma with high grade dysplasia in one patient, carcinoma in one patient, and carcinoid tumor in one patient. One patient (16%) developed post ERCP pancreatitis; this patient was kept in the hospital for 2 days. No other major complications were noted. Follow-up for these patients ranged from 2 to 5 years with EGD using duodenoscope at 3 months, one year and yearly thereafter. One patient had recurrence at 2 years which was thought to be recurrent tumor (4 mm). This patient was treated with repeat ampullectomy.

CONCLUSION:

This study demonstrates the safety and efficacy of endoscopic removal of minor ampullary tumors. Our case-series showed a comparable rate of procedure-related complication of (16.6%), as one out of six patients was found to have pancreatitis. The other 5 patients had no complications and were discharged within 24 hours. Among the patients who followed up, there were no recurrences of tumor and no patient was found to have cancer develop over a mean follow-up period of 2 to 5 years. This demonstrates that complete removal of these lesions via endoscopic resection is safe and has favorable outcomes.
2811 Outcomes of Endoscopic Ultrasonography (EUS) in Patients Referred for Biliary Dilation Without Significant Biochemical Cholestasis
Authors: Able Kelsey L. , Madhoun Mohammad , Hanafi Muhammad Z. , Hayat Maham , Bitar Hussein , Howard Trenton , Tierney William , Maple John
Published: October 2019

INTRODUCTION:

The diagnostic yield of endoscopic ultrasound (EUS) in non-jaundiced patients with unexplained biliary dilation has been reported to be 6-33%. In our experience, patients with unexplained biliary dilation who use chronic narcotic analgesics might have an even lower diagnostic yield at EUS. However, this correlation has not been well-described as yet.

METHODS:

We reviewed electronic medical records of patients referred to our center for EUS for the primary indication of unexplained biliary dilation between July 2007 and June 2017. Our database search yielded 767 potential subjects. Exclusion criteria included pancreaticobiliary masses, stones, or calcific chronic pancreatitis seen on prior imaging, a total serum bilirubin >3 mg/dl, or alkaline phosphatase (AP) > 1.5x the upper limit of normal. Data were also separately abstracted on patients with liver tests exceeding the above criteria, yet who had no other exclusion criteria.

RESULTS:

41 patients met all inclusion and exclusion criteria. The mean age was 62.4 ± 14.5 years, 37 (90.2%) were female, the mean bile duct diameter at EUS was 12.2 ± 3.8 mm, total bilirubin was 0.6 ± 0.3 mg/dL and AP was 112 ± 62.9 U/L. Most patients (33/41, 80.5%) were symptomatic, reporting abdominal pain or weight loss. A majority (29/41, 70.7%) of patients used oral narcotics. EUS demonstrated choledocholithiasis in 3/29 patients (10.3%) using narcotics and 1/12 (8.3%) not using narcotics. No masses or other relevant pathology was observed. This patient cohort was then combined with 39 additional patients with unexplained biliary dilation who had abnormal liver biochemical tests. Multivariable logistic regression analysis revealed that patients with abnormal liver biochemical tests were 3 times more likely to have positive EUS finding (OR 2.9, CI [1.5,5.7], P = 0.002). Patients using chronic narcotic analgesics were less likely to have positive EUS finding (OR 0.3, CI [0.1, 1.1], P = 0.06).

CONCLUSION:

A majority of patients referred for EUS to investigate biliary dilation without biochemical cholestasis were women using chronic narcotic analgesics. The diagnostic yield of EUS in this population was low (9.8%) and no neoplasia was found. In contrast, the yield of EUS in patients with biliary dilation and elevated liver tests was strikingly higher at 85%. Use of chronic narcotic analgesics appeared to predict a reassuring EUS examination.
2819 The Role of Prophylactic Antibiotics in Peritoneal Dialysis Patients Undergoing Colonoscopy: A Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Mohan Babu P. , Makar Ranjit , Ohri Ritika , Lankarani Daisy S. , Ohning Gordon
Published: October 2019

INTRODUCTION:

End stage renal disease patients on peritoneal dialysis (PD) are at risk of peritonitis due to possible bacterial translocation from the colon during preparation for colonoscopy or during performing colonoscopy. ASGE guidelines and ISPD (International Society for Peritoneal Dialysis) guidelines suggest antibiotic prophylaxis while European Society of Gastroenterology does not give a clear guideline in this regard. ASGE guidelines in this regard is based on weak evidence. We attempted to conduct a systematic literature review and a meta-analysis to provide more evidence in this area.

METHODS:

A systematic search of PubMed, Medline, Web of Science, and Google Scholar through April 2019 using PRISMA and MOOSE guidelines identified 3 studies that reported on the occurrence of peritonitis during colonoscopy in patients on peritoneal dialysis. Case reports were excluded. Only prospective and retrospective large series studies were included. Random-effects pooled odds ratio and 95% confidence intervals were estimated. Heterogeneity was measured by Cochrane Q and I2 statistics.

RESULTS:

A total of 3 studies reporting on 216 colonoscopy procedures performed on patients undergoing peritoneal dialysis were included in the final analysis. The mean age ranged from 44 to 64 years. The pooled Odd's ratio of developing peritonitis while on antibiotics during colonoscopy was 0.68 (95% 0.19-2.4, I2 = 0, P = 0.56). This was not statistically significant. No heterogeneity was noted in the analysis.

CONCLUSION:

Based on our study, the administration of antibiotics does not seem to affect the incidence of peritonitis in PD patients undergoing colonoscopy. However, this is based on very limited number of studies and unequal sample-size in comparison groups. We, therefore, cannot recommend or refute the usage of prophylactic antibiotics in PD patients undergoing colonoscopy. This analysis shows the paucity of data available at this time in this regard. More robust studies with similar comparison groups are warranted to guide decision making.
2820 A Retrospective Study to Assess Safety and Efficacy of the HET Bipolar Ligator System for the Treatment of Grade I and II Internal Hemorrhoids
Authors: Malik Fahad , Herrero Laura N. , Vadada Deepak , Deshpande Vrushak
Published: October 2019

INTRODUCTION:

Hemorrhoidal disease is a common condition, affecting about 80% of all Americans at some point in their life. There are two types of hemorrhoids: internal and external hemorrhoids. The internal hemorrhoids are further classified into four grades depending on their presentation. The HETTM Bipolar Ligator System is a nonsurgical safe and easy procedure that uses sterile, single-use bipolar forceps with a tapered tubular configuration for the treatment internal hemorrhoids. This study evaluated the efficacy and safety of the HETTM Bipolar Ligator System for the treatment of grade I and grade II hemorrhoids with the potential idea to improve overall patient care.

METHODS:

Primary goal was to evaluate the efficacy and safety of the HETTM Bipolar Ligator System for the treatment of grade I and grade II hemorrhoids. Using a chart review, all of the patients who had received elective treatment for grade I or grade II internal hemorrhoids with the HETTM Bipolar Ligator System from April 2013 to November 2016 in our community hospital. A total of 100 patients were studied for treatment with the HETTMsystem.

RESULTS:

Total of 100 patients received treatment with the HETTM system, 39 patients were male, and 61 were female. The mean age of the patients was 59 years. 27% of the patients complained of mild bleeding, 49% of moderate bleeding and 24% of severe bleeding. 31% of the patients complained of daily bleeding, 53% complained of bleeding at least once a week and 16% complained of bleeding less than once a week. 37% of patients had grade I hemorrhoids while 63% had grade II hemorrhoids. Only 11% of the patients reported pain at levels 1–2 (out of 5) immediately after the procedure, and in 15% of the patients, mild bleeding was observed. After the six-month follow-up period (Figure 3), 96% of the patients had a resolution of bleeding (primary goal). Lastly, all of the patients reported a high level of satisfaction with the procedure.

CONCLUSION:

All other hemorrhoidal treatments including rubber band ligation, sclerotherapy, bipolar diathermy, cryotherapy and laser photocoagulation were associated with complications such as postoperative pain and bleeding or required multiple treatments to provide relief. The HETTM ligation device is a novel treatment option for symptomatic grade I and grade II hemorrhoids. It is simple, cost effective, safe and highly effective in resolving bleeding hemorrhoids in a single non-surgical ambulatory setting.
2821 Trends and In-Hospital Outcomes in Gastrointestinal Malignancies: A National Perspective
Authors: Elkhattib Ismail , Desai Aakash , Noor Arish , Delasos Lukas
Published: October 2019

INTRODUCTION:

There is limited evidence available regarding the trends of hospitalization and in-hospital outcomes amongst various gastrointestinal malignancies. Our study measured the trends of hospitalization and the difference related to in-hospital outcomes, such as inpatient length of stay (LOS), cost and mortality in patients with various gastrointestinal malignancies.

METHODS:

The National Inpatient Sample (NIS) dataset was queried from 2009 to 2014 to identify all patients with a multilevel diagnosis of gastrointestinal neoplasms including cancer of the esophagus, cancer of the stomach, cancer of the colon, cancer of rectum/anus, cancer of the liver and intrahepatic bile duct and cancer of the pancreas. Categorical and continuous variables were tested using Chi-square test and Student t-test respectively.

RESULTS:

We identified a total of 1,995,281 patients with a diagnosis of neoplasm from 2009 to 2014. Among them, 15,276 (0.8%) had cancer of the esophagus, 28,018 (1.4%) had cancer of the stomach, 114,917 (5.8%) had cancer of the colon, 49,690 (2.5%) had cancer of the rectum and anus, 26,565 (1.3%) had cancer of liver and intrahepatic bile duct, 44,749 (2.2%) had cancer of the pancreas. We found that colon cancer had the highest inpatient mortality rate of 5.8% while esophageal cancer had the lowest at 0.8%. The mean LOS for cancer of the stomach was the longest (≈9.49 days) while the cost of care was highest for esophageal cancers (26752.84$). More importantly, the trend of hospitalization among all the major subtypes of gastrointestinal malignancies was significantly unchanged over the period of 5 years.

CONCLUSION:

Gastrointestinal malignancies in the United States represent a significant burden of disease. Our study provides further evidence that there is a significant burden of cost, hospitalization, as well as mortality in this cohort of patients. Given the alarming increase in the incidence of gastrointestinal malignancies and related deaths, such data may have profound implications regarding future demographics to focus research, screening or preventative measures accordingly.