bluuebunny/crossref_metadata_2025 huggingface dataset:
2931 Lumen-Apposing Metal Stent for Treating Pancreatic Fluid Collections in Patients at Sarasota Memorial Hospital: A Quality Improvement Initiative to Compare Outcomes With Meta-Analysis Benchmarks
Authors: Alkayali Talal , Ricardo Juan , Salem Ahmed I. , Smith Robert , Harris Cynthia L.
Published: October 2019

INTRODUCTION:

Acute pancreatitis can result in four different subtypes of fluid collections including acute peri-pancreatic fluid collection, pseudocyst, acute necrotic collection, and walled-off necrosis (WON). Complications including symptoms due to large size and infection may occur and warrant intervention. Endoscopic ultrasound (EUS)-guided drainage with a lumen-apposing metal stent (LAMS) is now commonly performed for cases where certain parameters are met. Evidence from academic centers reveals comparable or even superior technical and clinical outcomes over traditional drainage. The primary aim of our study is to evaluate technical and clinical outcomes of EUS-guided LAMS at a community-based hospital.

METHODS:

The Sarasota Memorial Hospital (SMH) Institutional Review Board (IRB) deemed this a quality improvement initiative, exempt from IRB review. Data was retrospectively collected from the SMH electronic medical records of 31 patients who underwent EUS-guided LAMS between April 2016 to October 2018. Contrast benchmarks were derived from a meta-analysis of eleven studies that evaluated efficacy of LAMS in the management in 688 patients.

RESULTS:

EUS-guided LAMS was performed by two endoscopists in 24 males and 7 females with median age of 55 years. Technical success was defined as correct placement of the stent with immediate drainage and occurred in 29 cases. Technical failure occurred in 2 cases, one due to solid debris preventing deployment of stent, and the other due to numerous varices surrounding the PFC resulting in limited access. Clinical success was defined as decrease of symptoms as well as decrease in size of the PFC and occurred in 25 cases. Four cases were considered a clinical failure: 3 patients required surgery, and one patient died due to complications from pancreatitis. Overall complications of LAMS placement included one pneumothorax, one infected WON in previously sterile WON, and one stent migration; Tables 1 and 2.

CONCLUSION:

EUS-guided LAMS for the treatment of pseudocyst or WON performed in a community hospital setting has equivalent technical and clinical outcomes and rate of complications compared to benchmarks established in an academic medical center.
2934 Thermal Ablation Is Effective for Recurrent Papillary Adenomas After Endoscopic Resection
Authors: Lee Jun Su , Kwon Hyeonwoo , Kim Seongmin , Cho Byungha , Choi Jongwook , Kim Ki Bae , Kim Hyoung Woo , Han Joung-Ho , Yoon Soon Man , Chae Hee Bok , Park Seon Mee , Youn Sei Jin
Published: October 2019

INTRODUCTION:

Endoscopic papillectomy (EP) has been regarded as a safe and effective treatment for benign or premalignant ampullary tumors. There were many studies about indications, techniques, short-term and long-term complications, and prognosis. However, 5%-24% of cases of complete resection by EP have been recurred within 6-24 months. Proper treatment for recurrent cases depends on the individual features. Because papilla changed to flat fibrous scar after EP, 2nd EP is usually impossible or induces severe complications. Thermal ablation with electrocautery or argon plasma coagulation, approved as an effective and safe procedure for recurrent papillary adenomas. However, there were few data about long-term effects of thermal ablation for recurred ampullary neoplasm. We retrospectively analyzed the cases of papillary tumors treated by conventional EP and followed for more than 5 years. For recurrent papillary adenomas, we treated with thermal ablation with bipolar electrocautery and followed for more than 3 years.

METHODS:

Twenty cases with papillary mass who underwent EP over a 10 year were reviewed. Endoscopic papillectomy was performed for benign or premalignant papillary tumors. Surveillance after EP was performed at 3, 9 months and yearly thereafter with side-viewing endoscopy. During follow-up, recurrent cases were treated depending on pathological diagnosis and long-term outcomes were analyzed. Mean duration of follow-up was 52 months.

RESULTS:

Pathologic diagnosis were low grade dysplasia (n = 11), high grade dysplasia (n = 3), adenomyoma (n = 3), inflammatory lesion (n = 2), and paraganglioma (n = 1). Complete resection achieved in 19 cases by en block in 18 cases (90%) and additional endoscopic thermal ablation in one case with low grade dysplasia. One case of incomplete resection revealed high grade dysplasia and was treated with surgical ampullectomy. Three sporadic cases and one familial colonic polyposis recurred at 16, 18, 24, and 36 months after surgery, respectively. Three low grade dysplasia and one high grade dysplasia diagnosed by papillectomy pathology revealed low grade dysplasia by surveillance biopsy. Four cases were treated with one or multiple sessions of electrocoagulation. During follow up period after 2nd treatment, recurrence did not occurred.

CONCLUSION:

Recurrence occurred frequently in ampullary adenomas after complete resection. However, they can be safely treated with thermal ablation. Careful surveillance more than 3 years is needed after EP for ampullary adenomas.
2935 Efficacy, Safety and Long-Term Follow-Up of a Single 7 Fr Double Pigtail Plastic Stent for EUS-Guided Pancreatic Pseudocyst Drainage
Authors: Rugivarodom Manus , Pausawasdi Nonthalee , Chantarojanasiri Tanyaporn , Chang Arunchai , Sirivatanauksorn Yongyut
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS) guided cystgastrostomy with placement of single or multiple 7 Fr or 10 Fr double-pigtail stent (DPS) is a standard treatment for symptomatic pancreatic pseudocyst (PP). However, using a single 7-Fr DPS is less popular in practice due to the concern of stent patency and adequacy of drainage. Aim: To assess the efficacy, complications and long-term outcomes of a single 7-Fr DPS in the drainage of uncomplicated PP with no detectable internal solid debris or infection.

METHODS:

Retrospective study of patients undergoing EUS-guided cystgastrostomy with a single 7-Fr DPS during 2010-2018.

RESULTS:

A total of 14 patients (9 males and 5 females) were identified. The mean age was 48.9 ± 12.5 years. 70% of pseudocysts were located in the pancreatic body; mean size of 10.2 cm (range, 5.5-16.0 cm). Abdominal pain was noted in 11/14 (79%) patients. The most common etiology was biliary pancreatitis (43%). Placement of a 7-Fr × 5 cm DPS had 100% technical success rate without significant complications. At 4 weeks follow-up, clinical success defined as complete resolution or ≥50% decrease in size of pseudocyst in association with resolution of symptoms was 100%. The status of pancreatic duct (PD) was assessed in 10/14 (71%) patients. Of these, 4/10 (40%) had PD leakage; 7/10 (70%) had complete PD disconnection. After a mean follow-up of 52 months (range, 10.1-102.8), pseudocysts resolved without recurrence or the need for additional procedures in 85% of patients. Eleven patients (64%) were noted to have spontaneous stent dislodgement at mean follow-up of 18.3 months (range 0.9-53.2). One patient with PD disruption developed stent migration into the cyst which required two additional sessions of EUS-guided drainage and underwent subsequent cystojejunostomy with stent removal. Another patient had infected cyst due to stent occlusion but she was treated successfully with EUS-guided drainage. Nonetheless, she underwent cystojejonostomy in the end given the presence of complete PD disruption and young age.

CONCLUSION:

This study demonstrated that treatment of true uncomplicated pseudocysts using a single 7 Fr DPS had an excellent technical and clinical success and respectable long term outcomes. True pseudocysts without internal solid debris are less common. Carefully selected pseudocysts may be effectively and safely treated with a single 7 Fr plastic stent.
2937 Endoscopic Ultrasound-Guided Drainage and Treatment of Symptomatic Walled-Off Pancreatic Necrosis: A Single Center Case Series
Authors: Rossow Brett , Hammoud Ghassan M. , Tahan Veysel , Ibdah Jamal A. , Mahdi Amin O. , Samiullah Sami , Romana Bhupinder
Published: October 2019

INTRODUCTION:

Walled-off pancreatic necrosis (WOPN) develops within 4-6 weeks after acute necrotizing pancreatitis. Endoscopic transgastric pancreatic necrosectomy has emerged as a promising therapy for WOPN. We aim to evaluate the clinical success and outcomes of patients treated with endoscopic therapy for symptomatic WOPN.

METHODS:

Retrospective chart review of all patients who underwent endoscopic pancreatic necrosectomy from January 2015 until November 2018 was performed. Patients' demographics were obtained including etiology of pancreatitis, size of WON, number of endoscopic necrosectomies, time to resolution of necrosis, and outcome.

RESULTS:

15 patients underwent endoscopic necrosectomy for symptomatic WOPN. 60% were male, average age was 56 years. Etiologies of pancreatitis included: Biliary (46%), alcohol induced (20%), hypertriglyceridemia (13%), and idiopathic (20%). Nine (60%) cases presented with infected necrosis diagnosed by cross-sectional imaging and clinical criteria. The Median size of peripancreatic fluid collections was 14 cm (Range: 8-20 cm). Endoscopic necrosectomy was performed through the transgastric route in all patients. All patients underwent initial necrosectomy at time of cystgastrostomy. 13 (87%) patients had luminal apposing stents (LAS) (Axios, Boston Scientific). Axios 15 mm × 10 mm were most common. The mean number of endoscopic therapy sessions was 3.4 (Range 1-8). Two (13%) patients had migrated LAS within 4 weeks. One patient underwent repeat cystgastrostomy to remove an internal migrated stent. There were no reported complications of bleeding, procedure-related infection, or perforation associated with cystgastrostomy or necrosectomy. None of the patients suffered death. Clinical success was achieved in 80% of our patient population defined by resolution of fluid collection and necrosis and clinical improvement. 3 (20%) patients required additional surgical intervention. One required surgical intervention for a pancreatic fluid collection not accessible by the endoscope. One underwent surgery prior to presenting to our center. The third had a large sized necrosis with multiple admission for sepsis and failure to thrive.

CONCLUSION:

Sequential endoscopic transgastric necrostectomy is a promising therapy for WOPN and should be the first modality to treat patients with infected or symptomatic walled-off necrosis. Large fluid collections, recurrent admissions, failure to thrive, and collections not accessible by the endoscope were indicators for surgical intervention.
2943 Should We Stop Screening Patients With F3 Fibrosis for Esophageal Varices?
Authors: El-Halawany Hani , Zafar Yousaf , Galappaththy Suguni Loku , Nazer Marjan , Noman Anas , Chauhan Mahak , Al-Sayyed Leen
Published: October 2019

INTRODUCTION:

Advanced liver fibrosis is an important predictor of liver disease progression and mortality, and current guidelines recommend screening for complications of cirrhosis once patients develop F3 fibrosis. Our study looked into patients with stage 3 (F3) fibrosis on liver biopsy and who had EGD subsequently for screening for varices.

METHODS:

We conducted a retrospective review of the patients who had a liver biopsy between 1/1/2017 to 10/1/2018 in our tertiary care institution. It was determined how many of the patients with F3 fibrosis underwent EGD and the results of those investigations are presented here. Furthermore, laboratory findings as well as risk factors for cirrhosis were analyzed among the patients with F3 fibrosis.

RESULTS:

A total of 18 patients were found who had a liver biopsy as part of work up for underlying liver pathology. All of the 18 patients had F3 stage fibrosis and underwent an EGD subsequently. None of these patients had any evidence of portal hypertension evidenced by varices. Only 44.4% (n = 8) of the patients had underlying transaminitis. All of them had normal serum creatinine and only 1 patient had underlying coagulopathy with an elevated INR of 1.9. Only 5 patients were actively drinking alcohol. None of these patients had underlying Hepatitis C or Hepatitis B infection.

CONCLUSION:

Our case series concludes that screening of F3 fibrosis may not be of any benefit for patients irrespective of the cause of their advanced fibrosis. Larger studies would be needed to prove this is the case as this study is limited by its retrospective nature and small number of subjects.
2945 Trend of NAFLD-Induced Cirrhosis and Mortality in National Population
Authors: Kirshan Ravi Shri Jai , Garg Rajat , Essrani Rajesh , Ravi Priyanika , Ahuja Satish Kumar , Ahuja Keerat Rai
Published: October 2019

INTRODUCTION:

Non alcoholic Fatty liver disease (NAFLD) is one of the leading cause of chronic liver disease in United States. Combined with diabetes and metabolic syndrome, NAFLD is expected to be the most common cause of liver transplantation. We sought to determine the trend of NAFLD induced cirrhosis in National Population. We also studied the risk of decompensation and in hospital mortality in patients with NAFLD cirrhosis.

METHODS:

We obtained data from Nationwide Inpatient sample database using International classification of Diseases, the 9th revision, clinical modification codes to identify patients who had diagnosis of Cirrhosis and NAFLD from 2006-2014. We also obtained data on decompensation and patient's mortality in patients who had cirrhosis with history of NAFLD. Decompensated cirrhosis was defined as patients with cirrhosis and having one or more of these conditions: hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, ascites or variceal bleeding. Data was extrapolated using SPSS statistics software.

RESULTS:

Total of 4,226,236 patients had diagnosis of cirrhosis, 114,972 had NAFLD diagnosis. Trend of NAFLD is significantly increasing from 2007 (1.2%) to 2014 (3%). 2,313,524 (54.7%) of patients had decompensated cirrhosis. NAFLD was present in 3.2% (74,557) of patients in decompensated cirrhosis as compared to 2.1% (40,415) of patients who had compensated cirrhosis (P < 0.001). In hospital mortality of patients in decompensated cirrhosis with history of NAFLD was 4.3% and without history of NAFLD was 7.9% (P < 0.001). On Univariate analysis, patients with NAFLD were at low risk of in hospital death as compared to patients without NAFLD OR 0.53 (CI: 0.513–0.550).

CONCLUSION:

There has been significant increasing trend of NAFLD induced cirrhosis in last decade. NAFLD is associated with increased risk of cirrhosis decompensation as compared to other causes of cirrhosis. Interestingly, NAFLD cirrhotic patients have lower in hospital mortality as compared to patients with other causes of cirrhosis.
2949 Diagnostic Comparison of Magnetic Resonance and Endoscopic Retrograde Cholangiopancreatography in Post-Orthotopic Liver Transplant Patients
Authors: Rotundo Laura , Patel Pavan , Kutner Matthew , Ahlawat Sushil
Published: October 2019

INTRODUCTION:

In post-liver transplant patients, biliary tract complications are one of the leading causes of morbidity, graft loss and mortality. Many patients with a cholestatic pattern of liver injury or findings of dilated ducts on imaging undergo magnetic resonance cholangiopancreatography (MRCP) as the initial test prior to definitive therapy. The gold standard for diagnosis and treatment is endoscopic retrograde cholangiopancreatography (ERCP). Currently, there are limited studies on the sensitivity and specificity of MRCP at diagnosing biliary complications. Our aim is to assess whether MRCP may prevent unnecessary invasive procedures or aid in the diagnosis of biliary complications.

METHODS:

This is a retrospective review of patients aged ≥18 years old who underwent a liver transplant at our tertiary level transplant center from January 2007 to December 2017. Of those post-transplant patients, individuals that had both an MRCP and ERCP performed for the same indication were selected. Reports were analyzed to assess for correlation between MRCP and ERCP findings. Other factors analyzed were age, sex, race, cause of prior end-stage liver disease, and liver enzyme levels.

RESULTS:

A total of 30 patients were included in this study. The mean age of patients was 56 years old with 73% being male. The most common indication for MRCP was abnormal liver function tests (LFTs), followed by transplant rejection (10%), fever (6.7%), abnormal imaging (3.3%), and abnormal biopsy findings (3.3%). Of these patients, 56.7% of MRCP findings correlated with ERCP findings. When divided among indication for MRCP, prior abnormal imaging (i.e., ultrasound or CT) was associated with the highest correlation (80%) between MRCP and ERCP. When an MRCP was performed due to abnormal LFTs, only 57.9% of cases correlated with ERCP findings. The sensitivity and specificity of MRCP in diagnosing biliary pathologies was 59% and 33%, respectively. In most cases, MRCP did not correlate with ERCP findings when it failed to detect an anastomotic stricture that was seen on ERCP.

CONCLUSION:

MRCP findings more closely correlated with ERCP findings when performed for abnormal prior imaging rather than for abnormal LFTs. Further studies are warranted to determine if MRCPs aid in the diagnosis of biliary disorders or delay time to definitive therapy via ERCP, as these findings suggest that cases of anastomotic strictures may go undiagnosed given the low sensitivity and specificity of MRCP.
2951 Patient Response to Ursodeoxycholic Acid (UDCA) in a Community Gastroenterology Practice
Authors: Mazzei Bonita A. , McKibbin Ralph D.
Published: October 2019

INTRODUCTION:

The American Association for the Study of Liver Diseases (AASLD) has recently updated practice guidelines for the treatment of primary biliary cholangitis (PBC). Our practice treats patients in one of the recognized disease incidence “hot spots” where risk factors or natural history may be different from the national average. Located at the northern tip of the Appalachian region we have limited access to subspecialty hepatology services. Up to 40% of patients will have inadequate response to UDCA using guideline criteria. Obeticholic acid (OCA) has been approved to be used in combination with UDCA to treat inadequacy of response or as monotherapy in UDCA intolerant patients. We assessed adequacy of treatment to identify possible candidates for OCA therapy.

METHODS:

We searched our electronic medical records for all patients with ICD-9 code 571.6 and ICD-10 code K74.3 and reviewed charts for age, gender, date of diagnosis, anti-mitochondrial antibodies (AMA), alkaline phosphatase (ALP), liver biopsy, weight, UDCA dosage and OCA usage. We used ALP upper limit of normal ratio and mg per kg to calculate UDCA dosage and response. All diagnoses were confirmed with review of AMA results and liver biopsy.

RESULTS:

Seventy-seven patients were identified with 68 females, 9 males with age range of 28 to 88. The average duration of care was 7.2 years ranging from a few months to 24 years. Sixty-four patients are on UDCA. All patients are receiving UDCA in the recommended dosing range. Two patients were referred to transplant, 3 refused care due to relocation, 5 patients had their diagnosis changed and 6 were lost to follow up. Eight patients died with 76 as the average age of death. Five patients are currently on OCA. Three additional patients were identified as possible OCA candidates.

CONCLUSION:

Our patients are receiving recommended UDCA dosing however 12.5% of patients in our “hot spot” population (Gastroenterology and Endoscopy News 2016; 67:5:36) may be candidates for OCA therapy. Our review identified additional patients who could benefit from updated therapy guidelines.
2963 Changes in Health Behaviors Among Veterans With Chronic Hepatitis C Receiving Direct Acting Antiviral Therapy
Authors: Iqbal Sara , Parmer Rinkuben , Burton Mary
Published: October 2019

INTRODUCTION:

Persons infected with hepatitis C virus (HCV) are more likely to use tobacco, consume larger quantities of alcohol, and use recreational cannabis as those without HCV infection. A recent multi-center study suggested that interferon-based treatment for HCV encouraged reduction in consumption of tobacco, alcohol and cannabis. Because direct acting antivirals (DAAs) require a shorter period of treatment, the same effect on lifestyle change may not be present. The purpose of this study was to evaluate changes in tobacco, alcohol and cannabis use in Veterans on HCV DAAs.

METHODS:

Veterans initiating HCV treatment with DAAs at the G V Sonny Montgomery VAMC were offered study enrollment. After providing written informed consent, veterans completed a survey of demographic information and current/past tobacco, alcohol and illicit drug use. Follow up visits occurred at weeks 4, 8 and 12 of treatment. Veterans self-reported on tobacco, alcohol or illicit drug use in the past 4 weeks. Data was analyzed using SPSS v.23. The G.V. Sonny Montgomery Institutional Review Board approved this study.

RESULTS:

Thirty veterans were enrolled between May 1, 2013 and Dec 31, 2014. Majority of patients were male (n = 26) and Caucasian (n = 17). The major infecting genotype was 1a (n = 13), followed by 1b (n = 9), 1 undifferentiated (n = 5) and 2b (n = 3). At baseline, 47% reported current tobacco use, 20% reported current alcohol use and 10% reported current cannabis use. At week 12, reported tobacco use decreased to 43% (P = 1.0), alcohol use decreased to 11% (P = 1.0) and marijuana decreased to 4% (P = 0.5).

CONCLUSION:

Limitations to our study include small sample size, self-reported data and lack of control group. There was however decreasing trend of tobacco, alcohol and cannabis use with the only intervention being initiation of direct acting antivirals for hepatitis C. We propose that HCV DAAs may represent an opportunity to promote healthy lifestyle changes for Veterans.
2981 Identifying Adventurous Eating Children: Associations With Sociodemographic Characteristics, Eating Behaviors, and Weight Gain
Authors: Afzal Soha , Appugliese Danielle , Miller Alison , Lumeng Julie , Pesch Megan
Published: October 2019

INTRODUCTION:

Adventurous eating in adulthood has been associated with increased dietary variety and healthy body mass index, however little is known about correlates of adventurous eating in children.

METHODS:

Data were collected at three time points: Baseline (age 4 years), Time point 1 (age 6 years), Time point 2 (age 8 years). At each time point mothers completed questionnaires and anthropometrics were measured. At baseline and Time point 1, children participated in observational eating tasks. Statistical analysis was done using cluster analysis.

RESULTS:

Two clusters were identified: Adventurous eaters and Non-adventurous eaters. Being an adventurous (vs. non) eater at time point 1 was correlated with greater child surgency, dietary variety, ability to delay gratification and maternal pressure to eat. Being an adventurous (vs. non) eater was associated with greater maternal restriction at time point 1. Adventurous eating was not associated with child body mass index z-score, or prospective weight gain.

CONCLUSION:

Adventurous eating is correlated with child temperamental traits that are associated with seeking novel experiences. There also may be maternal influence on child adventurous eating. Adventurous eating was not associated with cross-sectional or prospective body mass index z-score.
2982 Gastroenterology Journal Prestige and Impact: Analysis of Journal Rankings
Authors: Zafar Yousaf , Gondi Keerthi , Luke Alex
Published: October 2019

INTRODUCTION:

Scientific research is critical to the progression of the field of gastroenterology. Journals are given impact factor ratings annually to determine the utilization and citation of their published articles. The rankings of gastroenterology journals have not been investigated.

METHODS:

We conducted a retrospective study of gastroenterology journals from 2010 to 2017. Ranking scores from the SCImago Journal Rank (SJR) indicator, a composite score of impact factor, prestige, and closeness of citing articles. The top twenty journals in gastroenterology and hepatology were included and compared to the top ten journals in cardiovascular disease, general internal medicine, and general surgery.

RESULTS:

The number of gastroenterology journals increased from 134 to 143 in this time period. The top ten journals were Gastroenterology, Gut, Journal of Hepatology, American Journal of Gastroenterology, Alimentary Pharmacology & Therapeutics, Liver Cancer, Natural Clinical Practice Gastroenterology, Clinical Gastroenterology & Hepatology, and Journal Crohn’s and Colitis. Gastroenterology rankings increased from an average of 2.61 to 4.82 (185% increase), compared to a 322% increase and 254% increase in cardiovascular disease and general internal medicine, respectively. The percentage increase per year was significantly lower than similar increase in cardiovascular disease and general internal medicine journals (P < 0.05 for all years).

CONCLUSION:

Gastroenterology journals lag in citation and prestige compared to other major internal medicine fields. The reasons for this diminished impact should be investigated, and journals should explore mechanisms to disseminate research effectively and improve outreach.
2985 Low Diagnostic Yield of Routine Duodenal Biopsies in Asymptomatic Patients With Iron Deficiency Anemia
Authors: Kwon Alvin Guyun , Yoo Heesoo , Nam Myungwoo , Barsky Maria , Nguyen Nghia , Kalmaz Denise
Published: October 2019

INTRODUCTION:

It is estimated that 1.6 billion people worldwide are anemic. Iron deficiency anemia (IDA) is the most common form of anemia worldwide. In adults without an obvious source of blood loss, the explanation for IDA is generally thought to be due to chronic gastrointestinal blood loss. Current guidelines recommend performing both upper and lower endoscopies for patients with iron deficiency anemia. Duodenal biopsies are routinely performed to evaluate for celiac sprue as the etiology of IDA. The primary aim of this study is to determine the diagnostic yield of routine duodenal biopsies performed for investigation of asymptomatic patients with iron deficiency anemia (without malabsorption symptoms).

METHODS:

A retrospective chart review was performed of patients undergoing esophagogastroduodenoscopy (EGD) with duodenal biopsy as work up of IDA. All duodenal biopsies were performed from January 2011 through April 2019 at an academic tertiary referral center. Inclusion criteria was ferritin ≤45 ng/mL within 1 year prior to EGD. If ferritin data was unavailable, physician records were reviewed for diagnosis of iron deficiency anemia in patients who had proven serum MCV < 80 um3 within 1 year prior to EGD. Data was collected for asymptomatic patients, N = 250. Charts were reviewed and patients with malabsorption symptoms such as abdominal pain, weight loss, diarrhea, and bloating were excluded. In addition, patients with rectal bleeding, history of IBD, gastrointestinal cancer, lymphoma or abdominal surgery leading to malabsorption were also excluded. A diagnosis of celiac disease was defined as a Marsh type 2 or greater on tissue biopsy.

RESULTS:

The median age of patients was 60.6 ± 14.1 of whom 43% were female. A total of 59% of cases were Caucasian, 19% were Hispanic, 8% African American, 8% Asian and 9% other. The mean of Hgb was 9.2 ± 1.9 gm/dL, MCV, 76.4 ± 8.0% and ferritin, 21.7 ± 38.7 um3. Of the sample, 25% had DM2, 20% had CAD, 14% had CKD, 12% had atrial fibrillation and 6% had cirrhosis. The overall diagnostic yield of the duodenal biopsies was 0.4% in asymptomatic patients.

CONCLUSION:

These results suggest that performing routine duodenal biopsies for celiac disease in patients with IDA is low yield in asymptomatic patients. Further studies are needed to characterize which patients with IDA would benefit from a duodenal biopsy for diagnosis of celiac disease.
2986 Celiac Disease Among Hispanics Undergoing EGD for Workup of Unexplained Anemia in a Safety Net Population
Authors: Epistola Raisa , Hou Linda A. , Eysselein Viktor E. , Reicher Sofiya , Fleischman Wayne
Published: October 2019

INTRODUCTION:

Celiac disease (CD) affects roughly 1% of the population globally and 0.75% of the general US population. In individuals with confirmed iron deficiency anemia (IDA), the prevalence of CD is much higher, with nearly 4% of such individuals affected in large cohort studies. The prevalence of CD in Hispanics however remains largely unknown due to over representation of non-Hispanic whites in the studies. We aimed to examine the prevalence of CD in Hispanics with unexplained anemia and in those with confirmed IDA presenting to a large safety net health care system.

METHODS:

Electronic health records of all Hispanic patients (self-identified) referred for workup of unexplained anemia at our institution from 8/2013 to 4/2018 were retrospectively analyzed. Data were collected with regards to comorbidities, pre-procedure hemoglobin, and pre-procedure ferritin. All patients underwent EGD with duodenal biopsies from both the first and second portion of the duodenum as part of routine workup for unexplained anemia. Anemia was defined using the established World Health Organization criteria (hemoglobin <12 g/d for women, <13 g/dL for men). Pathology reports were reviewed for biopsy proven CD utilizing the Marsh classification system. Subgroup analysis of patients with confirmed IDA (ferritin <15 ng/mL) was also performed. Mean hemoglobin and ferritin were calculated in all patients. In those with biopsy confirmed CD, a mean Marsh classification score was also determined. Means and standard deviations were calculated for all continuous variables to better characterize our population cohort.

RESULTS:

96 Hispanic patients with unexplained anemia were identified; 36 were male; average age 53.9. In our patient cohort peptic ulcer disease 14.4% (14/96) and malignancy 6.2% (6/96), were most common identified etiologies of anemia. There were 5 cases of biopsy proven CD with an overall prevalence of 5.2% (5/96). Prevalence of CD among patients with confirmed IDA was 2.4% (1/41) (Table 1). At the time of diagnosis average Marsh score was 3 for all patients and for patients with IDA.

CONCLUSION:

Our data from large safety net health care system shows high rate CD among Hispanics with unexplained anemia suggesting the continued utility of screening for CD in work up of unexplained anemia in Hispanic patient population.
2987 Significance of Small Intestine Search in Dysphagia of Elderly People
Authors: Kurokawa Sei
Published: October 2019

INTRODUCTION:

Patients suspected of having small bowel disease tend to increase, and even in the elderly, it is often necessary to perform small bowel examination. However, elderly people often have dysphagia and may not be able to perform capsule endoscopy (CE) examination. The use of an advanced capsule endoscope insertion aid and an overtube was used to examine the usefulness of small intestine examination in elderly people with difficult swallowing.

METHODS:

In this study, patients aged 75 years and older who required small-bowel examination were treated as patients with dysphagia who required device as group A and patients who did not use as group B. We compared clinical data and retrospectively examined the usefulness of CE in elderly people with dysphagia. From July 2015 to April 2019, our hospital performed CE were 273 cases, 247 patients, elderly people over the age of 75 were 154 cases, 139 patients. Group A: 21 cases, 21 patients. Group B: 133 cases, 118 patients.

RESULTS:

Gender differences are male/female, A group 9/12, B group 62/71. The average age was 85.8 years for A group and 82.3 years for B group (P = 0.0018). Stomach transit time (min): A group average 64.9, B group average 53.9, small intestine transit time (min): A group average 350.4, B group average 349.9. In blood examination, RBC (× 104/μl): A group average 314.8, B group average 331.2, Hgb (g/dl): A group average 9.24, B group average 9.74, Alb (g/dl): A group average 3.08, B group average 3.43 (P = 0.0156), Cre (mg/dl): A group average 1.77, B group average 1.14 (P = 0.0060). Anticoagulant medications were 14 in A group (66.7%) and 74 in B group (55.6%). Mini-Mental State Examination (MMSE): A group 11.1, B group 22.0 (P < 0.0001). In OGIB for inspection purposes, 17 cases were A group (80.9%) and 100 cases were B group (75.2%). The incidence rate was 11 in A group (52.4%) and 78 in B group (58.6%) (P = 0.5890).

CONCLUSION:

In elderly patients who require small-bowel examination, it was possible to obtain the same finding rate as subjects who can swallow it, using a CE insertion aid together.
2991 Preoperative Imaging of Gastric Neuroendocrine Tumors and Lymph Node Metastases
Authors: Ragheb Jonathan , Bahdi Firas , Mehta Neal , Butler Robert , Chahal Prabhleen , Stevens Tyler , Cruise Michael , McNamara Michael , Walsh R. Matthew , Augustin Toms , Bhatt Amit
Published: October 2019

INTRODUCTION:

In recent years, detection of gastric neuroendocrine tumor (GNET) lymph node (LN) metastasis has become more apparent with innovative imaging such as endoscopic ultrasound and PET. Currently, the National Comprehensive Cancer Network recommends multiphasic CT or MRI as part of the initial workup for GNETS. We sought to evaluate these recommendations with respect to the detection of LN metastases and compare CT to alternative pre-operative modalities for gastric staging at our institution.

METHODS:

This is a single center retrospective study evaluating consecutive patients who underwent surgical resection or endoscopic submucosal dissection of biopsy proven GNET from April 1988 to January 2019 at a tertiary referral center. LN metastases were defined by positive nodes following resection. Local invasion was characterized by tumor involvement of any gastric layers beyond the mucosa. Regional metastases included perigastric (gastroduodenal, gastrohepatic, gastroepiploic, pyloric, pancreaticoduodenal), celiac, and peripancreatic LN abnormalities. Distant metastases were defined as involving another solid organ, retroperitoneal or distant LN. Imaging modalities included endoscopic ultrasound, CT, MRI, and PET.

RESULTS:

Thirty patients were included in the study with each patient's respective GNET imaging in Table 1. Mean age of diagnosis was 63.9 ± 12.3 years old. There were no type 2 NET's identified based on documented history. Twenty patients underwent CT, and 13 of these patients underwent additional imaging or preop staging (EUS, PET, MRI, Octreotide, pre-op surgical biopsy). Of those undergoing CT, 12.5% of patients were identified as having regional or distant metastases; however, when correlating CT findings in patients with LN pathology, no patients were correctly identified as having positive LN's (Table 2). Conversely, patients with regional LN metastases on biopsy had CT's showing no lymphadenopathy or local metastases.

CONCLUSION:

As in most cancers, successful interventions vary according to presence or absence of LN metastases. Despite a limited number of patients in this study who had true LN metastases resected, CT and alternative modalities appeared comparable in their ability to “rule out” LN metastases for GNET. Of some concern, none of the imaging appeared sensitive for GNET LN metastases. Investigation of imaging modalities more sensitive for GNET LN metastases, such as PET Dotatate, is needed to better inform decisions regarding medical and surgical intervention.
3001 A Rare Location for Signet Ring Cell Carcinoma
Authors: Ousley Joshua , Kumar Manoj , Mando Rufaat , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Roughly 96% of Signet Ring Cell Carcinoma (SRCC) occurs in the stomach. However, it has also been reported at extra-gastric locations such as the breast, colon, and gallbladder. Although still rare, the incidence of gastric signet ring cell carcinoma has been rising in the past decade and it is now being found in uncommon locations. Only 7 cases have been reported for the presence of a SRCC in pancreas. We report a case of pancreatic signet ring cell carcinoma which was diagnosed with EUS-guided biopsy.

CASE DESCRIPTION/METHODS:

Case A 71-year-old Caucasian male presented with diarrhea and abdominal pain for 1 month as well as a 10 lb weight loss over a 2-month period. Physical examination was positive for jaundice and initial labs showed a bilirubin of 9.8, AST 229, ALT 240, and alkaline phosphatase 420. MRI of the abdomen showed dilation of both the pancreatic duct and common bile duct (CBD), and a distal CBD stricture. The patient underwent an EUS, which showed a 2.8 cm × 2.5 cm hypoechoic ill-defined mass in the head of the pancreas with poorly defined, irregular borders. A 22-gauge needle was used to perform aspiration with four needle passes. ERCP was then performed to place a 10 Fr plastic stent across the CBD stricture. Pathology of the pancreatic mass aspiration revealed moderately to poorly differentiated adenocarcinoma with signet ring cell features. PET CT and abdominal CT were performed without evidence of distant metastasis. CA 19-9 levels were 352. Based on radiographic imaging and endoscopic ultrasound, the patient was staged IIA (T3N0M0) but was found not to be a surgical candidate due to multiple cardiopulmonary comorbidities and was started on neoadjuvant chemotherapy.

DISCUSSION:

The histopathology of SRCC in pancreas appears similar to that of the gastric variant in that the tumor is characterized by intra-cytoplasmic mucin vacuoles that expand the nucleus of the cell to the periphery. Little is known about the differences in prognosis and treatment. However, there is an overall poorer prognosis in patients with SRCC regardless of location. EUS guided biopsy provides a safe technique in the setting of co-morbidities which preclude surgery. Our case demonstrates the need for more research in SRCC on any location as well as targeted modalities for extra-gastric locations while also highlighting the usefulness of EUS as a tool for diagnosis.
3004 Recurrent Painful Pancreatitis After Puestow Procedure
Authors: Arroyo-Mercado Fray Martin M. , Noel Jude , Vignesh Shivakumar
Published: October 2019

INTRODUCTION:

Chronic pancreatitis (CP) is a progressive, irreversible inflammation and fibrosis of the pancreas, leading to irreversible damage, chronic pain, and pancreatic insufficiency due to loss of endocrine and exocrine function. The most common etiologies are alcohol abuse, autoimmune pancreatitis, ductal obstruction, hypercalcemia, and hypertriglyceridemia.1

CASE DESCRIPTION/METHODS:

A 23-year-old male with history pancreatitis, tobacco smoking with multiple admissions due to epigastric pain, nausea, and vomit after lateral pancreatojejunostomy. Prior workup for autoimmune pancreatitis and hypertriglyceridemia was negative. Evaluation was significant for an MRCP (Figure 1) that showed pancreatic duct stones with near complete atrophy of the remaining pancreatic gland and an abdominopelvic CT scan (Figure 2) that showed no gallstones or dilation of the common bile duct. Endoscopic ultrasound showed a duodenal ulcer negative for H. pylori., one major criteria A and three minor criteria. Findings consistent with chronic pancreatitis as per Rosemont classification. Repeated upper endoscopy showed no evidence of prior duodenal ulcer. Abdominal pain, nausea, and pain persisted without significant improvement for months after surgery, with more than four admissions in six months.

DISCUSSION:

CP is a debilitating painful condition. Pain from CP is associated with mechanical obstruction, damaged intrapancreatic nerves and increased intraductal pressure, leading to dilation of the pancreatic duct.2,3 Treatment is focused on pain control with non-steroidal anti-inflammatory drugs, opioids, and celiac plexus block. Medical therapy often fails, and patients tend to require invasive measures such as endoscopic therapy and surgical procedures.4 Invasive interventions are used to relieve obstruction caused by pancreaticolithiaisis or strictures. Whipple resection and Puestow procedure are surgical procedures used for pain control. Modified Puestow is associated with decreased morbidity and decreases length of hospital stay. This procedure is designed to preserve healthy pancreatic tissue retaining exocrine and endocrine function of the pancreas.5 Complete pain resolution occurs in 80% of patients after lateral pancreaticojejunostomy. Nonetheless, failure rates are prevalent in numerous, creating frustration and depression in patients with this debilitating condition. Newer options are available, but most of them are offered at specialized centers, leading to limited access of these novel therapies.6
3008 Painless Jaundice, Sclerosing Cholangitis, and IgG-4 Related Disease
Authors: Weiss Matthew J. , Banaszak Lauren
Published: October 2019

INTRODUCTION:

IgG4-RD can mimic PSC and Cholangiocarcinoma when presenting in the hepatobiliary system, and should be placed high on the differential diagnosis when there is multi-organ system involvement and negative workup for malignancy.

CASE DESCRIPTION/METHODS:

A 58 year-old male presented to the ED with painless jaundice and 6 months of episodic RUQ pain, cervical lymphadenopathy, increased anorexia, weight loss, and fatigue. Prior work-up included a CT abdomen/pelvis that showed intra-hepatic ductal dilation and possible stricture/mass at the common hepatic duct, as well as FNA biopsies of lymph nodes negative for malignancy. Initial lab work was significant for T bili of 8.5, AST of 289, AST of 231, and alkaline phosphatase of 1033, and lipase of 26. Physical exam was notable for scleral icterus, cervical lymphadenopathy, and jaundiced skin. Patient was admitted and underwent ERCP with findings of strictures with PSC-like beading; a stent was placed with improvement in his biliary obstruction. Brushings were obtained for cytology, which were negative for malignancy. Given concern for malignancy, further evaluation was performed including tumor markers which revealed an elevated CA 19-9. Staging chest CT revealed adenopathy concerning for metastases. Subsequent excisional biopsy of an enlarged cervical node was negative for malignancy but revealed a non-caseating granuloma. A second ERCP revealed an inflammatory stricture with brushings again negative for malignancy. Given lack of evidence of malignancy, an IgG4 level was checked which was elevated at 386. His presentation was thus thought to be most consistent with IgG4 sclerosing cholangitis, and he was started on systemic corticosteroids.

DISCUSSION:

IgG4-RD is characterized as a chronic relapsing fibro-inflammatory syndrome. Increased serum levels of IgG4 and infiltration of tissue by IgG4+ plasma cells are typical of IgG4-RD. Common histological findings include dense lymphoplasmacytic infiltrate with IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. The above serological and histological findings together make a diagnosis of IgG4-RD likely. IgG4-RD can occur in multiple organ systems, with typical presentation in the pancreatico-hepatobiliary system as Autoimmune Pancreatitis or Autoimmune Sclerosing Cholangitis. Steroids are first-line treatment, with refractory cases requiring more aggressive immunosuppressive agents, such as Rituximab, to decrease the recurrence of inflammation seen in patients.
3011 Metastatic Pancreatic Cancer in 19-Year-Old
Authors: Yarra Pradeep , Thakur Kshitij , Tripathi Nishant , Aknabi Olalekan , Kudaravalli Praneeth
Published: October 2019

INTRODUCTION:

Pancreatic cancer is a highly aggressive cancer. Worldwide, pancreatic cancer is the eighth leading cause of cancer deaths in both men (226,910 deaths annually) and women (205,332 deaths annually). Five-year survival rate even for node negative R0 pancreaticoduodenoectomy is only 30 percent and it is worse in case of node positive cancer at 10%.1 Here we present an extremely rare case of advanced metastatic cancer with metastasis to central nervous system at the age of 18 with no familial history.

CASE DESCRIPTION/METHODS:

19-year-old obese male presented as a transfer from outside hospital for increasing weakness and worsening confusion. His past medical history is significant for metastatic pancreatic cancer and smoking. On physical he was found to be lethargic, disoriented unable to answer questions with more than one word. Labs were CA 19-9 of 5423 and CEA of 244. MRI showed leptomeningeal enhancement and 3.8 cms mass at pancreatic head. Lumbar puncture was performed and CSF analysis showed the presence of malignant cells. He was now referred to hospice as he was no longer a treatment candidate.

DISCUSSION:

SEER (surveillance, epidemiology and end results program) database the incidence of pancreatic cancer in the age group our patient was in was 0.1% per 100,000 cases.2 In the NCRAS (National cancer registration and analysis service) database from 1998 to 2006 there were only 6 registered cases of pancreatic cancer.4 Early onset pancreatic cancer patients usually have an aggressive presentation and survivals are shorter with same tumor size.
3021 Recurrent Obstructive Jaundice from Iatrogenic Pancreatic Duct Stricture
Authors: Mehmood Faisal , Shah Yash , Korsten Mark
Published: October 2019

INTRODUCTION:

There is always an intrinsic risk of complications with ERCP. The most common early complication include pancreatitis, followed by infection, bleeding and perforation.1 Late complications include pancreatic ductal and parenchymal changes, stent migration and malfunction due to occlusion. Here we present a case of an elderly man with recurrent obstructive jaundice and underwent multiple ERCP.

CASE DESCRIPTION/METHODS:

An 81 years old man was admitted for two weeks history of dark brown urine, light brown colored stools and diffuse itching of the skin. His past medical history included HTN and HLD. He had admission for similar symptoms twice within last one year. On initial admission, he was noted to have obstructive jaundice picture with multiple gall stones, dilated intrahepatic ducts, CBD and pancreatic duct. He underwent ERCP with removal of multiple small gall stones and later underwent cholecystectomy with normal liver functions on follow up. He required sphincteroplasty on later admission. He denied fever, chills, abdominal pain, weight loss, nausea, vomiting, and changes bowel habits. He denied alcohol or any drug abuse. On physical examination, he was afebrile, and was found to have scleral icterus, yellowish discoloration of skin and excoriations in extremities. Laboratory investigation revealed worsening hepatic function with ALT 192, AST 140, ALP 779, GGT of 1098, total bilirubin of 11.3 and direct bilirubin of 8.1. Other blood test results were normal including WBCs, serum electrolytes, TSH, toxicology screen, kidney functions, viral hepatitis panel and coagulation profile. US abdomen showed dilated common bile duct to 18 mm, pancreatic duct and intrahepatic ducts. MRCP showed persistent chronic CBD dilated to 14 mm, pancreatic duct to 4 mm and marked intrahepatic biliary dilatation and a focal stricture was seen in proximal pancreatic duct. He underwent ERCP and was found to have ampullary stenosis. Sphincterotomy was performed. His signs and symptoms resolved on follow up visit.

DISCUSSION:

It is challenging to diagnose biliary strictures. Most pancreatic duct stricture are iatrogenic from operative trauma. Moreover, it is difficult to estimate the procedural complications as there is always an inherent bias and patient underreporting. However, ERCP is associated with fourfold increased rates of severe complications than other endoscopic procedures. To avoid these complications, the procedure should be performed by experienced provider and trend towards therapeutic approach as opposed to diagnostic approach.