bluuebunny/crossref_metadata_2025 huggingface dataset:
2901 Variation in Standard IBD Financial Charges Across Major U.S. Medical Systems
Authors: Beard Jonathan , Click Benjamin
Published: October 2019

INTRODUCTION:

Inflammatory bowel diseases (IBD) are costly chronic illnesses with routine services both inpatient and outpatient, preventative care, and costly biologic pharmaceuticals. Recent mandates require US hospitals to publish healthcare system financial charges. As many as 10-15% of IBD patients are uninsured and as such, are accountable for the entirety of their healthcare charges. We aimed to assess the variability in healthcare charges for standard tests and procedures routinely utilized in IBD care.

METHODS:

Financial charges from 25 geographically diverse healthcare systems were obtained and queried. Serum studies included metabolic, nutritional, inflammation, and infectious screening studies Stool studies included infectious testings and fecal calprotectin. Imaging studies included CT and MRI abdomen; endoscopy included EGD and colonoscopy with biopsy. Lab studies were divided into Basic (e.g., CBC, CMP, CRP) and Extended categories (e.g., EBV serology) to express differing views on the routine testing extent. Diagnosis-related groups for commonly billed encounters for IBD patients (DRG 329-331) were also examined.

RESULTS:

Most centers reported data on all serum, stool, and imaging studies queried; however, reporting on colonoscopy with biopsy (n = 14/25) and DRG charges (range 8-14) was inconsistent. There was significant variability in the charges for routine laboratory, imaging, and endoscopic evaluation across the healthcare systems (Figure 1). The median sum charge for Basic labs was $2,105 (IQR $1,576-3,522), Extended labs $4,596 (IQR $3,877-7,341), and rose to $9,671 (IQR $7677-12,051) and $13,085 (IQR $10,481-15,511) with the addition of CT plus colonoscopy, respectively. DRGs for inflammatory bowel disease demonstrated less variability (Figure 2). Median charge for IBD without complication or comorbidity was $64,268 (IQR $52,296-76,377), with complication/comorbidity $96,588 (IQR $71,962-109,674, and rose to $181,675 (IQR $133,962-235,744) with a major complication or comorbidity. The most inexpensive healthcare system averaged charges 65% below than the median, and the most costly averaged 232% higher.

CONCLUSION:

There is significant variability across healthcare systems in financial charges for commonly ordered tests and procedures in IBD patients that can reach staggering sums. Uniformity and transparency in healthcare pricing structures is desperately needed to ease the financial burden, particularly for uninsured populations.
2906 Significantly Increased Mucosal Eosinophils in Patients With Post-IBD IBS-D May Have a New Avenue
Authors: Tozlu Mukaddes , Beketaev Ilimbek , Younes Mamoun , Dar Wasim A. , Ju Changqing , Ertan Atilla
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) patients in remission who present with irritable bowel syndrome with diarrhea (IBS-D) like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD-IBS-D. This syndrome was first reported by Isgar et al. who documented IBS-type symptoms in 33% of their patients with chronic ulcerative colitis (CUC) in remission in 1983. In their meta-analysis of 13 studies incorporating 1703 patients, Halpin and Ford in 2012 calculated a pooled prevalence for IBS symptoms among IBD subjects in remission of 35%. The post-IBD IBS-D represents a source of considerable stress, incurs morbidity and impairs quality of life of these patients. The etiology of this syndrome is unknown and may be multifactorial such as environmental, psychological and genetic components and possibly by gut microbiome.

METHODS:

We conducted a retrospective, single-center electronic medical record review of patients with history of IBD and IBS-D like symptoms. The demographic characteristics, type of IBD, colonoscopy and biopsy findings with GI-hypoallergenic diet and budesonide treatment were analyzed.

RESULTS:

We have found significantly increased mucosal eosinophils (>30-50 HPF in both side of the colon examined) in our patients with post- IBD IBS-D syndrome. In this study, 15 patients with CUC and 20 Crohn's disease (CD) patients with this syndrome were investigated and showed no clinical, serological, mucosal or microscopic IBD activity. These patients had non-bloody diarrhea (3-20x daily), lower abdominal cramps (90%), mild weight loss (4-6 lbs), and fecal incontinence (25%) who were placed on the GI-hypoallergenic diet and budesonide therapy. Sixty-seven percent of these 35 patients with post- IBD IBS-D responded well clinically to this management. Increased mucosal eosinophils in these patients may have eosinophilic colopathy that may be related to intestinal permeability disarray. The epithelium in these IBD patients who are in remission may have the production of pro-inflammatory cytokines by the eosinophils, especially IL-23 and IL-33.

CONCLUSION:

In summary, this is an exciting new findings that significantly increased mucosal eosinophils in our patients with post-IBD IBS-D may have a new avenue, eosinophilic colopathy. Interestingly, these patients have responded to the GI-hypoallergenic diet and budesonide therapy. Obviously, we need more patients in the near future with a longer follow-up and we hope that the other investigators may confirm our findings.
2911 Older Onset Inflammatory Bowel Disease: Are Patients Well Informed?
Authors: Crooks Benjamin J. , McLaughlin John , Limdi Jimmy K.
Published: October 2019

INTRODUCTION:

In an aging population, 25-35% of those with inflammatory bowel disease (IBD) are over 60 years old. A third of these are diagnosed with IBD at or over the age of 60 (“older-onset” IBD). Patient-education is an important outcome modifier in chronic disease, yet, virtually no studies exist exploring disease related knowledge in older-onset IBD. We report a British experience aimed at understanding patient knowledge of disease using the validated Crohn's and Colitis Knowledge (CCKNOW) questionnaire in patients with older-onset IBD.
1

METHODS:

A prospective, questionnaire-based study is being conducted in the UK. Two-hundred patients with older-onset IBD will complete the 24-item CCKNOW questionnaire along with a questionnaire regarding patient demographics and disease specifics. We present an interim analysis of the first 29 patient responses.

RESULTS:

The mean age of respondents was 73.5 years (55% male, 93% Caucasian). 69% had ulcerative colitis and 31% had Crohn's disease. Mean disease duration was 6.2 years. The highest educational qualification recorded was as high-school (3%), post-secondary (3%), university degree (10%) and other professional qualification/diploma (28%), none (17%) and unspecified (39%). The mean total CCKNOW score was 5.7 with a median of 5 (range 0-21). Areas with the poorest scores were those relating to “pregnancy and fertility” (10% correct responses), “IBD related complications” (17%) and “Anatomy and physiology” (18%). Subgroups with the most correct responses were “IBD related symptoms” (55%) and “IBD diagnosis” (34%). There was no difference in CCKNOW scores between CD and UC (P = 0.71) and duration of disease has no relationship with total score (P = 0.67).

CONCLUSION:

Discussion Our initial data suggest that the IBD specific knowledge of patients with “older-onset” IBD is poor but comparable to other patient cohorts.
2
Given the impact patient knowledge has been shown to have on chronic disease outcomes, it is imperative that we can match patients' information needs to healthcare delivery and IBD information resources. A larger dataset will be presented at conference proceedings.
2913 Health-Related Quality of Life in Patients With Inflammatory Bowel Disease at the University Hospital of the West Indies
Authors: Smith Natalie M. , Dawkins Yvonne M. , Lee Michael G. , Arthurs Milton , Ferguson Trevor
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) is a chronic condition that can significantly affect health-related quality of life (HRQoL). The aim of this study is to determine the HRQoL of patients with IBD seen at the Gastroenterology clinic at the University Hospital of the West Indies (UHWI).

METHODS:

A cross sectional study was conducted, which included seventy patients with IBD (CD 25, UC 44 and one patient with Indeterminate colitis). Data analyses were restricted to 69 patients who had CD or UC. All the patients completed the validated Inflammatory Bowel Disease Questionnaire (IBDQ) and a questionnaire with demographic data. Disease activity was measured using Crohn's Disease Activity Index (CDAI) for CD and Truelove and Witts severity index for UC. Data analysis was conducted using Stata 14 statistical software.

RESULTS:

Mean age was 44.3 ± 16.2 years, 56.5% females, mean disease duration 12.0 ± 11.0 years and mean age at diagnosis of IBD was 31.5 ± 13.4 years. Patients with CD had more frequent hospital admissions (3.9 ± 3.7 vs 0.9 ± 1.8; P value 0.001) and surgeries (0.75 ± 0.8 vs 0.1 ± 0.4; P value 0.001) compared to those with UC. The mean total IBDQ score was 179.6 ± 34.4 (CD was 175.0 ± 37.1 and 182.1 ± 33.0 for patients with UC). Patients with higher IBDQ scores were more likely to be male gender (OR 1.93, 95% CI 0.69–5.39, P value 0.207), married (OR 2.25, 95% CI 0.60-7.31, P value 0.177), educated to secondary school level (OR 2.05, 95% CI 0.46-9.06, P value 0.343), employed in the private sector (OR 3.00, 95% CI 0.83-10.90, P value 0.095) and on no medications (OR 3.24, 95% CI 0.27–0.80, P value 0.006). Higher IBDQ score was associated with fewer hospital admissions (OR 0.90, 95% CI 0.73-1.10, P value 0.287). The best score was seen in the systemic domain. The lowest score was seen in emotional domain for both diseases. Overall male patients had a better score for all domains.

CONCLUSION:

The HRQoL for patients with IBD at the UHWI was comparable to those in other studies. Patients with UC and male gender appeared to have better quality of life, but comparisons were limited by small sample size.
2914 Difference in Presentation and Treatment Response of Inflammatory Bowel Disease in the Asian Population
Authors: Shinn Brianna , Asif Bilal , Cao Christopher , Nahar Ritu , Dhanekula Raja Koteswar , Kistler Charles , Ahmed Monjur
Published: October 2019

INTRODUCTION:

The prevalence of Inflammatory Bowel Disease (IBD) has historically been lower in Asian populations compared to the Western World, although the incidence of this disease has rapidly increased in Asian nations over the past two decades. This is thought to be secondary to environmental factors – including westernization of society, increased industrialization and urbanization - although past research shows that the genetics of this disease also differ between patient populations. Such differences may impact how Asian patients with IBD clinically present, optimal diagnosis, and management. We aimed to assess ethnic differences in the treatment response of IBD amongst the Asian population within the Jefferson Hospital Network by evaluating laboratory values, endoscopic response and clinical response.

METHODS:

This was a single center retrospective chart review of patients of Asian descent diagnosed with IBD using applicable ICD-10 codes. Patient's charts were queried for demographic data, laboratory studies, CT abdomen/pelvis reports, colonoscopy reports and subsequent histopathology biopsy data.

RESULTS:

We identified 18 patients (53% female, 32% inpatient) of Asian descent who had ICD 9/10 codes for inflammatory bowel disease (ICD-10: K51.90 or ICD-9: 560.89) between 2015 and 2017 in the Jefferson Hospital network; the average age of diagnosis was 36.2 years. 83% (n = 15) of these Asian patients were ultimately diagnosed with ulcerative colitis through colonoscopy and subsequent histopathologic analysis, the remaining had Crohn's Disease (16%, n = 3). 37% (n = 7) of our population were initiated on biologic agents, including Remicade, Humira, or Infliximab; 57% (n = 4) of these patients had a “good” response, defined as no recurrence of activity and no further change in therapy. Of the original 18, 61% (n = 11) were initiated on 5-aminosalicylic acid (5-ASA) agents, and 36% (n = 4) of these had a “good” response, defined as above. Only 2 (11%) patients in our cohort had need for surgery eventually.

CONCLUSION:

Majority of the Asian patients with IBD had ulcerative colitis. The management of IBD in Asian Americans was distinct from management of non-Asian groups. Majority of patients were started on 5-ASA. Response to 5-ASA and biologic agents was significant. Further studies are warranted to evaluate appropriate management for this specific population, particularly to evaluate response to different biologic therapies.
2919 Meta-Analysis: Retreatment of Inflammatory Bowel Disease Patients Who Previously Achieved Deep Remission With Anti-TNFa and Subsequently Stopped Therapy Electively
Authors: Alipour Omeed , Gulati Alakh , Shao Ling , Zhang Bing
Published: October 2019

INTRODUCTION:

Deep remission (DR) is an emerging therapeutic target in inflammatory bowel disease (IBD). Although there is no consensus definition, many consider DR as clinical remission with mucosal healing with or without additional criteria. Anti-TNFα demonstrate increased success in achieving DR, which lead to longer periods of remission and improved outcomes. However, 30-50% patients in DR relapse within one and two years after anti-TNFα withdrawal. Furthermore, despite the availability of biosimilars, the decision to withdrawal anti-TNFα agents is greatly influenced by cost and limited access in certain countries. This meta-analysis assesses the response to retreatment with anti-TNFα in patients who previously achieved DR with anti-TNFα but subsequently stopped therapy and relapsed.

METHODS:

Search terms (“inflammatory bowel diseases” OR “IBD” OR “crohn*” OR “ulcerative colitis” OR “UC” OR “colitis”) AND (“mucosal healing” OR “deep remission” OR “complete remission” OR “full remission” OR “endoscopic remission”) produced 7,514 articles from Pubmed and EMBASE on Oct 1, 2018. Inclusion criteria were adult IBD patients in DR after treatment with anti-TNFα, defined as clinical remission and mucosal healing, who were followed until clinical or endoscopic relapse and subsequently restarted on anti-TNFα. Exclusion criteria were studies including children, patients on steroid maintenance, and non-English publications. Two authors independently reviewed publications for inclusion; a third author served as tie-breaker. Statistics was performed using OpenMetaAnalyst.

RESULTS:

Five publications with 73 cases were included. Retreatment with anti-TNFa successfully induced clinical remission in 94.4% (68/73; I2 = 0, P = 0.685) of all patients. No significant difference existed among ulcerative colitis (19/21) and Crohn's disease (49/52) patients. However, eight patients required either dose escalation of their prior anti-TNFα therapy, or were switched to another anti-TNFα agent.

CONCLUSION:

Literature reports deep remission to be more durable with improved outcome compared to clinical remission. Incorporation of anti-TNFα agents into treatment logarithm increase the likelihood of achieving DR. However, patients' preferences, medication cost, and healthcare policies may lead to treatment termination. This meta-analysis demonstrates that cessation of anti-TNFα is a viable option for patients with DR, as retreatment leads to clinical remission in an overwhelming majority of these patients.
2922 Epidemiology of Indeterminate Colitis in the United States Between 2014 and 2019: A Population-Based National Study
Authors: Mansoor Emad , Jin-Dominguez Fangyuan , Cheema Tayyab , Saleh Mohannad Abou , Regueiro Miguel , Katz Jeffry , Cooper Gregory S.
Published: October 2019

INTRODUCTION:

It is estimated that Indeterminate Colitis (IC) accounts for 5-15% of new diagnosis of Inflammatory Bowel Disease (IBD). However, the epidemiology of IC in the United States (US) has not been studied extensively and is subject to debate. We sought to describe the epidemiology of IC in the US between 2014 and 201 9 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 1999 to 2019. We identified an aggregated patient cohort of eligible patients with “Indeterminate colitis” between June 2014 and 2019, based on Systemized Nomenclature Of Medicine – Clinical Terms. We calculated the prevalence of IC overall and among different patient groups and compared prevalence of IC with Crohn's disease (CD) and Ulcerative Colitis (UC).

RESULTS:

Of the 36,733,720 individuals active in the database from June 2014-2019, we identified 8,070 individuals with a diagnosis of IC with an overall prevalence rate of 22/100,000. Compared to IC, there were 165,930 individuals with CD and 139,810 individuals with UC with overall prevalence rates of 451/100,000 and 381/100,000 respectively (Figure 1). The prevalence of IC was increased in females at 27/100,000 [OR: 1.74, 95% CI: 1.66-1.83, P < 0.0001] compared to males at 16/100,000; elderly (aged >65 years) at 42/100,000 [OR: 2.61, 95% CI: 2.49-2.72, P < 0.0001] compared to non-elderly (aged <65 years) at 16/100,000 and Caucasians at 29/100,000 [OR: 3.22, 95% CI: 2.90-3.58, P < 0.0001] compared to African-Americans at 9/100,000 (Figure 2).

CONCLUSION:

This is one of the first large studies to date that has described the epidemiology of IC in the US. We found that the estimated prevalence of IC is low at 22/100,000. IC is more likely to be diagnosed in elderly, females and Caucasians.
2923 A Prospective Longitudinal Study of Proton Pump Inhibitors Effect on Inflammatory Bowel Disease Flares and Activity
Authors: Xu Anthony , Mallepally Niharika , Shapiro Jordan , Hou Jason
Published: October 2019

INTRODUCTION:

Proton pump inhibitors (PPIs) are one of the most commonly prescribed medications in the United States. Some recent studies have suggested that PPIs may have a negative effect on the gut microbiome. Dysbiosis of the gut microbiome has been linked with inflammatory bowel disease (IBD). We hypothesized that PPI use is associated with increased IBD flares and activity. This study was aimed to assess the effect of PPIs on IBD flares and activity.

METHODS:

We conducted a prospective longitudinal study of Veterans from the IBD clinic at the Michael E. DeBakey VA Medical Center from 2014 to 2018. Our eligibility criteria included patients who were at least 18 years of age, who were diagnosed with Crohn's Disease (CD) or Ulcerative Colitis (UC), and who had at least 1 clinic visit. IBD flare was defined by patient self-report of IBD flare between clinical encounters. IBD activity was quantified using the partial Mayo Score (pMayo) for UC, and the Harvey Bradshaw Index (HBI) for CD. Remission was defined by pMayo <2 for UC and HBI <5 for CD. Exposure of PPI was confirmed by chart review. Associations of PPI use with IBD flare and activity were assessed using T-tests and Chi-squared tests.

RESULTS:

A total of 132 patients were included in the analysis of which 74 had CD and 58 had UC. 40 patients were PPI users, and IBD flares occurred in 60 patients. No significant association between PPI usage and IBD flares were observed: 42.5% of PPI users developed flares compared to 46.7% of non-PPI users who developed flares, P-value = 0.658. In patients with CD, PPI use was associated with non-remission status (RR 2.53; 95% CI 1.04-6.15). In UC patients, PPI use was not associated with non- remission status (RR 1.10; 95% CI 0.67-1.79). 13 CD patients on PPIs discontinued the PPI between encounters, which was associated with a statistically significant decrease in HBI (3.62- >2.54, P-value = 0.005). Among UC patients who discontinued PPIs, there was a non-significant trend towards decreased pMayo (2.26- >1.59, P-value = 0.069).

CONCLUSION:

Amongst CD patients, PPI use was not associated with interval flare however, it was associated with non-remission status. Cessation of PPIs was associated with a statistically significant decrease in HBI in CD patients. In UC patients, no significant association between PPI use and flare or activity were observed. Decreasing unnecessary PPI use in patients with CD may decrease disease severity.
2924 Risk of Malignancy Due to Radiation Exposure in Patients With IBD
Authors: Zafar Yousaf , Zamir Harris , Jakhar Ishaan , Elkafrawy Ahmed A. , Asif Samia , Sahil Suman , Cheng An-Lin
Published: October 2019

INTRODUCTION:

Diagnostic imaging is routinely used in the management of IBD and in most cases, comes at the cost of repeated radiation exposure to the patient. We aim to show correlation between increased rates of cancer in patients with IBD and increased levels of radiation exposure. It is our purpose to demonstrate that efforts should be made to assessment and monitor total radiation exposure in patients with IBD.

METHODS:

We used a case-control design to compare patients with cancer diagnosis cases vs No cancer diagnosis controls. Cases were a composite of 74-cancer diagnosis. Cases were obtained from Cerner Healthfacts database, including 67 hospitals, using ICD9/10 codes for cancer after radiation exposure due to CT scans identified by CPT codes (74175, 74174, 74150, 74176, 74160, 74178, 74177, and 74170) in IBD patients, while controls were randomly selected from the remaining IBD patients with CT scans. Using sociodemographic and other medical diagnoses within the database, we screened candidate variables for a multivariable regression analysis for being a case and included all variables in the regression with P < 0.10 on univariate analysis.

RESULTS:

Between 01/01/2010 and 12/31/2016, we identified 132 patients with cancer out of 2,768 IBD patients who had radiation exposure (4.8%). Table 1 shows indication for the cancer. Combined with 2,636 controls, our study population had an average age of 48.0 (IQR: 34-62), 86.3% were white, and 59.3% were female. The two variables with P < 0.10 on univariable comparisons were included in the final model. After adjusting for confounders, older patients, and those on higher radiation doses had increased odds for developing cancer (Table 2). Steroid use and Immunomodulatory therapy, while significant on univariable analysis, were no longer significant risk factors after adjusting for confounders.

CONCLUSION:

Diagnostic imaging is a vital tool used to determine disease severity, extent, and response to treatment in IBD. As the disease tends to relapse and remit, repeat diagnostic imaging is a continuous part of disease management resulting in cumulative exposure to ionizing radiation over the lifetime of a patient. Patients with IBD have an increased risk of developing colorectal and small intestinal cancers than the general population irrespective of their exposure to radiation. Our data shows that additionally, the increased burden of radiation exposure increases the rates of cancer in these patients.
2926 The Reiationship of Bone Marrow Suppression and Remission by Immunomodulators in the Patients With Crohn's Disease
Authors: Cho Byungha , Kim Hyoung Woo , Kim Ki Bae , Han Joung-Ho , Chae Hee Bok , Park Seon Mee , Youn Sei Jin , Yoon Soon Man , Choi Jongwook , Kwon Hyeonwoo , Kim Seongmin , Lee Jun Su
Published: October 2019

INTRODUCTION:

Immunomodulator including azathioprine and 6-mercaptopurine has been widely used in the patients with Crohn's disease. Most common adverse event of immunomodulator has been known as bone marrow suppression such as leukopenia. We aim to evaluate the relationship of bone marrow suppression and the remission by immunomodulator in the patients with Crohn's disease.

METHODS:

We investigated 160 patients with Crohn's disease undertaken immunomodulator and analyzed the relationship of bone marrow suppression and the maintenance of remission and relapse rate by immunomodulator.

RESULTS:

Among the 160 patients (male:female, 122:38, age of 33 ± 12 years (range, 17-69)), 37 patients (23.1%) developed bone marrow suppression. Initial dose of azathioprine was 43 ± 18 mg (25-150 mg, 0.8 ± 0.3 mg/kg) and 81 ± 33 mg (25-175 mg, 1.3 ± 0.6 mg/kg) during maintenance. Only 2 patients were taken 6-mercaptopurine because of nausea with azathioprine. 5-aminosalicylic acid was most frequently co-administered drug with immunomodulator in patients who developed bone marrow suppression. The maintenance of remission and relapse rate showed no significant difference depending on bone marrow suppression during immunomodulator.

CONCLUSION:

The rate of bone marrow suppression by immunomodulator was relatively high. However, bone marrow suppression did not seem to be related to the maintenance of remission and relapse rate by immunomodulator in the patients with Crohn's disease.
2929 Correlation of Body Mass Index (BMI) and C-Reactive Protein (CRP) With Inflammatory Bowel Disease Progression in an Urban, Afro-Caribbean Population
Authors: Gupta Nikita , DeRoche Ketisha , Arroyo-Mercado Fray , Likhtshteyn Michelle , Chokshi Tanuj , Veluvolu Rajesh , Grossman Evan
Published: October 2019

INTRODUCTION:

Inflammatory Bowel Disease (IBD) is associated with changes in body composition of patients. Recent studies have shown that the prevalence of obesity is rising in patients with IBD, where 15-40% of adults are obese and 20-40% are considered overweight. One prospective study analyzed body composition in IBD patients overtime and noted that despite an overall increase in adiposity, the total muscle mass was decreased. Low lean muscle mass has an association with poor response to therapy, surgical outcomes and the quality of life in IBD patients. Low C-reactive protein (CRP) levels after initiation of anti-TNF therapy have been associated with mucosal healing on surveillance colonoscopies and clinical disease remission. The aim of this study is to analyze the association between BMI and CRP with progression of IBD, using anti- TNF use as a surrogate marker for disease severity.

METHODS:

Medical records at Kings County Medical Center in Brooklyn, New York were queried for patients with the ICD 9 and 10 code diagnoses for Crohn's disease (CD) and Ulcerative Colitis (UC) from 2015 to 2018. Biographical, laboratory and endoscopic data, including BMI and CRP, was collected and analyzed.

RESULTS:

148 patients with IBD were analyzed from 2015-2018; where 57.2% had UC and 42.8% had CD. Mean age of patients was 47.4 years, and 53.4% of patients were females. The average BMI prior to initiation of therapy was 27.6 kg/m2. The average years diagnosed with IBD was 11.1 years. Of the total patients, 37 were on biologic therapy. In the BMI group, the odds ratio was 0.905 indicating that patients with a lower BMI had more severe disease. The P value was 0.068, not significant but trended towards significance. In the CRP group, the odds Ratio was 1.020, which signified that patients with higher CRP values had more severe disease, with a P value of 0.046.

CONCLUSION:

The results of our small retrospective study suggest that a lower BMI and higher CRP are independent predictors of severe disease. Our study demonstrated that severe IBD, as measured by anti-TNF use, is associated with high CRP levels. We believe that low BMI and high CRP measurements may be used in conjunction with endoscopic findings and clinical presentation to escalate therapy early preventing worsening of disease. Further studies can be done to also incorporate endoscopic scoring system on surveillance colonoscopies to confirm the correlation between lower BMI and higher CRP with severity of disease.
2932 Histological Diagnosis of Pancreatic Serous Cystadenomas Using a 22G Core Biopsy Needle: A Case Series
Authors: Schwartz Michael , Esteban Marcus Juan , Jakate Shriram , Singh Ajaypal
Published: October 2019

INTRODUCTION:

Pancreatic Serous Cystadenoma or Pancreatic Cystic Serous Neoplasm (SCN) are a type of benign pancreatic tumor that account for 1-2% of all pancreatic masses. They are most often benign, with very rare malignant potential. SCN's will often have a cystic or honeycomb appearance on CT scan. In the past, the mainstay of diagnosing SCN has been via endoscopy ultrasound (EUS) with fine needle aspiration (FNA) to assess fluid for CEA levels and also for cytological analysis. However fluid can be difficult to obtain and often there is not enough cellularity for cytology. In this case series of 7 patients we performed fine needle biopsy (FNB) of the cell walls of pancreatic cysts as a technique for histological review.

METHODS:

We retrospectively reviewed medical records of patients who underwent EUS for FNA for fluid sampling of pancreatic cysts but due to microcystic nature a decision was made to proceed with FNB to obtain tissue for histology. FNB was done using 22 G FNB needle with slow stylet pull technique. The tissue was placed in formalin for histological analysis by an expert GI pathologist.

RESULTS:

A total of seven patients were evaluated. The mean age was 75 years old and 5 of the patients were female. All patients had one cyst that was sampled. The location of the cyst was on the head in 1 of the patients and body or tail of the other 6 patients. The mean cyst size was 31.1 mm (range 14-40 mm). There were no post procedure complications. All seven samples were adequate for histological analysis. Six out of the seven biopsy samples were consistent with serous cystadenomas. One samples showed benign pancreatic acinar tissue and stroma without malignancy.

CONCLUSION:

Management of pancreatic SCNs can be challenging as no follow up is recommended if the diagnosis is confirmed but lots of times a definite diagnosis cannot be made based on endosonographic and CT/MRI findings. These patients can be potentially subject to repeat imaging for surveillance. Here we show that pursuing FNB instead of FNA for microcystic lesions can yield enough tissue for histological diagnosis of SCNs and can alter management and avoid further imaging.
2948 Does Thrombocytopenia in Cirrhotic Patients Improve After Transjugular Intrahepatic Portosystemic Shunt?
Authors: Benrajab Karim , Ali Saad Emhmed , Frandah Wesam , Ismail Bahaaeldeen
Published: October 2019

INTRODUCTION:

Thrombocytopenia (TP) is commonly encountered in cirrhotic patients, likely secondary to splenic congestion from portal hypertension. The few available studies showed inconsistent effect of Transjugular Intrahepatic Portosystemic Shunt (TIPS) on thrombocytopenia and were limited mostly by short term (≤3 months) follow up after TIPS which can underestimate the effect. Moreover, the majority of studies did not examine the predictors of improved thrombocytopenia, so it is not clear which patients would benefit from the procedure. In this study, we assess the effect of TIPS on TP up to 6 months after TIPS.

METHODS:

We conducted a retrospective study including adults with cirrhosis who underwent TIPS at Tertiary referral center between January 2016 and June 2018. Only patients with average platelet count <150 k/ul in the 3 months before TIPS were included. Charts were manually reviewed to collect baseline and outcome variables. The shunt patency was ensured using Doppler ultrasound in 3-6 months after TIPS. Primary outcome was the percentage of patients with improved TP after TIPS. This was defined based on the difference between average count in the 3 months before TIPS and the average count in the 3-6 months after. Secondary outcome was to determine the predictors of improved TP on a multivariate logistic regression model.

RESULTS:

Forty-one patients were included. Table 1 shows the demographic and clinical characteristics of the patients. 22 patients (54%) had an improved TP after TIPS (median absolute rise 15.04 [0.25, 133.67], median percent increase 14.59% [0.40, 122.26] (Figure 1). The majority of patients (13/22) had mild improvement by <20 k/ul. The improved TP group had more variceal bleed as an indication for TIPS, lower pre-TIPS average platelet count, and a lower pre-TIPS portosystemic pressure gradient (PSPG). The predictors of improved TP were TIPS for variceal bleeding rather than refractory ascites; OR 31 [2.3-432], lower mean platelets count before TIPS, OR 0.96 [0.93-0.99] and lower change in PSPG; OR 0.55 [0.32-0.95].

CONCLUSION:

Our result is in agreement with previous studies that showed improvement in TP in a subset of patients following TIPS. However, the improvement was modest in most patients. Predictors of improvement in our cohort were lower pre-TIPS average platelet count, lower pre-TIPS PSPG, and variceal bleeding as an indication for TIPS placement. More studies are demanded to validate the role of TIPS in the management of TP.
2960 National Variation in Approach to HCV in Patients Listed for Liver Transplant
Authors: Durney Philip A. , Dhanekula Raja Koteswar , Shah Ashesh , Fenkel Jonathan
Published: October 2019

INTRODUCTION:

Due to recent progress in the treatment of hepatitis C virus (HCV), many providers specializing in transplant medicine face the difficult clinical decision of whether to treat HCV in patients before or after liver transplantation (LT). Eradicating HCV in the pre-LT population has a powerful impact on both the LT waitlist and on the types of donors offered to recipients. Concurrently, increasing availability of organs from high-risk donors is occurring, largely due to the US overdose epidemic. We sought to better understand how some of these clinical and social dynamics impact decisions at US transplant centers.

METHODS:

We surveyed all medical and surgical transplant directors from adult US. LT centers via an online survey in 2017. The survey queried directors about their program's specific approach to waitlisted patients with HCV pre-LT. The survey posed broad questions about patient demographics as well as more specific questions relating to the frequency with which Public Health Service-increased risk (PHS-IR) and HCV+ donors are offered, the degree to which PHS-IR and HCV+ offers are declined due to a lack of waitlisted patients with HCV, and the existence of any cutoffs for transplantation.

RESULTS:

28 respondents (17% response rate), representing programs in 10/11 UNOS regions, answered the survey. Respondents were primarily from university-affiliated LT programs (92.3%) and represented variably-sized programs (LT volume ≤50 in 46.4%, 51-100 in 35.7%, >100 in 17.9%). 93% of programs reported seeing >10% are PHS-IR offers, and 19% of programs reported >30% PHS-IR offers. 39.3% of programs reported >10% offers are from HCV+ donors. 50% of programs reported turning down offers for HCV+ organs due to lack of available HCV+ recipients on the waitlist. A minority of programs (14.3%) continue to use donor age cutoffs for HCV+ recipients and many programs do not attempt to treat chronic HCV in non-HCC patients with CPT-B (42.3%) and CPT-C (77.8%) cirrhosis.

CONCLUSION:

Significant heterogeneity in US LT centers' approach to HCV patients on the waitlist exists. There is a trend to leave the sickest HCV+ patients untreated, though organs may be discarded due to lack of available HCV+ recipients in some parts of the country. As utilization of HCV+ organs into HCV- recipients begins to increase in the US, consideration for a separate allocation strategy for these organs may be warranted.
2961 Characteristics and Outcomes of Patients Hospitalized With Autoimmune Hepatitis in the United States: Nationwide Analysis in 2016
Authors: Tunio Nahel A. , Tashtish Nour , Sclair Seth , Cohen Stanley Martin
Published: October 2019

INTRODUCTION:

Autoimmune hepatitis (AIH) is a rare inflammatory disorder of the liver, and is associated with liver cirrhosis or hepatic failure. There is scarce contemporary data on epidemiology and outcomes of AIH in the United States. We used a large database to describe the epidemiology of AIH in the hospitalized patient in the USA.

METHODS:

We used the 2016 National Inpatient Sample Database, to identify all hospitalized patients who were discharged with a primary or secondary diagnosis of AIH (ICD10 K75.4) in 2016. We analyzed the demographics, causes of admission, liver transplantation rates, inpatient mortality and hospital charges.

RESULTS:

A total of 21,850 (SE 534) patients were admitted with AIH (2405, SE 68 with primary diagnosis of AIH). The mean age of the patient cohort was 55.8 (SE 0.4) years, 12755 (58.4%) were Caucasians, 3530 (16.2%) were African Americans and 16815 (76.9%) were females. Primary causes of admission were AIH (2405, 11%), sepsis (1885, 8.6%), liver cirrhosis (910, 4.2%), acute kidney injury (495, 2.3%), and gastrointestinal bleeding (375, 1.7%). Overall, 330 (1.5%) underwent liver transplantation and 825 (3.8%) died during hospitalization. Mean hospitalization charges were $63,444 (SE 2122), and length of stay was 5.74 days (SE 0.11).

CONCLUSION:

In the NIS database, we described the demographics of patients admitted with a diagnosis of AIH. Hospital admissions for AIH are associated with high cost and mortality. Moreover, liver transplantation is utilized in a small percentage of AIH admissions.
2968 Juxta-Papillary Duodenal Diverticulum (JPDD) Are Associated With Pyogenic Liver Abscesses
Authors: Bhandari Priyanka , Shankar Uday , Panchal Ankur , Bansal Raghav , Walfish Aaron , Baum Joel A. , Weeks David , Aron Joshua , Ahmed Moiz
Published: October 2019

INTRODUCTION:

Juxta-papillary duodenal diverticulum (JPDD) has been implicated by association as a potential risk factor for ascending cholangitis. Putative mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. The relationship of JPDD to liver abscess has not been described. We hypothesize that JPDD is associated with pyogenic liver abscess (PLA).

METHODS:

We conducted an IRB approved retrospective chart review from 2008 to 2018 to identify 66 cases of pyogenic liver abscess. Inclusion criteria for the diagnosis of liver abscess included CT imaging and either culture or confirmed resolution after antibiotic therapy. A similar number of age and sex matched controls were identified who had abdominal CT scan performed for another reason. All cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Chi square statistic was used to test our hypothesis.

RESULTS:

8 out of 66 cases of PLA had JPDD compared to only 2 out of 66 controls. Chi square testing was statistically significant for association between JPDD and PLA (Chi Square statistic = 3.89; P = 0.048).

CONCLUSION:

JPDD has statistically significant association with PLA. This may suggest a role of JPDD in etiology of “idiopathic” liver abscesses by either mechanical effect or by increased colonization by the pathogenic bacteria.
2972 Treatment of Chronic Hepatitis C With SOF/LDV Leads to a Significant Decrease of Fasting Glycaemia in Cirrhotic and IFG/T2DM Patients but Treatment With 3D Combo Only in IFG/T2DM Patients
Authors: Drazilova Sylvia , Janicko Martin , Skladany Lubomir , Oltman Marian , Kristian Pavol , Jarcuska Peter
Published: October 2019

INTRODUCTION:

Chronic hepatitis C is a systemic disease and type 2 diabetes mellitus (T2DM) belongs to more common extrahepatic. The aim of our study was to compare the effect of sofosbuvir/ledipasvir (SOF/LDV) vs 3D combo treatment on the fasting glycemia (FG) in all chronic hepatitis C (CHC) patients, in cirrhotics and in patients with impaired fasting glucose (IFG) or T2DM.

METHODS:

We performed a longitudinal retrospective observational study focused on the patients undergoing SOF/LDV or 3D combo treatment of chronic hepatitis C. Data about FG, history of diabetes, hepatitis C virus, treatment, and stage of fibrosis were obtained at baseline (before treatment start), at the end of treatment (ET).

RESULTS:

We included 344 patients; 65% treated by 3D combo; 47% had liver cirrhosis and 49% had IFG or T2DM. FG decreased significantly by SOF/LDV treatment (baseline vs ET) in all CHC patients (6.33 ± 2.51 mmol/L vs 5.79 ± 1.78 mmol/L; P = 0.001); in cirrhotics (6.71 ± 2.97 mmol/L vs 5.89 ± 1.78 mmol/L; P = 0.008) and in IFG/T2DM patients (7.49 ± 2.91 mmol/L vs 6.38 ± 2.13 mmol/L; P = 0.0001). FG decreased significantly in 3D combo patients only in IFG/T2DM group (7.36 ± 2.22 mmol/L vs 6.67 ± 2.19 mmol/L; P = 0.008); but not in all CHC patients (6.09 ± 2.01 mmol/L vs 5.96 ± 1.83 mmol/L; NS) and not in cirrhotics (6.70 ± 2.50 mmol/L vs 6.25 ± 2.32 mmol/L; NS).

CONCLUSION:

Both SOF/LDV and 3D combo led to a significant decrease of FG in IFG/T2DM patients, but only SOF/LDV treatment resulted in a FG decrease in cirrhotics.
2974 PCSK9 Inhibitors Do Not Worsen Liver Function Tests in Patients With Hepatic Steatosis
Authors: Zafar Yousaf , Saeed Lyla , Suddaby Stephanie , Ullah Waqas , Cheng An-Lin
Published: October 2019

INTRODUCTION:

Hepatic Steatosis is associated with cardiovascular disease independently of classic risk factors. Hepatocytes secrete proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) which in turn inhibits the uptake of low-density lipo-proteins by targeting the receptor for degradation and possibly lipogenesis. Anti-PCSK9 drugs reduce LDL-cholesterol but it is unclear how it affects the liver function in patients with underlying steatosis. AIM: To evaluate the efficacy and safety of PCSK9 inhibitors in patients with Fatty Liver disease.

METHODS:

A retrospective chart review study was done from September 2015 to January 2018 to include patients currently prescribed PCSK9 inhibitors who had an ICD code of hepatic steatosis or fatty liver disease. Blood AST (aspartate aminotransferase), ALT (alanine aminotransferase), Triglycerides, Cholesterol and HBA1c were charted of patients who were started on this medication and were followed after interval of 12 months while on the medication. This was compared to a control of patients who were not on PCSK9 but did have underlying diagnosis of fatty liver disease.

RESULTS:

A total of 37 patients on PCSK9 were identified having the ICD 9 and 10 code for fatty liver disease. A random control of 73 patients with the same ICD9/10 code were identified. The mean age of all the patients was 63 (32-90 years), 36% male and 64% female. The mean ALT in the study group after 12 months of PCSK9 therapy was 51 which was not statistically different from the control group (P = 0.05). The average AST value was 43 in the group that was studied and was not statistically significant (P = 0.09). Mean Triglyceride value was 180 (P = 0.87) and mean cholesterol was 143 (P < 0.01). This shows that the drug does significantly reduce the cholesterol values.

CONCLUSION:

PCSK9 may not have a detrimental effect on the liver profile as observed in our study. There was no significant difference in the liver function test after initiation of the drug. These drugs may serve as alternative agents for those who have experienced or are at risk of hepatic injury.
2976 Risk of Developing Non-Alcoholic Fatty Liver Disease (NAFLD) With Increased Intake of High Fructose Corn Syrup (HFCS): A Systematic Review
Authors: Gopalakrishnan Ravikumar Naveen Prasad , Nallapeta Naren S. , Mahl Thomas
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) encompasses the spectrum of fatty liver disease without significant alcohol consumption. The pathogenesis of NAFLD is complex and according to the “multiple parallel hits hypothesis,” a number of different processes may contribute to liver inflammation. High fructose corn syrup (HFCS, a mixture of fructose and glucose monosaccharides) appears to have a major role in inducing fatty liver by both stimulating de novo lipogenesis and blocking β-fatty acid oxidation. We performed a systematic review to demonstrate the association of HFCS in NAFLD.

METHODS:

Two independent authors performed a thorough literature search of English language studies in PubMed, Embase, Medline, Google Scholar, and Science Citation Index to identify relevant studies between January 2010 to January 2018. Keywords used were “high fructose corn syrup,” “nonalcoholic fatty liver disease,” “nonalcoholic steatohepatitis,” “high fructose diet,” “fatty liver,” “hepatic metabolism,” “hepatic triglycerides,” “hepatic de novo lipogenesis” and “liver enzymes.” Effects of HFCS on changes in liver enzymes, hepatic metabolism, and risk of NAFLD were assessed. The strength of evidence was evaluated by considering precision, the risk of bias and consistency.

RESULTS:

Based on our search criteria 6 animal studies were identified and 3 were excluded after careful review. 3 animal (rat/mice) studies were included for our final analysis. We found a significant evidence from all three studies that consumption of HFCS diet increased de novo lipogenesis in association with up-regulation of fatty acid synthase, sterol regulatory element binding protein (SREBP)-1c and decreased β-oxidation with down-regulation of Peroxisome proliferator-activated receptor (PPARα) in the liver of rats. In addition, ALT (Alanine Aminotransferase) elevation and increased liver triglycerides content were observed in all the three studies.

CONCLUSION:

Our systematic review shows that HFCS intake is associated with increased risk of developing NAFLD. However, we need more trials looking at the association between HFCS intake and liver metabolism in the future.
2977 Mercury Exposure and Risk of Non-Alcoholic Fatty Liver Disease and Advanced Fibrosis: Findings From the 2011-2016 National Health and Nutrition Examination Survey
Authors: Reja Debashis , Visaria Aayush , Rustgi Vinod K.
Published: October 2019

INTRODUCTION:

Mercury (Hg) is a well-known toxic metal that is most commonly found in diet (seafood, rice), and other sources such as dental amalgams and batteries. The pathogenesis for hepatoxicity is theorized to be triggered by oxidative stress. We aim to investigate the association of Mercury with key demographic and clinical factors, as well as NAFLD and Advanced Fibrosis.

METHODS:

A population of 5,590 non-pregnant individuals age 18-74 were included in this secondary analysis of NHANES 2011-2016. Exclusion criteria: AST/ALT >500 IU/L, alcohol >10 drinks/week (females)/>20 drinks/week (males), transferrin saturation >50%, positive hepatitis B and C serology. NAFLD was defined by Fatty Liver Index score >60. Advanced fibrosis was defined by National Fibrosis Score >0.676. Student's T-test was used for continuous and Rao-Scott Chi-Square test for categorical variables. Comparison across quartiles were done with simple linear regression for continuous, Rao-Scott Chi-Square test for categorical variables. Demographics and patient confounders were adjusted using multivariate logistic regression (SAS 9.4) for odds of NAFLD/Advanced Fibrosis with respect to Mercury quartile.

RESULTS:

5,590 patients were included, 44% with NAFLD and 56% without NAFLD. Patients with NAFLD vs no NAFLD were more likely to be older (51.1 vs 47.7 years, P < 0.0001), men (55% vs 45%, P < 0.0001), have fewer years of schooling, >high school (60% vs 69%, P < 0.0001), have lower Mercury levels (1.25 vs 1.68, P < 0.0003) and were significantly more likely to have higher BMI, Diabetes incidence, Hypertension, Total Cholesterol. Demographic and clinical characteristics for increased Mercury Levels by Quartile are listed in Table 1. Of note, participants with more Mercury exposure, in quartile 4 vs quartile 1, were older (53.4 vs 45.6 years, P < 0.0001), more educated (>high school 79% vs 53%, P < 0.0001), leaner (BMI 27.4 vs 29.6, P < 0.0001), higher HDL (55.8 vs 50.1), but had similar rates of GGT, ALT, AST, Hypertension, and Diabetes. There was no significant association found for risk of NAFLD or Advanced Fibrosis with Blood Mercury levels in both univariate or multivariate analysis.

CONCLUSION:

Our results show that Mercury levels are decreased in NAFLD, and are with increased with higher education and lower BMI. Mercury levels did not significantly affect liver enzymes or NAFLD risk factors such as hypertension and diabetes. Further studies are needed to examine Mercury toxicity and liver function.