bluuebunny/crossref_metadata_2025 huggingface dataset:
1088 Achievement of SVR With Ledipasvir/Sofosbuvir in Patients With Hepatitis C and Moderate Chronic Kidney Disease May Lead to Improved Glomerular Filtration Rate
Authors: Obineme Chuma G. , Miller Lesley S.
Published: October 2019

INTRODUCTION:

Ledipasvir/Sofosbuvir (LDV/SOF) was approved for the therapy of hepatitis C virus (HCV) in 2014 and has become one of the most widely used direct-acting antiviral (DAA) therapies for HCV. There has been conflicting data in regards to the nephrotoxicity of LDV/SOF. Case reports and small studies have suggested a drug-induced intrinsic renal injury from treatment with LDV/SOF.

METHODS:

We assessed the renal function of patients who underwent 12-weeks of therapy with LDV/SOF in a safety-net hospital liver clinic. This was a single-center retrospective study and included all patients who achieved (sustained virologic response) SVR and were initiated on therapy from July 1st, 2015 to December 31st, 2015. Those who failed to achieve SVR or had combination therapies with non-DAA medications (i.e. ribavarin) were excluded. Charts were reviewed for demographics, baseline renal function and renal function at 12 weeks of therapy.

RESULTS:

A total of 88 patients were treated with 12 weeks of LDV/SOF therapy and completed renal function assessment at the start and at 12 weeks of therapy. Within the study group, the mean age was 57.2 years, 60 (68.2%) were men, 75 (85.2%) were African American, 34 (38.6%) had cirrhosis, and 45 (51.1%) had chronic kidney disease. Patients were followed for confirmation of SVR at 12 weeks. There was no significant difference between patients’ baseline creatinine and repeat creatinine after 12 weeks of LDV/SOF therapy (P = 0.835). Even in sub-group analysis where 51.1% of patients had chronic kidney disease, 38.6% had cirrhosis and 35.2% had type 2 diabetes no significant differences in creatinine were seen (P = 0.210, P = 0.388, P = 0.884 respectively). There were 2 (2.3%) patients who developed acute kidney injury (an increase of creatinine by 0.3mg/dL) during the course of therapy. 6 (6.8%) patients had clinical improvement in renal function (defined by decrease in creatinine of 0.3mg/dL). Patients who showed clinical improvement in renal function with HCV therapy had significantly lower baseline estimated glomerular filtration rate in comparison to the total study group (eGFR 76 vs 90 ml/min/1.73m2, P < .0001).

CONCLUSION:

In patients with HCV who underwent 12-week therapy with LDV/SOF and achieved SVR there were no significant differences in renal function after therapy. Patients with moderate chronic kidney disease (stages II and III) treated with LDV/SOF may preferentially show improvements in renal function if they achieve SVR.
1096 The Prevalence of Chronic Opioid and Benzodiazepine Use in Patients With Liver Cirrhosis: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Sarmini Muhammad Talal , Nehme Fredy , Young Mark , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Opioid and benzodiazepine use in cirrhotic patients is probably underestimated and results in a significant burden for both patients and the healthcare system. Recent epidemiologic studies reported an upward trend in the number of both prescriptions in this drug-sensitive patient population. This study therefore aimed to derive a robust prevalence estimate of chronic opioid and benzodiazepine use in patients with liver cirrhosis.

METHODS:

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May, 2019 to identify all studies that evaluated the prevalence of either chronic opioid use or benzodiazepine use in patients diagnosed with cirrhosis. We included studies that presented event rates with a 95% confidence interval (CI) or presented the data sufficient to calculate the event rate with a 95% CI. Although the definition of chronic opioid use varied between the involved studies, more than 60 days of either opioid or benzodiazepine use per annum was considered ‘chronic’ in this meta-analysis. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software.

RESULTS:

Seven studies with a total of 300472 patients with liver cirrhosis were included in the analysis of chronic opioid use with a pooled event rate of 34.7% (95% CI: 0.239 – 0.473) and a reported prevalence range of 22.3-64.7% among the included studies. (Figure 1) On the other hand, six studies with a total of 173127 patients with liver cirrhosis were included in the analysis of chronic benzodiazepine use with a pooled event rate of 15.9% (95% CI: 0.079 - 0.294) and a reported prevalence range of 7.9-37.1%. (Figure 2)

CONCLUSION:

Our results indicate that chronic opioid and benzodiazepine use are prevalent among patients with liver cirrhosis. This is clinically important as their use was shown to be associated with increased readmission rates, hepatic decompensation, and all-cause mortality. Physicians should be cognizant of the implications of prescribing these medications and consider pursuing other pharmacological and non-pharmacological forms of analgesia in this patient population.
1099 Epidemiology and Diagnostic Evaluation of Patients With Liver Abscesses at an Academic Hospital in Washington, DC
Authors: Cioffi Joseph H. , Siegel Marc
Published: October 2019

INTRODUCTION:

Liver abscesses often requires a multidisciplinary approach involving infectious diseases (ID), radiology, gastroenterology (GI) and occasionally surgery. Since there are no clinical guidelines for liver abscess management, regional epidemiology is important to refine management of these infections. This study reviewed the epidemiology, source evaluation and management of patients with liver abscesses in Washington, DC.

METHODS:

We performed a retrospective review of patients diagnosed with liver abscesses at our institution from 2012 through 2018. We reviewed patient demographics, predisposing conditions, abscess microbiology, hospital care and post-discharge management.

RESULTS:

105 patients were identified (mean age 57.1 years old, 62.9% men). 57.1% were African American (AA), 22.9% Caucasian, 7.6% Hispanic, 7.6% Asian, and 4.7% other races. 42.9% of patients had underlying risk factors including diabetes (21.9%), inflammatory bowel disease (4.8%), human immunodeficiency virus (3.8%), intravenous drug use (3.8%) and trauma (8.6%). 18.1% had known intraabdominal cancers (7 colonic, 5 pancreatic, 3 duodenal, 3 cholangiocarcinoma, and 1 ovarian). All patients underwent computed tomography, 52.4% ultrasound, 18.1% magnetic resonance imaging, and 6.7% MRCP. Abscess intervention was performed in 73.3% of patients. 56.7% of abscesses were monomicrobial and 43.3% polymicrobial. Cultures grew primarily Gram negatives (43%), followed by Gram positives (36.8%), anaerobes (11.4%), yeast (6.1%), and parasites (2.6%) (Figure 1). Blood cultures were positive in 41.9% of cases. ID was consulted in 68.6% of cases, while GI in only 39%. 23 patients underwent an inpatient procedure (14 ERCPs, 9 colonoscopies) with AA patients having statistically more ERCPs (21.7% vs 2.2%, P < 0.01). A source was identified in 69.2% of cases, with 32.4% having a biliary source. Those >50 years old were significantly more likely to have biliary disease than those < 50 years old (38.9% vs 18.2%, P < 0.05). When no source was identified, only 21.9% (7/32 patients) had outpatient GI follow up for further evaluation.

CONCLUSION:

Liver abscesses remain relatively uncommon. GI is not consulted in the majority of cases. Of concern is that a significant number of patients have no etiology identified and the majority of these do not get an appropriate outpatient evaluation. More frequent inpatient GI consultation, particularly for patients with no identifiable source, should be considered.
1105 Tenofovir Disoproxil Fumarate (TDF) to Prevent Hepatitis B Transmission in Mothers With High Viral Load in a Real World U.S. Cohort
Authors: Gayam Vijay , Wang Dan , Chen Bryan , Pan Calvin Q.
Published: October 2019

INTRODUCTION:

Maternal TDF treatment during the third trimester has been shown to reduce perinatal transmission of the hepatitis B virus (HBV) in highly viremic women in several RCTs. However, the data is limited on the effectiveness of TDF in the real-world setting. With this real-world study, we aimed to assess the efficacy and safety of TDF therapy for these mothers in a single center in the US.

METHODS:

All Hepatitis B e-antigen positive mothers with HBV DNA >6log10 copies/mL who received TDF in the third trimester and delivered from July 2010 to September 2018 were retrospectively analyzed. All infants received hepatitis B immunoglobulin and vaccination at birth and subsequently. Primary endpoints were the safety of TDF use and mother-to-child transmission rates. Secondary outcomes were maternal HBV DNA level suppression at delivery.

RESULTS:

Among the 75 patients enrolled, the mean (±SD) age of the patients was 30.47 ± 4.49 years, mean (±SD) gestational age was 37.87 ± 2.95 weeks, and the mean (±SD) treatment duration before delivery was 9.60 ± 3.36 weeks. A significantly lower level of the mean (±SD) serum HBV DNA was achieved at delivery vs. baseline (4.2 ± 1.2 vs. 7.6 ± 0.80 log10 copies/mL, respectively; P- < 0.01). Additionally, 80% (60/75) of mothers achieved HBV DNA < 6log10 copies/mL at delivery. The median (Interquartile range) alanine aminotransferase (ALT) level before treatment was 26 (20) IU/L, and at delivery was 27 (20) IU/L respectively. Vertical transmission rate among infants was 0%, and all infants were hepatitis B surface antigen negative between 28 -52 weeks after birth. Fatigue was the most common complaint reported by 52% (39/75) of mothers. No infants had a birth defect. On treatment, ALT flares were observed in 4.5% (6/75) of mothers.

CONCLUSION:

In this US cohort of real-world practice, TDF therapy for highly viremic mothers was well tolerated and reduced vertical transmission effectively. No severe adverse effects were reported in both mothers and infants. Our study supports the use of TDF treatment for highly viremic mothers in a real-world setting.
1135 What Causes Marginal Ulceration Following Gastric Bypass?
Authors: Duarte-Chavez Rodrigo , Martins Noel B. , Chaput Kimberly J. , Mehta Sagar V. , El Chaar Maher
Published: October 2019

INTRODUCTION:

The obesity epidemic affects more than one-third of the USA adult population, and over 350 000 bariatric procedures are performed annually. While bariatric surgery results in long lasting weight loss and resolution of comorbidities, complications can occur after surgery. Marginal ulceration (MU) is the most common complication following Roux-en-Y gastric bypass (RYGB), with an incidence reported to be between 1-9%. The etiology of MU is largely unknown but is believed to be secondary to technical aspects of the surgery as well as local factors such as inflammation and underlying macro and microvascular damage.The objective of this study is to investigate non-surgical factors and comorbidities that may contribute to the incidence of MU based on a national database.

METHODS:

After Institutional Review Board exemption was granted, we retrospectively reviewed the National Inpatient Sample database from 2003 to 2011. ICD-9 codes were used to abstract data including RYGB for obesity, gastrojejunal (GJ) ulcer, Helicobacter pyloriinfection (HPI), use of NSAIDs, use of aspirin, diabetes, hypertension, obstructive sleep apnea (OSA) and smoking. We compared groups using chi-squared and unadjusted odds ratio (OR). Multivariate logistic regression analysis was performed to adjust for confounders

RESULTS:

34830 patients with GJ ulcer after RYGB for obesity were identified. In univariate analysis, OSA had the highest OR of all the variables (91.22), whereas aspirin use had the lowest (3.09). All the listed factors were associated with increased risk for MU (Table 1). During multivariate analysis, NSAID use had the highest OR (13.14) followed by HPI (5.08) and OSA (4.03). Aspirin use was not found to be associated with the development of MU in our multivariate analysis (Table 2).

CONCLUSION:

To our knowledge this is the largest study assessing the risk factors for MU after RYGB for obesity and the first to report that OSA strongly correlates with the presence of MU. Our analysis demonstrated that the most significant risk factors for development of MU were in decreasing order NSAID, HPI, OSA and Smoking. Studies using bariatric specific databases should examine the issue. Prospective studies are also required to determine if correction or optimization of these risk factors can prevent MU after RYGB.
1165 Improving the Accuracy of Health Maintenance Reminders in the Electronic Medical Record to Promote Adherence to Colonoscopy Surveillance Guidelines
Authors: Kishfy Louis , Dimino Jennifer , Borges Lawrence
Published: October 2019

INTRODUCTION:

Health Maintenance (HM) reminders in the Epic electronic medical record (EMR) offer an opportunity to increase adherence to recommended colonoscopy surveillance intervals. However, HM reminders must be updated by providers with specific knowledge of surveillance guidelines, and providers must be comfortable using the HM functionality. This quality improvement initiative aimed to improve the rate at which gastroenterologists accurately update HM colonoscopy surveillance recommendations.

METHODS:

1,602 colonoscopies performed by 7 gastroenterologists at a single community hospital were tracked prospectively between April 2018–February 2019. For each colonoscopy, the gastroenterologist’s post-procedure surveillance recommendation was compared to the HM surveillance recommendation in the patient’s Epic EMR. Accuracy was defined as concordance between these two recommendations. After obtaining baseline data, group and individual performance rates were disseminated and the gastroenterologists underwent an educational intervention to improve familiarity with the HM functionality. Monthly HM accuracy rates were tracked for the subsequent 6 months. Accuracy rates in the post-intervention month and the last month of follow-up were compared to baseline using the student’s T-test.

RESULTS:

The baseline HM accuracy rate for the group was 69% overall and 56% for high-risk patients (defined as a recommended surveillance interval of ≤5 years). For the month immediately following the intervention, the overall accuracy rate rose significantly compared to baseline (86% vs 69% overall, P ≤ 0.001; 80% vs 56% for high-risk patients, P ≤ 0.001). However, for the last month of follow-up the overall accuracy rate had decreased back to baseline (70% vs 69%, P = 0.646). The high-risk accuracy rate in the last month remained significantly higher than baseline but had also declined (65% vs 56%, P = .008). Notably, 82% of discordant HM reminders recommended a longer surveillance interval than was clinically indicated.

CONCLUSION:

Sharing performance data and provider education can significantly improve the rate at which gastroenterologists accurately update colonoscopy HM surveillance intervals in the EMR. However, a single intervention is not sufficient to sustain this improvement over time. Repeated intervention is needed to ensure that HM surveillance intervals remain accurate, particularly since the majority of discordant HM reminders recommend a longer surveillance interval than is clinically indicated.
1171 National Burden of Gastrointestinal Tuberculosis: Insights From the Nationwide Inpatient Sample
Authors: Shah Ishani , Bhurwal Abhishek , Mehta Harsh , Kadkhodayan Kambiz
Published: October 2019

INTRODUCTION:

Gastrointestinal tuberculosis (GI TB) is a rare and morbid extrapulmonary manifestation of TB. There is scant published data regarding the prevalence of GI TB. ThE aim of our study was to assess the overall burden of inpatient GI TB in the United States. We also looked at demographic characteristics, comorbidities and all-cause inpatient mortality among patients with GI TB.

METHODS:

All adults hospitalized with the diagnosis of either gastric TB or intestinal TB or both, during the years 2010 to 2014, were identified using the Nationwide Inpatient Sample (NIS). Patients with tuberculous associated peritonitis were also included. We studied racial, regional and gender-specific characteristics of these patients. Other demographic data such as risk factors and comorbidities were also identified. Outcomes of interest included inpatient mortality and length of stay.

RESULTS:

During the five-year study period, there were a total of 2,300 inpatient hospital admissions for GI TB. We observed a downward trend in the prevalence of GI TB in the US during this time (469 vs 340 vs 380 vs 329 vs 78; P = 0.56) (Figure 1). Patients affected were predominantly Hispanic (36.04% vs 53.99% vs 24.78% vs 30.17%; P = 0.002) in all four regions. Several other comorbidities and conditions were identified as enlisted in Table 1. The overall inpatient mortality (6.25% vs 1.20% vs 2.61% vs 3.24%; P = 0.206) and mean length of stay (18.11 vs 9.07 vs 10.56 vs 14.57 days; P = 0.001) were highest in the NE region as compared to MW, SO and WE regions. In addition, hospitalized patients with GI TB were less likely to be female in Northeastern (NE) states (30.91% vs 56.29% vs 51.64% vs 50.64%; P = 0.05) as compared to Midwest (MW), Southern (SO) and Western (WE) states.

CONCLUSION:

Since the introduction of antituberculous therapy, the global and national overall burden of GI TB has decreased significantly. It is, however, important to note that although rare, GI TB continue to affect high-risk patient populations such as immigrants, prisoners, HIV patients and patients who are immunocompromised from receiving various biologic agents for treatment of several autoimmune diseases. Our study shows that although prevalent, overall inpatient admissions associated with GI TB have been decreasing over the last few years; however they are associated with high mortality. Our study highlights continued prevalence of GI TB amongst inpatients in the US, and emphasizes the importance of clinical suspicion when evaluating high risk patients.
1174 Cases of Angiotensin Receptor Blocker (ARB) Related Sprue-Like Enteropathy (SE): A Review of the Food and Drug Administration Adverse Event Reporting System (FAERS)
Authors: Khattab Ahmed , Burroughs Sarah , Villines Dana , Ehrenpreis Eli
Published: October 2019

INTRODUCTION:

In 2002, olmesartan, an ARB, was introduced to the market as Benicar. In 2012, Rubio-Tapia et al. reported 22 cases of SE related to olmesartan. In 2013, the Food and Drug Administration (FDA) issued a safety warning about SE related to olmesartan. In August 2017, Benicar’s manufacturer paid $300 million to settle claims from about 2,300 plaintiffs in SE cases. The FAERS is a publicly available database for voluntary reporting of adverse drug events to the FDA. No study has summarized the reports of ARB-related SE to the FAERS. Our aim is to establish the timeline of FAERS reports of SE from ARBs and to further characterize reports of olmesartan and another ARB-related SE to the FAERS.

METHODS:

A total of 9,144,290 FAERS reports from January 2013 to December 2018 were downloaded. Data was first queried for all patients using an ARB for hypertension. All drugs were limited to those defined as “Primary Suspect”. Gastrointestinal adverse events (GIAE), including SE and control reactions were then obtained for all ARBs and searched by both generic and trade names. Information regarding the timeline of reports and demographics of reporters was collected. Reporters are categorized as physicians, pharmacists, other health care professionals, consumers, and attorneys.

RESULTS:

A total of 77,245 FAERS reports of people for ARBs were analyzed. SE was identified in 5,290 (6.8%) cases. With the exception of 6 cases, all were related to olmesartan. All olmesartan cases were filed under its trade name Benicar. In addition to the SE cases reported, there were 7,402 (9.6%) cases of GIAE related to ARB. These included drugs other than olmesartan. The number of reports filed by each category each year is shown in Table 1 and Figure 1. Cases of SE were followed, and their outcomes identified (Table 2). Hospitalization was reported in 52.7% and death in 0.9%.

CONCLUSION:

The FDA reports for olmesartan-related SE and ARB-related GIAE have increased dramatically. Unlike some high-profile cases with dramatically increased lawyer reporting, these reports originate from physicians and consumers. All reports were for Benicar, none for generics and a few reports for combinations. This can be explained by the minimum of 2 years of ARB use prior symptoms onset suggested in the literature. Other explanations include Benicar’s large market share or potential problems with the Benicar formulation.
1181 Prevalence of Celiac Disease-Compatible Human Leukocyte Antigen Haplotypes Across Ethnicities and Regions in the United States
Authors: Kelly-Goss Molly R. , Lebwohl Benjamin , Zhan Jianan , Nhan Hoang , Koelsch Bertram , Kim Esther , Mountain Joanna , Green Peter H R
Published: October 2019

INTRODUCTION:

The prevalence of celiac disease (CD) is widely variable throughout the United States (US), with a higher prevalence of disease in the Northeast. The reasons for this variability are unknown. In a prior study, we detected ethnic differences within the US, using a name-based algorithm, with prevalence in patients of Jewish ethnicity similar to the overall population, and lower in persons of East Asian ethnicity. CD etiology is dependent on human leukocyte antigen (HLA) haplotype. Typically, either HLA DQ2.5 or DQ8 is required (but not sufficient) for the development of CD, with DQ2.5 being the highest-risk haplotype. To date, no study has characterized regional or ethnic differences in the frequency of CD-compatible HLA haplotypes. Thus, we aimed to measure the frequencies of DQ2.5 and DQ8 across regions and ethnicities in the US.

METHODS:

We assessed the frequencies of HLA DQ2.5 (DQA1*05:DQB1*02) and DQ8 (DQA1*03:DQB1*03) in an unselected group of genotyped individuals who have used direct-to-consumer genetic testing between 2013 and 2017. Eligible participants were 23andMe customers who consented to participate in research. We assayed two SNPs to classify individuals as DQ2.5 homozygous, DQ2.5 heterozygous, DQ2.5/DQ8, DQ8 homozygous, DQ8 heterozygous, and 0 detected variants. We compared the frequency of each haplotype across four regions of the US. Additionally, we used genome-wide array data to cluster participants into 8 categories that correlate highly with self-reported race and ethnicity, and compared the frequencies of these haplotypes across these ethnic categories (Table 1).

RESULTS:

Of 1,290,668 individuals studied, at least one CD-compatible haplotype was present in 38.7% of individuals, and this frequency was similar across the four US regions. The frequencies of DQ2.5 homozygotes were also similar across the Northeast, Midwest, South, and West (1.25%, 1.43%, 1.38%, and 1.37%, respectively). In contrast, frequencies differ across ethnic groups: the highest DQ2.5 and DQ8 frequencies were observed in European (12.01%) and Ashkenazi Jewish (16.39%) participants, respectively.

CONCLUSION:

Previously reported regional variability in CD prevalence in the US may not be due to differences in HLA-based susceptibility; rather, other genetic or environmental factors likely play a role in disease pathogenesis. In addition, these differences carry great significance in view of the development of HLA haplotype-specific non-dietary therapies for CD.
1206 Gastric Emptying Scans: Adherence to National Guidelines
Authors: Wise Journey , Vazquez-Roque Maria , Crowell Michael D. , Lacy Brian E.
Published: October 2019

INTRODUCTION:

Gastric-emptying scintigraphy (GES), routinely used to measure gastric emptying, is an essential tool to diagnose gastroparesis. An accurate diagnosis of gastroparesis relies upon the GES being performed according to a validated protocol. Jointly published protocol guidelines have been available for over a decade; however, the extent to which these guidelines are adhered to is unknown. This study aimed to assess national compliance with established GES protocol guidelines.

METHODS:

We developed a questionnaire addressing key protocol measures outlined in the published Procedure Guideline for Adult Solid-Meal Gastric Emptying Study 3.0. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), and reporting (7). Demographic data was also collected. The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. Data were entered manually and statistically assessed using JMP®, Version 14.0. SAS Institute Inc., Cary, NC.

RESULTS:

121 medical institutions (MI) responded; 49 (40.4%) were academic/teaching medical centers. The mean number of annual GES procedures was 199.9 (range, 5 to 2000 GES/year). On average, MI performed 64% (33.5/52) of protocol measures according to guidelines while academic medical centers performed 61% (31.5/52) of protocol measures according to guidelines. Only 59% of MI use the validated meal. 42% of MI reported stopping imaging prior to the validated 4-hour interval. Only 16% of MI test blood glucose levels prior to GES while 71% cancel or reschedule GES if blood glucose levels are above the validated cut-off. 68% of MI ask patients if they take narcotic pain medications; only 49% require that patients stop taking narcotic pain medications at least two days prior to the GES. Only 4.5% of MI perform GES while adhering to 3 critical measures: validated study duration; controlling blood glucose levels; and properly restricting medication use.

CONCLUSION:

Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and thus improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines.
1207 Differences of Gastric Cancer Characteristics Between With and Without Helicobacter pylori Eradication
Authors: Kodama Masaaki , Okimoto Tadayoshi , Mizukami Kazuhiro , Ogawa Ryo , Okamoto Kazuhisa , Matsunari Osamu , Fukuda Kensuke , Murakami Kazunari
Published: October 2019

INTRODUCTION:

Although the rate of gastric cancer (GC) after Helicobacter pylori (H. pylori) eradication has gradually increased over time, the features of GC following eradication remain to be examined. In this study, we investigate the clinicopathological features of GC following eradication in comparison with those of GC with H. pylori infection.

METHODS:

50 subjects with GC following eradication [HP(-) group] and 151 patients with GC with H. pylori infection [HP(+) group] were enrolled in this study. Clinicopathological features, such as age, gender, endoscopic atrophy, tumor form, location, depth of invasion, histology, were assessed. The manifestation of GC was further evaluated using immunohistochemistry of Ki-67, CDX22, p53, claudin18, E-cadherin, c-myc and In situ hybridization for detecting Epstein-Barr virus (EBV).

RESULTS:

Macroscopic analysis revealed a significantly higher ratio of depressed type/elevated type in HP(-) group compared with HP(+) group (30/19 vs. 61/77, P = 0.041). Tumor size was significantly greater in HP(-) group compared with the HP(+) group (13.02 ± 7.10 vs. 16.53 ± 11.12, P = 0.0019). The gastric mucin phenotype was more predominant in HP(-) group compared with HP(+) group, and the proportion of CDX2-positive cases was lower in HP(-) group (8 out of 18; 44.4%) compared with HP(+) group (18 out of 19; 94.7%) (P = 0.00082). Ki-67 labeling index was significantly lower in HP(-) group (32.03 ± 22.15) compared with the HP(+) group (79.20 ± 14.87, P < 0.0001). No patient in HP(-) group showed significant expression of EBV infection.

CONCLUSION:

The clinicopathological characteristics of GC following H. pylori eradication differ from those of GC in patients with H. pylori infection in morphology, mucin phenotype, and proliferation rate. It is necessary to be careful about these differences in GC screening.
1215 Helicobacter pylori Infection in Cancer Patients: MD Anderson Cancer Center Experience
Authors: Alasadi Mazen , Alasadi Mazen
Published: October 2019

INTRODUCTION:

Helicobacter Pylori infection is prevalent worldwide. Up to 50% of the world population is affected, with or without symptoms. H. pylori infection can lead to gastritis, gastric or duodenal ulcers, gastric cancer, and rarely gastric mucosa-associated lymphoid-tissue lymphoma. Patients with cancer are exposed to several factors that can affect H. pylori behavior, such as chemotherapy, radiotherapy, and other treatment modalities. Also, the diminished immunity of cancer patients might be a risk factor for H. pylori or play a role in the responsiveness of H. pylori disease to treatment. Nonetheless, clinical features and outcomes of H. pylori in cancer patients are not well studied. We aimed to describe clinical symptoms, treatments, and outcomes of H. pylori in cancer patients.

METHODS:

We retrospectively collected information from adult cancer patients who had a diagnosis of H. Pylori after cancer diagnosis between January 2010 and November 2018. Descriptive statistics were used to summarize the data. T-tests and Pearson's Chi-Square were used to compare variables by cancer type.

RESULTS:

A total of 101 cancer patients diagnosed with H. Pylori by gastric biopsies were included, 61 males and 40 females with a mean age of 58.82 years. Asian was the most common race (n = 28), followed by Hispanic (n = 20) and White (n = 20). Reflux disease was present in 52 patients, hiatal hernia in 19, and Barrett's esophagus in 13. The most common cancer type was those of the gastrointestinal tract (n = 45), followed by lymphoma (n = 16) and breast (n = 14). Regarding cancer treatment, 15 patients had surgery, 51 had chemotherapy, and 35 had chemoradiation. The most common presenting symptom was abdominal pain (n = 45) then bloating (n = 30). Complications of H. pylori infection were manifested as gastric ulcer in 7 patients, duodenal ulcer in 3 and Gastrointestinal bleeding in 4. H. Pylori was treated with Prevpac in 45 patients and Pylera in 36. A 72 patients had response to treatment with the infection recurred in 14 patients.

CONCLUSION:

In cancer patients with H. Pylori infection, Asian was the most common race, abdominal pain was the most common presenting symptom, GI cancer was the most common malignancy followed by lymphoma and breast cancer. 71% had responded to the treatment.
1288 Cystic Artery Pseudo-Aneurysm: A Rare Cause of Hemobilia and Jaundice
Authors: Rafiq Rehan , Rafiq Ariej S.
Published: October 2019

INTRODUCTION:

Aneurysms of the hepatic artery or its branches are rare, representing 0.01-2% of all arterial aneurysms.1 Causes of cystic artery aneurysms include abdominal trauma and intra-abdominal inflammatory processes such as cholecystitis.2 We present a case of gastrointestinal bleeding, jaundice and colicky right upper quadrant abdominal pain (Quincke's clinical triad) as a result of a ruptured pseudo-aneurysm of cystic artery.

CASE DESCRIPTION/METHODS:

A 79-year-old white man with a past history of cholecystectomy presented with colicky right upper quadrant pain, jaundice and melena. Physical examination showed stable vital signs. He had icterus. He was mildly tender in the epigastrium and right upper quadrant on palpation. His CBC showed a white cell count of 16.5 K/UL, hemoglobin 13.8 GM/DL, and hematocrit 42%. LFTs showed total bilirubin of 7.50 MG/DL, direct bilirubin 5.30 MG/DL, AST of 379 IU/L, ALT of 798 IU/L, and alkaline phosphatase was 337 IU/L. An ERCP was performed. The ERCP showed blood clots at the ampulla. Cholangiogram showed multiple filling defects consistent with blood clots. This was treated with placement of biliary stent. CT showed hemorrhage next to a fusiform pseudo-aneurysm measuring 13 × 6 mm, which appeared to arise in the region of the cystic artery. Embolization of pseudo-aneurysm resolved the patient's symptoms.

DISCUSSION:

Pseudo-aneurysm of cystic artery after laparoscopic cholecystectomy is rare. One report identified 27 published cases.3 It can occur up to 120 days after surgery.4 Among the possible causes are the excessive use of electrocautery and erosion of the cystic artery caused by the metal clip used to occlude the cystic duct.5 Pseudo-aneurysm of the hepatic artery or its branches presents with hemobilia in about 20% of cases in the early postoperative period.4,6 The classic triad of upper gastrointestinal bleeding, pain in the right upper quadrant and obstructive jaundice described by Quincke is present in 32% of patients.7,8 In our patient, the possibility of a pseudo-aneurysm was only considered after imaging. Angiography established the diagnosis. Doppler ultrasound is an alternative means of detecting the aneurysm.9 In patients with gastrointestinal bleeding, EGD and ERCP may be performed before arteriography.10,11 Transarterial embolisation is the treatment of choice in the presence of hemorrhage.6,10,12 When there is compression of the bile duct or a fistula or failure of embolisation, surgery is needed to repair or ligate the artery involved.7
1294 Large Common Bile Duct Stones Creating a Rare Distal Choledochoduodenal Fistula Requiring Unusual Extraction Method
Authors: Dinh Brian , Chen Patrick , Beck Gregory
Published: October 2019

INTRODUCTION:

Choledochoduodenal fistulas (CDF) are abnormal connections of the common bile duct to the duodenum separated into proximal and distal. Of the various enterobiliary fistula, the most common is cholecystoduodenal. The rare occurring distal CDF etiologies include cholecystolithiasis, malignancy, peptic ulcers and iatrogenic. In the case presented, common bile duct (CBD) stones were large enough to create a fistula from the common bile duct superior to the sphincter of Oddi requiring unique extraction.

CASE DESCRIPTION/METHODS:

A 75-year-old Caucasian female with past medical history significant for biliary colic status post cholecystectomy was found to have multiple large CBD stones on abdominal ultrasound outpatient. Physical exam and laboratory analysis was unremarkable. When the ERCP was performed, the papilla was identified and noted be abnormal. The papilla was downward facing. Shockingly, superior to the papilla was a CDF created by an impacted black CBD stone. Subsequently to this unexpected finding, selective deep cannulation of CDF, adjacent to the CBD stone, was done using a sphincterotome with a 0.035 wire. No attempts were made of cannulating the papilla. The cholangiogram showed multiple CBD stones throughout the distal CBD. A 13 mm sphincterotomy superiorly at the CDF, followed by balloon sweeps removing several large yellow cholesterol appearing stones.

DISCUSSION:

Distal CDF is diagnosed via endoscopy and categorized based on location using the Ikeda classification. Type 1 (distal) fistulas occur along longitudinal fold adjacent to the papilla, often due to an impacted stone. Type 2 (proximal) occurs on the posterior wall of the duodenal bulb. The classification system further separates CDF into type A, opening greater than 2 cm from the papilla, type B, opening within 2 cm from the papilla, and type C, opening on the papillary fold. In this rare case of distal CDF, the diagnosis was likely type 1A (distal and greater than 2 cm from the papilla). Treatment is often based upon the etiology of CDF formation. Given the rare occurrence, it is important for gastroenterologist to be aware of the classifications as it may assist in treatment and safe stone removal.
1334 Malakoplakia Mimicking Pancreatic Cancer
Authors: Iriana Sentia , Voaklander Rebecca , Hubbard Lauren , Rogers Douglas , Sossenheimer Michael
Published: October 2019

INTRODUCTION:

Malakoplakia is an indolent immune disorder of the urinary tract with isolated reports of skin, brain, and GI involvement. It may present as a mass, and is sometimes associated with malignancy. We report a patient on immunosuppression for heart transplantation who presented with a pancreatico-duodenal mass and biliary obstruction from malakoplakia.

CASE DESCRIPTION/METHODS:

A 67- year old heart transplant patient presented with fevers, malaise, leukocytosis and right upper quadrant pain. MRCP demonstrated a heterogeneously enhancing 10 cm pancreatic head mass. EUS with FNA for cytology, AFB, fungal, and aerobic/anaerobic cultures were obtained. Histology showed malakoplakia without malignancy. E.coli grew from one culture and was treated with ceftriaxone and metronidazole. He developed jaundice with worsening biliary and pancreatic duct obstruction and enlargement of the mass on repeat MRCP. ERCP showed a large periampullary ulcerated mass and distal common bile duct stricture. Histology, cultures, flow cytometry, and viral testing of the mass and brushings from the CBD showed histology consistent with malakoplakia. Cultures were positive for MAI complex, Candida guilliermondii, and staphylococcus epidermidis. Treatment with ampicillin-sulbactam, fluconazole, azithromycin, doxycycline, ethambutol, ganciclovir, and moxifloxacin resulted in clinical improvement and decreased size of the mass. Fluconazole, doxycycline and bethanechol as adjunctive therapy will be continued until imaging resolution of malacoplakia.

DISCUSSION:

Malakoplakia is a rare inflammatory reaction characterized by infiltration of large foamy macrophages, triggered by infections in immunosuppressed patients. While mostly found in the urogenital tract, the GI tract is the second most common site where malakoplakia may occur, and if mass forming may mimic malignancy. Antibiotics with intracellular penetration are required to treat the organisms that have been phagocytized by macrophages. In malakoplakia, decreased intracellular cyclic-guanosine monophosphate (cGMP) ratios alter microtubule function and decrease β-glucuronidase release, resulting in impaired phagolysosomal digestion. Bethanechol increases cGMP levels and ascorbic acid promotes phagosome bactericidal activity, theoretically resulting in more effective bacterial killing. This report highlights malakoplakia as a potential masquerade for pancreatic cancer, an important differential consideration in immunosuppressed patients.
1341 Not so Incidental: A Case of Incidentally Found Isolated Metastatic Melanoma of the Pancreas
Authors: Estepp Kayla , Meidinger Ross , Peng Hong Qi
Published: October 2019

INTRODUCTION:

Metastatic lesions of the pancreas are uncommon, with reported frequencies of intrapancreatic metastases ranging from 4.5% to 11%, with isolated metastases around 2% of cases. Metastases from malignant melanoma is quite rare, with fewer then 200 cases reported in literature.

CASE DESCRIPTION/METHODS:

79-year-old female who presented to ED in June 2018 with fever, dysuria, and dyspnea. Past medical history significant for prednisone dependent sarcoidosis, atrial fibrillation, and basal cell carcinoma. Labs showed elevated WBC and UA concern for UTI. She was admitted for treatment. CT scan was done due to dyspnea showing LLL consolidation. Incidentally, a new 2.6 × 1.8 cm mass within the pancreas neck was seen. At discharge she was referred to our facility for EUS and FNA. EUS showed a pancreatic mass abutting the superior mesenteric vein without invasion. Cytological analysis obtained by EUS-FNA (Figure 1) showed malignant melanoma with abundant melanin pigments (Figure 2). Positive for Sox-10, Melan A and HMB-45. Referral to medical oncology was made for further work-up. PET scan was preformed due to lack of previous melanoma history, showing no evidence of disease outside the pancreatic area (Figure 3). With no primary lesion identified further referrals to Dermatology and Ophthalmology, however these evaluations were negative for overt cutaneous or ocular melanoma. Colonoscopy was performed and showed no lesions. Due to the isolated lesion, deemed an appropriate candidate for resection. September 2018, partial pancreatectomy and regional lymph node resection completed. Pathology of the 4.5 cm pancreatic neck mass, in addition to celiac and portal lymph node, consistent with malignant melanoma. October 2018 started immunotherapy of Opdivo and Ipilumimab. Repeat PET scan showed nodule along right flank, superior to iliac crest, FDG avid, suspicious for melanoma and thought to be the sight of primary lesion. Tolerated immunotherapy well, but in December 2018, was admitted due to respiratory distress secondary to aspiration pneumonia, was transitioned to comfort cares due to worsening clinical status, passing away.

DISCUSSION:

This case is a unique presentation of an isolated metastatic pancreatic melanoma, found incidentally in an otherwise asymptomatic patient. With the widespread use of imaging, clinicians can expect an increasing number of “incidentalomas” being found, stressing the role of EUS-FNA in gaining a precise diagnosis which is critical in the overall prognosis and management of patients.
1359 A Case of Pancreatic Pseudoaneurysm
Authors: Gurala Dhineshreddy , Idiculla Pretty Sara , Polavarapu Abhishek , Daoud Magda , Gumaste Vivek
Published: October 2019

INTRODUCTION:

Pancreatic Pseudoaneurysm is a rare vascular complication of chronic pancreatitis. It may lead to fatal complications if left untreated. Here we report a case of pseudoaneurysm from a gastroduodenal artery in a patient with chronic pancreatitis which was managed successfully with coil embolization.

CASE DESCRIPTION/METHODS:

30-year old male with history of alcohol abuse, chronic pancreatitis, and splenic vein thrombosis on Xarelto presented to emergency department with epigastric pain. He was recently discharged from the hospital after an episode of acute pancreatitis. On admission, the pain was dull, radiating to the back with nausea but no vomiting, hematemesis or melena. Physical examination was grossly unremarkable. He was hemodynamically stable and blood work was unremarkable except for lipase 318 U/L. Computerized tomography of abdomen showed development of a pseudoaneurysm branching from the gastroduodenal artery with pancreatic inflammatory changes and fluid collections (Figure 1). Interventional Radiology were consulted, angiography was performed with coil embolization of inflow, outflow vessels, and the pseudo aneurysmal sac (Figures 2 and 3). His hemoglobin remained stable, and his symptoms resolved. Diet was advanced and Xarelto was resumed. He was discharged on the third day to follow up as outpatient.

DISCUSSION:

Pancreatic pseudoaneurysms are formed by erosion of the pancreatic or peripancreatic artery into a pseudocyst. These may occur after pancreatitis, as well as after pancreaticobiliary surgery, pancreatic transplantation, trauma, and motor vehicle accident. They are classified according to the artery they originate from, communication with gastrointestinal tract and exposure to pancreatic juice. Most commonly involved is splenic artery due to its proximity to the pancreas, followed by gastroduodenal artery, pancreaticoduodenal arteries, then superior mesenteric, left gastric, hepatic and small intrapancreatic arteries. Gastro-Duodenal Pseudoaneurysm commonly presents as gastrointestinal bleeding secondary to rupture. It can also present as abdominal pain, asymptomatic, rarely as retroperitoneal bleed or bleeding into pancreatic duct or common bile duct, which can cause obstructive jaundice. Treatment modalities include either embolization or surgery. Surgery is necessary when embolization is unsuccessful. Prompt diagnosis and early treatment of pancreatic pseudoaneurysm is mandatory because of potentially life-threatening consequences and increased mortality if left untreated.
1363 A Rare Case of Heterozygous Hemochromatosis Presenting as Recurrent Pancreatitis
Authors: Alomari Mohammad , Patel Ankit , Al Momani Laith , El Kurdi Bara , Khazaaleh Shrouq , Young Mark
Published: October 2019

INTRODUCTION:

Hemochromatosis induced pancreatitis is a relatively rare cause of acute pancreatitis that may complicate further into chronic or recurrent pancreatitis. However, heterozygous hemochromatosis is an exceptionally rare cause of overt disease with only a few cases reported to date. Herein we describe a case of heterozygous hemochromatosis solely presenting as recurrent pancreatitis.

CASE DESCRIPTION/METHODS:

A 32-year-old female patient with a past medical history of hypertension presented to our emergency department with epigastric pain of one-day duration. Her only medications were labetalol 300 mg and lorazepam 0.5 mg with reported alcohol use of two glasses of wine up to two to three times a week. On arrival, blood pressure was 177/116 mmHg. All vital signs were otherwise within normal limits. Physical examination was significant for mild epigastric and left upper quadrant tenderness. Initial laboratory workup was remarkable for elevated AST at 197 U/L, ALT of 63 U/L, alkaline phosphatase 124 U/L, and total Bilirubin 1.5 µmol/L. Lipase was within normal limits at 69 U/L. Urine toxicology screen was negative. IgG-4 level was within normal limits as well as triglycerides at 67 mg/dL. Magnetic resonance imaging of the abdomen (Figure 1) showed mild hepatomegaly and hepatic steatosis. The pancreas and gallbladder showed no acute changes. Hepatobiliary iminodiacetic acid (HIDA) scan showed a decreased ejection fraction at 6% (Figure 2). Magnetic resonance cholangiopancreatography (Figure 3) showed signs of chronic pancreatitis and a dilated pancreatic duct proximally. Signal characteristics in the spleen and marrow compartment suggested iron deposition leading to a more thorough investigation for hemochromatosis and hence transferrin saturation level returned elevated at 86% and ferritin at 800. She tested heterozygous for the C282Y mutation. The patient was managed conservatively and discharged home with plans for initiation of phlebotomy. The patient's transferrin saturation and ferritin normalized and reported no recurrent episodes of pancreatitis on follow up at 7 months.

DISCUSSION:

Hemochromatosis is a condition of iron overload and deposition leading to various organ dysfunction. On that spectrum, pancreatitis is considered an extremely rare manifestation, never mention, the sole presenting manifestation of this disease. Clinicians should be cognizant of the variety of medical conditions that can cause pancreatitis and investigate them when clinically indicated.