bluuebunny/crossref_metadata_2025 huggingface dataset:
A174 PATIENT PERSPECTIVES AND EXPECTATIONS IN INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW
Authors: Balram B , Al Khoury A , Bessissow T , Afif W , gonczi l , abreu m , Lakatos P L
Published: March 2021

Background

Shared decision making is gaining favour in clinical practice and increasingly patients want to be involved in their disease process.

Aims

In this systematic review, our objective was to assess inflammatory bowel disease (IBD) patient preferences and perspectives relating to their disease diagnosis, treatment, knowledge needs and telemedicine.

Methods

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Four databases and conference proceedings were searched between January 1, 1980, and May 1, 2020. The methodological quality of the included studies was assessed using the Standards for reporting qualitative research (SRQR) checklist.

Results

Our search identified 240 citations and 51 studies met the inclusion criteria. The major expectations of the patients are symptomatic and pain control, quality of life and normal endoscopy. Patients’ main concerns are access to information and healthcare, and shared decision making. At the time of diagnosis, patients expressed a greater need for knowledge about their IBD, preferentially by their treating gastroenterologist. The main treatment expectations in active disease are efficacy, safety and convenience. Patients are willing to accept relatively high risks of complications from medical therapy to avoid a permanent ostomy and to achieve durable remission. Patients are more interested in disease monitoring, research and development during the time of remission. Telemedicine and self-management with supervised e-health tools are feasible and acceptable amongst IBD patients.

Conclusions

This systematic review demonstrates that IBD patients expect more information about their disease process, shared decision making and symptom control. Further research is needed to help align patient and physician expectations in order to improve the quality of care provided to IBD patients.

Funding Agencies

None
A178 USTEKINUMAB FOLLOWING PRIMARY ANTI-TNF FAILURE AND SECONDARY LOSS OF RESPONSE TO VEDOLIZUMAB IN AN ADOLESCENT WITH ULCERATIVE PANCOLITIS
Authors: Entenmann A , Griffiths A
Published: March 2021

Background

Infliximab is, to date, the only biologic therapy approved for the treatment of ulcerative colitis (UC) in paediatric patients. Although often effective, primary mechanistic failure is more common in UC than in luminal inflammatory paediatric Crohn’s disease (CD). Alternate pathway biologics, specifically vedolizumab (anti-α4β7 integrin) and ustekinumab (anti-interleukins 12/23) are increasingly used in adults with UC. Emerging data from head to head trials of biologics and network meta-analyses of placebo-controlled trial data are being used to guide choice and sequencing of therapeutic agents. Even among adults with UC data concerning combination biologics are very limited.

Aims

To report the outcomes of addition of ustekinumab to vedolizumab in a patient with steroid dependent colitis, previous primary non-response to infliximab and secondary loss of response to vedolizumab monotherapy.

Methods

Case report

Results

A 17 years old girl was hospitalized with acute severe colitis (PUCAI 85) developing as oral prednisone was tapered below 30 mg daily despite ongoing intensified vedolizumab therapy (300 mg q4 weekly) and per rectal steroids. First presentation 2 years earlier with UC pancolitis, responsive to oral prednisone, maintained on oral 5-ASA until first exacerbation 8 months later. Responsive then to IV steroids, but unable to maintain steroid-free remission despite intensified infliximab with therapeutic levels. Vedolizumab initiated in setting of primary mechanistic anti-TNF failure. Steroid-free clinical remission for 7 months of q 8 weekly dosing with normalization of fecal calprotectin (16, 115 µg/g) when symptoms recurred and persisted despite shortening of vedolizumab dosing interval to 4 weeks. Vedolizumab level 34 µg/mL. Symptomatic response to oral prednisone 40 mg, but unsustained with tapering. Hospitalized with up to 10 bloody stools per day, nocturnal stools, abdominal pain and anemia requiring blood transfusion. High doses of IV steroids were given with slow response. Colectomy refused by family. IV ustekinumab 390 mg given. Vedolizumab continued q 8 weekly in view of prior responsiveness. Ustekinumab subcutaneous maintenance therapy initiated at week 8 and continuing q 4 weekly (levels 3.3 mg/L). Oral prednisone tapered and discontinued. At 5 months post ustekinumab initiation, patient is in steroid-free clinical remission (PUCAI 0). Fecal calprotectin has declined from >1800 to 723 µg/g.

Conclusions

In this patient with UC and primary failure of anti-TNF, ustekinumab has demonstrated short-term efficacy in alleviating steroid-dependency. The contribution of continued vedolizumab, to which there had previously been secondary loss of response, is unknown. Nevertheless, the safety profile of vedolizumab allows it to be combined with other therapies in selected treatment-refractory patients.

Funding Agencies

None
A179 GUT-DIRECTED SELF-HYPNOSIS FOR INFLAMMATORY BOWEL DISEASE PROTOCOL: COMPLIMENTARY PSYCHOTHERAPY FOR REMISSION AUGMENTATION, IBS-LIKE SYMPTOMS, AND SURGERY RECOVERY.
Authors: Paulton J P , Prevost J , Gill A K
Published: March 2021

Background

Gut-directed hypnosis (GDH) is a complimentary therapy for Inflammatory Bowel Disease (IBD), that can be learnt by patients to practice self-hypnosis. GDH in IBD has augmented remission and improved inflammation. GDH has a history of successful use for Irritable Bowel Syndrome (IBS). In IBD it may also improve IBS-like symptoms in remission and recovery from surgery. GDH is suitable for youth and adult IBD patients. In hypnosis, a relaxed state is inducted then suggestions to subconscious mind processes are made. In IBD, the mechanism of action of GDH is unknown but may influence the disease stress response.

Aims

Aims are the development of a GDH self-hypnosis protocol for IBD, with appropriate target symptoms. Patients first learn to practice with a clinician, then as complimentary psychotherapy for remission augmentation, IBS-like symptoms, and surgery recovery.

Methods

GDH is practiced first with a clinician, and then by patients as self-hypnosis (table 1). Patients receive psycho-education on GDH for IBD. Next, appropriate treatment goals are made, based on target symptoms. Relaxation techniques induce patient to a deeply relaxed state. Therapeutic suggestions specific to patient goals are given: verbal suggestions, visualizations, and post-hypnotic suggestions. Suggestions can focus on having a healthy digestive system, inflammation and symptoms reduction, and achievement and sustainment of remission. Patients emerge from hypnosis, are debriefed, and encouraged to practice ongoing self-hypnosis.

Results

In IBD, GDH self-hypnosis can be learnt from clinicians and practiced by patients as a complimentary therapy. Patients’ achievement and sustainment of remission, with clinical markers of inflammation can be monitored. Patients can monitor subjective improvement of IBS-like symptoms and post surgery, recovery progress can be monitored.

Conclusions

GDH has a history of use for IBS. In IBD, it has been shown to modulate remission, and may improve IBS-like symptoms, and in surgery recovery. The mechanism of action of GDH in IBD may influence the disease stress response. Clinicians trained in GDH are limited currently. Patients may learn GDH self-hypnosis as a complimentary psychotherapy.

Funding Agencies

None
A180 RISK FACTORS FOR INADEQUATE GESTATIONAL WEIGHT GAIN IN PREGNANT PATIENTS WITH INFLAMMATORY BOWEL DISEASES
Authors: Tandon P , Hanna Y , Cepo J , Maxwell C , Huang V W
Published: March 2021

Background

Patients with inflammatory bowel disease (IBD) are at a risk of inadequate gestational weight-gain (GWG) which in turn may increase the risk of adverse pregnancy outcomes.

Aims

To determine the risk factors for inadequate GWG in these patients and to determine the impact on adverse pregnancy outcomes.

Methods

Pregnant patients with IBD, both ulcerative colitis (UC) and Crohn’s disease (CD), were identified retrospectively at the Mount Sinai Hospital from 2016 to 2020. Total gestational weight-gain (GWG) was calculated as the difference of the weight recorded at time of labor and pre-pregnancy weight. GWG was further stratified into less than adequate, adequate, and more than adequate based on the pre-pregnancy body-mass index and standards set by the U.S. Institute of Medicine. Pregnancy-related outcomes were also recorded for each patient. Disease activity was recorded at each trimester visit and defined by a fecal calprotectin (FCP) > 250 ug/g. Differences in the mean GWG were compared using independent T-test with standard deviations (SD) whereas categorical variables were compared using the Chi-square (x2) test.

Results

71 pregnancies in 71 patients were included (33 UC and 38 CD). Thirteen patients (18.3%) had less than adequate, 23 (32.4%) adequate, and 35 (49.3%) more than adequate GWG. Of the 33 patients with UC, 4 (12.2%) had less than adequate, 15 (45.5%) had adequate, and 14 (42.4%) had more than adequate GWG. Of the 38 patients with CD, 9 (23.7%) had less than adequate, 8 (21.1%) had adequate, and 21 (55.3%) had more than adequate GWG (p=0.07) for CD vs. UC). In those with CD, both fistulizing and stricturing CD phenotypes appeared to be numerically associated with inadequate GWG. Specifically, none of the 13 patients with fistulizing CD had adequate GWG compared to 32.0% (8/25) in those without fistulizing disease (p=0.07). Similarly, only 2/22 (9.1%) of those with stricturing CD had adequate GWG compared to 6/16 (37.5%) in those without stricturing disease (p=0.07). Furthermore, of seven patients with active disease in the first trimester, only one had adequate GWG (14.3%) compared to 37.5% (3/8) of those in clinical remission (p=0.044). Active disease in trimesters two and three was not associated with inadequate GWG. Finally, the mean GWG was higher in those undergoing Cesarean (37.8 kg (SD 14.1) vs. 30.4 kg (SD 10.5), p=0.014)) and emergency Cesarean delivery (43.5 kg (SD 17.6) vs. 31.9 kg (SD 10.7) (p=0.004) compared to vaginal delivery respectively.

Conclusions

Patients with CD, but not UC, and those with active disease in the first trimester, are at risk of inadequate GWG during pregnancy. In those with larger GWG, a higher rate of emergency Cesarean birth was noted. Optimal intervention to achieve recommended gestational weight-gains in patients with IBD remains to be determined.

Funding Agencies

None
A183 TELEHEALTH USE IN RURAL SASKATCHEWAN AND INFLAMMATORY BOWEL DISEASE OUTCOMES
Authors: Patterson M , Gozdzik M , Peña-Sánchez J , Fowler S
Published: March 2021

Background

Appropriate management of inflammatory bowel disease (IBD) often requires multiple specialist appointments per year. Living in rural locations may pose a barrier to regular specialist care. Saskatchewan (SK) has a large rural population. Prior to COVID-19, telehealth (TH) in SK was not routinely used for either patient assessment or follow up. Furthermore, TH was exclusively between hospitals and specific TH sites without direct contact using patient’s personal phones.

Aims

The objective of this study was to assess the differences in demographics, disease characteristics, outcomes, and health care utilization between patients from rural SK with IBD who used TH and those who did not.

Methods

A retrospective chart review was completed on all rural patients (postal code S0*) with IBD in SK who were followed at the Multidisciplinary IBD Clinic in Saskatoon between January 2018 and February 2020. Patients were classified as using TH if they had ever used it. Information on demographics, disease characteristics, and access to IBD-related health care in the year prior to their last IBD clinic visit or endoscopy was collected. Data was not collected for clinic visits after March 1, 2020 as all outpatient care became remote secondary to the COVID-19 pandemic. Mean, standard deviations, median and interquartile ranges (IQR) were reported. Mann-Witney U and Chi-Square tests were used to determine differences between the groups.

Results

In total, 288 rural SK IBD patients were included, 30 (10.4%) used TH and 258 (89.6%) did not. Patient demographics were not significantly different between the two groups; although, there was a statistically significant difference in the proportion of ulcerative colitis patients (17% TH vs. 38% non-TH, p=0.02). The percentage of patients with clinical remission was 87% for TH patients and 74% for non-TH patients (p=0.13). There were no significant differences in health care utilization patterns and biochemical markers of disease, including c-reactive protein (CRP) and fecal calprotectin (FCP) (p>0.05).

Conclusions

Prior to the pandemic, a small percentage of patients with IBD in rural SK ever used TH. A small proportion of UC patients used TH. No significant differences in disease characteristics, outcomes, or health care utilization were identified. Further study is warranted to identify barriers to use of this technology to tailor care to this patient group and improve access to care, especially now as the COVID-19 pandemic has drastically changed the use of virtual care.

Funding Agencies

None
A197 COLONIC AMYLOIDOSIS: A CAUSE OF RECURRENT HYPOVOLEMIA
Authors: Tsoukas S E , Mayrand S
Published: March 2021

Background

Systemic amyloidosis is a multi-organ disease characterized by abnormal extracellular protein deposition. The most common type is primary (AL) amyloid relating to underlying plasma cell dyscrasias. Other major variants include secondary (AA) amyloid from chronic inflammation, dialysis related amyloid (DRA) with β2-microglobulin, and heritable protein mutations. Management of the underlying disorder can limit further organ damage; however, no definitive treatment exists for familial causes. While uncommon, gastrointestinal involvement is variable and can cause asymptomatic infiltration, liver impairment, bleeding, or chronic diarrhea.

Aims

To discuss an unusual case of gastrointestinal amyloidosis as a cause of recurrent diarrhea and hypovolemic shock.

Methods

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

Results

An 87-year-old male with dementia, coronary artery disease and end stage renal disease from PCKD presented in hypovolemic shock. He had a two-week history of gradual onset, non-bloody, watery diarrhea with up to 20 bowel movements daily. He denied fever, sick contacts, travel, or recent antibiotic use. He had previously foregone endoscopy for a remote history of self-resolved hematochezia. Examination was notable for an uncomplicated inguinal hernia. Labs showed an anion-gap metabolic acidosis but no leukocytosis. He initially received iv hydration, vasopressors, and empiric antibiotics. CT showed diffuse wall thickening of the terminal ileum, colon and rectum with relative sigmoid sparing concerning for enterocolitis. Stool culture grew C. albicans, but C. difficile toxin and Ova and Parasite PCR were negative. He clinically improved with loperamide and was discharged only to be readmitted four days later with recurrent diarrhea and hypovolemia. Repeat cultures were negative. Endoscopy showed diffuse well-demarcated clean-based ulcers and colonic edema. Biopsies excluded viral causes but showed a classic appearance of apple-green birefringence on Congo red staining suggesting amyloid deposition. Raised light chain immunoglobulins and lysozyme on proteomic analysis indicated either AL or a heritable amyloid but excluded AA and DRA. Full diagnostic criteria for AL were not met as free light chain ratio was preserved without clear monoclonality. While his diarrhea again improved, next-of-kin opted for palliative care due to repeated admissions for delirium and generalized deterioration.

Conclusions

This case was indicative of atypical AL amyloidosis versus a rare lysozyme mutation involving renal and GI systems. AL amyloid has a classic appearance on special stains and mass spectrometry that distinguishes it from most subtypes, however, given elevated lysozyme levels further genetic analysis is needed to guide management. In the appropriate clinical context, gastrointestinal amyloidosis can be considered as a rare cause of recurrent unexplained diarrhea.

Funding Agencies

None
A203 PAVING THE WAY TO THE DUODENUM: A CASE REPORT OF DUODENAL TUBERCULOSIS
Authors: Yanofsky R , Singh K S , Parent J , Frenette C , Haegert D , Bessissow T
Published: March 2021

Background

Duodenal tuberculosis (DTB) is an uncommon manifestation of tuberculosis (TB), representing only 0.5% of all TB cases. The nonspecific features of its clinical presentation make diagnosis challenging, which can lead to delayed identification and even inappropriate treatments. Further, the location is also difficult to reach on conventional endoscopy and there are few studies on the use of balloon enteroscopy to diagnose DTB.

Aims

We report a case of DTB diagnosed using balloon enteroscopy that was successfully treated with symptom resolution. We also highlight uncommon features of DTB, including cobblestoning seen on endoscopy and villous blunting with duodenal lymphocytosis seen on histopathology.

Methods

Case report

Results

A 30-year-old previously healthy male returning from India 16 months prior presented to the emergency department with 1 month of abdominal distension, non-bloody diarrhea, and night-sweats. Examination was notable for fever and a distended abdomen. Computed-tomography showed thickening of the jejunum and ileum, with omental fat-stranding and intra-abdominal lymphadenopathy. As the lesion appeared out of reach for conventional endoscopy, balloon enteroscopy was performed, revealing an area of cobblestoning in the duodenum. Acid-fast bacilli (AFB) staining was negative. While TB culture was pending, a second balloon enteroscopy was performed, with AFB staining negative on repeat biopsy. Pathology showed villous blunting and increased intraepithelial lymphocytes but was negative for granulomas. As the diagnosis remained uncertain, endoscopic ultrasound-guided lymph node biopsy was performed and multiple lymph nodes were seen in the gastro-hepatic area. Lymph node biopsy AFB staining was also negative. 4 weeks later, pathology from the first balloon enteroscopy returned positive for TB. The remaining biopsy cultures were negative for TB. The patient was treated with standard of care treatment. At 2 and 4 months of follow-up, he reported complete resolution of symptoms.

Conclusions

The diagnosis of DTB is challenging due its non-specific presentation and rarity. Our case highlights the difficulty of diagnosis as endoscopic findings such as cobblestoning are highly uncommon. We provide support for the use of balloon enteroscopy as a novel method for diagnosis of DTB. With early identification, we were able to provide appropriate therapy and prevent propagation of the disease.

Funding Agencies

None
A206 EVOLUTION OF PEDIATRIC AUTOIMMUNE CHOLANGITIS AND PRIMARY SCLEROSING CHOLANGITIS INTO ADULTHOOD
Authors: Willems P , Hercun J , Vincent C , Alvarez F
Published: March 2021

Background

The natural history of primary sclerosing cholangitis (PSC) in children seems to differ from PSC in adults. However, studies on this matter have been limited by short follow-up periods and inconsistent classification of patients with autoimmune cholangitis (AIC) (or overlap syndrome). Consequently, it remains unclear if long-term outcomes are affected by the clinical phenotype.

Aims

The aims of this is study are to describe the long-term evolution of PSC and AIC in a pediatric cohort with extension of follow-up into adulthood and to evaluate the influence of phenotype on clinical outcomes.

Methods

This is a retrospective study of patients with AIC or PSC followed at CHU-Sainte-Justine, a pediatric referral center in Montreal. All charts between January 1998 and December 2019 were reviewed. Patients were classified as either AIC (duct disease on cholangiography with histological features of autoimmune hepatitis) or PSC (large or small duct disease on cholangiography and/or histology). Extension of follow-up after the age of 18 was done for patients followed at the Centre hospitalier de l’Université de Montréal. Clinical features at diagnosis, response to treatment at one year and liver-related outcomes were compared.

Results

40 patients (27 PSC and 13 AIC) were followed for a median time of 71 months (range 2 to 347), with 52.5% followed into adulthood. 70% (28/40) had associated inflammatory bowel disease (IBD) (78% PSC vs 54% AIC; p=0.15). A similar proportion of patients had biopsy-proven significant fibrosis at diagnosis (45% PSC vs 67% AIC; p=0.23). Baseline liver tests were similar in both groups.

At diagnosis, all patients were treated with ursodeoxycholic acid. Significantly more patients with AIC (77% AIC vs 30 % PSC; p=0.005) were initially treated with immunosuppressive drugs, without a significant difference in the use of Anti-TNF agents (0% AIC vs 15% PSC; p= 0.12). At one year, 55% (15/27) of patients in the PSC group had normal liver tests versus only 15% (2/13) in the AIC group (p=0.02).

During follow-up, more liver-related events (cholangitis, liver transplant and cirrhosis) were reported in the AIC group (HR=3.7 (95% CI: 1.4–10), p=0.01). Abnormal liver tests at one year were a strong predictor of liver-related events during follow-up (HR=8.9(95% CI: 1.2–67.4), p=0.03), while having IBD was not (HR=0.48 (95% CI: 0.15–1.5), p=0.22). 5 patients required liver transplantation with no difference between both groups (8% CAI vs 15% CSP; p=0.53).

Conclusions

Pediatric patients with AIC and PSC show, at onset, similar stage of liver disease with comparable clinical and biochemical characteristics. However, patients with AIC receive more often immunosuppressive therapy and treatment response is less frequent. AIC is associated with more liver-related events and abnormal liver tests at one year are predictor of bad outcomes.

Funding Agencies

None
A207 DE NOVO DONOR-SPECIFIC ANTIBODY FORMATION IN LIVER TRANSPLANTS: RISK FACTORS FOR DEVELOPMENT AND IMPACT ON GRAFT SURVIVAL.
Authors: Wang C , Montano-Loza A J , Campbell P M , Bain V
Published: March 2021

Background

Antibody mediated rejection (AMR) is an area of great importance in solid organ transplantation. Donor-specific antibodies (DSA) have emerged as relevant biomarkers in predicting graft function and survival. DSA detected post-transplant may either be preformed or de novo and emerging evidence suggests de novo DSA, in particular, is associated with inferior graft outcomes. In contrast to the clear role that AMR plays in renal and thoracic organ transplantation, its importance in liver transplants remains controversial.

Aims

The aim of this study was to determine the risk factors associated with de novo DSA formation and to evaluate its role in determining clinical outcomes after liver transplantation.

Methods

This single-center retrospective study compiled data on liver transplants performed between 2005 and 2019 in Edmonton, Canada. Data collected from medical charts included gender, age at transplant, reason for transplant, and immunosuppressive regimens, among several others. The presence of DSA was determined by single antigen flow beads until 2009 and by Luminex thereafter. Potential predictors of DSA formation were evaluated using Cox proportional hazard models. Graft survival estimates were obtained using the Kaplan-Meier method and comparisons between patient groups were conducted using the log-rank test.

Results

Between 2005–2019, 131 patients had measurements of DSA both before and after liver transplantation. In this cohort, 17 patients (13%) tested negative on DSA screening before transplant but developed new antibodies against either Class I or Class II molecules post-transplant. Risk factor analysis revealed transplants performed in the setting of autoimmune liver disease (PSC, PBC, and autoimmune hepatitis) had higher risks of developing de novo DSA post-transplant (p=0.002. See Table 1). Graft survival probability at 5- and 10-years was 72% and 61% in those with de novo DSA formation, compared to 93% and 89% in patients without de novo DSA formation (p=0.04. See Figure 1). Overall patient survival was similar between the two groups.

Conclusions

In this single-center study, a transplant done in the setting of autoimmune liver disease had a higher risk of de novo DSA formation. Furthermore, de novo DSA formation lead to a decreased graft survival time in liver transplant patients but overall patient survival was not significantly decreased. A standard approach to DSA monitoring, especially in high risk populations, is required to better understand its prevalence and impact in liver transplantation.

Funding Agencies

None
A213 OUTCOMES OF INCIDENTAL CHOLANGIOCARCINOMA IN LIVER TRANSPLANT PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS
Authors: JAMES L J , Kulai T , MCLEOD M , PELTEKIAN K , Yoshida E M , Zhu J
Published: March 2021

Background

Primary sclerosing cholangitis (PSC) is a predisposing factor for cholangiocarcinoma(CCA).Patients with CCA have poor outcomes post-transplant.Intrahepatic CCA is difficult to detect pre-operatively in cirrhosis.Few outcomes are reported among PSC transplant patients where CCA was incidental.

Aims

To determine the incidence of incidental CCA (iCCA) in PSC liver explants and the impact of iCCA on post-transplant survival for patients with PSC

Methods

This was a retrospective cohort study in which the medical records of PSC patients who underwent transplant at QEII Health Sciences Center in Halifax between January 1987 to March 2020 were reviewed. The incidence of iCCA was calculated. Survival analysis was performed to determine the mean time to survival among iCCA and non-iCCA groups

Results

A total of 94 patients were transplanted for PSC during the study period.The mean age was 43 years.Twenty-six percent were women and 74% were men.Three were iCCA, one hilar and two intrahepatic CCA. All iCCAs occurred prior to 2008.

All iCCA patients had contrast enhanced CT, ERCP with cholangiogram and MRI.Two of the ERCPs reported CBD related strictures and the brushings had no evidence of malignancy.CA19-9 level was measured in one and reported as normal.Contrast enhanced MRI was not available prior to 2007.

The PSC patients had 1, 5, and 10-year survival rates of 93.8%, 88.6% and 81.9% respectively.One patient required re-transplant for graft failure and died within 3 months post-transplant due to complications. In all other cases the cause of death was not identified.

Among patients with iCCA, two deaths were due to metastatic cholangiocarcinoma and the other due to surgical complication in the immediate post-transplant period. None survived beyond 2 years.

Conclusions

Observed PSC survival in this cohort was above national average in the same period.The 3 iCCA cases identified occurred before the availability of contrast enhanced MRI. Patients with iCCA and liver transplant had poor survival at 1 and 2 years.There were no iCCA identified after 2007.These findings suggest incidental cholangiocarcinoma was effectively reduced by the advent of high-resolution imaging modality, and improvements in pre-transplant screening, including tumor marker CA19-9 and stringent patient selection. Further study involving multiple centres is necessary to draw a definite conclusion.

Funding Agencies

None
A214 BARIATRIC SURGERY PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE HAVE DIFFERENT VISCERAL ADIPOSE TISSUE GENE EXPRESSION COMPARED TO THOSE WITH NORMAL LIVER
Authors: Keshavjee S , Yadav J , Schwenger K , Fischer S , Jackson T D , Okrainec A , Allard J
Published: March 2021

Background

Non-alcoholic fatty liver disease (NAFLD) includes simple steatosis (SS) and nonalcoholic steatohepatitis (NASH). It affects 74–98% of individuals with morbid obesity undergoing bariatric surgery (BSX). Among several factors contributing to NAFLD pathogenesis, adipokines secreted by visceral adipose tissue (VAT) can play a role by regulating glucose/lipid metabolism and inflammation.

Aims

This study aims to determine if visceral adipose tissue adipokine and cytokine gene expression are associated with NAFLD (SS and NASH) at the time of BSX.

Methods

Patients were recruited from the Toronto Western Hospital Bariatric Clinic. Demographic data was recorded. The VAT and liver biopsies were collected at the time of bariatric surgery. VAT adipokines and other mediators were assessed by RT-PCR and included markers of thermogenic capacity, inflammation, fibrosis, adipokines, and others. Liver histology was assessed by a pathologist using the Brunt system and individuals were diagnosed as either SS, NASH, or having a healthy liver (HL). Blood samples were collected pre-BSX to measure liver and metabolic syndrome related parameters, including HOMA-IR, HbA1c, liver enzymes, and lipid profile. Anthropometry was also assessed. Groups were compared using Kruskal-Wallis test followed by Wilcoxon ranked sum, or chi-square and Fisher’s exact test as necessary. Data was considered to be statistically significant with a p-value less than 0.05.

Results

We are presenting data on 126 patients, 80.2% females with a median age of 49 and a body mass index (BMI) of 46.9. Fifty-seven patients had SS, 34 had NASH and 35 had a healthy liver (HL). BMI, age, and sex did not differ between the three groups. First, we found that those with NASH had significantly higher VAT expression of fibrosis (Loxl2), inflammation (CCL4 and TGFb1) and proliferation markers (E2F1) and significantly lower expression of adipokines (TNFa and resistin) compared to HL. Also, we found that SS had significantly higher fibrosis (Col3a1, Col6a1, Loxl2, CD9 and Acta2), inflammation (Nox2, TGFb1, IFNg and Clec10a), browning (PPARa, PPARg and Glut1) and proliferation (E2F1) marker expression compared to HL.

Conclusions

Results show that there is a significant difference in the expression pattern of VAT fibrotic and inflammatory markers between HL, SS and NASH patients. The observed increase of inflammatory markers in NAFLD is in line with prior research outlining the ability of inflammatory mediators from VAT to contribute to liver pathology via portal circulation. The relationship between VAT characteristics and NAFLD are important in understanding the widespread metabolic effects of obesity.

Funding Agencies

CIHRCanadian Liver foundation
A221 CLINICAL CHARACTERISITICS OF PORTAL VEIN THROMBOSIS AMONG AN INPATIENT COHORT WITH CIRRHOSIS
Authors: Dadgar K , Kelly E M
Published: March 2021

Background

Portal vein thrombosis (PVT) has a reported prevalence ranging from 0.6 to 26% in cirrhotic patients and yet optimal management in these patients remains unclear [1]. PVT can lead to poor outcomes including increased risk of bleeding, intestinal injury, and deterioration in liver function. Conversely, treatment of PVT in cirrhotic patients increases their risk of bleeding complications, particularly in patients with known varices.

Aims

The aim of this study is to better characterize the prevalence and impact of PVT in cirrhotic inpatients.

Methods

We conducted a retrospective cohort study based on data collected on adult patients admitted to the Ottawa Hospital between January 1, 2011 and December 31, 2015. We included patients with a diagnosis of cirrhosis either before or during index admission. Patients with a radiology report indicating a PVT were compared to those without PVT. Non-Ontario residents were excluded and where there were multiple admissions per patient one admission was randomly selected to be used. Ethics approval was obtained from the Research Ethics Board at the University of Ottawa.

Results

This study found 34 patients with cirrhosis diagnosed with PVT during their hospitalization (3.73%). Of the patients with PVT, 23 were acute and 11 were chronic based on radiologic appearance. Mean age was similar between groups (PVT: 61.7, SD=9.8; No PVT: 62.3, SD=12.3). The mean Na-MELD was also similar (PVT: 17.6, no PVT: 17.3, p=0.82). Among patients with PVT, 11 patients presented with ascites, 10 with hepatic encephalopathy (HE), 5 with abdominal pain and 5 with an upper GI bleed. Spontaneous bacterial peritonitis (SBP) occurred in 11.76% of patients with PVT as compared to 3% of patients without PVT (p value= 0.006). There also seemed to be a trend towards more HE in the cohort with PVT (20.6% vs 10.7%, p value= 0.07). With regards to screening for varices, 2 patients had an EGD in the 6 months prior to admission, 11 had an EGD on admission, 1 after anticoagulation due to bleeding, and 18 had no screening in the 6 months prior to admission. Twelve patients were treated for PVT, 17 were untreated and 5 did not have documentation about treatment. Of the patients that were not treated, 9 were due to palliative goals of care, 1 due to bleeding, 1 due to thrombocytopenia, 2 due to chronicity on imaging and 4 did not have reasons documented.

Conclusions

PVT is a known complication of cirrhosis, however the clinical significance and optimal management of patients with PVT is poorly understood. Although prevalence of PVT was low in this cohort, our data suggests some possible association between liver related complications and PVT, including SBP and HE. Further research is needed to determine how to best manage patients with PVT.

1. Garcia-Pagan JC, Valla DC. Portal vein thrombosis: a predictable milestone in cirrhosis? Journal of hepatology. 2009 Oct 1;51(4):632–4.

Funding Agencies

None
A222 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED PATIENTS WITH CIRRHOSIS
Authors: Tan P , Yau K , Ukos M , Miller C , Lombardi J , Kelly E
Published: March 2021

Background

Proton pump inhibitors (PPIs) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy.

Aims

We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis and prevalence of HE and SBP.

Methods

This was a retrospective cohort study of 953 adult patients (mean age 62.3 (SD=12.2)) with cirrhosis admitted to the Ottawa Hospital between January 1, 2011 and December 31, 2015. A chart review was conducted and relevant information extracted.

Results

Average MELD-Na on admission was 17.4 (SD = 7.5) with no significant differences when stratified by in-hospital PPI use (p=0.53). 14.7% of patients had a prior history of HE, 5.4% SBP, 31.6% ascites, 9.3% hepatocellular carcinoma and 1.2% hepatorenal syndrome. 26.4% of patients had a history of varices, of which 34.4% had previous variceal bleeding. 45.4% of patients were on a PPI prior to admission and 69.8% during their hospitalization. Patients with a previous history of HE (16.8% vs. 9.6% p=0.006), varices (31.4% vs. 14.2% p<0.001) and variceal bleed (11.6% vs. 3.1% p<0.001) were more likely to be exposed to a PPI in-hospital. Mortality rate during index admission was 19.4%.

There was no significant association noted between the incidence of HE (31.2% vs. 25.0% p=0.06) or SBP (10.4% vs. 8.0% p=0.25) and in-hospital PPI use. There was also no significant association between PPI use and infectious complications, including bacteremia (8.6% vs. 7.6% p=0.63), pneumonia (12.7% vs. 12.5% p=0.95), urinary tract infections (9.2% vs. 6.6% p=0.19) and clostridium difficile (3.8% vs. 2.1% p=0.18). Patients on a PPI had greater in-hospital mortality (22.0% vs. 13. 5% p=0.002), although there was no significance between cause of death (p=0.31) nor death from infectious complications (18.5% vs. 23.1% p=0.52) between groups. Length of stay (LOS) was longer in patients exposed to PPI (median (IQR) 7 (4–17) vs 6 (3–13) p=0.03). Similar findings were noted on subgroup analysis of decompensated patients.

Conclusions

We did not observe a significant difference in HE, SBP or infectious complications among this cohort of cirrhotic patients by in-hospital PPI use. However, there was a significantly higher mortality rate noted in hospital and longer LOS, despite similar baseline MELD-Na and causes of death. Further study and judicious PPI prescribing practices in this vulnerable population of patients is warranted.

Funding Agencies

None
A227 UMBILICAL HERNIA INCARCERATION IN LIVER CIRRHOSIS: A RARE COMPLICATION OF PARACENTESIS
Authors: LAGROTTERIA A , Aruljothy A , Tsoi K
Published: March 2021

Background

Patients with decompensated liver cirrhosis with ascites frequently have umbilical hernias with a prevalence of 20% and are managed with large volume paracentesis (LVP). Common complications of LVP include hemorrhage, infection, and bowel perforation that occur infrequently with a frequency of less than 1%. However, incarceration of umbilical hernias has been reported as a rare complication of LVP and is speculated to be from ascitic fluid decompression that reduces the umbilical hernia ring diameter resulting in entrapment of the hernia sac. It is unclear whether the quantity or the fluid removal rate increases the herniation risk. Based on case series, this rare complication occurs within 48 hours of the LVP and requires emergent surgical repair and involves a high risk of morbidity and mortality due to potential infection, bleeding, and poor wound healing.

Aims

We describe a case report of an incarcerated umbilical hernia following a bedside large-volume paracentesis.

Methods

Case report

Results

A 59-year-old Caucasian male presented to the emergency department with a 24-hour history of acute abdominal pain following his outpatient LVP. His medical history included Child-Pugh class C alcoholic liver cirrhosis with refractory ascites managed with biweekly outpatient LVP and a reducible umbilical hernia. He reported the onset of his abdominal pain 2-hours after his LVP with an inability to reduce his umbilical hernia. Seven liters of clear, straw-coloured asitic fluid was drained. Laboratory values at presentation revealed a hemoglobin of 139 g/L, leukocyte count of 4.9 x109 /L, platelet count of 110 xo 109 /L, and a lactate of 2.7 mmol/L His physical exam demonstrated an irreducible 4 cm umbilical hernia and bulging flanks with a positive fluid wave test. Abdominal computed tomography showed a small bowel obstruction due to herniation of a proximal ileal loop into the anterior abdominal wall hernia, with afferent loop dilation measuring up to 3.4 cm. He was evaluated by the General Surgery consultation service and underwent an emergent laparoscopic hernia repair. There was 5 cm of small bowel noted to be ecchymotic but viable, with no devitalized tissue. He tolerated the surgical intervention with no post-operative complications and was discharged home.

Conclusions

Ultrasound-guided bedside paracentesis is a common procedure used in the management of refractory ascites and abdominal wall hernia incarceration should be recognized as a potential rare complication. To prevent hernia incarceration, patients with liver cirrhosis should be examined closely for hernias and an attempt should be made for external reduction prior to LVP. A high index of suspicion for this potential life-threatening condition should be had in patients who present with symptoms of bowel obstruction following a LVP.

Funding Agencies

None
A232 AUTONOMIC FUNCTION ANALYSIS VIA HEART RATE VARIABILITY ASSOCIATED WITH PROPULSIVE MOTOR PATTERNS OF THE HUMAN COLON
Authors: Ali M , Liu L , Chen J , Huizinga J D
Published: March 2021

Background

Although parasympathetic activity is the primary driver of colonic propulsive activity, and sympathetic activity a major inhibitor of colonic motility, they are rarely measured and almost play no role in diagnosis of dysfunction or standard treatments.

Aims

Our aim was to develop assessment of autonomic nervous system activity associated with the major propulsive motor patterns, an essential part of defecation reflexes in the human colon orchestrated by neural reflexes.

Methods

One hundred and forty-five motor patterns were recorded from eleven healthy volunteers using high resolution colonic manometry (HRCM) with concurrent electro- and impedance cardiography to evaluate changes in parameters of heart rate variability (HRV).

Results

High-amplitude propagating pressure waves (HAPWs) that often start in the proximal colon, traverse distally and end with anal sphincter relaxation, were associated with a 8.2% (P<0.02) increase in the respiratory sinus arrhythmia (RSA) value, a 24.6% increase in the root mean square of successive differences of beat to beat intervals (RMSSD), indicated a strong parasympathetic reactivity that subsided within 2 min of termination of the HAPW (Figure 1). The measure of sympathetic reactivity to motor patterns was best reflected by the Baevsky Stress Index (or Sympathetic Index, SI) that reduced by 45% (P<0.02). We developed a measure of autonomic balance, the SI/RSA ratio that changed from 18.8 to 8.7 (54%; P<0.01) during motor activity and recovered to 16.1 immediately after (P<0.005). The SI/RMSSD reduced by 65% (P<0.01). When HAPWs occurred in quick succession, the parasympathetic activity showed rhythmicity at the HAPW frequency that slowly terminated when motor activity stopped. During motor activity, the heart rate did not significantly change.

Conclusions

The major propulsive motor pattern of the human colon, the HAPW as measured by HRCM that is part of the major defecation reflexes, is associated with marked changes in parasympathetic and sympathetic activity that is reflected and measurable as heart rate variability parameters. This opens the way to evaluate autonomic dysfunction in patients with colon motor disorders.

Funding Agencies

CIHRNSERC, Farncombe Institute
A237 IMPROVEMENT IN ABDOMINAL SYMPTOMS WITH LINACLOTIDE IN PATIENTS WITH IRRITABLE BOWEL SYNDROME WITH CONSTIPATION: RESULTS FROM A PHASE 3B TRIAL
Authors: Sidani S , Boutros K , Sayuk G S , Gonzalez H , Brenner D M
Published: March 2021

Background

Linaclotide (LIN) is a guanylate cyclase-C agonist approved to treat irritable bowel syndrome with constipation (IBS-C) in adults. Abdominal symptoms are important to patients with IBS-C. In a recent Phase 3b study, LIN significantly improved a composite score of abdominal bloating, pain, and discomfort (Abdominal Score), which was used as the primary endpoint in the study.

Aims

To evaluate the efficacy of LIN for improving additional efficacy abdominal symptom endpoints in a randomized, double-blind, placebo (PBO)-controlled Phase 3 study of LIN in patients with IBS-C.

Methods

Adults with IBS-C were randomized to PBO (N=308) or LIN 290 μg (N=306) once daily for 12 weeks. Patients recorded their daily abdominal symptoms, including the individual items of bloating, pain, and discomfort, using an 11-point scale (0–10; 0=none, 10=worst possible). The primary endpoint was the Abdominal Score. Additional efficacy endpoints included 6/12-week abdominal pain and constipation (APC)+1 responder, 6/12-week abdominal bloating responder, 6/12-week abdominal pain responder, and 6/12-week abdominal discomfort responder. For individual symptoms, a responder was a patient who had an improvement from baseline of ≥2 points in the respective endpoint for ≥6 of the 12 weeks. Changes from baseline (CFB) over 12 weeks in abdominal bloating, pain, and discomfort were evaluated using a mixed model with repeated measures framework. Proportions of responders were compared between groups for each responder endpoint using a Cochran-Mantel-Haenszel test.

Results

614 patients (mean age, 46.7 years; 81% female; similar baseline abdominal symptoms) were randomized. LIN-treated patients had greater least-squares mean (LSM) CFB in abdominal bloating (LSM difference [95% CI]: –0.889 [–1.249, –0.530], p<0.001), pain (–0.881 [–1.238, –0.524], p<0.001), and discomfort (–0.837 [–1.196, –0.478], p<0.001) compared to PBO-treated patients. There was a greater proportion of LIN-treated vs. PBO-treated patients who were 6/12-week APC+1 (29% vs. 17%; p=0.0003), bloating (40% vs. 24%; p<0.001), pain (42% vs. 25%; p<0.001), and discomfort (42% vs. 26%; p<0.001) responders (Figure). Diarrhea was the most common treatment-emergent adverse event (LIN: 4.6%; PBO: 1.6%).

Conclusions

LIN significantly improved multiple abdominal symptom and secondary responder endpoints in patients with IBS-C. These results support the effectiveness of LIN for improving a spectrum of abdominal symptoms in IBS-C.

Funding Agencies

This study was sponsored by Allergan plc, Dublin, Ireland (prior to acquisition by AbbVie Inc.). Writing and editorial assistance were provided to the authors by Brittany Y. Jarrett, PhD, Jane Beck, MA, and Rebecca Fletcher, BA(Hons) of Complete HealthVizion, Inc., Chicago, IL, USA and funded by Allergan plc (prior to acquisition by AbbVie Inc.).
Accidental digital epinephrine injection injury: a case of conservative management
Authors: Mortada Hatan , Ahmed Bandari Abdullah , Arab Khalid
Published: March 2021

The open access to epinephrine autoinjectors has resulted in an increased number of reports related to accidental injection into the digits. The appropriate management after accidental injection remains controversial. This study presents the first case in Saudi Arabia of a young man who accidentally injected epinephrine into the thumb and a literature review of the treatment options available. A 19-year-old man presented with accidental injection of 300 mcg of epinephrine into the volar pulp of his right thumb while treating an allergic reaction. The embedded needle was removed by countertraction and irrigation. The examination results were normal. The patient was discharged with prophylactic antibiotic and analgesia. Later, the puncture wound healed and vascularity and sensation remained intact. Conservative management and observation are advantageous in certain cases if vascular function is uncompromised. This case highlights the importance of education about the correct handling and administration of the epinephrine injection.
SARS-CoV-2 in peritoneal swabs from asymptomatic patients undergoing emergency abdominal surgery
Authors: AlAradi Jasim , AlHarmi Rawan A Rahman , AlKooheji Mariam , Almahari Sayed Ali , Isa Mohamed Abdulla , AlMarzooq Raed
Published: March 2021

This is a case series of five patients with acute abdomen requiring surgery who tested positive for coronavirus disease 2019 (COVID-19) and were asymptomatic, with the purpose of detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in peritoneal fluid. Nasopharyngeal swab was done as a prerequisite for admission or prior to admission as part of random testing. Two methods of viral testing were employed: Xpert® Xpress SARS-CoV-2 (rapid test) and real-time reverse transcription polymerase chain reaction (RT-PCR). Either or both tests were done, with the former performed for patients requiring surgery immediately. Surgery was performed within 24–36 h from admission. Peritoneal fluid swabs were obtained for the detection of SARS-CoV-2 using RT-PCR test. Swabs were immediately placed in viral transfer media and delivered to the public health laboratory in an ice bag. SARS-CoV-2 was not detected in peritoneal swabs. Due to the limited number of patients, further studies are required; yet, protective measures should still be taken by surgeons when dealing with COVID-19 cases.