bluuebunny/crossref_metadata_2025 huggingface dataset:
2761 Adenocarcinoma Presented as Massive Gastric Distention
Authors: Zakaria Ali , Khan Faizan , Ahmed Shehbaz , Turk Issam , Levinson Jay
Published: October 2019

INTRODUCTION:

Chronic gastric distention is a rare condition that can occur due to an underlying obstruction or dysmotility. Gastric outlet obstruction can be secondary to luminal, mural or extrinsic compression. Gastric adenocarcinoma can rarely manifest as massive gastric distention due to partially obstructing mass or peptic stricture. Herein we presented a case of chronic massive gastric distention due to pyloric adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 60 y/o male patient with PMHx of hepatitis C, hypertension and polysubstance abuse, presented to the ER complaining of diffuse abdominal pain, intermittent nausea and vomiting, early satiety and 25lb weight loss over the last 8 months. He seeked medical attention due to worsening symptoms. He described normal bowel movements. He denied any fever, hematemesis, hematochezia, or melena. On exam: Pulse 84 bpm, temp 36.6 C°, BP 144/68 and RR 18 bpm. His BMI was 22. He was alert and oriented with mild distress due to abdominal pain. His abdomen was mildly distended with tympanic percussion and normal active bowel sounds. His lab results revealed WBC 4.7k/mcl, Hgb 12.9 mg/dl and normal basic metabolic panel. CT scan of the abdominal revealed markedly distended stomach with ingested debris extending to the pelvis with a mass effect on surrounding abdominal structures [Figure 1]. He was treated conservatively with NG tube placement and 3L of fluid removed. EGD revealed ulcerated partially obstructive pyloric malignant looking lesion with large amount of retained bezoar/food [Figure 2]. Histopathology confirmed the diagnosis of gastric adenocarcinoma with mucinous differentiation and signet ring cells. The patient underwent total gastrectomy with Roux-en-Y reconstruction with plan for outpatient follow up.

DISCUSSION:

Gastric distention was initially described by Duplay in 1833. Benign underlying etiology account for vast majority of cases, with one study calculated up to 90% of cases were seen in the setting of peptic ulcer disease alone. Amongst the malignant causes, gastric adenocarcinoma is important to consider, despite its rarity in the western countries. Gastric adenocarcinoma often presents with nonspecific symptoms and diagnosed at an advanced incurable stage. Serious complications of massive gastric distention include dehydration, ischemia and perforation that might lead to sepsis, multi-organ failure and death. Treating physician should keep high index of suspicion with prompt decompression and surgical intervention to prevent these dreadful sequelae.
2772 Choleperitoneum Due to Gastric Perforation Masquerading as Acute Pancreatitis in a Roux-En-Y Gastric Bypass Patient
Authors: Dixit Priyadarshini , Ponna Pramod , Diaczok Benjamin
Published: October 2019

INTRODUCTION:

Approximately 200,000 patient undergo weight loss surgery in the United States annually. Nearly half undergo Roux-en-Y gastric bypass (RYGB). After RYGB, bile acid may reflux into the gastric remnant resulting in inflammation and occasionally, perforation. The prevalence of this complication in RYGB is under 1%. We present a patient with RYGB who was initially diagnosed with pancreatitis. When the patient did not respond to treatment, reevaluation revealed gastric perforation resulting in choleperitoneum. Physicians should be aware of complications related to weight loss surgery.

CASE DESCRIPTION/METHODS:

A 68-year-old lady with RYGB, cholecystectomy, and osteoarthritis, recently treated with naproxen 500 mg BID, presented with sudden onset sharp, continuous, 8 / 10, epigastric pain radiating to the right upper quadrant. She had no alleviating or aggravating factor. She had no associated nausea, vomiting, sweats or chills. Vital signs were unremarkable. Her abdomen was not distended. BS present. She had no pain to percussion, but tender to palpation in the epigastric region. Initial labs demonstrated WBC 14,800/mm3, AST 12 U/L; ALT 21 U/L; amylase 1,761 U/L and lipase 926 U/L. CT demonstrated a small volume of ascites, but no fat stranding or inflammation of the pancreas. A clinical diagnosis of pancreatitis due to naproxen was made. Despite conservative treatment, the patient deteriorated. Her abdomen became distended. Repeat CT demonstrated a large volume of ascites. Analysis of ascitic fluid revealed RBC 2/mm3; WBC 4/mm3; albumin 1.1 gm/dL with SAAG 0.9 gm/dL; and total bilirubin 7.5mg/dL. Choleperitonitis was diagnosed. Emergent laparotomy revealed a gastric perforation of the remnant stomach which was surgically repaired.

DISCUSSION:

Choleperitoneum is defined as the presence of bile in the peritoneum. An ascitic fluid bilirubin concentration greater than 6 mg/dL with an ascitic fluid/serum bilirubin ratio greater than 1.0 is diagnostic. Etiologies include liver laceration, gall bladder rupture, or bile duct leak. Amylase and lipase may be elevated. The clues suggesting an alternative diagnosis to pancreatitis was the sudden onset of pain (consistent with rupture of viscus) and normal appearing pancreas on CT despite elevations of amylase and lipase and a small collection of ascites. Physicians should keep in mind the prevalence and complications of weight loss surgery when evaluating abdominal pain.
2773 Gastric Small Cell Cancer: An Extremely Rare and Lethal Type of Stomach Cancer
Authors: Aamar Ali , Barakat Mohamed , Aloreidi Khalil , Tsipotis Evangelos , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Small cell carcinoma commonly originates in the lung, but it can also arise from many extrapulmonary sites including the stomach. Gastric small cell carcinomas (GSCC) are extremely rare and comprise less than 0.1% of all gastric cancers. GSCC has aggressive clinical course with early metastases. The median survival time for localized disease is 1.4 to 3.5 years. We report a rare case of metastatic gastric small cell cancer in an elderly female.

CASE DESCRIPTION/METHODS:

A 79-year-old African American female with past medical history of hypertension presented with vomiting and 15-pound weight loss over 2 months. She also reported solid food dysphagia for 2 weeks. CT abdomen showed innumerable hypodense lesions throughout the liver, compatible with metastases and several necrotic appearing enlarged lymph nodes in the gastrohepatic ligament. EGD revealed a single cratered and linear ulcer on the lesser curvature of body of the stomach 3 cm below the gastroesophageal junction (Figure 1). It measured 8 × 1.5 cm in size. Multiple biopsies were taken. EUS showed multiple discrete hyperechoic lesions in the left lobe of the liver consistent with liver metastases (Figure 2). Liver biopsy was performed. Biopsy suggested invasive small cell carcinoma with necrosis. CT chest was negative for lung cancer. Bone scan showed multiple focal bony lesions consistent with bone metastases. Patient was started on chemotherapy by oncology for stage IV small cell gastric cancer. Unfortunately, the patient died within few months of initial diagnosis.

DISCUSSION:

GSCC is very rare and it was first reported in 1976. It has poor prognosis even in patients with localized disease. Epigastric pain, dysphagia and melena are common clinical presentations of GSCC. GSCC frequently metastasize to the liver, followed by lymph nodes and bones. Surgical resection is considered standard therapy for localized disease. Chemotherapy can increase median survival from 6 to 12 months for advanced disease. Early recognition and treatment of small cell gastric cancer in very important as advanced disease has dismal prognosis and it is universally fatal.
2788 Double Pylorus in a Patient With Alcoholic Cirrhosis and Intractable Vomiting
Authors: Deshmukh Farah , Francisco Peter , Merrell Nancy
Published: October 2019

INTRODUCTION:

Gastroduodenal fistula (GDF) or double pylorus is a rare, often asymptomatic, condition with a prevalence of approximately 0.02-0.08%. The majority of previously reported cases have been in Asian countries and it has been found to be more prevalent in males than females. Although Helicobacter pylori and NSAID use has been associated with the formation of gastroduodenal fistulae, the actual mechanism of the condition is unknown.

CASE DESCRIPTION/METHODS:

We present the case of a 65-year old female with alcoholic cirrhosis and a long history of intractable vomiting due to unknown etiology. She was found to have a pre-pyloric gastric antral ulcer during an emergent endoscopy for an episode of hematemesis seven years ago. Follow up endoscopies over a course of three years found the antral ulcer to be healing. Seven years from the discovery of the initial lesion, a gastroduodenal fistula was found. The pre-pyloric antral ulcer in the process of healing fistulized into the duodenal bulb creating the appearance of a double pylorus.

DISCUSSION:

Gastroduodenal fistula or double pylorus can be acquired or congenital. Acquired GDF is a very rare complication of peptic ulcer disease. They can be a result of healing due to bridging fibrosis within the pylorus or, as in this case, fistulization from the gastric antral ulcer. Most GDF are found incidentally during endoscopy that was done for another reason. This case report follows the serial endoscopic examination of a cirrhotic patient with a pre-pyloric antral ulcer that developed into GDF. We propose that the GDF was caused by fistulization of a pre-pyloric antral ulcer with no other predisposing factors and gastrointestinal fistulization processes.
2789 Abdominal Pain Unveils a Gastric Psammoma Fascinoma
Authors: Harris Patrick , Winters Jennifer , Al Diffalha Sameer , Weber Frederick H.
Published: October 2019

INTRODUCTION:

Carney Complex (CNC) is a rare multiple neoplasia syndrome of autosomal dominant inheritance characterized by skin pigment abnormalities, myxomas, endocrine tumors or hormonal hypersecretion, and schwannomas. The clinical presentation varies and median age at detection is age 20.

CASE DESCRIPTION/METHODS:

A 22-yr-old African American male presented with 3-months of intermittent left-sided abdominal pain. He had a large cell calcifying Sertoli cell testicular tumor (LCCSCT) removed by right orchiectomy at age 12. CT showed a 12.9 × 11.8 cm well circumscribed retroperitoneal mass involving the left adrenal gland with mass effect on adjacent organs and a 4.0 × 3.0 cm well-defined mass in the gastric body. EUS revealed a cystic gastric body sub-epithelial mass measuring 3.5 cm × 2 cm. The patient underwent partial gastrectomy, orchiectomy, and adrenalectomy revealing pathology consistent with a gastric psammomatous melanotic schwannoma (PMS), adrenocortical carcinoma, and a second LCCSCT. H&E stained sections of the gastric lesion show a well-demarcated subepithelial lesion with multiple psammomatous calcifications. Marked accumulation of melanin in tumor cells and melanophages were identified. Histological and immunophentypic features were consistent with a gastric melanotic schwannoma with psammomatous calcifications. These findings are diagnostic of CNC.

DISCUSSION:

CNC is caused by a harmful mutation in the PRKAR1A gene, which this patient was found to have upon genetic testing. Many individuals with CNC will have distinctive skin pigmentation and an increased risk for development of cutaneous and cardiac myxomas. As a result of this patient’s diagnosis, his mother was evaluated and was found to also have a PRKAR1A mutation; imaging led to discovery of a cardiac myxoma requiring surgical removal. CNC is also associated with multiple endocrine tumors with or without hormonal hypersecretion. LCCSCT occur in almost all adult males with CNC and are typically bilateral and benign. PMS, tumors of the nerve sheath, occur in approximately 8% of individuals with CNC. These can occur anywhere in the central and peripheral nervous system but most frequently occur in the GI tract (stomach/esophagus) or in the paraspinal sympathetic chain. PMS have distinct pathology including heavy pigmentation (melanin), frequent calcifications, and the presence of psammoma bodies. The importance of recognizing these pathological features is emphasized by the fact that approximately half of patients with PMS have CNC.
2795 The Effect of an Invasive Approach for Infected Necrotizing Pancreatitis on Mortality: A Retrospective Large Multi-Center Cohort Study
Authors: Horibe Masayasu , Minami Kazuhiro , Sanui Masamitsu , Sasaki Mitsuhito , Iwasaki Eisuke , Mayumi Toshihiko , Kanai Takanori
Published: October 2019

INTRODUCTION:

Infection of acute pancreatic necrosis is associated with a high mortality rate. The relative merits of invasive therapies for preventing death among patients with this condition are unclear.

METHODS:

This retrospective multicenter cohort study was conducted from 2009 to 2013 at 44 treatment centers in Japan. Patients who underwent invasive treatment for suspected infection of pancreatic necrosis were enrolled into three treatments groups: the primary open necrosectomy before drainage, secondary open necrosectomy after drainage, and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was assessed using multivariate analysis after adjusting for age, severity according to the revised Atlanta criteria, and the Charlson index.

RESULTS:

Of 1159 patients with acute pancreatitis, 118 patients underwent invasive treatment for infected pancreatic necrosis. Of these, nine, 20, and 89 patients underwent a primary open necrosectomy, secondary open necrosectomy, and minimally invasive treatment (three laparoscopies, 49 percutaneous treatments, 37 endoscopies), respectively. The mortality rate was 33.9% (40/118). Multivariate analysis showed no significant association between the type of intervention or Charlson index and mortality (P = 0.35 and P = 0.12, respectively). The mortality odds ratio (OR) for the secondary open necrosectomy versus minimally invasive treatment was 1.25 (95% confidence interval [CI]: 0.40–3.84, P = 0.69) while that for the primary open necrosectomy versus minimally invasive treatment was 3.13 (95% CI 0.66–17.5, P = 0.15). However, age (OR 1.04, 95% CI [1.01–1.08], P = 0.0067) and severity (OR 7.57, 95%CI [2.27–25.2], P = 0.0002) were significantly associated with mortality.

CONCLUSION:

In patients with infection of acute pancreatic necrosis, age and severity based on the revised Atlanta criteria, but not intervention type, were significantly associated with mortality. For patients undergoing an open necrosectomy, performing drainage after rather than before the procedure may produce better outcomes.
2797 Fenofibrate and PSC: A Case Series From a Single Center Liver Registry
Authors: Shah Shivani , Silveira Marina , Assis David , Cusack Laura
Published: October 2019

INTRODUCTION:

Background: Primary sclerosing cholangitis (PSC) is a cholestatic liver disease with no current effective therapy. Ursodeoxycholic acid (UDCA) is often used, however it does not slow disease progression despite improvement in serum alkaline phosphatase (ALP). Fenofibrate (FF) improves cholestasis in patients with primary biliary cholangitis (PBC). We present a retrospective single-center case series of Fenofibrate in PSC patients.

METHODS:

Methods: Patients were identified within a Liver Registry with large-duct PSC on FF. Overlap cases with PBC or autoimmune hepatitis were excluded. The mean age at diagnosis was 39.7 ± 19.2 years; 4 were males, 5 Caucasian and 2 Hispanic. Five had inflammatory bowel disease, five had intra/extrahepatic disease and two had intrahepatic disease. All patients received UDCA. FF was added 5-396 months post diagnosis.

RESULTS:

Mean ALP pre-FF was 654 U/L ± 646 and after 4-6 months improved by a mean of 176 ± 263.4 U/L; 4/7 patients had ALP reduction with FF and 3 achieved a normal ALP level (Figure 1). MRI post FF was available in five patients; 3 had worsening of strictures after 6-12 months of FF while 2/5 were stable). ERCP was performed for stricture management on 4 patients and 2 required repeat ERCP. One patient developed cirrhosis; no patients developed ascites, encephalopathy, cholangiocarcinoma or hepatocellular carcinoma. One patient had a transplant evaluation for refractory pruritus. Of four with pruritus pre-FF, 1; one had moderate improvement. Of 6 patients with fatigue, 3 had persistence post-FF and 1 had new fatigue. Of 3 patients who had cholangitis pre-FF, 2 had recurrent episodes post-FF. No patients developed myopathy or acute kidney injury. FF was discontinued in one patient due to lack of ALP improvement at 6 months. Amsterdam-Oxford Risk Score (Figure 2) was calculated at time of FF, 4-6 months after FF, and at 1- and 2- years for those with data beyond 6 months. Among the 4 patients with ALP improvement, there was mild improvement in the risk score (not sustained beyond 2 years in 3 patients).

CONCLUSION:

Conclusion: This case series suggests a potential use for FF in the treatment of PSC. However, despite reduction in ALP, fatigue, pruritus, and recurrent cholangitis persisted and FF did not improve strictures, similar to UDCA studies in PSC. Future aims of this study involve examining elastography data pre- and post-FF. The role of FF in PSC treatment should be examined in larger, longitudinal studies.
2801 Does Rapid On-Site Evaluation by a Cytopathologist During Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS FNA) of Pancreatic Masses Improve Diagnostic Yield and Accuracy? A Systematic Review and Meta-Analysis
Authors: Kamal Faisal , Khan Muhammad Ali , Tariq Raseen , Bayoumi Mahmoud , Marella Hemnishil K. , Reddy Yala , Ismail Mohammad , Tombazzi Caludio
Published: October 2019

INTRODUCTION:

EUS FNA plays an important role in the diagnostic evaluation of pancreatic masses. Studies comparing the diagnostic yield of EUS FNA of pancreatic masses when performed with rapid onsite evaluation (ROSE) by a cytopathologist vs. without ROSE have reported conflicting results. By systematic review and meta-analysis, we aim to compare the diagnostic yield and diagnostic accuracy of EUS FNA when performed with and without ROSE in the evaluation of pancreatic masses.

METHODS:

We reviewed Pubmed, Scopus and Web of Science from inception to November 15, 2018 to identify studies comparing EUS FNA with and without ROSE for evaluation of pancreatic masses. The primary outcome of interest was diagnostic yield for malignancy. Secondary outcomes were diagnostic accuracy and sample inadequacy. A random effects model was used to analyze the data. Pooled odds ratios (ORs) with 95% confidence interval (CI) were used to summarize the data. Heterogeneity was assessed by I2statistic.

RESULTS:

We included 7 studies (6 publications and 1 abstract) comprising 1327 patients. EUS FNA was performed with and without ROSE in 641 and 686 patients, respectively. 5 studies were retrospective and 2 were randomized controlled trials. Diagnostic yield and accuracy were similar between the two groups. Seven studies reported data on diagnostic yield for malignancy; pooled OR was 0.96 (0.71, 1.31) with low heterogeneity (I2 = 26%; Figure 1). 4 studies reported data on diagnostic accuracy; pooled OR was 0.73 (0.39, 1.36) with low heterogeneity (I2 = 42%; Figure 2). 4 studies reported data on inadequate samples; no difference was observed between groups (OR 1.99; 95% CI 0.82, 4.85; I2 = 36%).

CONCLUSION:

This meta-analysis found that ROSE by a cytopathologist during EUS FNA of pancreatic masses does not improve diagnostic yield or diagnostic accuracy.
2808 Gastrointestinal Bleeding After Pancreatic Transplant, Beyond the Usual Suspects: A Systematic Review
Authors: Pena Polanco Nathalie A. , Keihanian Tara , Barkin Jodie A. , Barkin Jamie S.
Published: October 2019

INTRODUCTION:

Pancreatic transplant represents the ultimate treatment for certain patients with diabetes mellitus & end-stage renal disease. Despite good outcomes, it carries a high rate of vascular complications, & with increased numbers of enterically-drained grafts, obscure gastrointestinal bleeding (GIB) can be the initial presentation. Delayed diagnosis & treatment of life-threatening hemorrhage can ensue if clinicians are not aware of this association. Therefore, we aimed to perform a systematic review of the literature, evaluating the presentation, diagnosis & treatment of patients with GIB caused by complications from enterically-drained pancreatic transplants.

METHODS:

We performed a systematic search of published data, regarding GIB due to complications from pancreatic transplant. Specific keywords including pancreatic transplant & gastrointestinal bleeding, with all possible permutations & associated MeSH terms were used, from inception of PubMed database to 04/30/2019. 107 results matched initial search criteria. After assessment to determine appropriateness, 26 publications with complications resulting in GIB at presentation were included. A recursive search was performed from bibliographies, yielding the remaining results.

RESULTS:

36 publications met final inclusion criteria (25 case reports & 11 case series) dating from 1989 to 2019, for a total of 69 patients, (47.8% men, mean age 41.4 years). Of these, 67 (97%) presented with overt bleeding, with lower GIB as the most common presentation (59.4%), followed by cases of both upper & lower GIB (8.7%), & occult GIB the least common (2.9%). Sentinel GIB was reported in 49.3% of cases. GIB etiologies included formation of fistulas (52.2%), anastomotic ulcer & donor duodenal bleed (11.6% each) & pseudoaneurysms (8.7%), with other rare causes (mucosal rejection, cytomegalovirus-related ulcers) also identified. Diagnosis was made by angiography in 31.9% & by surgery in 21.7% of cases, respectively. Endoscopic diagnosis was only successful in 7 patients. Surgery (n = 42) & interventional radiology procedures (n = 19) were the mainstays for treatment. Overall, 50.7% of patients had pancreatic graft loss prior to GIB.

CONCLUSION:

GIB after pancreatic transplant can be devastating. In our review, failed grafts were found in half the cases, with lower GIB due to arterial-enteric fistulas being the most common presentation. Angiography & surgery were the most common diagnostic & therapeutic modalities.
2817 Efficacy of Fecal Microbial Transplant in Treatment of Recurrent Clostridioides difficileInfection in Community Hospitals in Las Vegas
Authors: Brumand Azadeh , Hoang Lynda , Akbar Azaan , Carlson Brian
Published: October 2019

INTRODUCTION:

Fecal microbial transplant (FMT) has been established as an effective treatment for recurrent Clostridioides difficile infection (CDI); however, current treatment guidelines for recurrent CDI in the community hospital setting remain unclear. Recurrence is defined as resolution followed by recurrence of CDI symptoms within 2-8 weeks after discontinuing antibiotic treatment. Recurrent CDI is seen in 10-25% of patients most commonly within 30 days but up to 2 months after completion of antibiotic therapy. In 2013, a randomized control trial demonstrated 81% response rate to FMT therapy for recurrent CDI versus 31% with vancomycin alone. The goal of our study was to evaluate the efficacy of FMT as a treatment modality for recurrent CDI in the community hospital setting.

METHODS:

In a retrospective data collection study, 27 patients diagnosed with 2 or more recurrences of CDI were selected for cecal infusion of FMT at 3 different community hospitals in Las Vegas between March 2017 and December 2018. Donor feces were obtained from OpenBiome and prepared according to the manufacturer’s instructions. Patients were screened for HIV, HAV, HBV, HCV and enteric bacterial pathogens. Antibiotics were discontinued 24-48 hours prior to FMT. All patients underwent bowel preparation with 4 liters polyethylene glycol. 250 cc of donor feces was delivered into the cecum via colonoscopy. Patients were re-evaluated at 8-weeks follow-up visits.

RESULTS:

Of the 27 patients treated with cecal infusion of FMT, 18 were available for 8-weeks follow-up evaluations. 14 of these patients reported complete resolution of CDI symptoms without recurrence. 3 patients had refractory CDI. 1 patient had persistent diarrhea due to Crohn’s disease. 1 patient died of septic shock during a hospital readmission. 8 patients were lost to follow-up.

CONCLUSION:

This study demonstrated FMT was effective in 78% of patients with recurrent CDI in community hospitals. Of the 3 patients with refractory CDI, 1 responded to a second FMT, 1 failed two additional FMTs but ultimately responded to an extended course of vancomycin and 1 remains on an extended course of vancomycin. Our study was limited by missing data; 30% of our patients were lost to follow-up. Although high rates of inadequate bowel prep were observed, further studies are needed to explore the significance of poor prep on FMT outcomes. Overall, the response rate supports the use of FMT for recurrent CDI in community hospitals.
2831 Altering Perceptions of In-Hospital Stool Testing for Clostridioides difficile Infection Reduces Inappropriate Prescribing of Antibiotics and Length of Hospital Stay
Authors: Malik Fahad , Patel Bhavin , Kim Marina , Dunn Kelsey , Gonzalez Manuel O. , Muhammad Wafa , Saverimuttu Jessie
Published: October 2019

INTRODUCTION:

Clostridium Difficile Infection (CDI) occurs predominantly in the intestinal tract due to alteration of normal gut flora often due to antibiotics. Testing for CDI is common on the inpatient setting. However, we recognized that over 95% of ordered stool tests are negative for CDI which indirectly was associated with an increased length of hospital stay, the unnecessary use of antibiotics and placing patients on isolation precautions. A hospital initiative led by our team that included provider education and a special electronic order set increased the accuracy of testing for CDI at our institution.

METHODS:

A one-year retrospective study was done evaluating the number of symptomatic and asymptomatic patients that were tested by the toxin A/B EIA and PCR assays. Similar data was obtained from the following year after the initiation of our hospital initiative. The hospital initiative included education for all hospital prescribers as well as the creation of a special electronic order set including alerts and special restrictions implementing the Infectious Disease Society of American (IDSA) guidelines. CDI cases were reported and compared between the two groups.

RESULTS:

During the first study period, there were a total of 877 CDI Antigen & Toxin tests ordered for inpatients. This resulted in 712 or 81% negative results for both antigen & toxin. Out of 877 tests, 120 were found to have antigen positivity but negative for CD toxin (indeterminate results). These 120 patients were further analyzed by polymerase chain reaction (PCR). Only 45 out of 877 were truly positive for CDI antigen & toxin (5% of total ordered tests). During the second study period, post intervention a total of 828 total CDI tests were ordered. This result showed 678 CDI tests or 82% ordered tests were negative for CDI antigen & toxin. Out of 828, 101 tests were antigen positive but negative for toxin which were further analyzed by PCR. Only 49 resulted positive for CDI antigen & toxin (6% of total tests ordered with positive for CDI).

CONCLUSION:

Our hospital initiative that included guideline-based education for ordering physicians as well as implanting an electronic order set enforcing testing criteria was effective at identifying more true positive results of CDI. We can infer that the underlying cause for the majority of symptomatic patients resulted from an etiology other than CDI. Further practitioner education with stricter measures must be enforced to reduce excessive testing.
2834 Sex, Cancer Survivorship, and Colorectal Cancer Screening Among U.S. Adults: Analysis of a National Survey
Authors: Laiyemo Adeyinka , Kibreab Angesom , Scott Victor , Lee Edward , Brim Hassan , Jack Momodu , Mekasha Getachew , Howell Charles , Ashktorab Hassan , Aduli Farshad
Published: October 2019

INTRODUCTION:

Men suffer higher burden from colorectal cancer (CRC) when compared to women. It is uncertain if this is due to poorer health services utilization or biological differences. It is well established that patients become more health conscious after a cancer diagnosis “as a wake-up call”. Aim: To determine uptake of CRC screening (with fecal occult blood test or endoscopy) among adult men and women in the United States and evaluate whether screening uptake differs by sex after a diagnosis of any cancer.

METHODS:

Methods: We used the 2013 Health Information National Trends Survey (HINTS) 4 cycle 3 conducted by the National Cancer Institute. A total of 1,829 respondents (weighted population size = 90,313,161) were 50 years and older. There were 732 (45.9%) men (weighted population size = 41,452,732) and 1,097 (54.1%) women (weighted population size = 48,860,429). There were 356 (14.7%) cancer survivors (weighted population size = 13,267,800) and 1,473 (85.3%) (weighted population size = 77,045,361) without any history of cancer. We evaluated whether survey respondents were ever screened for CRC (with fecal occult blood test or endoscopy) and compared CRC screening by cancer survivorship among men and women. All percentages were weighted.

RESULTS:

Overall, there were no sex differences in CRC screening rates among respondents (70.5% versus 75.2%; OR = 0.79; 95% CI: 0.58-1.07; P value = 0.13) regardless of cancer status. However, cancer survivors had increased CRC screening uptake (85.5% versus 70.5%: OR = 2.48; 95% CI: 1.46-4.22; P value = 0.001) regardless of sex in unadjusted analysis. Although there was an absolute 20.2% increase in CRC screening among men and an absolute 11.7% increase in CRC screening among women who have been diagnosed with a cancer, the differences were not statistically significant after adjustment for healthcare insurance status (Table 1).

CONCLUSION:

Conclusion: Increased efforts should be made to improve CRC prevention education and healthcare insurance coverage of US adults.
2836 Association of Body Mass Index (Bmi) and Sedative Use During Screening Colonoscopy
Authors: Atassi Hadi , Shine Amal , Liu Nanlong , Thomas Chandler , Furmanek Stephen , Liu David , McClain Craig
Published: October 2019

INTRODUCTION:

Colonoscopy is a key tool for colorectal cancer screening, but like any procedure, it is not without risk. The procedure can be done with conscious sedation. Risks from sedation include hypotension or hypoxia, sometimes requiring hospitalization and even endotracheal intubation. Therefore, endoscopists aim to minimize the amount of sedation needed to keep a patient comfortable and still be able to complete the procedure. We sought to examine the relationship between a patient’s body mass index (BMI) and the amount of sedation used during colonoscopy.

METHODS:

Data was collected on 640 patients undergoing conscious sedation screening colonoscopies at Louisville Veterans Affairs Medical Center, and 501 were excluded based on specific exclusion criteria, including known colonic disorders (e.g., IBD history, pre-existing malignancies) and lack of documented sedative use. Of 139 patients included, median age was 62, 86% patients were male, and 72% were white. Data were gathered by retrospective chart review of patient’s BMI as well as dosage of Midazolam, Fentanyl, and Diphenhydramine used during colonoscopy. Multiple Regression Model was used for analysis with corresponding P-values calculated. Statistical significance was set at P < 0.05. The total number of polyps detected was controlled for, as this was thought to affect the duration of colonoscopy.

RESULTS:

Our study indicates that, although a higher BMI was hypothesized to be associated with increased sedative use, the association was not statistically significant for any of the three sedatives in this study. This is most likely due to the fact that there was little variability between the doses of each sedative and the small sample size.

CONCLUSION:

Data in literature is scarce regarding the association between BMI and sedation use for colonoscopy. Most society guidelines on sedation in obesity are based on expert opinion. Factors affecting sedation use include longer cecal intubation times due to difficult technique in patients with obesity, reluctance to use higher amounts of sedation in patients with obesity due to increased risk of airway compromise, and prior alcohol or drug use. Larger studies are needed to further explore these findings, which may have future clinical implications regarding the introduction of specific guidelines for sedative use in patients with obesity.
2837 Reliability of Fecal DNA Testing for Colorectal Cancer (CRC) Screening: A Retrospective Study
Authors: Mazumder Mohammed , Thorpe Candy , Horenstein Frances , Mazumder Jubaida , Thompson Darlene M.
Published: October 2019

INTRODUCTION:

Colorectal Cancer (CRC) is the leading cause of death in the US. The gold standard for CRC screening is a Colonoscopy, which allows for diagnostic evaluation and endoscopic interventions-excision and Biopsy of polyp. In 2014 a Fecal DNA testing modality, (Cologuard; Exact Sciences), was approved by the FDA as an option for CRC screening. Fecal DNA testing is a combination of fecal immunochemical testing (FIT) and markers for abnormal DNA. The utilization of Fecal DNA testing has increased, and continues to rise due to its noninvasive technique. A diagnostic colonoscopy is recommended for all positive results.

METHODS:

The aim of this study is to determine the reliability of Fecal DNA testing in regards to CRC screening. This study took place in a community hospital in central Ohio, Between January 2017 and February 2019. 100 average risk individuals whom had a positive fecal DNA test were analyzed.

RESULTS:

100 patients had a positive Fecal DNA test. Among them 12 patients did not undergo colonoscopy. Our results are based on patients’ (100-12 = 88) findings who underwent a colonoscopy. 64 Patients were found to have adenomatous polyps (AP), High grade dysplasia or adenocarcinoma during examination (72.73%). Out of these 64 patients whom had positive findings, 61 were APs (95.31% of total positive endoscopic findings), and 3 were high-grade dysplasia or adenocarcinoma (4.69% of total positive endoscopic findings). 24 patients were found to have no adenomas (27.27% of patients with positive stool test).

CONCLUSION:

When comparing findings to statistics published by Exact Sciences, data is dissimilar. Exact sciences reports approximately 13% of tests are false positives, while our data revealed 27.27% false positive tests. Although there were a large number of patients with positive testing resulting in adenoma detection, the overall reliability of this testing strategy is difficult to determine due to the large number of false positive results. Further data is needed to evaluate if this testing technique is appropriate for CRC screening.
2850 Fecal Immunochemical Test in Asymptomatic People
Authors: Jurado da Silva Edson
Published: October 2019

INTRODUCTION:

Occult blood is strategy for colorectal cancer screening. The aim of this study is to analyze the value of quantitative monoclonal antibodies against human Hemoglobin for colonoscopy screening.

METHODS:

One hundred asymptomatic adult patients, aged over 40 up to 77, with no risky group, have had one sample of stool specimens collected for qualitative immunochromatography with monoclonal antibodies against human hemoglobin, following several days later by complete colonoscopy. Chi-square was used to compare proportional data whereas Student t test to compare means. P < 0.05 was considered significant. This was a prospective stufy, All patients signed the informed consent The author has no finantial disclosures.

RESULTS:

A total of 100 patients being 36 men aged 67 ± 7 and women 64 aged 65,5 ± 8 P > 0.05, distributed by age in patients with colon neoplasia and positve occult blood in stools, 67 ± 6 N1 = 20, with negative occult blood in stools with neoplasia aged 68 ± 6 N2 = 11, with positive occult blood in stools without neoplasia 65,5 ± 9 N3 = 21 and negative occult blood in stools withou neoplasia 64,5 ± 8 N4 = 48 P > 0.05.Thirty-one (31%) of the patients had diagnosisof colon neoplasia, being 20 (64%) with positive occult blood in stools and 11 (35%) negative, P < 0.01. In the Group with positive occult blood in stools, two patients had diagnosis of adenocarcinoma, the others were adenomas. In the Group of negative occult blood in stools all were adenomas. We had 69 patients without neoplasia, of whom 21 (30.5%) had positive occult blood in stools and 48 (69%) negative, P < 0.01. In this Group without neoplasia, 12 (17%) had an abnormal colonoscopy, 5 (41.5%) with positive occult blood in stools and 7 (58%) negative P > 0.05. Abnormalities without neoplasia in patients with or withou occult blood in stools were angiodysplasia in ascending colon, shallow ulcer in ileocecal valve or ascending colon in NSAID user and uncomplicated diverticular disease.

CONCLUSION:

The age of the Group studied was similar, Adenocarcinoma only occurred in patients with positive blood in stools. Adenoma was present in positive and negative, although significantly more frequent in the positive ones. For bether conclusion, we need a greater number of asymptomatic people to be studied. The ideal test would be one that diagnoses cancer for treatment and adenoma for endoscopic prevention.
2859 Acetic Acid Chromoendoscopy in Barrett’s Esophagus Surveillance Is Superior to the Standardized Random Biopsy Protocol in Detecting Neoplasia: A Prospective Randomized Trial in a Community Setting
Authors: Castano Juan , Veeramachaneni Ravindra , Yamba Lana , Chacon Ingrid , Zamir Asif
Published: October 2019

INTRODUCTION:

Barrett's esophagus (BE) is the most important precursor lesion and risk factor for development of esophageal adenocarcinoma (EAC) with annual risk of 0.12–0.5%. Surveillance endoscopy with random biopsies of Barrett’s tissue at established intervals is recommended. Targeted biopsies may eliminate the need for random biopsies. Those found with earlier neoplasia during surveillance have the best prognosis. Acetic acid chromoendoscopy (AAC) has been found to be useful in increasing the yield of neoplasia detection during BE surveillance. Use of AAC in a community setting has not been investigated.

METHODS:

A prospective randomized clinical trial was done including patients 18 years and older with confirmed diagnosis of BE in a community setting in a South Texas gastroenterology office. A total of 104 patients were required. Patients from two gastroenterologists were included. Patients were recruited from a BE Surveillance Program and were screened via medical chart reviews. Exclusion criteria included history of esophageal ulcerations, esophageal Candida, esophageal varices, history of dysplasia, and history of ablation therapy. Patients were randomized into two groups. The intervention arm had the esophageal mucosa sprayed with 10cc of 2.5% acetic acid solution before inspection and biopsy. The control group underwent random biopsies as per guidelines.

RESULTS:

A total of 61 patients were enrolled and 30 were excluded including 18 due to negative biopsies, 10 due to missed appointments, and 2 due to esophagitis. A total of 31 patients were randomized (Acetic Acid n = 20, Control n = 11) and of these 1 patient had EAC at the target site [Acetic Acid n = 1 (5%), Control n = 0 (0%)]. It was found that 78% of the sample were patients with short segment BE (SSBE). Results suggested that the study was under-powered. A total of 1176 (Acetic Acid n = 588, Control n = 588) patients would be required in order for the study to have sufficient power to be statistically significant. The sample sizes required were not feasible for a single community practice; therefore, the study was discontinued.

CONCLUSION:

Our study was halted due to lack of sample power required to prove the hypothesis. The prevalence of neoplasia in our community was low given the high percentage of enrolled patients with SSBE. In order to validate this cost-effective technique in a community setting in the United States, a randomized trial with a larger collective effort involving multiple community centers will be required.
2861 Importance of Barrett's Surveillance in the Senior Population
Authors: Sheikh Akber , Godil Aslam , Chang Andrew , Foliente Roy , Hill Kevin , Brichler Benjamin
Published: October 2019

INTRODUCTION:

It is estimated that 5.6% of adults in the United States have Barrett’s esophagus (1). The annual cancer incidence in patients with Barrett’s esophagus is 0.1-0.4% per year, with it being higher among men, older patients, and patients with long segment Barrett’s mucosa. In patients with Barrett’s esophagus with low grade dysplasia (LGD), the annual incidence rates of esophageal adenocarcinoma (EAC) is 0.54% and of high-grade dysplasia (HGD) and/or EAC is 1.73%. Although the benefit of surveillance endoscopy remains unclear, current guidelines recommend surveillance endoscopy to detect dysplasia or EAC early enough to provide effective treatment. Currently there is no consensus on the age limit for Barrett’s surveillance, nor is there a recommended duration of surveillance. This may lead to endoscopic surveillance being performed without clear benefit. (2,3) Our aim was to assess the role of Barrett’s surveillance in detecting dysplasia and malignancy in all age groups; and evaluate the incidence and progression of Barrett's dysplasia to determine an age or duration limit to endoscopic surveillance.

METHODS:

A retrospective single center, longitudinal study was done by Sierra Nevada Gastroenterology Medical Associates, Inc., a community based gastroenterology group in Grass Valley, California. All outpatient upper endoscopies for Barrett’s screening and surveillance were included in the study. 300 electronic medical records were randomly selected and reviewed from Jan 2005 to Oct 2018. Data was collected on age, gender, race, ASA class, procedure findings, complications, pathology, and dysplasia status.

RESULTS:

See attached tables.

CONCLUSION:

In this study LGD was found in 10%, HGD in 0.3% and EAC in 0.3% of patients. In the subgroup of patients with LGD: 27% were detected in patients over 80 years old, 87% detected in patients with short Barrett's, 97% regressed to no dysplasia, and 3% progressed to HGD requiring ablation therapy. 16% of patients over 80 years old maintained or had dysplasia progress. Overall, 1 patient presented with EAC at index endoscopy. 91% of our study population had short Barrett's. There was no dysplasia before age 50 and dysplasia incidence increased with age. There were no endoscopy related complications. In patients over 80 years old, the incidence and progression of dysplasia remains significant. When evaluating endoscopy in this population, risks and benefits need to be considered, but age alone should not exclude a patient from surveillance.
2865 Acid Suppressants and Erosive Tooth Wear: An Analysis of National Health and Nutrition Examination Survey Data
Authors: Meek Reghan E. , Gumustop Derin R. , Rosenberg Jacob , Meek Patrick D. , Gumustop Bora
Published: October 2019

INTRODUCTION:

Antacids and acid suppressants (i.e., proton pump inhibitors and histamine2-blockers) are commonly used by individuals with heartburn and gastroesophageal reflux disease (GERD). Frequent heartburn and breakthrough symptoms of GERD have been shown to contribute to dental complications. The aim of this study is to compare the likelihood of erosive tooth wear (ETW) among users of antacids or acid suppressants.

METHODS:

We used data from the National Health and Nutrition Examination Survey (NHANES, 2003-2004) to identify a nationally representative sample of adults (age ≥ 18) who underwent an oral health exam by trained dental examiners. Self-reports of use of antacids and prescribed acid suppressants were collected by trained personnel during a home interview and used to classify individuals into groups. Erosive tooth wear was defined in NHANES using Smith and Knight's Tooth Wear Index modified by Millward, et al., which rates the severity of ETW from 0 (sound tooth surface) to 3 (complete loss of enamel). Erosive tooth wear was evaluated for 40 tooth surfaces; 24 proximal (facial or incisal) and 16 distal (lingual or occlusal) surfaces. Erosions were categorized based on location and severity. We used weighted linear and logistic regression to compare means and estimate the prevalence of erosions for each group. Estimates were adjusted for age, sex, and race/ethnicity.

RESULTS:

NHANES ETW data were available for 4,414 adults; antacid users (n = 595), acid suppressant users (n = 386), and non-users (n = 3,433). The mean number of assessable tooth surfaces varied between groups (P > 0.001). Erosive tooth wear was more prevalent among those who reported the use of antacids or acid suppressants compared with non-users, however the difference was not statistically significant (P = 0.06). The percent of patients with ETW on at least one distal tooth surface was higher for antacid and acid suppressant users (P = 0.01). In addition, acid suppressant users had a higher prevalence of extensive tooth wear (P = 0.007).

CONCLUSION:

Individuals using antacids or acid suppressants (potentially for control of acid-reflux symptoms) are associated with a higher rate of dental complications, as suggested by the prevalence of erosions on distal tooth surfaces. In addition, extensive erosions were more common among users of acid suppressants than non-users. Emphasizing the importance of following recommendations from the American Dental Association for routine dental care may be particularly important for these individuals.
2871 Obstructive Sleep Apnea Could Be a Hidden Cause for Gastroesophageal Reflex
Authors: Al-Aboodi Yasir , Al-Chalabi Ahmed , Muhammad Ali , Sodeman Thomas , Nawras Ali
Published: October 2019

INTRODUCTION:

Gastroesophageal reflex disease (GERD) and obstructive sleep apnea (OSA)are common conditions in the modern life. There have been stipulation that there might be association between GERD and OSA. In this study we tried to examined the association between them using a very large national data registry.

METHODS:

A binary logistic regression is performed to examine the association between OSA and GERD. The National Inpatient Sample (NIS) database for 2014 is used. Its the largest publicly available all payer data and it includes more than 7 millions inpatient admissions.The variables included in this study are identified using the international code for diseases version 9 (ICD9).

RESULTS:

5066557 with GERD diagnosis are included with mean age of 63 years (± 18). 40.8% are male and 59.2% are females. Majority of them are white (72.9%), (11.6%) black, Hispanic, (6.4%), Asians (1.4%), native Indians (0.5% and other (2.1%). Individuals with (OSA) are 2.4 more likely to have a diagnosis of GERD. (P < 0.000, CI (41-2.42), OR = 2.4). With control for known predisposing factors for GERD, patients with hiatal hernia has 5 times more likelihood to have GERD (P < 0.05; 95% CI (5.01-5.06), OR = 5.037). Scleroderma patients are 2.4 more likely to have GERD (P < 0.05; CI (2.29- 2.64; OR = 2.46). Obesity, smoking and alcohol abuse are 1.6 ,1.2 and 0.8 r are likely to have GERD respectively. (P < 0.05, 95% CI (1.59-160), OR = 1.60; P < 0.05, CI (1.24-1.250), OR = 1.253); P < 0.005, CI (81-0.830), OR = 0.824 respectively.

CONCLUSION:

Patients with obstructive sleep apnea are two times more likely to have GERD than people without OSA. . As our study design is cross sectional ,further Prorspective studies needed to confirm the association and or causation if any between GERD and OSA.