bluuebunny/crossref_metadata_2025 huggingface dataset:
2688 Blame It on the Migrating Stent: A Case Report
Authors: Phan Ethan , Patel Pratik , Gollol Raju Narasimha Swamy , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Endoscopic implantation of plastic or metal stents is widely used to manage gastric and biliary disorders. However, complications from stent migration have also been well-documented. Biliary stents usually pass through the intestine without complications. In the case where invasive intervention is necessary, endoscopic retrieval is preferred to prevent surgical intervention. We report an acute abdominal pain case presumably from stent migration.

CASE DESCRIPTION/METHODS:

A 56 yo woman with past medical history of SMA chronic mesenteric ischemia status post revascularization and choledocholithiasis status post stent placement presented to the hospital for acute abdominal pain with nausea and vomiting. One month ago, she had a metal common bile duct stent placed for choledocholithiasis with biliary obstruction. Imaging showed showed the dislodged stent and mild mid-small bowel loop thickening with mid-small bowel stent. Initially, gastroenterology recommended watchful waiting and she was discharged home in stable condition. She returned to the hospital for persistent abdominal pain. Repeat imaging showed the dislodged common bile duct stent within the distal loop of small bowel, now appearing abnormally thickened and hyperemic but no evidence for bowel obstruction. After review with the surgery team, she was taken for combined mesenteric angiogram and exploratory laparotomy as the stent was inaccessible by endoscopy due to its location. On angiogram, all GI vasculature was patent, however a stricture was found adjacent to the stent. The strictured bowel was surgically resected and the stent was removed. The stricture was related to the ischemic changes that she previously suffered from prior revascularization. Abdominal pain improved and she was discharged home after tolerating a regular diet.

DISCUSSION:

This case illustrates that when abdominal pain is out of proportion to the physical exam, a broader differential would provide a different perspective. Initially, the diagnosis was homed in on the stent migration as the etiology of acute abdominal pain. Unfortunately, histories of previous abdominal surgeries and SMA revascularization were not explored until later. The stricture was only discovered after exploratory laparotomy. This case demonstrates premature diagnosis can be detrimental to patient care. It is imperative to understand the entirety of the patient’s history in order to make not only the correct diagnosis but to intervene in a timely manner to prevent morbidity and mortality.
2704 Urosepsis Is Difficult to Stomach!
Authors: Jarodiya Vijay , Kher Chirag , Singh Tejveer , Khan Zarak
Published: October 2019

INTRODUCTION:

Gastric ischemia is a rare condition associated with poor prognosis typically presenting with abdominal pain, GI bleed and altered mentation and may be caused due to states of shock. We present a rare case of gastric ischemia due to urosepsis.

CASE DESCRIPTION/METHODS:

A 70 year-old male with past medical history of peripheral vascular disease, chronic Foley catheter and dementia presented with altered mentation, hypotension, tachycardia and decreased urine output. The Foley catheter was replaced revealing purulent urine. Initial labs revealed acute kidney injury, lactic acidosis, and leukocytosis. CT abdomen pelvis without contrast revealed gastric pneumatosis with adjacent left upper quadrant portal venous gas and branching portal venous gas throughout the liver. Esophagogastroduodenoscopy was performed which showed proximal gastric ischemia and necrosis from the midbody to the fundus; biopsies revealed acute hemorrhagic gastritis, and gastroenterology recommended resection. General surgery was consulted who recommended conservative management. Patient improved clinically while receiving antibiotic therapy, intermittent nasogastric tube suction, intravenous proton pump inhibitor therapy and parenteral nutrition. Repeat imaging showed resolution of portal gas and gastric pneumatosis and repeat EGD showed resolution of gastric ischemia.

DISCUSSION:

Gastric ischemia is a serious condition which is under-recognized clinically. Etiologies include systemic hypotension, vasculitis or disseminated thromboembolism. Gastric pneumatosis or portal venous gas on imaging suggest ischemia; EGD with biopsy is the diagnostic gold standard. Gastric ischemia is either managed surgically or medically with fluid resuscitation, nasogastric tube placement to prevent gastric distension and acid reduction along with antibiotics for patients with gastric pneumatosis.
2706 Ischemic Duodenal Ulcer: A Rare Complication of Embolization of the Gastroduodenal Artery in Yttrium-90 Radioembolization Therapy
Authors: Le Han N. , Chaaya Adib
Published: October 2019

INTRODUCTION:

Selective internal radiation therapy (radioembolization) with yttrium-90 (Y-90) resin microspheres is an effective and increasingly popular treatment option for unresectable primary and metastatic liver malignancies. Gastric complications are detected in 4% to 27% of liver radioembolization cases. Most of these cases arise from non-targeted flow of microspheres with aberrant deposition into various non-selected organs. The gastroduodenal artery is routinely embolized prior to deposition Y-90 microspheres to decrease the risk of non-targeted dissemination of the microspheres. We present a rare case of duodenal ulcer which developed as a result of ischemia induced by embolization of the gastroduodenal artery.

CASE DESCRIPTION/METHODS:

A 68 year-old woman with a history of stage IV colon adenocarcinoma with metastasis to the liver presented to the hospital with a several week history of severe abdominal pain two months after receiving radioembolization therapy with Y-90 microspheres. She was found to have a duodenal ulcer and was treated with acid suppression therapy. She was re-evaluated six months later for severe abdominal pain. Repeat endoscopy showed a larger duodenal ulcer with multiple coils eroding through the center of the ulcer bed suggesting ischemic injury caused directly from the embolization coils. She was treated with acid suppressive therapy with resolution of her symptoms.

DISCUSSION:

Radioembolization with Y-90 microspheres is now a widely performed locoregional treatment for primary and metastatic liver lesions not amenable to resection. Our case is unique because the patient’s duodenal ulcer was likely ischemia-induced from mechanical occlusion of and direct injury to the gastroduodenal artery from the embolization coils. It is imperative that clinicians caring for patients who have received radioembolization therapy be familiar with the many gastrointestinal complications associated with this therapy. There is increasing awareness of radiation-induced mucosal injury in the literature. However, providers should also know that despite the presence of multiple collaterals in the gastroduodenal territory, chronic coil-induced ischemia can also form ulcers as a complication of selective embolization of the gastroduodenal artery.
2708 An Atypical Case of Lymphocytic Gastritis
Authors: Penmetsa Amulya , Santa Stephanie , Marino Danielle E.
Published: October 2019

INTRODUCTION:

Lymphocytic Gastritis (LG) is an uncommon gastritis that is typically associated with Helicobacter Pylori (HP) and Celiac disease. We present the case of a patient with persistent LG on repeat biopsies without either aforementioned association, which improved with steroids.

CASE DESCRIPTION/METHODS:

A 48-year old woman with a history of Raynaud’s and Undifferentiated Connective Tissue Disorder (UCTD) presented with abdominal pain, early satiety, and weight loss of forty-five pounds over three years. She was taking Advil twice weekly for headaches. CT Abdomen/Pelvis was unremarkable. Esophagogastroduodenoscopy (EGD) showed diffuse nodular mucosa with normal rugae (Figure 1); biopsies showed LG. There was no HP and duodenal biopsies were normal. She was started on Prednisone 40 mg daily for one week and tapered by 10 mg weekly, which significantly improved her symptoms. EGD three months later demonstrated a nodular stomach and biopsies showed mild to moderate LG, similar to prior exam. Steroids were not restarted as the patient was asymptomatic with weight increase of five pounds. In follow up two years later, she continued to be asymptomatic and had total weight increase of eighty pounds. Repeat EGD showed erythema and edema throughout gastric body with nodular-like appearance; this was improved from the first endoscopy. Biopsies at this time were normal without LG.

DISCUSSION:

LG is a rare subset of gastritis, seen in less than 1.5% of cases. Histologically, it is defined as a lymphocyte fraction of greater than twenty-five out of one hundred epithelial cells. Endoscopic appearance can include small, nodular erosions with enlarged rugae (an entity known as gastritis varioliformis), or it can present as giant fold gastritis. It has been described as a reaction to either HP infection or celiac sprue, which has been identified in up to 45% of cases. In this particular case, we describe a slightly different endoscopic appearance; HP and Celiac disease were both ruled out with negative biopsies. The literature has also identified a correlation of LG with Menetrier’s disease, autoimmune disorders, Crohn’s disease, viral (HIV) or parasitic infections. In this case, it is possible that she was predisposed to LG given her concurrent history of autoimmune disorders in the form of UCTD. NSAIDs may also have played a role, as they do in lymphocytic colitis. This case illustrates the successful treatment of LG with steroid therapy, which can lead to symptomatic and histologic remission.
2731 Duodenal Pressure Ulcer Secondary to Migratory PEG Tube
Authors: Nagirimadugu Ankita , Dong Ray , Weisberg Ilan
Published: October 2019

INTRODUCTION:

Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term nutritional support in patients with preserved gastrointestinal function and dysphagia. The procedure and long-term presence of a PEG tube is well tolerated, with a complication rate of 0.4% to 4.4%. Adverse events include infection, skin breakdown, and aspiration. Upper GI bleeding, secondary to gastric or duodenal pressure ulcers is a rare complication. We present a case of duodenal pressure ulcers secondary to a PEG tube, along with a review of the literature and a proposed mechanism for this injury.

CASE DESCRIPTION/METHODS:

A 94-year-old non-verbal woman with a history of dementia and oral squamous cell carcinoma presented to the ED for RLQ abdominal pain. She was found to have leakage around the replacement PEG tube. Given comorbidities, patient was initially managed conservatively, but eventually underwent an endoscopy (EGD) due to persistent melena and down trending hemoglobin. The EGD demonstrated that the intragastric retention balloon had migrated beyond the pyloric channel resulting in a partial gastric outlet obstruction. The balloon was deflated revealing a large nonbleeding duodenal pressure ulcer. Since no stigmata of bleeding were identified, the replacement PEG was removed and new mushroom catheter and internal bumper was placed through the original tract. The patient was placed on an IV PPI to allow for adequate healing and melena resolved.

DISCUSSION:

Standard replacement PEG tubes are secured with an external bumper on the skin with an intragastric saline filled balloon. Ideal distance between the retainer and skin is 1-2 cm. If a PEG balloon is pulled too tightly there is a risk for pressure ulcer formation at the gastrostomy site. Conversely, if the PEG tube is too loose there is the risk of PEG balloon migration. With intense gastric peristalsis, the saline-filled balloon can migrate through the stomach, pylorus, and into the duodenum. While this is rare, case reports of gastric and duodenal outlet obstruction have been observed. In this case, the migration of the balloon into the duodenum led to a partial gastric outlet obstruction leading the patient to present with leakage, pain, melena, and anemia due to a large duodenal pressure ulcer. Proper PEG placement and care should be the main source of pressure ulcer prevention, and this rare complication should be considered in patients with melena and anemia.
2747 A Rare Case of Esophageal Squamous Cell Carcinoma With Intramural Gastric Metastasis
Authors: Kassim Gassan , Liu Yingheng , Smith Michael S.
Published: October 2019

INTRODUCTION:

Esophageal cancer makes up about 1% of all cancers diagnosed in the United States . Gastric metastasis from esophageal cancer is relatively rare. Four different types of metastatic mechanisms were reported: 1) via peri-gastric lymph nodes; 2) gastric intramural metastasis; 3) direct invasion of the gastric wall, and 4) intra-epithelial spread to the gastric epithelium . Here we present a case with intramural gastric metastasis in a patient with esophageal squamous cell carcinoma.

CASE DESCRIPTION/METHODS:

A 76-year-old Indian male with past medical history significant for idiopathic pulmonary fibrosis and coronary artery disease, recently started on aspirin and clopidogrel, presented with new onset fatigue and five days of black tarry stools. Hemoglobin (Hgb) on admission was 7.1 g/dL. Despite transfusion of one unit of packed red blood cells, repeat Hgb dropped to 6.6 g/dL. Emergent upper endoscopy was performed for suspected active gastrointestinal bleeding in the setting of blood thinner use. Endoscopy showed a 3 cm, non-bleeding, fungating and ulcerated mass in the middle third of the esophagus, as well as a 4-5 cm fungating, infiltrative and ulcerated gastric mass in the cardia with stigmata of recent bleeding (adherent clot) (see Figure 1). Removal of the clot revealed underlying oozing from the ulcer bed which was treated successfully with dilute epinephrine injection followed by hemostatic clip placement. Forceps biopsies of both the esophageal and cardia masses were obtained. Histopathology of both lesions revealed keratinized squamous cell carcinoma. CT of the chest, abdomen and pelvis showed no evidence of other metastatic disease. Oncology consultation was scheduled to discuss potential chemotherapy, radiation, and endoscopic interventions.

DISCUSSION:

Esophageal cancer with intramural gastric metastasis is very rare compared to other mechanisms of tumor spread. The prognosis is very poor with the mean survival time reported to be 8.6 months . Conventional chemotherapy or radiotherapy after surgery were ineffective in improving prognosis in current report, suggesting other techniques could provide a benefit when used adjunctively or in combination with more traditional approaches.
2751 Endoscopic Folie à Deux: Atypical Manifestations of Gastric Amyloid in Concurrent Cases
Authors: Ladhani Sanah , McCabe Patrick , Szmit Andrew , Bhuket Taft , Liu Benny , Wong Robert
Published: October 2019

INTRODUCTION:

Gastrointestinal amyloidosis is rare with variable, nonspecific presentations, signs, and endoscopic findings. We describe two cases featuring unusual endoscopic findings produced by histologically confirmed gastric amyloid.

CASE DESCRIPTION/METHODS:

Case 1: A 60 year old man with Child B cirrhosis due to chronic hepatitis C virus (HCV) infection, hidradenitis suppurativa, and end-stage renal disease from biopsy-proven amyloidosis on hemodialysis presented with melena and severe anemia. EGD showed diffuse gastric hemorrhagic, fibrinous exudates (Figure 1). On biopsy, Congo red stain showed apple green birefringence with plane polarized light microscopy consistent with amyloid. Four months later, after recurrent melena and bloody diarrhea, along with severe hypotension due to newly diagnosed adrenal insufficiency, the patient died while on comfort care. Case 2: A 63 year old man with Child C cirrhosis from chronic HCV, end-stage renal disease on hemodialysis, and prior intravenous drug use presented with hyperkalemia after missing his scheduled dialysis session. During his hospitalization, he developed melena and underwent an EGD, which showed scattered patchy moderate submucosal hemorrhages in a partially ringed pattern throughout the gastric body (Figure 2). On biopsy, Congo red stain showed apple green birefringence with plane polarized light microscopy; protein identification showed AA-type amyloid (Figure 3). Three months later, and to-date, the patient is hospitalized in the ICU for altered mental status, septic shock, and respiratory failure, with his hospital course complicated by repeated episodes of GI bleeding.

DISCUSSION:

These two cases of melena had distinctive, initially puzzling endoscopic findings, with biopsy results indicating gastric amyloid, a rare and atypical presentation of systemic amyloidosis. It is interesting that both patients in these cases had HCV infection. While AA-type, secondary amyloid can be caused by a chronic infectious state, there are no studies thus far that establish a causal link between HCV and amyloidosis. The patients in these two cases also carry other risk factors for amyloidosis, including hidradenitis suppurativa, end-stage renal disease, and intravenous drug use. Thus, while gastric amyloid is rare, endoscopists should keep it in the differential and note its potential for causing GI bleeding, especially in patients with risk factors, as it is a difficult condition to treat and its endoscopic findings can be dramatic.
2810 Endoscopic Ultrasound in Diabetics: Is There a Protective Role of Metformin Therapy for Pancreatic Ductal Adenocarcinoma?
Authors: Schwartz Ingrid , Satiya Jinendra , Singh Harjit , Abraham Rtika , Girotra Mohit
Published: October 2019

INTRODUCTION:

The relationship between diabetes mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) is a field of immense interest. Studies have proposed that metformin therapy (MT) could play a protective role in risk reduction for PDAC; however, the prevalence of pancreatic structural abnormalities in patients on MT is unknown. We aimed to identify the prevalence and distribution of pancreatic parenchymal and ductal changes during endoscopic ultrasound (EUS) of diabetic patients on MT, compared to patients non-MT.

METHODS:

We performed a retrospective chart review of diabetic patients who underwent EUS at the University of Miami Health System between 2010-2018. Patients with known history of chronic pancreatitis (CP), pancreatic mass/PDAC or pancreatic surgery were excluded.

RESULTS:

Seventy-eight patients were identified (mean age = 65 ± 13.6 years; M:F = 31:47): 18 (23%) African-American, 17 (22%) Caucasian and 43 (55%) Hispanic. Mean BMI was 31.55 ± 9.8. Four patients (5%) had DM type 1 and 74 (95%) had type 2, with mean hemoglobin A1c of 6.45 ± 2%. Diabetic complications were seen in 44 patients (56.4%): nephropathy = 25, neuropathy = 26 and retinopathy = 6. Forty-four (56.7%) patients were on MT and 34 (43.5%) patients were on either insulin (n = 20) or insulin secretagogue (n = 14), defined as non-MT group (Table 1) Indications for EUS included abdominal pain (24), submucosal esophageal (2), gastric (11) or duodenal (3) lesion, common biliary narrowing or dilation (18), abnormal hepatic panel (3), lymphadenopathy on imaging (5), suspected choledocholithiasis (3), jaundice (2), and elevated CA-19-9 (2). Parenchymal or ductal endosonographic findings were present in 34% (n = 15) of the patients on MT versus 53% (18) of patients non-MT (Table 2). Among the 44 patients on MT, 2 patients met criteria for chronic pancreatitis (CP), 1 was indeterminate and 41 (93.2%) were classified as normal pancreas, according to the Rosemont classification. In non-MT patients, 32 (94.11%) were classified as having normal pancreas, 2 were indeterminate and no patients met criteria for CP. Following EUS examination, PDAC was diagnosed in 1 (2.2%) patient in MT group, versus 3 patients (8.8%) in the non-MT group.

CONCLUSION:

Pancreatic structural abnormalities occurred equally in diabetic patients in MT (6.8%) versus non-MT (5.8%) groups (P = ns). Higher number of PDAC were diagnosed in non-MT group; however, whether or not this finding could explain the proposed protective role of MT on the risk of developing PDAC is yet unclear.
2825 Colorectal Cancer Is Not Associated With Obstructive Sleep Apnea: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Kwak Hakyong Gloria , Sarmini Muhammad Talal , El Kurdi Bara , Thota Prashanthi N. , Young Mark , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Multiple studies have attempted to evaluate the risk obstructive sleep apnea (OSA) imposes on certain malignancies. Particularly the association between OSA and colorectal cancer and cancer-related mortality have been scarcely studied with contradicting results. This study aims to review the literature on OSA and its association with colorectal cancer.

METHODS:

A systematic review was conducted in Pubmed, MEDLINE, EMBASE, and Cochrane databases from inception through May 2019 to identify the studies which explored the association between OSA and colorectal cancer. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird and a pooled odds ratio (OR) was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS:

Three studies with a total of 1,705,003 patients with OSA were included in this analysis. Of them, 3,835 patients had an incident colorectal cancer diagnosis. The pooled OR for colorectal cancer in patients with OSA was 0.968 (95% CI: 0.940 - 0.997, P = 0.029) compared to the control group.

CONCLUSION:

Our meta-analysis found that OSA is not associated with an increase incidence of colorectal cancer. Further studies might be needed to explore this association and its effect on the disease course mortality.
2877 Electronic APP vs. Paper Form Stool Diary for Fecal Incontinence
Authors: Yan Yun , Karunaratne Tennekoon , Jimenez Enoe , Sharma Amol , Parr Rachael , Herekar Anam , Eubanks Audrey , Sanku Amalesh , Rao Satish
Published: October 2019

INTRODUCTION:

The irregular and unpredictable bowel movements (BM) and leakage events makes it challenging for patients with fecal incontinence (FI) to accurately recall, describe or quantify stool habit. Although paper stool diary has been used in clinical trials, patients find these diary entries cumbersome or embarrassing and has not gained popular use. Cell phone apps provides a unique opportunity to instantly record BM and FI events and protect privacy. We developed an electronic FI stool diary app and assessed its reliability/reproducibility and psychometrics and compared this with paper stool diary.

METHODS:

In a randomized cross-over study, FI patients (≥1 FI episode/week), completed both a paper and app diary for 2 weeks each. The 10-item diary recorded number of bowel movements (BM), FI leakage events, severity and associated symptoms. Also, we assessed functionality and ease of use. Data was assessed and compared for reliability, reproducibility, validity and separately for ease of use (Visual analogue scale, VAS scores 0-10). Intraclass correlation coefficients (ICC) assessed equivalence.

RESULTS:

Ten patients (18.7 ± 5.9 years, F/M = 9/1) completed assessments for this analysis. The app showed significant correlation between pad use, stool frequency and percentage of BM with urgency (ICC >0.703) between week 1 and week 2, and demonstrated high reliability and test-retest reproducibility (Table 1). The weekly FI episodes trended towards significant correlation between week 1 and week 2 (ICC = 0.676, P = 0.054). The mean stool consistency (ICC = 0.944, P < 0.0001), number of normal (Bristol Stool Form Scale, BSFS type 3-5) and loose stools (BSFS type 6-7) were significantly correlated between week 1 and week 2. The number of FI episodes and use of pads over 2 weeks in app were significantly correlated with paper stool diary (ICC >0.812). Also, stool frequency, percentage of BM with urgency, stool consistency, number of normal and loose stools were significantly correlated with paper diary. The psychometrics parameters were significantly better (P < 0.01) compared to paper diary, but other parameters although better were not significant (Table 3).

CONCLUSION:

The App is a reliable and reproducible instrument for documenting and assessing FI symptoms, and demonstrates comparable accuracy against paper diary. This user-friendly diary could improve our ability to provide optimal care for FI patients by accurately characterizing their symptoms.
2884 How Delay in Colonoscopy Impacts Diagnosis of Significant Medical Conditions
Authors: Borecky Thomas , Borecky Michael , Chang Lauren , Chang Alexander , Sheikh Akber , Chang Andrew , Godil Aslam , Foliente Roy , Hill Kevin , Brichler Benjamin
Published: October 2019

INTRODUCTION:

Colonoscopy cancellations will lead to delaying diagnosis of medical conditions that may be found at colonoscopy. The delay in diagnosing a treatable medical condition can lead to unnecessary increases in patient morbidity and mortality. This study evaluates the impact of a delayed colonoscopy on diagnosing significant medical conditions and the risk factors that may predict significant findings at colonoscopy.

METHODS:

Retrospective study done at Sierra Nevada Gastroenterology Medical Associates and Sierra Endoscopy Center, both located in Grass Valley, California. Electronic medical records of 421 patients were reviewed from January 2016 through December 2017. Demographics, insurance, reasons for cancellations, timing of rescheduled colonoscopy, indications and significant findings of colonoscopy were recorded.

RESULTS:

421 patients cancelled their colonoscopy and 223 (53%) rescheduled. 157 (70%) rescheduled their colonoscopy within 3 months. Demographics, insurance, rescheduled timing.

Reasons for cancellations, indications, and findings of colonoscopy.

CONCLUSION:

Most patients cancel their colonoscopy without realizing the impact that may have on their health. This study shows that significant findings were diagnosed in 98 (44%) of patients, including polyps, colitis and colon cancers. Delaying the diagnosis of these conditions can lead to increased morbidity and mortality. Symptoms, indications or demographic characteristics did not consistently predict significant colon pathology. Therefore, all patients should be encouraged to follow through on their colonoscopy as quickly as possible.
2895 Recurrent Bleeding in Patients With LVADs: Endoscopic Yield and Impact of Endoscopic Intervention
Authors: Palchaudhuri Sonali , Dhawan Ishita , Siddique Shazia M. , Mehta Shivan , Coniglio Mary , Fisher Laurel
Published: October 2019

INTRODUCTION:

Patients with LVADs are at increased risk for gastrointestinal bleeds (GIBs) because of chronic anticoagulation and high flow states. A prior retrospective study at our institution confirmed that 22% of patients with LVADs had a GIB after implantation, consistent with prior literature. There are no evidence-based guidelines regarding the role of repeat endoscopic procedures for recurrent GIB, resulting in varying practice patterns among Cardiology and GI teams. It is unknown how often repeat inpatient endoscopic examinations during hospitalizations result in intervention or reduction in future GIB episodes. We sought to assess the proportion of endoscopic intervention and impact on recurrent GIB.

METHODS:

We conducted a retrospective cohort study of all patients at one academic institution who underwent LVAD implantation between March 2016 through February 2018. For each patient, we assessed post implant hospital encounters for GIBs through May 2019. The primary outcome was the odds ratio for a future GIB based on the occurrence of endoscopic intervention versus none (endoscopy with no intervention or no procedure). Secondary outcomes included endoscopic intervention based on overt versus occult GIB.

RESULTS:

The cohort included 105 patients who had LVADs implanted during the stated time. 34 patients (32%) presented for GIBs during the study period, with a total of 71 encounters. A third or higher encounter occurred in 26% of patients (9/34) and accounted for 27% (19/71) of encounters. 79% of all encounters (56/71) included at least one invasive endoscopic evaluation; an endoscopic intervention was performed in 41% (23/56). The odds ratio for future GIB after endoscopic intervention during the first GIB (34/71) was 0.2 (95% CI 0.04-0.97, P = 0.046) but was not statistically significant if the intervention was during a recurrent GIB (37/71) (0.33, 95% CI 0.08 - 1.41, P = 0.14). The odds ratio of performing an intervention during endoscopic procedure for overt versus occult GIB was 3.4 (95% CI 0.98-11.7231, P = 0.053), trending towards significant.

CONCLUSION:

Patients with LVADs who have recurrent GIBs experience repeat admissions and endoscopic procedures. In our cohort, endoscopic interventions for repeat GIB did not have an impact on future episodes of GIB. Our data suggest that the endoscopic yield is likely lower with occult GIB.There is a clinical need to identify characteristics of LVAD patients at risk and to develop guidelines for the management of patients with recurrent GIB.
2908 Clinical Factors Associated With Vitamin D Deficiency in Patients With Ulcerative Colitis
Authors: Choi Jongwook , Cho Byungha , Kim Seongmin , Kwon Hyeonwoo , Lee Jun Su , Park JiSook , Ji Jung Woong , Kim DaeHyun , Kim Hyoung Woo , Kim Ki Bae , Han Joung-Ho , Chae Hee Bok , Park Seon Mee , Youn Sei Jin , Yoon Soon Man
Published: October 2019

INTRODUCTION:

Vitamin D has known to play a role in the development and the course of Crohn's disease and ulcerative colitis (UC). However, little is known about the clinical factors associated with vitamin D status in patients with UC. Therefore, we aimed to identify the clinical characteristics associated with vitamin D status and also evaluate the patients' quality of life (QOL) according to vitamin D status in UC patients.

METHODS:

We enrolled 81 patients with UC and measured serum 25-OH vitamin D levels. We investigated patients' clinical characteristics, disease activity, laboratory findings such as CRP, albumin, and fecal calprotectin. In addition, we evaluated patients'' QOL using IBD-specific questionnaire according to vitamin D status.

RESULTS:

The median age at vitamin D measurement was 46.4 ± 1.8 years (range: 19-82, M/F: 48/33) and the median vitamin D level was 18.6 ± 0.9 ng/mL. Among 81 patients, 75 patients (92.6%) revealed vitamin D deficiency (<30 ng/mL). Fecal calprotectin level had negative correlation with vitamin D level (r = −0.324, P < 0.028). However, there was no correlation with CRP, albumin, and disease activity according to vitamin D level. In addition, the patients’ QOL was not associated with vitamin D level. The patients with vitamin D deficiency showed higher fecal calprotectin level than patients with normal level (P = 0.038). However, there were no significant differences of CRP, history of steroid use, smoking status, and disease activity according to vitamin D status.

CONCLUSION:

Vitamin D deficiency was pretty common in UC patients. Fecal calprotectin levels were inversely correlated with vitamin D levels. However, there was no association between vitamin D status and disease activity or patients' QOL in UC patients.
2912 Higher Induction Propofol Dosing Decreases Induction Time for Sedation of Inflammatory Bowel Disease Patients Undergoing Elective Endoscopic Procedures
Authors: Zhang Daniel S. , Stana Roman , Abraham Bincy
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) patients undergo frequent endoscopic procedures. As a result, they may be exposed to anesthesia and its associated risks.1–2 Prior studies have indicated that IBD patients may require higher sedation needs.3–5 We conducted a retrospective study comparing the induction sedation dose and time by an anesthesiologist experienced with IBD patients (IBD-e) compared to anesthesiologists not experienced with IBD patients (IBD-ne).

METHODS:

Patients 18 and older with documented IBD and an American Society of Anesthesiologists (ASA) score of 2 or less undergoing an elective endoscopic procedure using total intravenous anesthesia (TIVA) were included in the study. These anesthesiologists were either experienced or inexperienced with sedating IBD patients. Exclusion criteria included pregnancy, recipient of any sedative other than propofol, or inpatient status. Age, body mass index (BMI), relevant comorbidities, medications, and validated disease activity scores were recorded. Any adverse events were recorded. The primary outcome was the time required to achieve adequate sedation (seconds) as determined by the level of consciousness by the anesthesiologist. Secondary outcome was the induction dose of propofol per kilogram patient weight (mg/kg) required to achieve sedation. The sample size needed for the primary outcome of sedation time with 80% power and an alpha 0.05 was 144 total patients.

RESULTS:

A total of 180 IBD patients were analyzed, with 108 patients in the IBD-e group and 72 in the IBD-ne group. Baseline characteristics including were similar between the groups (Table 1). Specific IBD scores of endoscopic disease activity were also similar between the two groups (Table 2). Sedation time was significantly reduced in the IBD-e group 38.9 ± 2.1 sec when compared to the IBD-ne group 94.2 ± 10.7 sec (P < 0.05). The induction dosage of propofol was significantly higher in the IBD-e group 3.42 ± 0.39 mg/kg than the IBD-ne group 2.09 ± 0.21 mg/kg (P < 0.05) (Table 3). No significant adverse events were reported in either group.

CONCLUSION:

We have shown that higher induction propofol decreases induction time for sedation of IBD patients undergoing elective endoscopic procedures regardless of age, gender, BMI or endoscopic disease activity. Understanding these findings, anesthesiologists may achieve more efficient sedation in IBD patients. Further studies are needed to validate our findings.
2930 Does Triple Antibiotic Therapy Reduce Faecal Calprotectin Levels and Gastrointestinal Symptoms in Patients With Ulcerative Colitis? A Retrospective Study
Authors: Hesari Niloufar Roshan , Gunaratne Anoja W. , Clancy Annabel , Benstock Simon , Tu Jeffrey , Borody Thomas
Published: October 2019

INTRODUCTION:

Ulcerative colitis (UC) is characterised by inflammation in the colon and the rectum. The primary symptoms include abdominal pain, diarrhoea, fever, weight loss and anaemia. Fusobacterium varium (F. varium) is present in the colonic mucosa of approximately 80% of patients with UC. Butyric acid, a derivative of F. varium culture supernatants has shown to cause UC-like lesions in mice. F. varium shows susceptibility to a combination of antibiotics whose efficacy in inhibiting inflammation was investigated in this study. Aims To assess the efficacy of triple antibiotic therapy in reducing faecal calprotectin in patients with UC at 6 and 12 weeks.

METHODS:

A retrospective analysis of patients with UC, who were treated with triple antibiotic therapy between July 2014 and December 2018 was conducted. Patients were treated with three antibiotics tinidazole, rifaximin and nitazoxanide for 12 weeks. Gastrointestinal symptoms and faecal calprotectin were recorded pre-treatment and at 6 and 12 weeks on the treatment. Elevated faecal calprotectin in the stool indicates intestinal inflammation (Normal range ≤ 50 µg/g). Wilcoxon matched-pairs signed rank test was used to compare the differences between data sets, and a P value < 0.05 was considered statistically significant.

RESULTS:

A total of N = 63 patients (32 M, average age 42 years) with UC treated with the antibiotics were identified. Baseline calprotectin was available for 22 patients, follow-up values at 6 weeks in 8 patients and in 15 patients at 12 weeks of treatment. A significant reduction in faecal calprotectin was observed at 12 weeks on the treatment (median: 64 µg/g) (P = 0.003) but not at 6 weeks (P = 0.382) compared to baseline (median: 252.5 µg/g) (Figure 1). Baseline symptoms were reported for 57 patients, of which 31 patients at 6 weeks and 39 patients reported symptoms at 12 weeks. Diarrhoea and blood in the stool resolved significantly at 6 and 12 weeks on the treatment (P ≤ 0.006) (Figure 2). No changes were seen in constipation, pain, nausea, vomiting, mucus in the stool or weight loss at 6 or 12 week on the treatment versus pre-treatment (P ≥ 0.077).

CONCLUSION:

A significant improvement in gastrointestinal symptoms and a fall in faecal calprotectin were observed in patients with UC who were treated with a triple antibiotic regimen. Future prospective studies are required to evaluate the efficacy of this therapy in inducing endoscopic remission.
2939 Outcomes of Patients With Large Colonic Polyps Referred to a Tertiary Center for Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection
Authors: Lamm Vladimir , Olaiya Babatunde , Lou Hui , Chen Huimin , Xia Liang , Vachaparambil Cicily , Kapil Neil , Xu Jennifer , Yu Michael , Cai Qiang
Published: October 2019

INTRODUCTION:

Large colonic polyps (>2 cm), flat or sessile, are difficult to remove by endoscopy. These difficult polyps are usually referred to experienced advanced endoscopists for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). There is no data regarding outcomes of referred polypectomies to a tertiary care center for endoscopic management. We aimed to examine outcomes of patients referred to a tertiary center for EMR and ESD and thereby provide feedback to referring physicians.

METHODS:

A retrospective study of patients with difficult polyps referred to an experienced advanced endoscopist at a large academic center for EMR and ESD between February 2016-August 2018 was completed. 141 referred patients were enrolled. Charts were reviewed for outcomes including: procedure setting, procedure type, need for surgical consult, duration, complete removal, complications, antibiotic use, hospital days, pathology, and repeat colonoscopy findings.

RESULTS:

The average size of referred polyps was 3.39 cm, with most being flat or sessile. Procedures were largely performed in the surgical ambulatory center. EMR constituted the majority of procedures, followed by ESD, and snare cautery polypectomy. Complete removal with first session colonoscopy was originally noted with 87% of polyps. For this group, mean procedure time was 47 minutes with a complication rate of 8.9%, consisting mainly of hematochezia. Of this subset of patients, 46.4% had a repeat colonoscopy/pathology at time of study with majority of findings unremarkable. When accounting for residual polyps on repeat colonoscopy, 62.4% of patients had complete removal at first colonoscopy. Overall, 7.8% required a surgical consult. Most patients did not require hospitalization after procedure or antibiotics. Comparative analysis revealed no significant difference between different techniques.

CONCLUSION:

Most polypectomies referred to an experienced advanced endoscopist for EMR and ESD can be performed in an outpatient ambulatory surgical center. Most of the polyps were removed by EMR. ESD was performed in a small percentage of patients. Currently there are no guide lines regarding what kind of polyps should be referred. The majority of referred difficult polyps were completed removed at the first colonoscopy within a relatively short procedure time. At least a portion of those polyps should be able to be resected at the index colonoscopy, without referral, to reduce health care cost and patient inconvenience.
2946 Does Non-Alcoholic Fatty Liver Disease Increase the Risk of Cholangiocarcinoma? A Single Center Retrospective Review
Authors: Martinez-Tapia Ana , Bahirwani Janak , Folterman Christopher , Chaput Kimberly J. , Duarte-Chavez Rodrigo , Martins Noel B.
Published: October 2019

INTRODUCTION:

Cholangiocarcinoma is a highly aggressive cancer of the bile duct epithelium, usually diagnosed at an advanced stage. Limited research has shown evolving risk factors and pathogenesis of cholangiocarcinoma. Studies have revealed a link between Non-Alcoholic Fatty Liver Disease (NAFLD) and cholangiocarcinoma, mainly intrahepatic cholangiocarcinoma. The major risk factors for NAFLD- include obesity, impaired fasting glucose, dyslipidemia, and metabolic syndrome. In this study, we aim to determine a possible association between NAFLD and cholangiocarcinoma.

METHODS:

The electronic medical records were retrospectively reviewed for adults with NAFLD, Intrahepatic cholangiocarcinoma (ICC) and Extrahepatic cholangiocarcinoma (ECC) by ICD code, imaging, or pathological report. Exclusion criteria were; alcoholic liver disease, primary sclerosing cholangitis, hepatitis B & C, HIV infection, and inflammatory bowel disease between March 2012-2019. Analysis was conducted on possible risk factors such as NAFLD, metabolic syndrome and subsequent risks; diabetes mellitus, BMI, dyslipidemia, hypertension (HTN), and coronary artery disease.

RESULTS:

A total of 59 patients with diagnosis of cholangiocarcinoma was collected and classified into ICC (N = 48) and ECC (N = 10) with mean age of 72 years. Gender distribution was 54% females and 46% males, in ICC and 40% females vs 60% males in ECC, respectifully. 18% of patients with ICC had NAFLD in comparison with 0% in the ECC class. Fisher exact test showed 37.5% of patients with ICC had metabolic syndrome vs 30% of patients with ECC, but this was statistically not significant. Each individual risk factor for metabolic syndrome was further analyzed and among these 81% of patients with ICC had HTN and was statistically significant vs 50% of ECC cases had HTN.

CONCLUSION:

Our cohort did not demonstrate an association between NAFLD and cholangiocarcinoma. Our sample size was low and ICC had more representation than ECC. Diagnoses of NAFLD was obtained mainly by imaging and pathology results rather than ICD codes, but underrepresented in our study in comparison to the general population, likely from undercoding. There was no association between gender, age, metabolic syndrome or its risk factors, except HTN, which was prevalent in the ICC group with statistical significance. This finding was not seen in prior studies. This could likely represent more prevalence of HTN overall in the cohort, however more research is helpful in determining this possible association.
2967 Post Prandial Lipemia: A Potential Diagnostic Modality for NAFLD
Authors: Nath Gautam
Published: October 2019

INTRODUCTION:

Clinically, NAFLD encompasses a broad spectrum of hepatic derangements ranging from fat accumulation (steatosis) to severe inflammation and fibrosis (NASH, nonalcoholic steatohepatitis) that can lead to cirrhosis and subsequently to hepatocellular carcinoma. NAFLD is now more common than alcoholic liver disease owing to the rapid rise in the prevalence of obesity, and NAFLD is the most common cause of abnormal liver function tests.

METHODS:

Twenty consecutive Patients with age range 30-60 yrs attending our OPD during the years 2014-2016 with ultrasonographically proven hepatic steatosis and satisfying following criteria were selected: Alcohol intake less than 20 g/day, absence of autoimmune hepatitis (on the basis of clinical findings, raised globulin, AST/ALT ratio), absence of viral hepatitis (on the basis of serology for viral markers of HBV, HCV), absence of history of intake of any hepatotoxic drug.

RESULTS:

Considering the fasting lipid profile, difference was observed between the groups in serum TG (177.15 ± 16.18 VS 128.3 ± 22.4), total cholesterol (221.45 ± 31.26 vs 179.35 ± 26.59) and HDL (42.2 ± 6.13 vs 49.8 ± 4.39). The difference found was statistically significant (P < 0.001). Summing up for the cases, a higher value was recorded for alkaline phosphatise which was statistically not significant. The postprandial lipemic response of the subjects were estimated using serum triglyceride (TG) level measurement considering the same being the most dynamic parameter considering fat challenge. The serial estimations of TG at 2 hourly interval have also shown a significant difference in serum TG levels between cases and control groups with (P < 0.001). In order to calculate the magnitude of lipaemia, the Area under the curve (AUC) was calculated for the two groups using trapezoid rule, which showed a statistically significant (P < 0.001) between the two groups (1814.20 ± 166.46 vs 1341.25 ± 153.36).

CONCLUSION:

We have observed that all subjects from the case group have had a TG surge of greater than 240 mg% as opposed to the healthy controls, this difference could possibly serve as a useful tool provided a standardized diet challenge is implemented prior to test.
2993 Interaction Between Internet Browsing Habit and Dyspepsia Syndrome in Adolescents
Authors: Bayupurnama Putut , Sofia Noor Asyiqah , Cahyani Angelin Utami
Published: October 2019

INTRODUCTION:

There were many patients, including adolescents, with dyspepsia symptoms in our daily clinical practice have been interacting with internet search engine to find medical information which induced or worsened their dyspeptic symptoms. Aim of the study is to know the pattern of internet browsing habit and dyspepsia syndrome in adolescents

METHODS:

Grade 12 level students of senior high schools in Yogyakarta, Indonesia were included in the study with stratified random sampling. Students with confirmed organic dyspepsia diagnosis were excluded. We use two simple questions to reveal the students internet browsing habit, question no 1:“Did you ever browse information about diseases in the internet?” (answer choice: a. never; b. once; c. more than once); question no 2.: “Did you ever browse information about your medical complaint in the internet?” (answer choice: a. never; b. once; c. more than once). We used validated Gastrointestinal Symptom score (GIS) to reveal the students dyspepsia symptoms. Data were analyzed with chi-square test and anova.

RESULTS:

There were 665 (477 girls and 188 boys) senior high school students (age range: 16-20 years old) included in this study. Based on question no 1 (Table 1) the result showed significantly different (P < 0.001) between students with and without the dyspepsia syndrome, and the question no 2 (Table 2) also showed similar result (P = 0.002). The anova between GIS and question no 1 showed significantly different (P < 0.001) and the similar result was also found between GIS and question no 2 (P < 0.001).

CONCLUSION:

Many patients with dyspepsia symptoms who came to our private and hospital clinics have been interacting with the internet search engine to find medical information about their symptoms including fake medical information that may influenced their psychogenic pain perception. This study showed that the internet browsing habit may influenced the development of dyspepsia syndrome in adolescents and further study is needed to find the cause and effect relationship.