bluuebunny/crossref_metadata_2025 huggingface dataset:
2824 Inpatient Fecal Microbiota Transplantation for the Treatment of Refractory Severe-Complicated Clostridioides difficile Infection
Authors: Pardi Ryan , Saha Srishti , Pardi Darrell , Khanna Sahil
Published: October 2019

INTRODUCTION:

Currently, surgery is the primary treatment option for refractory, severe-complicated Clostridioides difficile infection (CDI) in the inpatient setting. There are limited series reporting the efficacy of Fecal Microbiota Transplantation (FMT) to treat such cases as an alternative to surgery or in patients who are not surgical candidates. We aimed to assess the response rate and prognosis of these patients after inpatient FMT.

METHODS:

We conducted a retrospective chart review of patients with CDI (watery diarrhea with positive stool assay) admitted in the ICU, and who received FMT from January 2013 to July 2016. Potential cases were identified by diagnosis codes and eligibility was confirmed through manual chart review. Severe-complicated CDI was defined as CDI with any of the following: ICU admission, hypotension, shock, sepsis, megacolon, colectomy or death due to CDI. CDI was termed refractory in the absence of clinical response to antibiotics after 5 days. Recurrence was defined as typical CDI symptoms and positive stool assay within 56 days of treatment with interim symptom resolution. The primary outcome was resolution of CDI (clinical cure with no recurrence). Secondary outcomes included risk of recurrent CDI and mortality. Microsoft Excel was used for descriptive statistical analysis.

RESULTS:

Of 273 patients screened, 6 cases met inclusion criteria. Five patients received FMT via colonoscopy, one via retention enema. The mean age at time of FMT was 72 (range, 54-88) years, 4 (66%) patients were female. All had severe-complicated CDI, 3 had concomitant diverticulosis and none had inflammatory bowel disease (IBD). The median follow-up after FMT was 8.5 (range, 1-18) months. Three patients received non-CDI antibiotics within 6 months post-FMT, 3 received acid suppression therapy (Table 1). FMT was performed after a median of 3 (range, 1-5) episodes of CDI with a median of 4.5 previous courses of antibiotics (range 2-6 courses) (Table 1). Four of the six patients (66%) had resolution of CDI, 2 patients had recurrence. One patient died due to sepsis secondary to CDI; 3 died due to unrelated causes.

CONCLUSION:

In this small retrospective study, inpatient FMT was effective for treating refractory severe-complicated CDI. There was one CDI-related mortality by the end of follow up. FMT may be an alternative therapy in patients with severe-complicated CDI.
2828 Understanding the Role of Osteopathic Manipulative Medicine in the Management of Gastrointestinal Disorders and Symptoms: A Survey Study
Authors: Shah Ruchit N. , Diehl David L. , Graham Jove , Kim Alexander H. , Loughlin Michael T.
Published: October 2019

INTRODUCTION:

Patients with gastrointestinal (GI) disorders can present with a myriad of symptoms. Osteopathic Manipulative Medicine (OMM) is a well-established anatomy-based modality where adjustments to the neuromusculoskeletal system may restore motility of the viscera via regulation of the autonomic nervous system. OMM is performed by specially trained physicians using palpatory skills to diagnose and treat illnesses. Pharmacologic therapies often lack efficacy for some GI symptoms, so OMM could be a safe and effective alternative treatment. Our aim was to study the clinical use of OMM in the management GI symptoms, and begin to understand which conditions it might be best suited for.

METHODS:

We conducted a web-based survey study targeting academic osteopathic physicians practicing OMM throughout the US. In this 16-item questionnaire, physicians were asked about their use, outcomes, and preferences pertaining to OMM for treating GI symptoms. Data on the types of GI disorders encountered, duration and modality of techniques used, and the respondent’s departmental specialty were gathered. Online surveys were followed by a detailed telephone interview.

RESULTS:

A total of 220 emails were sent and 64 surveys were completed (29%). Ninety-one% of respondents utilized OMM for GI symptoms. Constipation was the most commonly encountered GI symptom with the best response to OMM (87%) followed by bloating (56%) and heartburn (55%). Visceral manipulation techniques such as mesenteric release and colonic stimulation were the most commonly used OMM modalities (98% of respondents). Only 13% of the respondents reported adverse events with transient pain and fatigue being the most common complaints post-OMM. Telephone interviews revealed that nearly 50% of patients achieved a sustained response after 3-4 months of OMM. Respondents did not report a difference to OMM response in patients on chronic narcotics compared to those not on opioids.

CONCLUSION:

The results of this study suggest that a multifaceted therapeutic approach utilizing OMM may have a role in the management of GI disorders. OMM is a safe and cost-effective approach that can be performed in an inpatient or outpatient setting. OMM could also have applications in treating patients with functional GI disorders such as IBS and other motility-related disorders of the brain-gut pathway. Randomized controlled trials and prospective studies need to be conducted to build an evidence-based rationale for OMM in patients with GI disorders.
2829 Patients Eligible for Trials of Microbiota-Based Therapeutics Do Not Represent the Population With Recurrent Clostridioides difficile Infection
Authors: Kelly Colleen R. , Fischer Monika , Grinspan Ari , Rupawala Abbas , Allegretti Jessica R.
Published: October 2019

INTRODUCTION:

Industry-funded trials of microbiota-based therapeutics for treatment of Clostridioides difficile are ongoing, however due to strict enrollment criteria, not all patients are eligible. Furthermore, given the widespread availability of fecal microbiota transplantation (FMT) and overwhelming evidence supporting its efficacy, patients may refuse enrollment in trials with a placebo-arm.

METHODS:

This is a retrospective study performed at four tertiary referral centers for FMT. The electronic medical record at each was reviewed to capture patients referred for recurrent CDI over a 6- month time period. FMT eligibility was determined based on current CDI treatment guidelines.3 Inclusion and exclusion criteria for a clinical trial of an oral microbiota-based therapeutic were applied to determine eligibility, based on current enrolling trials at these centers.

RESULTS:

Of 199 patients referred for a diagnosis of recurrent CDI, 130 (65%) were deemed to be eligible for FMT based on the number and severity of episodes. Of the patients in whom FMT was determined to be an appropriate option, 94 (72%) met inclusion criteria for an RCT of a microbiota-based therapeutic drug, however 62 (66%) of those meeting inclusion criteria had one or more exclusion criteria (Table 1) precluding participation and 16 (17%) were eligible but refused to enroll. Only 16 (12%) of FMT-eligible patients were enrolled in the drug trial. Conventional FMT using stool-bank donor material was performed in 96 patients (74%) of those deemed eligible to undergo the procedure (Figure 1). Most patients (79%) met a single exclusion criterion, 14.5% met two criteria and 6.5% met three criteria. The most common reason for study exclusion was immunocompromise (17; 27%). Other common exclusions were inflammatory bowel disease (13; 21%), having already received more than 21 days of vancomycin (11; 18%) and diarrhea-predominant irritable bowel syndrome (10; 16%).

CONCLUSION:

Less than half of patients deemed eligible for FMT based on clinical history of recurrent CDI met eligibility criteria for a clinical trial of an encapsulated microbiota product. A smaller but relevant proportion of eligible patients refused to participate. Restrictions on stool banks would have detrimental effects on patient access to FMT. Furthermore, these results demonstrate that a relevant number of patients affected by recurrent CDI are currently being excluded from industry-funded trials.
2835 The Impact of Patient Educational Poster in Colorectal Cancer Screening at a Resident Primary Care Clinic
Authors: De La Guerra Ramiro , Sealey Mary Lynn
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the third leading cause of death in the US in women and the second leading cause of death in men. CRC mortality has been progressively declining since 1990, thanks in part to an increased rate of CRC screening. One of the biggest deterrents to CRC screening is lack of information about the various screening modalities and preparation process. Additional information for patients would be beneficial for increased adherence to guideline-directed CRC screening.

METHODS:

In this study, aggregate data was collected via EHR for the WPMA Medicine Resident Clinic cohort to establish baseline patient adherence to CRC screening (defined by referral and follow through with CRC screening e.g. via colonoscopy, ColoGuard, or FIT screening). A poster was developed with information on CRC screening that included information on procedures, specimen collections, and insurance coverage for each modality and placed in resident examination rooms. Adherence data was collected in aggregate every 5 weeks (equivalent to a 5-week cycle of resident cohort rotations). Another resident clinic in which no posters were placed was used as a control group.

RESULTS:

Baseline adherence to CRC screening for the selected cohort was 28.5%. Since the placement of educational posters screening adherence collected in 5-week intervals showing an increase in adherence with rates of 36.0%, 37.6%, 36.2%, 37.3%, a total increase of approximately 8.8%. The control group with similar screening adherence revealed an increase of adherence of 2%.

CONCLUSION:

Data collection is ongoing, and we hypothesize that the implementation of patient education through posters in resident examination rooms will increase adherence to appropriate screening.
2838 An Evaluation of the Multi-Target Stool DNA Test for Colorectal Cancer Screening in Individuals Aged 45-49 at Average Risk for Colorectal Cancer: Act Now Study
Authors: Imperiale Thomas , Kisiel John , Itzkowitz Steven , Scheu Bradley , Piscitello Andrew , Statz Sandra , Berger Barry M. , Limburg Paul
Published: October 2019

INTRODUCTION:

Due to the rising incidence and mortality of colorectal cancer (CRC) in individuals < 55 years (Siegel R, et al, JNCI, 2017), American Cancer Society (ACS) guidelines now recommend average-risk CRC screening beginning at age 45 years. The multi-target stool DNA (mt-sDNA) test, an FDA-approved screening test for average-risk individuals ≥50 years, is one ACS-recommended option for this age group. To minimize invasive testing in the younger age group, a screening test with high specificity is necessary to triage patients for diagnostic colonoscopy. To date, most endorsed CRC screening tests have not been rigorously studied in younger age groups. The objective of this study (the Act Now study [NCT03728348]) is to quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49.

METHODS:

Act Now is an ongoing prospective, cross-sectional, multi-center study in subjects ages 45-49 at average risk for CRC. 942 subjects are targeted for enrollment and will complete a mt-sDNA test prior to undergoing a screening colonoscopy (blinded to mt-sDNA test results). Specificity for advanced colorectal neoplasia will be determined by comparing mt-sDNA test results to the most advanced finding on colonoscopy, based on procedure report and histopathological findings. Due to the low prevalence of CRC in this age group, mt-sDNA test sensitivity will be a secondary measure.

RESULTS:

To date, 480 subjects have completed a mt-sDNA test and screening colonoscopy. A total of 468 subjects (97.5%) have no first-degree relative (FDR) with CRC and 12 subjects (2.5%) have an FDR diagnosed at age ≥60 years. No subject has had a previous screening colonoscopy. The study population has a mean age of 47.4 years and is 48.8% female. Self-reported race includes 84.2% white, 11.5% black/African American, 3.3% Asian, and 1.0% other. Self-reported ethnicity includes 95.2% not Hispanic or Latino, 4.6% Hispanic or Latino, and 0.2% other. The mean BMI of subjects is 29.6 kg/m2. Most subjects (67.1%) have never smoked cigarettes, while 21.9% are former smokers and 11.0% are current smokers.

CONCLUSION:

The ongoing Act Now study will quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49. Given concerns regarding the resources required to screen this age group for CRC, a noninvasive screening test with high specificity and sensitivity will help to optimize use of colonoscopy resources.
2839 Outcomes of a Positive Cologuard Test in an Outpatient Internal Medicine Practice
Authors: Satiya Jinendra , Dziadkowiec Karolina N. , Bagatell Stuart , Marcus Akiva
Published: October 2019

INTRODUCTION:

In the United States, colorectal cancer (CRC) is the second leading cause of death. Colonoscopy and fecal immunochemical test (FIT) are recommended as first tier tests for colorectal cancer screening. Cologuard is an attractive and effective modality of screening in patients apprehensive of undergoing a colonoscopy with a sensitivity and specificity of upto 90%. We performed a retrospective chart review to assess the outcomes of cologuard testing and subsequent colonoscopy results in an outpatient population.

METHODS:

A total of 550 patients underwent cologuard testing in our outpatient internal medicine practice. We performed a retrospective chart review to identify patient characteristics in patients with a positive cologuard test and correlate them with colonoscopy findings. Primary outcome was to identify colonoscopy findings in patients with a positive cologuard test. Secondary outcome was to identify patient characteristics in this patient population.

RESULTS:

52 of these patients (9.45%) had a positive cologuard test. The average age of these patients was 68 years. 222 of these were males and 328 females. Most of them were non-hispanic or non-latino whites (39), with two hispanics, and one American Indian. Nine patients refused to report their ethnicity. All of these patients were referred to gastroenterology for a screening colonoscopy. Out of the 52 patients that were referred, 34 (65.38%) underwent a screening colonoscopy. Four patients were lost to follow-up, eight patients could not undergo a screening colonoscopy secondary to significant medical co-morbidities and six declined the colonoscopy. 29 (85.29%) patients had an abnormal colonoscopy with significant findings. Five patients had a normal colonoscopy with no remarkable findings. The total number of polyps found in these patients was 70, ranging from one polyp seen in nine patients to 12 polyps seen in one patient. The most common location for a polyp was the sigmoid colon followed by the transverse colon, with fewest polyps seen in the cecum. The most common histological diagnosis was hyperplastic, followed by sessile serrated and villous adenomas.

CONCLUSION:

We noted a high degree of correlation between a positive cologuard test and the presence of colonic polyps. Cologuard is an effective and convenient non-invasive screening modality in patients that do not wish to undergo a colonoscopy. Appropriate follow-up and referral to gastroenterology is essential for patients with a positive cologuard test.
2840 The Association of Polish Ethnicity and Polyp Risk on Screening Colonoscopy in a Local Brooklyn Population
Authors: Catalano Carmine , Dros Matthew , Reddy Madhavi , Gurram Krishna C.
Published: October 2019

INTRODUCTION:

The Brooklyn Hospital Center (TBHC) serves an ethnically diverse community with a large Polish immigrant population. There was a perceived increased quantity of polyps in our Polish patients. Multiple adenomas, larger sized adenomas, and adenomas with advanced histology on index colonoscopy are associated with increased risk for colorectal cancer (CRC). Studies in African Americans demonstrated higher incidence of CRC and mortality compared to whites suggesting different ethnic groups may be at increased risk for CRC. The goal of our study is to see if the Polish population is at increased risk for adenomatous polyps, large polyps(≥1 cm), multiple adenomas(≥3), or advanced adenomas(tubulovillous, villous, or high grade dysplasia) when compared to the non-Polish white population.

METHODS:

A retrospective chart review was performed from 1/2012 to 10/2018. Inclusion criteria were patients ≥50 years of age undergoing screening colonoscopy. Exclusion criteria consisted of an incomplete exam, personal or family history of CRC, or indication other than screening. Polish and non-Polish whites were identified by demographic data. 121 Polish patients were matched to 121 non-Polish white patients by gender and age. High-risk patients were those having large, multiple or advanced adenomas. Statistical analysis utilized student’s 2 sample t-test for P-values, with an alpha level of 0.05, and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS:

Each arm consisted of 56 men (46%) and 65 women (54%) with an average age of 64.3 years in both. There was a statistically significant difference between the number of high-risk Polish vs. non-Polish white patients (OR 1.95, 95% CI: 1.07-3.53; P = 0.026). Although not statistically significant, Polish patients had an increased prevalence of total polyps (OR 1.22, 95% CI: 0.73-2.0; P = 0.23), large polyps (OR 1.69, 95% CI:0.88-3.22; P = 0.10), adenomas (OR 1.38, 95% CI: 0.81-2.32; P = 0.23), multiple adenomas (OR 1.63, 95% CI: 0.60-4.35; P = 0.33), and advanced adenomas (OR 1.85, 95% CI: 0.74-4.58; P = 0.18). We also found 2 cases of CRC in the Polish group and no cases in the non-Polish group (P = 0.15).

CONCLUSION:

These results show a statistically significant difference in the number of high-risk Polish vs. non-Polish white patients with an increase rate of CRC in the Polish group although not statistically significant. These findings warrant larger population based studies to further investigate the benefit of earlier screening for these patients similar to African Americans.
2844 Does Access Matter? A Retrospective Analysis of Patients Undergoing Colonoscopy for Colorectal Cancer Screening Based on Health Insurance
Authors: Chintalapudi Ananya , Koya Laxmi Deepika , Mallavarapu Ramitha , Chintalapudi Mastan , Patel Nishi
Published: October 2019

INTRODUCTION:

Implementation of the Affordable Care Act (ACA) in 2010 has expanded access to health care for millions of Americans. Although there were few large registry based studies that showed a positive impact of ACA on colorectal cancer screening and early cancer detection there are no published studies from community practice setting. The aim of this retrospective study in a single provider gastroenterology community practice is to study the ultilization of colonoscopy for colorectal cancer screening among patients with health exchange plans.

METHODS:

This is a retrospective study from a single provider gastroenterology community practice. All the patients who had colonoscopy for colon cancer screening between January 1st 2018 and December 31, 2018 were extracted from the database. Colorectal polyp rates based on health insurance plan (health exchange AC insurance/commercial insurance/Medicare and Tricare) were studied.

RESULTS:

A total of 746 (Male 310, Female 436) patient records who had a colonoscopy for screening were reviewed. Median age was 59 years. 54% (400/746) of them had Affordable Care Insurance. 59% (437/746) were found to have polyps. Among those with colon polyps 49% (214/437) had Affordable Care Insurance, 28% had commercial insurance and 22% had Medicare and Tricare. 54% (214/400; median age 59) of patients with health exchange plans, 73% (98/135; median age 69) of patients with medicare/tricare, 59% (120/202; median age 57) of patients with commercial insurance plans had colon polyps.

CONCLUSION:

About half of the patient cohort with colorectal polyps relied on Affordable Care Insurance to receive colorectal cancer screening. About 74% of patients with colorectal polyps were under the age of 65. As expected patients with medicare plan had high rates of colorectal polyps (73%) compared to commercial and health exchange insurance plans. If access to preventive care via ACA is not available a significant proportion of patients with colorectal polyps would have not had their screening. If they were to wait untill they are eligible for medicare to get their colonoscopy for screening a significant proportion of these patients would develop advanced adenomas or cancer. So it is important to have access to preventive health via ACA. This issue is particularly more important now with attention being brought to the ACA and the possibility of it being repealed.
2845 Harm versus Benefit Ratio in Colonoscopy Preparation With Polyethylene Glycol: An Opportunity for Improvement
Authors: Bilal Muhammad , Chang Eric Y. , Umar Anam , Stevens Elyse , Abe Temidayo , Pantangi Pramod
Published: October 2019

INTRODUCTION:

Colonoscopy is the gold standard for colon cancer screening and has shown to decrease morbidity and mortality. However, the use of colonoscopy is limited by factors such as the patient's fear of the procedure and inadequate bowel preparation. The quality of bowel preparation is directly related to the endoscopist’s ability to detect adenomas. We carried out a retrospective descriptive analysis to assess the degree of preparation, and its effect on colonoscopy outcomes in a safety-net academic center.

METHODS:

We obtained data from the electronic medical record of a large, academic, safety-net hospital. Data for patients who underwent colonoscopy between January-June 2018 were reviewed. The data points extracted included: age, race, gender, indication for the colonoscopy, type of colonoscopy (screening, diagnostic or surveillance), procedure results, degree of the bowel preparation, and recommendations for a repeat colonoscopy. All the patients received polyethylene glycol (PEG).

RESULTS:

Our patient population was predominantly African American (98%). Of the 601 total colonoscopies performed, 454 (76%) were done for screening, 84 (14%) for diagnosis, and 59 (10%) for surveillance. Per documentation by the gastroenterologist, the adequacy of the bowel preparation was excellent in 1.1% (n = 7/601), good in 57% (n = 344), fair in 27% (n = 182) and poor in 10% (n = 66). More than 50% of colonoscopies were affected due to improper bowel preparation. 137 colonoscopies (23%) were canceled secondary to poor bowel preparation and were re-scheduled. 191 patients (32%) were advised to have repeat colonoscopy earlier than recommended guidelines due to inadequate preparation. The odds of a poor preparation versus good preparation having a canceled colonoscopy was 26.04, (CI 15.6-43.5, P =< 0.00001).

CONCLUSION:

Our analysis revealed that in >50% of patients who did not have good bowel preparation, the gastroenterologist’s ability to perform optimal colon cancer screening was negatively affected. This not only increases the risk of missing small polyps which carries the risk of malignant transformation but is also associated with increased cost burden and decreased patient satisfaction. Given that all our patients used PEG for bowel prep, we wonder whether the type, and/or amount of bowel preparation agent is contributory to poor preparation. Further prospective studies are needed to assess the adequacy of bowel preparation in our patient population using other formulas that have been approved by the FDA.
2848 The Impact of Multitarget Stool DNA (Cologuard) Testing in a Real World Population
Authors: Turse Erica , Dailey Francis , Tahan Veysel , Turse John
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) remains the second leading cause of death for carcinomas. Effective screening for CRC is paramount to prevent morbidity and mortality. Several options for screening alternatives exist with the newest, as of 2014, being the recommendation for multitarget stool DNA testing. A cross-sectional study at 90 sites, including private and academic centers, throughout the US and Canada evaluated average-risk patients utilizing stool specimens and follow-up screening colonoscopy. This 2014 study found that sensitivity for stool DNA testing of detecting colorectal cancer was 92.3%, advanced precancerous lesions 42.4%, and high-grade dysplasia 69.2%.

METHODS:

We collected real-world prospective data from January 31, 2017 through May 31, 2019 of 157 patients who had positive stool DNA testing and documented their colonoscopy findings. The patients all underwent colonoscopy at the same outpatient endoscopy center which has four board certified gastroenterologists, all more than 10 years out of training. Patients were all average-risk prior to receiving stool DNA screening.

RESULTS:

The mean age of patients was 68.8 years, with 99 female patients and 66 male patients. Three patients were found to have invasive adenocarcinoma which included the cecum, sigmoid and rectum. A total of 81 patients had no pathology or hyperplastic polyps and 73 patients had polyps that were either tubular adenomas or sessile serrated adenomas.

CONCLUSION:

In our study, 48% of patients had a positive predictive value (PPV) indicating those who had stool DNA testing followed by positive initial screening colonoscopies. We compared our data to the initial 2014 clinical trial by Imperiale et al with a 41.37% PPV. Interestingly, the number needed to treat in the clinical trial found that 166 individuals would have to undergo multitarget DNA testing for any colorectal cancer to be found and 31 for advanced precancerous lesions. Our real-world study determined that it took about 52 patients (3 in 157) to identify colorectal cancer and 1 in 2.15 patients for advanced precancerous lesions. Our study highlights the continued necessity of colonoscopies as the first line therapy for screening, even among average risk populations.
2851 Assessing the Risk of Gastroesophageal Reflux Disease in Patients With Constipation
Authors: Asfari Mohammad Maysara , Sarmini Muhammad Talal , Ellison Steven B. , Vega Kenneth J.
Published: October 2019

INTRODUCTION:

Constipation is a common gastrointestinal disorder which can result in infrequent stools, difficult stool passage with pain and stiffness or both. Constipation is frequently associated with straining which also can promote GERD. Multiple comorbidities are reported in the literature secondary to chronic constipation but data on the presence of GERD in patients reporting constipation is limited. The aim of this study was to investigate if constipation increases the risk for gastroesophageal reflux disease (GERD) using a large patient database.

METHODS:

Using data from the National Inpatient Sample (NIS) database between 2004 and 2014, we identified patients who were diagnosed with constipation using appropriate ICD 9 coding. The control group were patients who did not have a diagnosis of constipation. Demographic information, tobacco use, hernia presence and GERD diagnosis was then compared between the 2 groups to determine if any association between constipation and GERD existed using univariate and multivariate logistic regression.

RESULTS:

The total population was comprised of 85,317,627 patients, of which 2,419,827 (2.8%) were diagnosed with constipation. Constipated patients were older (62 vs 48 yrs old) and more likely to be females (60.3% vs 58.2%) compared to non-constipated group (P < 0.01 for all). Constipated patients were more obese (9.1% vs 7.4%) , had more tobacco use (11.1% vs 10.1%) and had more diaphragm hernias (3% vs 1%) compared to the control group (P < 0.01 for all). Using Multivariate logistic regression, and after adjusting for age, gender, race, smoking, alcohol, diaphragmatic hernia and obesity, constipated patients had a statistically significant higher rate of GERD (Odds Ratio [OR], 1.599, 95% confidence interval [CI], 1.593 -1.605, P < 0.001) compared to the non-constipated control group.

CONCLUSION:

Constipation is associated with almost 60% increased risk of GERD. Screening for GERD and treating GERD, if present, is essential in the optimal management of constipated patients.
2852 Stenting and Suturing for Esophageal Cancer in Neo-Adjuvant Setting: A Tertiary Community Cancer Center Experience
Authors: Sharma Neil , Gopakumar Harishankar , Krishnakurup Jay , Rumancik Brad , Kota Sharwani , Zelt Christina , Gupta Saurabh
Published: October 2019

INTRODUCTION:

The place of esophageal stents for dysphagia in the neoadjuvant setting for esophageal cancer has recently been debated with recent Radiation oncology literature calling into question its use. Given the paucity of data and lack of clear guidelines, we performed a review our high volume esophageal cancer practice and analyze the outcomes in patients undergoing esophageal stent placement for malignant dysphagia in the neoadjuvant setting.

METHODS:

The data was collected retrospectively on all patients who underwent esophageal stent placement for malignant dysphagia due to esophageal cancer in a neoadjuvant setting at the Parkview Cancer Institute from September 2015 to November 2018.

RESULTS:

This case series includes 32 patients, collectively underwent placement of a total of 33 stents (fully covered self-expandable metal stents (FCSEMS)) of which 25 were anchored using esophageal suturing. The stent migration was only 6% (n = 2) compared to 30 -50% reported in literature. One key factor contributing to the low incidence of stent migrations could be the high proportion of endoscopic suturing performed. Out of the 33 stents, 25 (75%) were anchored to the esophagus by endoscopic suturing. 13 patients had successful completion of neoadjuvant therapy and subsequent esophagectomy. Seven patients decided not to undergo surgery due to stent unrelated issues. All of the patients had significant improvement in dysphagia immediately following stent placement. Only three patients developed eventual complications that resulted in need for repeat intervention with removal or replacement of stent. Overall rate of compilations for patients who received stent placement in neoadjuvant setting was 5 out of 33 (15.15%) (Table 1).

CONCLUSION:

This is a single center experience with significantly low number of stent migration, which can be attributed to the fact that all the stents were placed by a single advanced interventional endoscopy trained physician who maintains currently a high volume of esophageal stent placement of at least 15 to 20 procedures annually. This allows for increased proficiency, both in stent selection and placement. We use only fully covered metals stents and are extremely selective in stent length and diameter and almost always when possible, these stents are secured by sutures. This meticulous approach in esophageal stenting, tailoring to each individual patient has significantly contributed to the decrease in patient discomfort, migration and radiation toxicity.
2853 Esophagogastric Junction Outflow Obstruction Association With Mood Disorders: A Retrospective Study
Authors: Haberstroh William , Farah Guillaume , Alkully Turki , Benjamin Stanley , Shafa Shervin
Published: October 2019

INTRODUCTION:

Esophagogastric Junction Outflow Obstruction (EGJOO) is a manometry abnormality at the level of the lower esophageal sphincter (LES) which is associated with elevated Integrated Relaxation Pressure (IRP). This is similar to achalasia; however, EGJOO has retained peristalsis and it is largely distinguished by poor relaxation at the LES. This diagnosis is becoming increasingly prevalent as use of esophageal High-Resolution Manometry (HRM) becomes more widespread. As EGJOO’s prevalence grows, it is important to augment our knowledge. Our objective from this analysis was to find comorbid associations which may give aide in identifying at risk patients and aide with treatment modalities. Depression and anxiety were focused upon in this study.

METHODS:

We performed a retrospective study of patients who were diagnosed with EGJOO by HRM from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). Chart review was performed to assess for comorbid conditions. Statistical significance was performed with a Chi Square Test of Independence.

RESULTS:

We identified 93 patients with EGJOO and a reliable past medical history documented in their chart. Upon analysis of our patient population, it was found that previously diagnosed depression (13.98%) and anxiety (12.9%) were common comorbidities. This was significantly higher than the prevalence of depression (6.7%, P = 0.0049) and anxiety (3.1%, P = 0.0001) in the United States.

CONCLUSION:

Depression and anxiety appear to show increased prevalence within patients diagnosed with EGJOO. EGJOO is generally known to be associated with structural obstructions, but importantly also seen in functional obstruction. This relation to mood disorders could suggest a psychosomatic component within certain subgroups. Whether EGJOO is an incidental finding or a true contributor to symptoms is not entirely clear. These correlations could trigger practitioners to think further about a diagnosis of EGJOO in their patients with anxiety or depression if they are displaying symptoms of dysphagia with associated manometric findings. Current treatment for EGJOO is not clearly established and treatment response is highly variable. Further studies looking into the relation of mood disorders with functional obstruction could lead to potential novel therapies.
2854 High Resolution Esophageal Manometry Findings in Patients With Esophageal Symptoms After Head and Neck Radiation Therapy
Authors: Qureshi Talha , Shafi Mehnaz A. , Husain Nisreen S.
Published: October 2019

INTRODUCTION:

Head and neck radiation therapy is known to cause esophagitis and esophageal strictures as early and late effects after radiation exposure, respectively. The negative effects of radiation on esophageal motor function have been speculated in case reports but have not been studied in a larger population with high resolution manometry (HRM). The aim of this study was to evaluate HRM findings in patients who received head and neck or mediastinal radiation and presented with esophageal symptoms.

METHODS:

There were a total of 718 patients who received HRM from 2010 to 2018 at the Michael E. DeBakey VA Medical Center. Patients were excluded if they had undergone esophageal surgery, found to have oro-pharyngeal dysphagia, or if they had a mechanical cause on esophagogastroduodenoscopy of esophageal symptoms. Among the cohort, 14 patients met our inclusion criteria of receiving head and neck or mediastinal radiation prior to HRM. Chicago Classification v3.0 was used for HRM diagnoses.

RESULTS:

The most common symptom for which HRM was performed was esophageal dysphagia in 8 patients. Regurgitation and chest pain were each reported in 3 patients. Heartburn (n = 2), odynophagia (n = 1), and hoarseness (n = 1) were also reported symptoms. Seven of 14 patients (50.0%) were found to have abnormal findings on HRM (Table 1). Findings included hypotensive lower esophageal sphincter (LES) (n = 2), hypertensive LES (n = 1), hypotensive upper esophageal sphincter (UES) (n = 1), UES stricture (n = 1), spastic achalasia (n = 1), and ineffective esophageal motility (n = 1). There was no difference in HRM findings based on radiation dose received (Figure 1). There was an association towards increased HRM abnormalities with time since last radiation (Figure 2).

CONCLUSION:

This is one of the largest studies to show the effects of head and neck radiation on esophageal motility using HRM. Fifty percent of patients in this cohort exposed to head and neck radiation had abnormalities on HRM. We have also shown an association towards increased abnormal HRM findings with time, especially greater than five years after radiation exposure. Similar to our study, achalasia and ineffective peristalsis have been reported both early and late after head and neck radiation. Despite reports of esophageal motility complications with increasing doses of radiation, we were unable to demonstrate this. Our findings suggest that patients with esophageal symptoms after radiation exposure should be investigated for esophageal motor dysfunction.
2862 Severity of EGJOO and Correlation to Elevations in IRP
Authors: Farah Guillaume , Haberstroh William , Alkully Turki , Benjamin Stanley , Shafa Shervin
Published: October 2019

INTRODUCTION:

Esophagogastric Junction Outflow Obstruction (EGJOO) is an abnormality of the lower esophageal sphincter (LES) which is associated with an elevation of the Integrated Relaxation Pressure (IRP). EGJOO is part of a group of disorders associated with impaired relaxation of the LES, however it remains separate from Achalasia (types I-III) due to retained peristalsis. Delayed bolus transit is frequently impaired in EGJOO due to this collection of abnormalities within the esophagus. Our goal with this retrospective analysis was to determine if there existed a correlation between an elevated IRP and solid/viscous bolus transit in patients with EGJOO.

METHODS:

We performed a retrospective analysis of patients who were diagnosed with EGJOO by high resolution manometry from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). An IRP of 20 or above was the cutoff in this analysis. This analysis collected a sample size of 100 patients whose manometry studies were consistent with EGJOO.

RESULTS:

A linear regression analysis was performed on the 100 patients reviewed. There was a weakly negative correlation between bolus transit time and an elevation in IRP. However, overall, IRP increase did not have a statistically significant impact on liquid/viscous bolus transit.

CONCLUSION:

In summary, an elevated integrated residual pressure (IRP) coupled with preserved esophageal body peristalsis is required for diagnosis of EGJOO. Our data revealed no statistically significant correlation between an elevated IRP and an increase in liquid/viscous bolus transit time. As such, an increase in IRP may not indicate severity of EGJOO. Therefore, success of endoscopic intervention may not be accurately indicated by observation of IRP by HRM. More data is needed to better correlate endoscopic intervention with IRP values.
2863 Epidemiological and Clinical Characteristics of Esophageal Carcinoma: A Four-Year Experience From Largest Referral Centre of Karachi, Pakistan
Authors: Butt Nazish , Soomro Sabir , Mahesar Ghulam Basit , Abbasi Amanullah , Haider Ghulam
Published: October 2019

INTRODUCTION:

Esophageal cancer (EC) is an aggressive tumor that carries a poor prognosis. EC is the fourth commonest malignant tumor reported in Pakistan. Objective of this study was to assess epidemiological and clinical characteristics of EC, identified over a 4-year period at the largest referral centre of Karachi, Pakistan.

METHODS:

This retrospective study covered all histopathologically confirmed cases of esophageal carcinoma from endoscopic biopsy, seen within the 4-year period from January 2015 to December 2018.

RESULTS:

Over the period of 4 years, 548 patients with EC had been identified, 45 patients were excluded due to incomplete records. Their ages ranged from 15 to 92 years with a mean of 49.20 years (SD ± 14.35). Female were 286 (56.9%) and male 217 (43.1%). Dysphagia and weight loss were the most common symptoms. Most of the patients were belong to the province of Sindh 420 (83.5%). Beetle nuts, pan and gutka were the most predominant risk factors in 378(75.1%) of patients. The most common cancer subtype was squamous cell carcinoma (SCC), which included 417(83%) patients. Adenocarcinoma (AC) was diagnosed in 86 (17%) of patients. EC predominantly involved mid to distal esophagus (64%).

CONCLUSION:

Esophageal carcinoma is one of the most prevalent cancers in Pakistan, and its incidence is increasing day by day. The reason for raised incidence was associated with increased consumption of beetle nuts and gutka in certain parts of the country. It is hoped that this study will be an important step towards developing a comprehensive laws against consumption of gutka and beetle nuts.
2864 Utility of HRM for Improving Diagnosis and Detection of Esophageal Disorders in a Community Clinic
Authors: Tran Victoria , Litynski James , Tadros Micheal
Published: October 2019

INTRODUCTION:

High resolution manometry (HRM) has improved the ability to diagnosis esophageal motility disorders. HRM has the potential to provide diagnostic clarity to patients who suffer from dysphagia, gastroesophageal reflux disease, unexplained chest pain, and other non-specific symptoms. The purpose of this study is to explore the diagnostic yield of HRM in classifying esophageal dysmotility, specifically in a community clinic setting rather than the tertiary care center. High diagnostic accuracy better serves patients. Ultimately, community-based HRM prevents overload at large hospitals and improves access to care for patients.

METHODS:

We reviewed motility studies performed for the past 18 months at a satellite office built to serve the community. We reviewed the indications and diagnostic yield of HRM.

RESULTS:

From the cohort of 90 patients, the most common indication was esophageal dysphagia (45.5%). Refractory heartburn made up 32.3% of indications; unexplained chest pain made up 12.2%. Preoperative and postoperative assessments made up 7.7% and 2.2%, respectively. 3 patients were unable to finish the study. 87 were able to complete it. Diagnosis was based on the Chicago Classification version 3.0. Of those who completed the study, 44.8% were classified as normal; 29.8% of cases were EGJ outflow obstruction; 6.8% of cases classified as achalasia; distal spasm was not found in any patients; 3.4% of patients classified as hypercontractile esophagus; 4.6% of cases had absent contractility; 8% had ineffective motility; 1.1% had fragmented peristalsis; post-Nissen assessment was done for 1 patient.

CONCLUSION:

In our study population, HRM had a high diagnostic yield with its ability to identify esophageal dysmotility by narrowing down the pathogenesis of symptoms like dysphagia, heartburn, and chest pain.. For most patients in this cohort, HRM was well-tolerated. With careful patient selection, HRM has a high diagnostic yield. Because of the clinic location, we were able to assist patients in the rural community and minimize delay in care delivery. Furthermore, community-based HRM has the potential to reduce patient load at larger hospitals. By providing this resource in the community, providers in small-scale clinics improve patient access to care. Gyawali CP, Roman S, Bredenoord AJ, et al. Classification of esophageal motor findings in gastroesophageal reflux disease: Conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29:e13104.
2869 Retrospective Study of Patients With Esophageal Squamous Cell Carcinoma in an Urban Safety Net County Hospital
Authors: Ayyala Divya , Park Caron , Ma Yanling , Idos Gregory , Shaker Anisa
Published: October 2019

INTRODUCTION:

Esophageal squamous cell carcinoma (ESCC) accounts for 90% of esophageal cancers worldwide but is less common in the developed world. Our aim was to report patient and tumor characteristics of individuals diagnosed with ESCC within the underserved Los Angeles County population.

METHODS:

Review of the hospital pathology database identified 65 cases of patients ages 18-80 with a pathologic diagnosis of ESCC from 2003-2015. A retrospective chart review of electronic health records was conducted excluding patients of unknown ethnicity leaving 61 patients. Patients were characterized by gender, age, alcohol and tobacco use, and family history. Endoscopy and pathology reports were reviewed to confirm tumor location, length, and pathological staging. Frequency counts and percentages were reported for categorical characteristics. A chi-square test or Fisher’s Exact test was performed to assess if characteristic variables differed by ethnicity.

RESULTS:

Patients identified with ESCC in our cohort were predominantly Hispanic (59%, n = 36) and 41% were non-Hispanic (n = 10 Asian, n = 10 African Americans, and n = 5 Caucasian). ESCC was more commonly diagnosed in males vs. females in Hispanics and non-Hispanics (83.3% and 80% vs 16.7% and 20%, P = 0.75). Age of diagnosis was between the ages of 18-60 years in nearly 56% and greater than 60 years in 44% of Hispanics and non-Hispanics (P = 0.97). Most Hispanics and non-Hispanics had exposure to alcohol (74.1% and 85%, P = 0.48) or tobacco (53.9% and 68.2%, P = .31). Most Hispanic and non-Hispanics did not have a family history of cancer (72% and 80%, P = 0.73). Tumor location was most often proximal in Hispanic and non-Hispanics (66.7% and 83.3%, P = 0.16) and of similar length (P = 0.29). Most tumors in both Hispanic and non-Hispanic patients were moderately/poorly differentiated (82.9% and 91.3%, P = 0.46). Hispanics were less likely to present with metastatic ESCC as compared to non-Hispanic patients (42.3% vs. 75%, P = 0.03).

CONCLUSION:

ESCC in both groups within the Los Angeles County population were diagnosed most often in the proximal esophagus of males with history of exposure to alcohol and/or tobacco. Despite similar patient and tumor characteristics, ESCC in Hispanics was less often metastatic at the time of diagnosis compared to non-Hispanics. Despite the small numbers, our study is one of the few to include a large cohort of Hispanics and support further investigation of factors in different ethnicities that may be protective against advanced disease.