bluuebunny/crossref_metadata_2025 huggingface dataset:
330 Increased Risk of Colorectal Cancer in Individuals With Hypothyroidism and Hyperthyroidism: Results From a Population-Based National Study
Authors: Mansoor Emad , Chouhan Vijit , Saleh Mohannad Abou , Sheriff Zaahid M. , Cooper Gregory S.
Published: October 2019

INTRODUCTION:

Prior epidemiologic studies have linked thyroid dysfunction and cancer, however, a few studies have looked at the association with CRC. These prior studies have shown conflicting results and have been limited by small sample size. We sought to describe the prevalence of CRC in individuals with hypothyroidism (hypoT) and hyperthyroidism (hyperT) in the United States (US) between 2014 and 2019 utilizing a large population based database.

METHODS:

We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of Electronic Health Record data from 26 major integrated healthcare systems in the US from 2014 to 2019. We identified an aggregated patient cohort of eligible patients with “hypothyroidism”, “hyperthyroidism” and first-ever diagnosis of “Primary malignant neoplasm of cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum” aged ≥18 years, at least 1 day after a diagnosis of hypoT or hyperT between June 2014 and 2019, based on Systemized Nomenclature Of Medicine – Clinical Terms, individuals with family history of CRC were excluded from analysis. We calculated the prevalence of CRC in hypoT, hyperT and individuals without thyroid dysfunction.

RESULTS:

Of the 30,132,930 individuals active in the database from 2014-2019, we identified 2,377,510 and 317,490 individuals with hypoT and hyperT with overall prevalence rates of 7.8% and 1.1% respectively. The prevalence of CRC in hypoT, hyperT and individuals without thyroid dysfunction was 0.5%, 0.5% and 0.3% respectively (Figure 1). The risk of CRC was higher in hypoT [OR: 1.71, P < 0.0001] and hyperT [OR: 1.57, P < 0.0001] compared to individuals without thyroid dysfunction. Within hyperT, risk of CRC was higher in males at 0.67% [OR: 1.46, P < 0.0001] compared to females at 0.45% and elderly (aged >65 years) at 0.97 % [OR: 4.40, P < 0.0001] compared to adults (aged 18-65 years) at 0.22%. Within hypoT, risk of CRC was higher in males at 0.72% [OR: 1.46, P < 0.0001] compared to females at 0.49% and elderly at 0.88 % [OR: 3.89, P < 0.0001] compared to adults at 0.23%. There were no differences in prevalence of CRC between Caucasians and African-Americans in hypoT or hyperT (Figure 2).

CONCLUSION:

This is one of the first large studies to date that has described the epidemiology of CRC in hypoT and hyperT in the US in individuals aged ≥18 years. We found that the risk of CRC is increased overall in hypoT and hyperT and is particularly high in males and elderly.
356 Mucosal Ablation and Suturing at the Esophagogastric Junction (MASE): A Novel Procedure for the Management of Gastroesophageal Reflux Disease in Altered Anatomy Patients
Authors: Sowa Piotr , Fortinsky Kyle , Chin Mathew , Samarasena Jason , Chang Kenneth J.
Published: October 2019

INTRODUCTION:

Gastroesophageal reflux disease (GERD) is caused by reflux of gastric contents into the esophagus. For patients with esophageal or gastric surgery there are limited options for endoscopic or surgical therapy for GERD. There has recently been introduced an endoscopic suturing platform that allows for full thickness suturing. We created a technique called Mucosal Ablation and Suturing at the Esophagogastric Junction (MASE) to anatomically correct the GEJ in patients where other surgical or endoscopic options may not be possible.

METHODS:

This is a single-center prospective observational study. The standardized procedure involved APC ablation below the GE junction to improve tissue apposition prior to suturing. Three sutures were placed along the lesser curvature of the cardia immediately below the EGJ. This creates a tightening and tissue bulge that acts as a barrier to reflux. The primary outcome evaluated was 30% improvement in reflux disease questionnaire (RDQ) and GERD Health Related Quality of Life Questionnaire. The secondary outcomes evaluated were reduction in PPI use, procedure tolerance and safety.

RESULTS:

10 patients with a mean age of 63 years with altered anatomy: Fundoplication (N = 5), Billroth II (N = 1), Roux-en-Y (N = 3), and Sleeve gastrectomy (N = 1) underwent MASE procedure. The RDQ and HRQL questionnaires were recorded for each patient before and after MASE. Mean follow-up time was 113 days. Primary outcome of 30% improvement in RDQ and GERD HRQL were achieved for all patients (Figure 1). There was a 90 % reduction in PPI use in the study group; 6 patients (66%) were able to discontinue PPI use, and 2 patients (22%) reduced their dose. The most common side effect was self-limited post-procedure epigastric pain (9%).

CONCLUSION:

The MASE procedure represents a novel endoscopic treatment option for management of GERD in patients with altered anatomy. Altered anatomy patients have limited treatment options once they fail standard PPI therapy. The MASE procedure can reduce GERD symptoms in this difficult to treat patient population and reduce reliance of daily anti-secretory medication use. Further studies need to be performed to determine longevity of this procedure.
361 WATS3D vs. Traditional Forceps Biopsy in Screening of Barrett’s Esophagus: A Community Hospital Experience
Authors: Srinivasan Sachin , Agha Yasmine Hussein , Hyder Jeffrey , Wuthnow Chelsea , Kilgore William , Tofteland Nathan , Salyers William
Published: October 2019

INTRODUCTION:

Barrett’s esophagus (BE) is a pre-malignant condition of the esophagus currently diagnosed using systematic 4-quadrant cold forceps biopsies during endoscopy. Demonstration of intestinal metaplasia on histopathology and the degree of dysplasia is the cornerstone of BE diagnosis and management. This current method of biopsy is fraught with errors due to the randomness of sampling and experience of the operator. Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS3D) is an emerging technique to collect esophageal samples and improve detection of BE. We compared WATS3D with traditional biopsy as a screening tool in BE.

METHODS:

We reviewed the charts of adult patients that underwent BE screening by 3 of our gastroenterologists involved in the study with WATS3D and traditional cold forceps biopsy (FB) over the last year across community hospitals in Wichita, KS. The biopsy specimens were processed and analyzed by in-house pathologists while the WATS3D specimen were sent to CDX technology labs, NY. WATS3D specimens were obtained after FB in all instances.

RESULTS:

A total of 108 patients were identified to have undergone both WATS3D and FB at the same time for BE screening. FB detected 62 cases (57.4%) while WATS3D detected 83 (76%) cases of BE. This attributed to an absolute increase in 21 cases (18.6%) of incident BE detection by WATS3D. The number needed to test (to detect an additional patient with BE) with WATS3D was 5. We divided the sample into 4 groups – WATS3D+FB+, WATS3D+FB-, WATS3D-FB+, WATS3D-FB- to compare the agreement across the 4 groups (Table 1). Overall agreement by kappa statistic was 0.74 (good). There were 62 and 23 cases that were identified as positive and negative respectively by both methods. The pathologist read both cases of FB+ that was WATS3D- as intestinal metaplasia with no dysplasia. Of the 21 cases that were FB-, WATS3D identified 15 cases of goblet cell metaplasia, 4 cases of crypt dysplasia, 1 case of low-grade dysplasia and 1 case of adenocarcinoma. There were no immediate complications reported among the patients studied.

CONCLUSION:

WATS3D identified 20 cases of BE missed by FB, including 1 case of low-grade dysplasia and 1 case of adenocarcinoma. It is possible that the cases missed by WATS3D were due to the presence of an island of BE that was removed during FB. Overall, with no added increase in complications, WATS3D improved incident detection of BE compared to FB alone.
481 Motility Abnormalities Identified by Wireless Motility Capsule in Postural Orthostatic Tachycardia Syndrome
Authors: Zikos Thomas A. , Zhou Wendy , Clarke John O. , Nguyen Linda A. , Neshatian Leila
Published: October 2019

INTRODUCTION:

Gastrointestinal symptoms are common in patients with postural tachycardia syndrome (POTS). Previous studies have reported a wide range of abnormalities, particularly delayed gastric emptying in POTS. Wireless motility capsule (WMC) is a minimally invasive test that allows the evaluation of gastrointestinal physiology. We aimed to investigate the diagnostic yield of WMC in patients with POTS.

METHODS:

We conducted a retrospective review of all patients at our institution with both formal WMC testing (SmartpillTM) and autonomic testing for evaluation of gastrointestinal and neurological symptoms respectively. Patient demographics and results of respective testing were extracted. We compared transit abnormalities and contraction patterns between patients meeting diagnostic criteria for POTS and those without POTS. Transit abnormality percentages were compared using chi2 testing, and contraction pattern parameters were compared using 2-sample t-testing.

RESULTS:

A total of 27 women with both WMC and autonomic testing were studied. The mean age was 39.6 (range 18-68). Fourteen patients had POTS, while the other 13 had either mild or no autonomic abnormalities. Patients with POTS were more likely to have delayed small bowel transit (42.9% vs 7.69%, P = 0.037), but no differences were seen in gastric or colonic transit delays (Table 1). Additionally, POTS patients were more likely to exhibit a hypocontractile pattern throughout the gastrointestinal tract compared to non-POTS patients. Specifically, maximal gastric pressure, and small bowel peak amplitude and motility index were significantly lower in POTS patients. There was a trend towards lower colonic maximum pressure, contraction/min and peak amplitude in POTS patients that did not reach significance (Table 1).

CONCLUSION:

Our data shows that gastrointestinal motility abnormalities, as observed in WMC, are more common in patients with POTS. Patients with POTS were more likely to have delayed small bowel transit, as well as hypocontractile gastrointestinal patterns, particularly in the small bowel, compared to non-POTS patients. WMC offers a unique opportunity to evaluate patients with autonomic dysfunction and POTS. Further prospective evaluation and higher sample sizes are needed.
491 Wireless Motility Capsule Testing Results in New Diagnostic Information in 38% of Patients With Suspected GI Dysmotility: A 6-Year Review
Authors: Irshad Quratulain , Abu-Sbeih Hamzah , Stroehlein John , Shafi Mehnaz A.
Published: October 2019

INTRODUCTION:

GI motility disturbances often present with upper and lower GI symptoms or a combination of both. Wireless Motility Capsule (WMC) is a standardized pH based test that can measure regional and whole gut actual transit times. Aims: 1. Determine the prevalence of transit time abnormalities in patients with GI dysmotility symptoms. 2. Correlate regional transit abnormality with clinical symptoms. 3. Assess change in patients' diagnosis based on WMC testing.

METHODS:

A prospective study of patients with suspected GI dysmotility who underwent WMC testing between 2012 and 2018. Patients were placed into three groups: 1) Upper GI symptoms: nausea, vomiting, bloating, and abdominal pain. 2) Lower GI symptoms: constipation and diarrhea. 3) Both upper and lower GI symptoms. Assessments of gastric emptying time (GET), small bowel transit time (SBTT), and colonic transit time (CTT) were recorded in each group and the diagnostic yield was evaluated.

RESULTS:

72 patients were evaluated with WMC. 59 patients had complete study data and were included in the analysis. Mean age was 46 ± 14 years. 62 (86 %) were female. 21 (29%) had a h/o cancer. 22 (31%) were diabetic. 43/59 (73%) patients had an abnormal WMC result (Table 1). In patients with upper GI symptoms (n = 31), 15 (48%) had delayed GET (Table 2). New diagnostic information was obtained in 14/31 (45%). Of the 13 patients with lower GI symptoms, only 3 (23%) had a prolonged CTT. No patients had isolated abnormality of GET or SBTT. New diagnostic information was obtained in 5/13 (38%). In the group with overlapping upper and lower GI symptoms, only 2 (13%) had multiregional dysmotility. 8/15 (53%) patients had normal transit studies. This resulted in 5 patients (33%) with new diagnostic information.

CONCLUSION:

GI symptoms are not an accurate predictor of disease localization. Only15 (48%) of the patients with upper GI symptoms had gastroparesis, and 3 (23%) of the patients with lower GI symptoms had slow transit constipation. WMC study resulted in new diagnostic information in 45% of patients with upper GI symptoms, 38% of patients with lower GI symptoms and 33 % of patients with pan GI symptoms, including the presence of isolated and whole gut dysmotility that was not suspected based on the patient's presentation. Therefore patients with suspected GI dysmotility should undergo tests of the entire GI tract, as reported symptoms are poor indicators of the affected gut region.
493 Epidemiology and Healthcare Resource Utilization Associated With Adults Hospitalized With Short Bowel Syndrome
Authors: Siddiqui Mohamed Tausif , Singh Amandeep , Bilal Mohammad , Kirby Donald F.
Published: October 2019

INTRODUCTION:

Multiple intestinal surgeries or massive resection often lead to short bowel syndrome (SBS) which is associated with frequent hospitalizations and has high morbidly and resource utilization. But, data on these outcomes are lacking. We aimed to assess the trends of SBS-related hospitalizations, mortality and costs associated with these hospitalizations.

METHODS:

We used United States' Nationwide In-patient Sample (NIS) Database for 10 years beginning from 2005 to 2014. SBS does not have a unique International Classification of Diseases 9th Clinical Modification (ICD-9-CM) Code, therefore, we used a previously described methodology which identified SBS via combination of two diagnostic ICD-9 codes. Any hospital discharge with the presence of ICD9: “579.3: Other and unspecified postsurgical non-absorption” and ICD9: “99.15: Parenteral infusion of concentrated nutrition substances” was labeled in our study as an SBS case. We excluded the cases with missing information of in-hospital mortality (N = 40).

RESULTS:

A total of 53,040 hospitalizations associated with SBS were included in the final analysis. Our study population consisted of 65% females and 78% were Caucasians. Ages 51-56 and >65 were the most prevalent age groups (37% and 30%, respectively) and Medicare the major payer in the study populations (Table 1). Overall, SBS-related hospitalizations have increased from 4037 in 2005 to 6265 in 2014. But, all cause in-hospital mortality has decreased from 40/1000 hospitalizations in 2005 to 29/1000 hospitalizations in 2014. Most common concurrent diagnoses were protein-calorie malnutrition (N = 13063, 24.6%), hypertension (N = 11450, 21.5%), hypokalemia (N = 11334 21.3%), acute kidney injury (N = 10611, 20.01%) and dehydration (N = 9649, 18.1%). A total 15,761 (29.7%) patients received packed red cell transfusion. Mean length of stay for SBS-related hospitalization was 14.7 days and average hospital cost was US$ 31,921.

CONCLUSION:

Our results suggests that SBS-hospitalizations have increased by 54% in the last decade but in-hospital mortality associated with SBS has decreased by 27.5%. Further studies are required to assess the causes related to increased hospitalizations and improved mortality outcomes.
573 Safety of Esophagogastroduodenoscopy in Patients With Active Cocaine Use: A Pilot Study
Authors: Nguyen Alexander , Desai Parth M. , Yap John , Yu Jie , Kotwal Vikram , Attar Bashar M.
Published: October 2019

INTRODUCTION:

The timing of when to perform endoscopy in patients with a positive cocaine urine drug screen (UDS+C) varies across institutions and is based on expert opinions and personal experience. There are no clear published guidelines or reported studies in the English literature examining the safety of endoscopy in active users of cocaine. This study aimed to describe the incidence of adverse events of esophagogastroduodenoscopy (EGD) in patients with active cocaine use in a single inner-city tertiary hospital in Chicago.

METHODS:

We examined consecutive records of patients who underwent an EGD at the John H. Stroger, Jr. Hospital of Cook County from October 2016 to October 2018 and identified those who had a UDS + C within 4 days. We examined the demographics and outcomes of these patients including pre- and post-procedure hemodynamics. Paired T-tests were used to analyze the periprocedural hemodynamics.

RESULTS:

A total of 2122 patients were identified during the study period of which 129 patients had a positive urine drug screen and 50 had a UDS + C. From these patients, we identified 20 who had a UDS + C within 4 days of an EGD. These active users were predominately male (n=16) and African-American (n = 14). The majority underwent urgent procedures (n=16) in an inpatient setting (n = 19). The average time since a UDS + C was 2.3 days (SD ± 1.26). 8 patients were ASA class II and 12 were ASA class III. 14 patients underwent monitored anesthesia care (MAC) sedation and 6 underwent general anesthesia. 12 patients had abnormal electrocardiograms. The most frequent comorbidity was concurrent drug or alcohol abuse (n = 14) followed by hypertension (n = 7). There were no adverse endoscopic or anesthesia events, but 3 patients had transient procedural events (1 with oxygen desaturation and 2 with hypotension). Pre- and post-procedure hemodynamics were within normal ranges and blood pressure showed a statistically but not clinically significant decrease from a mean of 136/79 mmHg to 129/77 mmHg (P < 0.05).

CONCLUSION:

No major adverse events occurred in the active cocaine users undergoing EGD in our retrospective single center study. The decrease in blood pressure in our study was statistically but not clinically significant. Our study suggests that EGD with anesthesia support appears to be safe in patients with active cocaine use. More studies with larger sample sizes are needed to confirm these findings and further guide the safety and timing of endoscopy in cocaine users.
652 Ustekinumab Intravenous Reinduction Therapy Is Effective at Recapturing Response in Patients With Crohn's Disease
Authors: Hudson Joshua , Barnes Edward L. , Herfarth Hans
Published: October 2019

INTRODUCTION:

Ustekinumab is a monoclonal antibody used in the treatment of Crohn's Disease that acts as an antagonist to interleukin-12 and interleukin-23. It is administered as a single intravenous infusion followed by subcutaneous maintenance dosing. There is paucity of literature evaluating the efficacy of repeating an intravenous infusion to recapture response among patients experiencing secondary loss of response to ustekinumab. We report on a cohort of patients who received a second intravenous ustekinumab loading dose after secondary loss of response at a large, academic IBD center.

METHODS:

We performed a retrospective cohort study of patients, who lost response to ustekinumab after initial intravenous standard induction followed by subcutaneous maintenance therapy and received a second intravenous ustekinumab loading dose following the standard weight-based dosing recommendations. We analyzed clinical and demographic characteristics of this patient population, including phenotype, prior therapies, and the efficacy of ustekinumab after the second infusion, including the subsequent maintenance dose after the second infusion. Response was defined as resolution or improvement of clinical symptoms that led to a second intravenous infusion.

RESULTS:

Among 372 patients treated with ustekinumab between 2016 and 2019, 18 (5%) patients received a second intravenous loading dose after experiencing secondary loss of response to their initial standard intravenous regimen. These patients had all failed prior biologic therapy and were placed on ustekinumab as second line (22%), third line (27%), fourth line (33%), fifth line (6%), or sixth line therapy (11%). After the second intravenous re-induction clinical response was observed in 15 patients (83%), whereas 3 (17%) patients did not respond and ustekinumab was stopped. Clinical and demographic characteristics of patients receiving a second loading dose are shown in Table 1. Among the 15 patients remaining on ustekinumab, 5 (33%) continued every 8-week dosing, 6 (40%) utilized every 6-week dosing, and 4 (27%) required every 4-week dosing regimens.

CONCLUSION:

A second intravenous ustekinumab loading dose is an effective strategy to recapture the therapeutic efficacy of ustekinumab after secondary loss of response. In addition, our data suggests that escalation in dosing frequency of maintenance subcutaneous therapy after a second intravenous loading dose should be considered for an ongoing durable response to ustekinumab.
688 Probability of Vedolizumab Response as Defined by Clinical Decision Support Tool Is Associated With Lower Risk of Serious Infection in Patients With Inflammatory Bowel Disease
Authors: Dulai Parambir , Feng Ding , Lasch Karen
Published: October 2019

INTRODUCTION:

Disease activity is an independent predictor of infection in patients receiving biologics; non-response to a therapy might therefore present a higher risk of serious infection due to persistence of disease activity. We hypothesized that a clinical decision support tool (CDST) predicting lower treatment response may be predictive of a higher risk of infection.

METHODS:

Two validated CDSTs predicting vedolizumab (VDZ) response in ulcerative colitis (UC) and Crohn's disease (CD) were used on GEMINI phase 3 clinical trial data. After stratification by baseline variables into low, intermediate, or high probability of response to VDZ, time-to-event with Cox proportional hazard models was used to compare the risk of infection across groups and to identify independent predictors of infections among subgroups.

RESULTS:

618 UC and 1023 CD patients were included. Those categorized as having low-intermediate probability of response (n = 479 UC, n = 814 CD) to VDZ were more likely to develop infectious complications while on therapy than those categorized as having high probability (n = 139 UC, n = 209 CD) response to VDZ (UC: hazard ratio [HR] 1.383, 95% confidence interval [CI] 1.024−1.868; CD: HR 1.458, 95% CI 1.124−1.893). Serious infections were observed in 1% of UC and 3% of CD patients in the high probability of response groups vs 2% of UC and 5% of CD patients in the low-intermediate groups. Among the low-intermediate probability of response UC group, independent predictors of developing infection were: baseline extraintestinal manifestations (no vs yes; HR 0.755, 95% CI 0.569−1.001); previous tumor necrosis factor antagonist exposure (no vs yes; HR 0.671, 95% CI 0.497−0.906); and baseline fecal calprotectin (log transformed; HR 1.135, 95% CI 1.016−1.268). Among the low-intermediate probability of response CD group, an independent predictor of developing infection was exposure to opioids during treatment (yes vs no; HR 1.829, 95% CI 1.469−2.277).

CONCLUSION:

This analysis confirms a pattern of inverse correlation between CDST-predicted efficacy and risk of infection. Data are consistent with the VDZ safety profile and suggest that infectious events seen were related to persistence of disease activity as opposed to drug-related mechanisms.
733 Leukocyte Ratios in Adults 20-70 Years Old With Inflammatory Bowel Disease in the United States Population: NHANES 2009-2010
Authors: Ndulue Chidozie , Obiajunwa Chiagoziem , Ndulue Jideofor
Published: October 2019

INTRODUCTION:

To assess the association between neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR) and neutrophil to monocyte ratio (NMR) in adults 20-70 years old with inflammatory bowel disease (IBD) using a nationally representative database of the United States population.

METHODS:

Analysis was performed on 4,739 persons aged 20-70 years from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) who responded to the question “has a doctor or health professional ever told you that you have ulcerative colitis or crohns disease. Participants with a diagnosis of cancer were excluded in the analysis. Mean values of neutrophils (N), lymphocytes (L), monocytes (M) and their ratios were compared between groups of participants with and without inflammatory bowel disease.

RESULTS:

There was no significant difference in NLR and LMR between participants with and without inflammatory bowel disease. Compared with participants without IBD, participants with IBD had a higher NMR (7.95 95%CI: 7.80, 8.09 vs 8.84, 95% CI: 7.91, 9.76).

CONCLUSION:

A high NMR might be effective, readily available and low-cost biomarker for assessment of people with inflammatory bowel disease. Further studies are needed to clarify the difference in NMR between people with and without IBD.
835 Can Ustekinemab Relieve the Symptoms of IBD-Associated Arthropathy?
Authors: Vizuete John A. , Randall Charles W. , Martinez Nicholas
Published: October 2019

INTRODUCTION:

Arthropathy is the most common extra intestinal manifestation observed in patients with Inflammatory Bowel Disease (IBD). Various studies have shown that up to 40% or more of patients with IBD may experience arthropathy. Ustekinemab is a relatively new drug approved for the management of moderate to severe Crohn’s disease (Oct 2016) and phase 3 trials for ulcerative colitis have now been completed. It is also FDA approved for management of psoriatic arthritis. The purpose of this study was to determine if a small cohort of patients with enteroarthropathy had symptom improvement while receiving ustekinemab in a longitudinal retrospective cohort.

METHODS:

Adult patients with IBD and arthropathy with who were treated with ustekinumab were included in the cohort. We followed the minimal disease activity index (MDA) which includes 7 broadly accepted parameters. We chose to collect data on 5 of those parameters including 1) joint tenderness, 2) swollen joint count, 3) tender points, 4) standardized graphic pain scales (VAS or GRS), and 5) a global assessment score from 0-5 (GAS). Two parameters (psoriatic area and severity index and health disability index) were not assessed. At each visit outcome measures were evaluated for changes in arthritic symptoms.

RESULTS:

15 patients were included for review. 11 had Crohn’s disease and 4 had ulcerative colitis. Patients were followed for an average of 12 months (range 9-16). Eleven of 15 patients had joint tenderness on palpation at the start of therapy with 1 to 3 affected joints per patient while the others had subjective tenderness. Five patients had visibly swollen joints and 1 had both. The mean GAS was 3 with a range of 2 to 4. The pain GRS had a mean score of four out of 10 with a range of 2 to 8. The mean number of tender points was 3. After ustekinumab therapy, 14 of 15 patients had a drop in the global assessment score and the pain GRS score. Fourteen patients had resolution of joint swelling and tenderness. At the conclusion of the study, 6 of 15 patients complete resolution of all five scales. Four patients had resolution in three of the five scales, while 4 patients had resolution of two of the five scales. 1 patient did not exhibit improvement in any area.

CONCLUSION:

In this small observational cohort, ustekinumab improved arthropathy in 14 of 15 patients. We hope this stimulates interest in trials observing larger number of patients with this debilitating extra international manifestation of IBD.
869 A Comparison of ERCP Outcomes Between High Volume and Low Volume Centers
Authors: Hudhud Dania , Al-Obaid Lolwa , Enezate Tariq
Published: October 2019

INTRODUCTION:

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a commonly performed procedure for simultaneous diagnosis and treatment of biliary disease, which has several potential post-procedural complications. Few studies have addressed the association between hospital ERCP volume and post procedural complications. This study aims to examine the difference in the rate of post ERCP complications between high and low volume centers.

METHODS:

The study population was extracted from the 2016 Nationwide Readmissions Database using International Classification of Diseases, Tenth Revision, and Clinical Modification/Procedure Coding System for ERCP and in-hospital outcomes. Centers that performed > 200 ERCPs during the year of 2016 were considered high-volume, whereas centers that performed < 200 ERCPs were considered low-volume. Study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), post ERCP pancreatitis, and infection rates.

RESULTS:

A total of 137,825 ERCPs were identified, of which 39.8% were diagnostic ERCPs while 60.2% were therapeutic ERCPs. The mean age of patients was 59.7 years. 56.9% of the study population were female. High-volume centers performed 54,640 procedures while low-volume centers performed 83,185 procedures. In regards to complications, high-volume centers compared to low-volume centers, had a significantly higher rate of all-cause mortality (1.9% vs 1.4%, P < 0.01), post-op pancreatitis (7.0% vs 6.2%, P < 0.01), post-procedural infection (0.7% vs 0.5%, P < 0.01), and LOS (6.7 days vs 5.9 days, P < 0.01). This pattern was consistent for ERCP procedures performed for both diagnostic and therapeutic purposes, with the exception of similar rates of post-procedural pancreatitis associated with ERCP performed for diagnostic purposes in both high and low volume centers.

CONCLUSION:

In this preliminary analysis of a large database, hospitals with high ERCP volume were associated with a higher rate of complications including post procedural in-hospital mortality, morbidity, and length of stay. While procedural technique and operators vary amongst centers, we hypothesize that the higher rate of complications seen in patients being treated at high volume centers may, in part be due to a higher complexity in patients been seen at high volume centers.
1128 Effect of Sleeve Gastrectomy on Ghrelin, GLP-1, PYY, and GIP Gut Hormones: A Systematic Review and Meta-Analysis
Authors: McCarty Thomas R. , Jirapinyo Pichamol , Thompson Christopher C.
Published: October 2019

INTRODUCTION:

Despite sleeve gastrectomy becoming the most common surgical weight loss procedure, weight loss mechanisms remain less clear. The primary aim of this study was to perform a structured systematic review and meta-analysis of all eligible studies to evaluate changes in various gut hormone levels in patients following sleeve gastrectomy.

METHODS:

Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through April 1, 2019 in accordance with PRISMA and MOOSE guidelines. Measured outcomes included pre- and post-operative hormones: fasting ghrelin, post-prandial glucagon-like peptide-1 (GLP-1), post-prandial peptide YY (PYY), and fasting gastric inhibitory peptide (GIP) levels. Hedge’s g was used to determine pooled effect size and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed with Cochran Q test and I
2 statistics. Study quality was evaluated with the Newcastle-Ottawa Quality Assessment Scale (NOS) score for observational studies and JADAD score for randomized controlled trials. Publication bias was evaluated by funnel plot using Egger and Begg tests.

RESULTS:

A total of 28 studies (n = 653; 29.56% male) were included. Mean age was 42.00 ± 5.48 years with average follow-up of 11.70 ± 11.38 months. Pre-procedure BMI was 46.01 ± 4.07 kg/m2 with a post-sleeve gastrectomy BMI of 34.07 ± 3.73 kg/m2 (%EWL 57.48 ± 9.64). Ghrelin decreased [Hedge’s g of -1.486 (95% CI, -1.884 to -1.089); I
2 = 91.95%; Q-value of 310.57] while GLP-1 and PYY increased post-procedure [Hedge’s g of 1.095 (95% CI, 0.509 to 1.642); I
2 = 84.38%; Q-value of 70.43) and Hedge’s g of 1.396 (95% CI, 0.781 to 2.011); I
2 = 84.02%; Q-value of 62.59), respectively]. GIP did not significantly change [Hedge’s g of -0.213 (95% CI, -1.019 to 0.592; I
2 = 79.65%; Q-value of 4.92]. Baseline characteristics as stratified by individual gut hormone are shown in Table 1. Quality assessment revealed all studies to be of high quality (i.e., NOS score ≥4 or JADAD score of ≥3). Classic fail-safe determined it would take 2044, 244, and 248 non-significant studies to nullify the difference in gut hormone levels for ghrelin, GLP-1, and PYY, respectively.

CONCLUSION:

Ghrelin levels decrease while post-prandial GLP-1 and PYY increase after sleeve gastrectomy. GIP levels remain unchanged. Future studies are needed to assess the role of these gut hormones and relationship to weight loss and metabolic outcomes. These results may have the potential to optimize patient selection in an era personalized medicine.
1311 Acute Pancreatitis in a Patient Using Liraglutide for Weight Loss
Authors: Fatakhova Karina , Rahman Ali , Al-Naqeeb Ghadah , Al Yassin Sarmed , Alqaisi Sura , Ramdass Adesh
Published: October 2019

INTRODUCTION:

Liraglutide is a GLP -1 agonist, a class of type two diabetes mellitus injectable treatments, which has shown benefits of controlling blood glucose levels with a minimal risk of hypoglycemia. Liraglutide delays the movement of food from the stomach into the small intestine which causes early satiety and a decrease in appetite.

CASE DESCRIPTION/METHODS:

A 40-year-old female presented to the emergency department with a two-day history of acute onset of sharp epigastric pain radiating to the back associated with nausea. The lipase level was elevated at 1,595 U/L and triglycerides were normal. Upon further evaluation, right upper quadrant ultrasound revealed cholelithiasis. CT abdomen and pelvis revealed cholelithiasis without evidence of cholecystitis. Magnetic Resonance Cholangiopancreatography (MRCP) showed gallstones and mild gallbladder wall thickening. There were no signs of pancreatic ductal dilatation or mass lesions. The patient's medical history was significant for obesity, hypertension and asthma. Liraglutide injections were started four weeks prior to her presentation for weight loss. She denied any history of pancreatic disease, alcohol use, tobacco use or herbal supplementations. The patient medications were significant for lisinopril and pantoprazole.

DISCUSSION:

In 2014 liiraglutide has been approved by the Food and Drug Administration (FDA) for weight loss at a higher dose. In the phase III trials Liraglutide Effect and Action in Diabetes (LEAD), liraglutide was shown to have a substantial decrease not only in hemoglobin A1C over a placebo, but in weight reduction as well. Since its use for weight loss, there have been concerns for acute pancreatitis. Acute pancreatitis is an inflammatory disease of the pancreas. Etiologies most commonly include gallstones or alcohol use. In cases where there is no history of alcohol use or obstructive gallstone disease it is imperative to search for alternative causes. In the case we presented, the patient underwent MRCP which did not reveal signs of pancreatic ductal obstructions. A careful review of her medical history and medications did not provide any risk factors for developing pancreatitis except for liraglutide injections for weight loss. The possibility of autoimmune or viral acute pancreatitis was ruled out. Liraglutide has been reported to cause acute pancreatitis. It has been suggested that it is more common to develop acute pancreatitis while on liraglutide in patients who have a history of pancreatitis or gall bladder disease.
1487 Vedolizumab-Induced Remission of Refractory Microscopic Colitis: A Single Institution Case Series
Authors: Perry Courtney , Pekez Marijeta , Kudaravalli Praneeth , Hashim Mahmoud , Akanbi Olalekan , Yarra Pradeep , Barrett Terrence
Published: October 2019

INTRODUCTION:

Microscopic colitis (MC) is a chronic inflammatory disease of the colon that is responsible for up to 10-15% of chronic watery diarrhea (Cotter TG, Binder M, Loftus EV, et al. Gut 2018). While this disease is often self-limiting, some patients suffer from severe disease that can be refractory to standard medical therapies, such as Imodium and budesonide. These patients are often referred to tertiary care facilities for initiation of anti-tumor necrosis factor agents (anti-TNFs) as they have shown some benefit in refractory disease. However, a significant side effect profile does accompany these agents which can make their use less desirable. Vedolizumab, a monoclonal human antibody to α4β7-integrin that blocks lymphocyte trafficking to the gut, has an excellent safety profile (Battat R, Ma C, et al. Drug Safety 2019) and is an appealing option for patients with severe refractory MC.

CASE DESCRIPTION/METHODS:

Three patients presenting to the University of Kentucky with severe microscopic colitis refractory to maximum budesonide and Imodium therapy were treated with vedolizumab. Vedolizumab was given at standard induction dosing (300 mg IV at week 0, 2 and 6, and then every 8 weeks). Clinical remission was defined as <3 stools a day following induction of vedolizumab with ability to wean budesonide.

DISCUSSION:

All three patients had remission of their MC as evidenced by cessation of diarrhea and ability to wean budesonide and Imodium after induction vedolizumab, including one patient who had suffered from microscopic colitis for over 20 years. This case series supports the small number of case reports that have surfaced in publications over the past 18 months, the largest of which consisted of 11 patients. While the definitive mechanism of microscopic colitis remains unknown, one of the proposed mechanisms details activation of CD8 T suppressor cells in the IEC and NF-ƙβ pathway activation leading to tissue damage in epithelial cells and barrier dysfunction (Gentile N, Yen E. Gut Liver 2018). The efficacy of vedolizumab in inducing MC remission supports this proposed mechanism, given its mechanism of action to bind α4β7-integrin and prevent T-cell adhesion. Larger scale clinical trials are needed to support routine clinical use of vedolizumab in refractory microscopic colitis, but this drug presents a promising, low-side effect profile treatment option for MC suffers.
1545 Drug-Induced Colitis With Nintedanib Therapy
Authors: Penmetsa Amulya , Santa Stephanie , Abu-Farsakh Sohaib , Drage Michael , Ettel Mark , DeCross Arthur , Marino Danielle E.
Published: October 2019

INTRODUCTION:

Nintedanib has emerged as an important treatment agent for Idiopathic Pulmonary Fibrosis (IPF). Gastrointestinal side effects, such as diarrhea and nausea, have been reported. However, Nintedanib-Induced Colitis, as described in the following cases, is a rare finding.

CASE DESCRIPTION/METHODS:

Case 1: 65 year-old man with a history of IPF on Nintedanib for three years presented with diarrhea. He reported two watery, non-bloody bowel movements daily with urgency, despite taking four tablets of loperamide daily. He had lower abdominal pain and an eighty-pound weight loss. A colonoscopy revealed mild edema, loss of vascular markings throughout the colon, and significant patches of submucosal hemorrhage/petechiae in the right colon. Biopsies revealed subepithelial deposition of amorphous eosinophilic material, prominently filling the subepithelial capillaries (Figure 1). Masson trichrome stain highlights dense blue staining, indicating collagen. The patient's symptoms resolved within a few days of discontinuing Nintedanib, and returned with rechallenge. Case 2: 76 year-old man with IPF on Nintedanib for three years presented with four loose, non-bloody bowel movements daily. He had bowel urgency, abdominal pain, and ten-pound weight loss despite loperamide use. Colonoscopy showed diffuse villous clubbing and erythema in the ileum. The entire colon revealed erythema and loss of vascular markings without ulcers (Figure 2). Histopathology revealed a paucicellular area of eosinophilic change in the lamina propria of the colon (Figure 3). There was no definite collagen deposition in this case. Nintedanib was discontinued and the patient's diarrhea resolved within two days; it returned with rechallenge.

DISCUSSION:

Nintedanib is a tyrosine kinase inhibitor, which is associated with diarrhea in about half of patients. Diarrhea is usually reported in the first three months of treatment and is generally adequately treated with anti-diarrheal medications. However, the specific entity of Nintedanib-induced colitis is a rare finding. There have only been two cases reported in the literature, neither of which described any particular pathologic findings. Our two cases demonstrate that symptoms resolve rapidly with drug withdrawal, recur rapidly upon rechallenge, and resolve again on withdrawal, suggesting a hypersensitivity reaction. Both cases demonstrate deposition of subepithelial eosinophilic material, which may offer a diagnostic clue to this drug induced diarrhea.
1724 Acquired Broncho-Esophageal Fistula After 10 Years of Esophageal Stent Placement
Authors: Elkhouly Mohamed A. , Attar Bashar M. , Elkafrawy Ahmed A. , Haque Zohaib , Salazar Miguel , Vohra Ishaan
Published: October 2019

INTRODUCTION:

Acquired benign Broncho-esophageal fistulas (BEF) are uncommon and develops as a complication of inflammatory processes, malignant neoplasm and traumas of the chest but it has been rarely reported with esophageal or tracheal stents. We are reporting a case of Lt BEF after 10 years of esophageal stent placement for recurrent benign esophageal stricture.

CASE DESCRIPTION/METHODS:

A 52 years-old-female with history of HIV-1 infection was admitted with dysphagia to solid food. Her condition started 10 years ago after she presented with progressive odynophagia and dysphagia to solids and liquids. EGD at that time showed giant aphthous esophageal ulcer, 25 to 34 cm from the incisors, involving entire esophageal circumference. Biopsy showed ulcerated squamous mucosa with diffuse acute and chronic inflammation, negative stains for acid fast bacilli, fungal infection, CMV and HSV. She was treated with pantoprazole, hydrocortisone and thalidomide without improvement of her symptoms. Repeated EGD showed formation of benign esophageal stricture with negative repeated biopsy results. Over 6 months, she underwent multiple balloon dilatation of the stricture until 16 to 20 mm × 120 mm in length, Polyflex stent was placed with improvement of her symptoms She was lost for follow up before presenting again with progressive dysphagia to solids of 3 months duration associated with progressive weight loss. Esophagogram showed stable position of the stent in the mid esophagus with stable dilated proximal esophagus and no esophageal stricture. Due to concern of stent malfunction, the stent was removed but the patient continued to have dysphagia. Repeated esophagogram four days later, showed contrast media in the Left main bronchus tracking to the left lower lung lobe. Bronchoscopy and upper endoscopy showed chronic acquired Broncho-esophageal fistula extending from the lateral edge of membranous left main bronchus to the esophagus, 25 cm from incisors. PEG tube was placed for nutrition and she is planned for fistula repair in two weeks.

DISCUSSION:

BEF is a serious condition and treatment is mandatory to avoid continuous aspiration, chronic sepsis, and pulmonary failure, mainly in immunocompromised patients. There are no studies on the incidence of such fistulas after esophageal stent placements. On the other hand, some studies favored tracheal or esophageal stents as a corrective measure, although neither are free from complications, and they are palliative measures, making surgical repair the best option.
1824 Acute Esophageal Necrosis Secondary to Intrathoracic Gastric Volvulus Without Deadly Outcome
Authors: Chowdhury Nazif , Alom Md S. , Saleem Atif
Published: October 2019

INTRODUCTION:

Esophageal necrosis is one of the rarely seen conditions of the esophagus. It usually happens in elderly patients and occurs secondary to impaired blood flow in combination with gastric outlet obstruction or gastroesophageal reflux disease. Gastric volvulus is also a rare condition for adults after the age of 50 and is a surgical emergency. Esophageal necrosis and gastric volvulus carry a very high mortality and morbidity if not treated quickly.

CASE DESCRIPTION/METHODS:

This is an 85-year-old female with past medical history of hypertension and hyperlipidemia. She presented to the hospital with dysphagia to solid food for one week. She complained of abdominal pain, nausea, vomiting, and chest discomfort. Physical examination revealed abdominal distention, mild epigastric tenderness and normal bowel sounds. CT scan of the abdomen and pelvis showed a very large hiatal hernia with the entire stomach herniated into the chest. There was a high clinical suspicion for esophageal necrosis and gastric volvulus given her continued symptoms and thus the decision was made to do an emergent upper GI endoscopy. The upper GI endoscopy showed necrosis of the mid and distal esophagus with a sharp demarcation at the mid esophagus. There was blackish discoloration with severe ulcerative esophagitis in the lower third of the esophagus. There was also a large 7 to 8 cm hiatal hernia with a large para-esophageal component. There was evidence of gastric volvulus. A nasogastric tube was placed endoscopically past the volvulus to decompress the stomach.The patient was taken for emergent laparoscopic surgery. Surgery revealed a large hiatal hernia with intrathoracic stomach, and lower esophageal necrotic ulcerations with perforation. This was evidenced by a 7 mm sized opening at the left lateral distal esophagus with leakage of saliva and gastric contents. The perforation and hiatal hernia were repaired and a G tube was placed. Patient did very well and was discharged home two weeks after surgery.

DISCUSSION:

Diagnosis of acute esophageal necrosis is often incidental during upper GI endoscopy for evaluation of upper GI bleeding. There are no laboratory or imaging findings specific for acute esophageal necrosis. A high clinical suspicion and urgent upper GI endoscopy are needed to make the diagnosis. This case demonstrates that emergent upper GI endoscopy followed by surgical repair can lead to a favorable outcome.