bluuebunny/crossref_metadata_2025 huggingface dataset:
2870 Flexible Endoscopic Diverticultomy: Development of a Community-Based Referral Program and Ways to Improve Efficiency and Outcomes
Authors: Sharma Neil , Krishnakurup Jay , Rumancik Brad , Kota Sharwani , Gopakumar Harishankar , Kanuru Reshi , Zelt Christina , Gupta Saurabh , Grabowski Michael
Published: October 2019

INTRODUCTION:

Until recently Flexible endoscopic diverticulotomy (FED) has not gained momentum among GI endoscopists in USA due to a variety of reasons including new skill set, referral patterns, procedural risks and complexity. Thus far it has been limited to select university hospitals, restricting its availability. We present a case series of FED performed in our community hospital system.

METHODS:

Retrospective review was performed from the start of the FED program over 3 months in 2018. We established a new multi-disciplinary Advanced GERD & Esophageal Services (PAGES) program through which patients were reviewed and selected. All were performed by a single interventional ESD (endoscopic submucosal dissection) trained endoscopist.

RESULTS:

Mean age 69yrs; mean Eckardt score (EDS) 5. Prominent symptoms were dysphagia and weight loss. Diagnosis was established by imaging or EGD. ESD knives were used. Clips were placed on the diverticular base. The thickness and length of the cricopharyngeal bar varied from 0.7- 3 cm (mean: 1.8) and 3- 5 cm (mean: 3.6) respectively. Total operative time depended on the length of the septum, thickness, the type of knife used and varied from 25-168 min (mean:62). The transition from other ESD knives to scissor type knives reduced our operative time by 50% (168 down to 40min) (Table 1). Patients were discharged home 6 hrs post-procedure. A routine predischarge esophagogram was obtained to document complete excision of cricopharyngeal bar. One case of intraoperative bleeding was controlled using a coagrasper. No blood transfusions or second endoscopic procedures were required to control bleeding. One patient was readmitted within 24 hrs of discharge for control of N/V. The success of the procedure was measured using 4 week post-operative EDS. Three of five patients achieved complete symptom resolution at week 1. Two patients had occasional dysphagia (EDS:1) and regurgitation (EDS:1) respectively. All were symptom free at the end of week 4 (EDS: 0 -1) (Table 2).

CONCLUSION:

Transoral FED gives the gastroenterologists the opportunity to be the forerunners in managing ZD. The vast majority of these patients present to GI physicians with a complaint of dysphagia. The development of the multi-disciplinary program to identify and triage patients, scissor type ESD knife, and a fellowship trained advanced endoscopist are the recipe to success for a tertiary community program.
2872 Efficacy of Robotic Dor Fundoplication on Severe Nocturnal Gastroesophageal Reflux Disease in Patients With Scleroderma
Authors: Loganathan Priyadarshini , Davis Brian , McCallum Richard
Published: October 2019

INTRODUCTION:

Scleroderma is a systemic disease and its effect on the GI tract is atrophy and replacement fibrosis of the smooth muscles. The esophagus is invariably involved and approximately eighty percent of patients with scleroderma develop both gastroesophageal reflux disease (GERD) and dysphagia. The nocturnal GERD can lead to regurgitation and aspiration which further worsens the pulmonary fibrosis from scleroderma. Performing the standard fundoplication would worsen their dysphagia. Aim- Our goal was to investigate whether a Dor fundoplication (a 270-degree anterior wrap) can reduce nocturnal heartburn and regurgitation without worsening of the dysphagia in patients with scleroderma and severe GERD.

METHODS:

5 scleroderma patients with drug refractory severe GERD underwent Dor fundoplication procedure (Figure 1) with a median follow up of 18 months. All had undergone a preoperative high-resolution manometry documenting very impaired esophageal motility. Patients were interviewed post operatively and were assessed for nocturnal and diurnal GERD symptoms and treatment response, status of dysphagia and adverse effects of surgery.

RESULTS:

All 5 patients were female with average age 50 years (range 36-65). 4 of the 5 patients (80%) reported 90% improvement in both diurnal and nocturnal GERD symptoms since surgery, they no longer suffered from nocturnal reflux, heart burn or regurgitation and that they are able to sleep well at night without requiring any more pillows or wedges. 50% of patients reported decrease in their proton pump inhibitor dosage after surgery compared to before surgery. There was no surgical complication reported and specifically no worsening of dysphagia. 100% of the patients were able to belch, burp better effectively after surgery. 4 out of 5 patients reported that they would strongly recommend this surgery to another scleroderma patient suffering from drug refractory GERD symptoms. In one patient, there was no change in symptoms after the surgery but no worsening of dysphagia.

CONCLUSION:

Robotic Dor fundoplication is very effective in drug refractory GERD secondary to scleroderma dominated by nocturnal regurgitation. This procedure resulted in significant symptom reduction in 80% of our patient group which in turn improved their quality of life and nocturnal sleep without affecting dysphagia.
2879 Evaluating the Pattern of Probiotic Use by Patients and Gastroenterology Providers
Authors: Park Sa Ra , Kim Margaret , Lee Daniel , Wynter Javelle , Copland Andrew , Frye Jeanetta
Published: October 2019

INTRODUCTION:

Probiotic use for management of GI conditions is becoming more popular, as it is perceived to be a natural and low-risk therapeutic option. Despite their increasing use, how patients choose to use probiotics or how GI providers make recommendations has not been well-studied. This survey aims to characterize the pattern of probiotic use by patients and GI providers.

METHODS:

Surveys were distributed to patients seen at a GI clinic at a single tertiary medical center. Surveys were also distributed to GI providers who attended a regional postgraduate course. Survey questions included basic demographics, indication for probiotic use, subjective clinical response to probiotics, side effects, brand of probiotics, and factors that influenced choice of probiotics.

RESULTS:

76 patient surveys and 58 provider responses were collected. Patients used probiotics for general digestive health (22%), IBS (17%), and GERD (16%), while providers recommended probiotics for IBS (81%), Clostridioides difficile infection (64%), and IBD (45%). For symptoms, patients used probiotics to treat abdominal pain (38%) and bloating (26%), while providers recommended it for bloating (76%) and diarrhea (71%). 45% of patients reported improvement of GI symptoms, whereas 21% reported no improvement. Side effects were uncommon, but bloating and diarrhea were most frequently reported. Providers recommended specific brands and bacterial strains, while patients took a wide variety of brands without knowing specific strains. Most patients (82%) chose to take probiotics without their provider’s recommendations. Patients’ selection of probiotics was driven by cost, variety of strain, and number of colonies forming units. 91% of providers felt the need for more specific guidelines on probiotic use.

CONCLUSION:

This study shows that patients and their gastroenterologists have vastly different probiotic “prescribing” patterns. Despite a relative lack of evidence for many conditions, probiotics were frequently utilized. Patients use probiotics for different symptoms and conditions than physicians and have remarkably different factors that influence selection of a probiotic. Providers should proactively discuss current evidence on probiotic use and help patients identify key features and differences between probiotic products.
2880 Prevalence of Irritable Bowel Syndrome Among Medical Students of Puerto Rico
Authors: Velasco-Corrada Paloma , Amill Reinaldo Ramirez , Torres Esther
Published: October 2019

INTRODUCTION:

Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain and altered bowel habits. A high prevalence has been reported in medical students around the globe. Data in the population of Puerto Rico (PR) is sparse. This study aimed to investigate the prevalence of IBS and associated risk factors in medical students in PR.

METHODS:

A cross sectional study was conducted in a sample of medical students from first to fourth year currently enrolled at the University of Puerto Rico School of Medicine. Participants completed a self-administered, anonymous questionnaire that contained questions about general socio-demographic data, lifestyle habits, degree of subjective psychological stress and the Rome III criteria: IBS Module. Students were grouped as preclinical (first and second year) and clerkship (third and fourth year) for comparison. Results were analyzed using Chi-square (X 2) test and Fisher's exact test. A P value < 0.05 was considered statistically significant. Statistical analysis was performed using STATA software v. 11.1.

RESULTS:

314 medical students (137 preclinical and 177 clerkship students) were included for analysis. The mean age was 24.8 ± 3.25; 48.1% were females. The prevalence of IBS was 36.3% (33.1% for females and 39.3% males; P = 0.291). Among the IBS subjects, 78 (24.8%) were classified as IBS-M (mixed). Family history of IBS, psychological stress and cigarette smoking were significantly associated to IBS (P < 0.05). There was no significant difference in the presence of IBS between preclinical and clerkship students (45 of 137 [32.85%] versus 69 of 177 [38.98%]; P = 0.262). No statistically significant relationship was found between IBS and age, gender, BMI, eating habits, exercise frequency, and caffeine consumption.

CONCLUSION:

This is the first study to describe the prevalence of IBS in medical students in PR. A higher prevalence of IBS was found as compared to that reported for medical students in other countries. Moreover, when comparing to the general population of North America and other Hispanic groups in both Central and South America, the prevalence rate of IBS in our students was higher. Additional studies aimed at estimating the impact of IBS on quality of life and academic performance of the medical students are essential. Studies focusing on determining the prevalence of IBS in the general population of PR as well as identifying other associated factors are also needed.
2881 Can Eluxadoline Be Useful in Managing Patients With Functional Diarrhea?
Authors: Vizuete John A. , Randall Charles W. , Martinez Nicholas
Published: October 2019

INTRODUCTION:

Eluxadoline is an FDA approved medication for use in patients with irritable bowel syndrome with diarrhea (IBS-d). It is a peripheral mu-opioid receptor agonist resulting in a reduction in colonic motility while antagonizing central delta receptors that modify pain and thus targets the two key components of IBS-d. Functional diarrhea (FD) is similar to IBS-d, but there is no pain with FD and there are currently no FDA approved medications for its treatment. This caseseries examines the efficacy of eluxadoline in managing FD.

METHODS:

Electronic medical records at a private gastroenterology clinic were reviewed from May 2015-present. Patients must have undergone diagnostic evaluation including stool elastase, lactoferrin, breath testing, celiac serology, and both upper and lower endoscopy with biopsies. Detailed clinical histories and medication reconciliation were also performed to exclude other causes for diarrhea. Patients found to have other FGIDs, IBD, bowel obstruction, malabsorption, or cholecystectomy were excluded. Patients must also have failed or demonstrated intolerance to OTC anti-diarrheals, dietary changes and supplemental fiber, and anticholinergics or tricyclics. Eligible patients were treated for 6 months with open label eluxadoline and clinical follow up was required. All patients began 100 mg bid, but were allowed to reduce the dose to 75 mg bid if constipation or abdominal discomfort occurred. There were 2 primary endpoints: Improvement in Bristol Stool Scale (BSS) and decrease in daily stool frequency by 30%.

RESULTS:

Eleven patients with FD were identified by Rome IV criteria and were included in the series. All completed 6 months of therapy with eluxadoline. Patients had a mean BSS of 6.2 (range 6-7) and mean daily stool frequency of 4.8 (range 3-10) at baseline. Eight patients (73%) satisfied both clinical endpoints with an average reduction in stool frequency to 2.8 (range: every other day to 4 per day). The mean BSS decreased from 6.2 to 4.2, with a range of 2-5. 2 patients developed constipation but responded to the lower dose. The remaining 3 patients (27%) showed moderate clinical improvement but did not meet one or both of the primary endpoints.

CONCLUSION:

1. Eluxadoline may be an effective tool in managing FD where conventional therapy has failed. 2. The length of the trial demonstrated durability. 3. This open label case series should stimulate interest into funding a blinded placebo controlled trial.
2882 Analysis of Risk Factors for Poor Bowel Preparation in Hospitalized Patients
Authors: Dickson Zachary , Park Sa Ra , Tung William , Douglas Scott R. , Haug Rebecca , Shenoy Abhishek , Milner Paul , Desai Nisa , Earasi Athidi , Wynter Emmett , Hunold Thomas , Powell Steven
Published: October 2019

INTRODUCTION:

Poor bowel preparation for colonoscopy is associated with reduced diagnostic yield, increased risk of perforation, and longer length of hospitalization. Prior studies have demonstrated inpatient status as a risk factor for poor bowel preparation. Research at our institution has identified risk factors that are associated with poor bowel preparation, but this study consisted primarily of an outpatient population. The aim of this study is to investigate the impact of known risk factors on bowel preparation quality in an inpatient population.

METHODS:

A retrospective chart review was performed for all patients undergoing inpatient colonoscopies from July 2017 - April 2019 at a single academic medical center. ICU patients were excluded. The indication for colonoscopy, amount of bowel preparation (4L vs >4L of polyethylene glycol), and documented quality of the bowel preparation (adequate vs poor) were reviewed. Previously identified risk factors for poor bowel preparation including gender, type 2 diabetes (T2DM) with end-organ damage, COPD, neurologic disease (stroke, dementia, Parkinson’s disease), TCA use, opioid use, and laxative use were recorded. Association of risk factors with poor bowel preparation was analyzed using chi-square tests.

RESULTS:

306 patients underwent inpatient colonoscopy. 42 patients (13.7%) had poor bowel preparation. 31.7% (n = 13) of patients with at least 3 risk factors had poor bowel preparation while only 11.5% (n = 29) of patients with two or less risk factors had poor bowel preparation (P = 0.01). This statistically significant relationship was upheld when controlled for standard colonoscopy preparation (P = 0.03). Among the 42 patients with poor bowel preparation, 54.7% (n = 23) were male, 38% (n = 16) had active opioid use, 26% (n = 11) had T2DM with end-organ dysfunction, 26% (n = 11) had active laxative use, 14.2% (n = 6) had neurological disease, 11.9% (n = 5) had COPD, and 2.3% (n = 1) had active TCA use.

CONCLUSION:

To date, there is not a nationally accepted risk stratification system for identifying patients at high risk for poor bowel preparation in the inpatient setting. This study shows that patients with at least 3 risk factors were associated with a higher incidence of poor bowel preparation in hospitalized patients. Recognition of these risk factors and individualized bowel preparation could lead to a reduction in the incidence of poorly visualized colonoscopies in the inpatient setting.
2883 How Well Are We Prepped? Synopsis of Quality of Bowel Prep at a Community Hospital
Authors: Khuttan Akhilesh K. , Tripathi Shalini , Ale Shirisha , Charilaou Paris , Yegneswaran Balaji
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the third most common cause of cancer death in the United States in women, and the second leading cause of death in men. Colonoscopy involves visual inspection of colonic mucosa for detection of pre-cancerous lesion and possible intervention to prevent CRC. The success of the procedure is closely linked to adequacy of bowel preparation. However, up to 20-25% of preparation are inadequate for colonoscopies. Poor bowel prep can lead to inadequate mucosal surveillance, with failure to detect a pre-cancerous lesion, requiring rescheduling which further increases health care cost and patient dissatisfaction. In our study, we have analyzed quality outpatient colonoscopies.

METHODS:

Retrospective analysis of bowel preparation in outpatient colonoscopy during the period of 03/01/2019 to 03/29/2019. Data was collected from medical records and included date of procedure, indication, physician performing the procedure, findings, quality of bowel preparation.

RESULTS:

Total 99 charts were reviewed. Mean age was 60.35 years; Male to Female ratio was 9:10. Among the indication of colonoscopy 32.3% were for diagnostic study and 67.7% were screening and follow-up studies. 70.7% of bowel prep were reported as qualitative scoring (The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology Taskforce), 25.2% had quantitative scoring of Boston Bowel Preparation Score (BBPS) and 4% had no scoring. Among qualitative scoring 12.8% were excellent, 57.1% were good, 4.3% were adequate, 15.7% were fair, 1% were suboptimal or satisfactory preparations. Of quantitative scoring almost all preparations were more than or equal to 6, among these 36% had BBPS score of 9. In 60.6% cases where polyps were detected, 33.3% cases had qualitative assessment of good preparation with only 1% being excellent preparation and 6.7% had BBPS of 6 and 9 respectively. Polyp detection was noted in 11.7% of fair preparations.

CONCLUSION:

Highest percentage of polyp detection was observed in good bowel prep or BBPS of 6. Variation in scoring method qualitative versus quantitative was observed, which remains an area of endoscopist preference.
2888 Hospitalization for Colonoscopy Preparation and Its Effects on Prep Quality
Authors: El-Halawany Hani , Khan Shahryar , Elkafrawy Ahmed A. , Choudhry Iqra , Poonia Jasmin , Abuamr Khalil
Published: October 2019

INTRODUCTION:

Colonoscopy is the most commonly used method for colon cancer screening. The quality of prep greatly affects the examination. Risk factors for inadequate prep include prior inadequate prep, male gender, prior surgery, diabetes, low health literacy and cognitive delay. Studies have shown improvement in colonoscopy prep using split-dosing however despite this, inadequate prep continues to be a problem. One solution at our institution is to hospitalize selected patients with prior failed outpatient colonoscopy prep in an attempt to improve the prep quality.

METHODS:

We retrospectively identified all patients who were hospitalized for colonoscopy prep from 2016 to 2018. Patients who did not have documentation of prep quality were excluded. Data including age, gender, indication for procedure and presence of risk factors was gathered. The prior prep quality and prep quality after admission was documented.

RESULTS:

122 patients were included in the study. “Screening” was the most common indication for the procedure. Most of the patients had at least one risk factor for inadequate prep. 90 patients had improvement in their prep quality.

CONCLUSION:

Bowel prep continues to be inadequate in up to 25% of examinations. Several patient related risk factors for inadequate prep have been identified in previous studies. Patients who have risk factors for slow bowel transit such as immobility, CVA and chronic use of narcotics can also be factors in colon prep. We believe the improvement in bowel prep in our study is related to adherence to dietary restrictions, accurate laxative consumption, and improved assessment of stool clearance. Our study also showed a significant number of improved bowel prep quality in patients who had risk factors for poor prep. The cost of hospitalization was not evaluated in our study. We believe that an adequate bowel would result in a longer time-interval for subsequent colonoscopies and reduced overall cost. Our study is limited given its retrospective design and small number of patients. In addition, given that our software does not allow use of the Boston Bowel Prep Scale, the results may be difficult to generalize to other populations. Repeat studies would be needed to assess cost effectiveness. Quality of bowel prep continues to be a barrier to high quality colonoscopy. This study shows that hospitalized bowel prep may help improve prep quality in a select group of patients in the underserved population and with known risk factors.
2889 Upper and Lower Gastrointestinal Endoscopy and Concomitant Anesthesia in a Central Canadian Province: A Population-Based Study
Authors: Singh Harminder , Derksen Shelley , Sirski Monica , McCulloch Scott , Lix Lisa
Published: October 2019

INTRODUCTION:

There are limited data on upper and lower gastrointestinal endoscopy (GIE) and concomitant anesthesia in universal health care systems, despite their increasing use. All Canadian provinces advocate for fecal occult blood test based colorectal cancer screening, which theoretically should lead to less lower GIE use. We evaluated the time trends and variations in use of upper and lower GIE and concomitant anesthesia in the province of Manitoba between April 1, 1984 and March 31, 2017.

METHODS:

Physicians claims reimbursement data from the provincial health ministry were used to ascertain upper, lower GIE and anesthesia use. Provincial population in each year was determined from the registrants’ database. Hospitalization discharge database was used to identify procedures performed in hospitals. Generalized linear models with generalized estimating equations were used to test the linear trend over time and differences amongst age groups, health regions, income quintiles. Logistic regression analysis with generalized estimating equations was used to assess predictors of anesthesia use.

RESULTS:

410, 685 individuals had at least one procedure between 1984-2017. Although approximately half of the procedures were performed outside the recommended CRC screening age group of 50-74 years (38% among those less than 50 years), the rate of increase stabilized among the > 75 years group over the last 5 years of the study (Figure 1). There were marked regional differences in the last ten years, with the slowest increase in the largest urban region (Figure 2). There were much more marked variation in anesthesia use, ranging from 1% in the largest region to 80% in a rural region (Figure 3).

CONCLUSION:

There are marked variations in GIE use and concomitant anesthesia use in a universal health care system. The potential good news is that the rate of GIE use is no longer increasing among the older individuals. We have identified several endoscopist factors which could lead to targeted information dissemination, individual provider review and feedback and continuing medical education initiatives.
2891 Designing the GI Cloud
Authors: Shergill Annie , Narasimhan V. Lakshmi , Garg Deepti , Sala Amruth K.
Published: October 2019

INTRODUCTION:

Gastroenterology is a field of medicine that has its roots deeply embedded in the technological revolution of the 21st century. It emerges as a specialty dominated by ever-evolving imaging and diagnostic modalities that have surpassed archaic means of diagnosing and treating various GI disorders. This article highlights advancement in Cloud computing technology that has the potential to change the way healthcare professionals in GI work in the inpatient and outpatient setting. Cloud based technology for storing, retrieving and manipulating patient specific data is set to transcend from being used in government or corporate organizations to outpatient and inpatient GI services.

METHODS:

A comprehensive review of cloud computing and its application to facilitate a cohesive method of functioning that ties one end of the expanding patient database and procedural reporting to the other end of effective reproduction and recall of this data.

RESULTS:

An emerging challenge in the field of GI today is the need to accommodate an enlarging patient database, while concurrently balancing a myriad of quality determining factors, such as information security, privacy, reliability and interoperability of data. Considering this, Cloud based technology emerges as the single most vied advancement to address this issue. The Cloud environment refers to the practice of using a network of remote servers hosted on the internet to store, manage and process data, rather than a local server or a personal computer. Cloud computing can transform the way information technology is consumed and managed, resulting in improved cost efficiencies, accelerated innovation and the ability to scale applications on demand.

CONCLUSION:

Groundbreaking advancements always stem from the absolute need to bring about a change in the existing methodology. There is a void emerging from the disparity between increasing volume of patient specific data and a concomitant lack of infrastructure to handle the same. There is also an increasing need to introduce automated features that facilitate patient specific data storage, search, retrieval and processing. Hence, the quest to pursue cloud based technology as the mainstay of data handling and processing in GI. In a dynamic field like GI, brand new concepts are crucial to challenge those that already exist and alternative techniques and modalities are vital. Therefore, Cloud computing offers an efficient solution to several data processing problems and issues encountered in GI.
2894 The Gastrointestinal Phenotype of Cowden’s Syndrome and Effects of Surveillance
Authors: Khare Anshika , Burke Carol A. , Leach Brandie , O'Malley Margaret , LaGuardia Lisa , Eng Charis , Mankaney Gautam
Published: October 2019

INTRODUCTION:

Cowden’s syndrome is an autosomal dominant hamartoma syndrome characterized by germline mutations in the phosphatase and tensin (PTEN) homolog gene, the protein product of which negatively regulates the PI3K-AKT-mTOR pathway. Clinically, individuals develop multiple hamartomas in body tissues, including the stomach and colon, and have a high risk of developing cancer. To mitigate the risks, individuals undergo upper and lower endoscopic surveillance. The effectiveness of endoscopic surveillance and polypectomy remains unknown.

METHODS:

17 individuals who met relaxed international Cowden consortium criteria and had undergone at least two upper or lower endoscopies were included. We describe polyp number, size, location, pathology, and interventions over the surveillance period.

RESULTS:

The average age was 69 (43-88). 6 were males and 11 females. Average number of upper and lower endoscopies was 2 (1-8) and 5 (2-14), respectively. The average interval between upper and lower endoscopies was noted to be 2.64 years (standard deviation = 1.53) and 3.03 years (standard deviation = 2.14). One patient developed a cancerous polyp that was identified on the second colonoscopy. The polyp was located in the transverse colon and removed via snare polypectomy. Pathology showed invasive adenocarcinoma. Patient underwent colectomy with ileocolic anastomosis without chemotherapy. 68.5% of upper and lower endoscopies had an intervention performed including polypectomy with cold biopsy forceps (n = 40), cold snare (n = 7), hot biopsy forceps (n = 16), and hot snare (n = 33). Polyp pathologies in the stomach and upper intestine included hamartomas (n = 4), hyperplastic (n = 6), adenomas (n = 2), and fundic gland polyps (n = 6). Polyp pathologies in the colon included hamartomas (n = 14), hyperplastic (n = 40), ganglioneuromas (n = 2), adenomas (n = 81), inflammatory (n = 4), and sessile serrated (n = 7). 3 patients had more than one upper endoscopy, 2 of whom had a decrease in polyp size while 1 had no change. In the colon, the sizes of the polyps decreased over time in 11 of the 17 patients, 4 did not change, and 2 had an increase in size.

CONCLUSION:

We show that the overall size of polyps decrease in both the stomach and colon with endoscopic surveillance. One patient had a malignant polyp treated with endoscopic polypectomy.
2897 Prognostic Factors for Identifying Etiology of Subacute Drops of Hemoglobin in Hospitalized Patients Without Overt Gastrointestinal Bleeding
Authors: Raman Daya
Published: October 2019

INTRODUCTION:

Studies have shown hospitalized patients have a decrease in hemoglobin (Hb) concentration with no overt blood loss. GI consultation and endoscopy are routinely requested for a decrease in Hb. In this study, we retrospectively reviewed hospitalized patients who had a subacute drop in hemoglobin without evidence of GI bleeding. Our aim was to identify prognostic factors that could be predictive of endoscopic findings.

METHODS:

Electronic health records were obtained to identify patients admitted to our hospital from October 2016 to May 2018 that had undergone an endoscopic procedure during their hospitalization. Next, we excluded those with an admitting diagnosis of a gastrointestinal bleed (hemorrhage, melena via ICD10 code). We then manually identified those with a subacute drop in Hb, defined as a drop in Hb ≥ 3 from baseline admission. This resulted in a cohort of 113 patients. Hb changes for each patient were examined and the maximum drop in Hb was categorized into four groups: minimal drop was defined as 3-3.5 mg/dL, moderate drop was 3.6–5.5 mg/dL, high drop 5.6-7.5 mg/dL and very high drop >7.5 mg/dl. Endoscopic procedure outcomes for each patient were analyzed and grouped into either category “bleed” or “no bleed”. “Bleed” was categorized as an ulcer, frank bleeding, varices and/or neoplasm which are lesions that can be the cause of drop in Hb. Normal endoscopy, gastritis, duodenitis, and/or polyps were categorized as “no bleed” which are unlikely the cause in drop in Hb.

RESULTS:

Sixty-two patients (56%) belonged to the "no-bleed group" and fifty-one patients (44%) to the “bleed” group. Patients with minimal Hb drop were found to be predominantly in the “no-bleed” group, 85% compared to 15% for the “bleed” group. There were equal numbers of "bleed" and "no bleed” patients in both the moderate and high Hb drop groups. For very high Hb drop >7.5, the number of patients in the "bleed" group were greater than "non-bleed" group, 71% vs 29%. Comorbidities such as HTN, Type 2 Diabetes, CAD, Liver disease, CVA, GERD, and Kidney disease were also considered in association with a subacute drop in Hb and outcomes of bleed vs. no bleed. Using multivariate modeling, patients with Diabetes or those receiving packed RBCs were found to have a statistically significant predictor of "bleed", P-value 0.047 and 0.044, respectively.

CONCLUSION:

For the majority of patients, the primary reason for a subacute drop in hemoglobin is multifactorial and cannot be unambiguously attributed to GI bleed.
2899 Description of Outcomes in Inflammatory Bowel Disease Patients With Granuloma on Histology: A Single-Center Experience
Authors: Wehbe Hisham , Hosni Mohammad N. , Binion David , Hashash Jana G.
Published: October 2019

INTRODUCTION:

It has been suggested that the presence of granulomas on surgical pathology of patients with Crohn’s disease (CD) is associated with a more aggressive disease phenotype. We sought to investigate the outcomes of patients who had granulomas present on their surgical specimens.

METHODS:

This was a retrospective chart review that identified all inflammatory bowel disease patients who had the word ‘granuloma’ listed on their pathology report, whether from an endoscopic procedure (EGD or colonoscopy) or surgical resection specimen. We search reports from 1997 to 2019. All patients who had an intestinal granuloma were identified. Demographic, clinical, and histologic information was obtained from the medical records of these patients.

RESULTS:

A total of 41 CD patients were found to have a granuloma on their surgical specimen; 8 were found on a surgical resection specimen while 33 were found on endoscopic biopsies. Of the 41 patients, 53.7% were males, 41.7% were smokers, and the average age at diagnosis of these patients was 32 ± 15 years. The most common site for granuloma detection was the ileum accounting for 23 cases (56%). A total of 13 patients had granulomas present in more than one site/location (31.7%). The median C-reactive protein within 2 weeks of colonoscopy for patients with granuloma was 16.5mg/L; IQR 2.9-58 (normal < 2.5mg/L), median erythrocyte sedimentation rate was 25mm/hr; IQR 15-45 (normal 17.5mm/hr), and median hemoglobin of these patients was 12g/dL; IQR 10.3-13.6 (normal 12.5g/dL). Of the 41 CD patients with granulomas, 42.5% were on a biologic agent, 41% on an immunomodulatory, and 20% had received a steroid at any time for their disease. A total of 9 patients (24.3%) had stricturing disease, 15.2% had a history of an intra-abdominal abscess, and 13.9% had a history of peri-anal disease. A total of 32.5% of granuloma CD patients had an intestinal resection and 34% had a CD related hospitalization.

CONCLUSION:

As part of this study, we are hoping to match (age and gender) our CD patients with granulomas to CD patients who were not found to have granulomas on their surgical specimens and to compare the outcomes amongst these groups. Based on our descriptive data of the granuloma patients, we suspect that these patients will a more aggressive disease course.
2904 Influenza and Pneumococcal Vaccination in Patients With Inflammatory Bowel Disease: Findings From a Large Safety Net Hospital
Authors: Ajose Taiwo A. , Kagbokue Suaka , Gboluaje Temitayo , Abe Temidayo , Ajose Afolarin , Chineke Iloabueke , Simien Melvin , Richter Seth
Published: October 2019

INTRODUCTION:

Inflammatory Bowel Disease (IBD) inherently predisposes to infections due to a lack of appropriate innate and adaptive immune responses to infectious agents. Immunomodulators and biological therapies further increase the risk of infections in IBD patients by dampening the immune response of an already dysregulated intestinal immunity. Many of these infections are preventable with vaccinations. Advisory committee on immunization practices recommends pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPSV23) and annual influenza vaccine for all IBD patients. Despite these recommendations, vaccination rates continue to be suboptimal. We present our findings on the vaccination rate at a large safety net hospital.

METHODS:

We hypothesized that vaccination rate are low at most outpatient centers. In order to test this, we retrieved electronic medical records (EMR) from one of the outpatient departments of a large safety net hospital between November 2017 and March 2018. Patients with a diagnosis of IBD were identified and EMR were reviewed. Data regarding influenza vaccine, PCV13, PPSV23, immunosuppressive medications and comorbidities were obtained. Microsoft Excel and SPSS software version 21 were used for data management and analyses. Two-sided P-value < 0.05 was considered statistically significant.

RESULTS:

181 patients were included in the study, 51.9% female and 48.1% male. Majority were African American (86.7%). The mean age was 45 years with 56.9% of patients being ≤49 years, 38.7% were between 50-69 years and 4.4% were over 70 years. 59.1% of patients were on immunosuppressive therapy. Overall, only 54.1% received an annual influenza vaccine. 24.9%, received PPSV23 alone, 4.4% received PCV13 alone and 13.8% patients received both P13 and PPSV23. Patients within the ages of 50-69 years were more likely to receive influenza vaccine (r = 0.358, P < 0.001). 43.1% of our patient populations were uninsured and 53.5% were unemployed.

CONCLUSION:

Our study revealed suboptimal implementation of national recommendation on influenza and pneumococcal vaccination among IBD patients at the selected institution, consistent with previous studies. We also found that older age predicts vaccination uptake. We propose that continuous education on the vaccination guidelines should be consistently provided to physicians involved in the care of IBD patients. Incorporating reminder alerts and patient education materials on vaccination guidelines in the EMR might improve its uptake and rate.
2907 Knowledge and Perception of Gastroenterologists Regarding Medical Marijuana Use in Patients With Inflammatory Bowel Disease
Authors: Santiago Artemio , Torres Esther
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease is a chronic debilitating condition whose cause is still not completely understood. Goals of therapy include relief of symptoms, mucosal healing, decrease in need for hospitalization and surgery and improved quality of life. Giventhe varying results achieved with conventional medical therapy, patients are turning to a variety of complementary and alternative options for relief, cannabis products being one of the most common. In 2014, Puerto Rico (PR) legalized medicinal marijuana including Crohn's and ulcerative colitis as indications. We questioned whether the gastroenterology community was prepared to confidently and correctly answer the questions brought by their patients. The purpose of this study was to collect data regarding Puerto Rican gastroenterologists' knowledge, comfort and perceptions regarding medical cannabis use in patients with IBD.

METHODS:

An anonymous 20 question online survey was distributed among gastroenterologists and trainees who are members of the Puerto Rican Gastroenterology Association. The protocol was approved by the MSC IRB.

RESULTS:

Forty-five responses (25% response rate) were received and analyzed. Participants were mostly males (69%) between the ages of 25-45 (63%) and mainly have private practices (56%) in the metropolitan area (60%). 71% of physicians see less than 15 patients with IBD in one month. Most of the participants (85%) feel informed regarding IBD practice guidelines, and uninformed (51%) regarding their knowledge of the endocannabinoid system. 20% of participants are aware of the requirements to obtain medical marijuana in PR and only 42% know the approved indication. 75% of physicians think that cannabis should be a therapeutic option for IBD patients, however only 40% would recommend it to their patients. 46% of participants reported that their patients have used cannabis for IBD, and pain (80%) is the most common reason. 86% of gastroenterologists cite medical literature as the leading factor in their decision to recommend its use or not and 100% of them would be interested in receiving more information regarding this topic.

CONCLUSION:

Puerto Rican gastroenterologists are misinformed regarding medical cannabis use in patients with IBD. Although the study sample is small, it highlights the need for education in our community to improve patient care. Strategies to address this concern are needed and would be well received by physicians.
2915 Acute Pancreatitis and Celiac Disease—Is There an Association?
Authors: Wadhwa Vaibhav , Gupta Kapil , Gonzalez Adalberto , Singh Harjinder , Garg Sushil , Bilal Mohammad , Lara Luis
Published: October 2019

INTRODUCTION:

The association of Acute Pancreatitis and Celiac Disease (CD) has been sparingly reported in the literature. CD is known to affect approximately 1% of the western population. A Swedish national database study reported a 3-fold increased risk of developing pancreatitis in patients with CD. The exact mechanism of this is unknown but it could be related to untreated celiac disease affecting the major papilla causing stenosis or exocrine pancreatic insufficiency that has been reported previously. The aim of this study was to look at the association between acute pancreatitis and celiac disease. We also looked whether there was any association between chronic pancreatitis and celiac disease.

METHODS:

We performed a retrospective cross-sectional cohort study using the 2013 National Inpatient Sample (NIS) database. We included all patients who were hospitalized with either acute pancreatitis (ICD Code 577.0) or Chronic Pancreatitis (577.1). Patients who had diagnoses of both acute and chronic pancreatitis were considered to have acute on chronic pancreatitis and combined with the chronic pancreatitis group. We then analyzed both groups for presence or absence of celiac disease. Continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. All analyses were performed using SAS Survey Procedures (version 9.4, The SAS Institute, Cary, NC).

RESULTS:

We analyzed more than 35 million hospitalizations in 2013 out of which 378,715 had a primary discharge diagnosis of acute pancreatitis and 155,130 had a primary discharge diagnosis of chronic pancreatitis. The mean age in the acute pancreatitis group was 53.3 yrs and in chronic pancreatitis group was 51.7 yrs. There were more males in chronic pancreatitis group (55.1%) than females (44.9%). There was significantly higher prevalence of acute pancreatitis in CD (2.3%) than non-CD patients (1.2%) (Figure 1, P = 0.001). Similarly, there was higher prevalence of chronic pancreatitis (1.2%) than the control group (0.43%) (Figure 1, P < 0.001).

CONCLUSION:

There is a higher prevalence of acute pancreatitis in patients with CD. Patients were also found to have much higher prevalence of chronic pancreatitis in CD. This could be related to recurrent acute pancreatitis episodes in CD patients. Further studies are needed to validate these findings.
2920 Prior Pharmacotherapy Patterns Among Patients With IBD in the USA Initiating Biologic Therapy
Authors: Bornheimer Rebecca , Hass Steve , Nag Arpita , Oster Gerry
Published: October 2019

INTRODUCTION:

Treatment for inflammatory bowel disease (IBD: Crohn's disease [CD] and ulcerative colitis [UC]) has shifted from symptom management using corticosteroids to targeted therapies such as tumor necrosis factor (TNF) inhibitors. Increasing therapeutic options warrants a better understanding of current treatment pathways. This study reports on the pharmacotherapy history of patients with CD and UC prior to initiation of an IBD-targeted biologic.

METHODS:

Using the IQVIATM Real-World Data Adjudicated Claims Database – US, we identified adults (≥18 years) with CD or UC who initiated biologic treatment from Jan 1, 2016 to Jun 30, 2017. Analysis was limited to biologics indicated for CD/UC during the study period. Patients were stratified based on most recent biologic received; the date of initiation was designated the index date. Patients with <12 months of continuous medical coverage prior to the index date were excluded. Patterns of prior IBD-related pharmacotherapy, in terms of number and type of biologics, and time spent on the biologic, were examined in relation to the index biologic, for the study period Jan 1, 2011 to Jun 30, 2017.

RESULTS:

A total of 5210 patients with CD and 3010 with UC were identified. Among patients with CD, 2634, 1436, 737, 241 and 162 began treatment with adalimumab, infliximab, vedolizumab, certolizumab, and ustekinumab, respectively. Among patients with UC, 1285, 977, 587 and 161 initiated treatment with adalimumab, infliximab, vedolizumab and golimumab, respectively. Most patients beginning treatment with infliximab or adalimumab were previously biologic-naïve (CD: 77.8%, 84.6%, respectively; UC: 79.9%, 89.3%, respectively). Patients starting treatment with other biologics, however, typically had received at least one IBD-related biologic previously (Figure 1). Among patients who were not biologic-naïve at initiation of therapy, mean total duration of prior exposure was 26.6 and 17.8 months for patients with CD and UC, respectively.

CONCLUSION:

While newer IBD-related biologics (i.e., vedolizumab, ustekinumab) are typically preceded by treatment with other biologics, most patients receiving one of the first biologics approved for IBD (i.e., infliximab, adalimumab) are biologic-naïve. Patients with a treatment history of two biologics had a longer overall period of biologic exposure than those who had previously received only one biologic.
2925 Effect of Short Bowel Syndrome on Disease Activity in Patients With Crohn's Disease
Authors: Singh Amandeep , Nan Lan , Shen Bo , Kirby Donald F. , Regueiro Miguel
Published: October 2019

INTRODUCTION:

Despite advancements in medical therapies a significant number of Crohn's disease (CD) patient's end up requiring surgical intervention, often leading to short bowel syndrome (SBS). We aimed to assess the changes in clinical activity in CD patients before and after the diagnosis of SBS and assess the association between endoscopic disease activity and length of remaining bowel.

METHODS:

Using our home parenteral nutrition (PN) database all patients with the diagnosis of CD and SBS requiring PN or IV fluid support between January 1990 and June 2018 were identified. Data on baseline demographics, co-morbidities and concomitant medications was collected. Laboratory data, Simple Endoscopy score [SES], patient reported outcomes (PROs) and medications at baseline and 6-12 months after SBS diagnosis were collected. We also assessed exacerbation of IBD, hospitalization and adverse events after SBS diagnosis.

RESULTS:

A total of 86 patients were included in the final analysis. Out cohort consisted of 58% females and 87% were Caucasians. At the time of SBS surgery, nearly 60% were current or ex-smokers, 38% had perianal disease and 17% had fistulas. After the surgery leading to SBS, mean bowel length was 154.0 ± 68 cms. stoma was present in 77%, colon in 63%, ileocecal valve in 12.5% and 92% of them were PN-dependent. At baseline and after 6-12 months of diagnosis of SBS, there were no significant changes in BMI, laboratory data, endoscopic disease activity or extraintestinal manifestations (P > 0.05 for all). In terms of symptoms, there was a trend towards more diarrhea after the diagnosis of SBS (P = 0.06) but no significant change in abdominal pain and bleeding (P > 0.05) were noted. The use of salicylates decreased after SBS (38% vs. 22%, P = 0.02) but more patients were on vedolizumab after SBS diagnosis (0 vs. 13%, P = 0.001), there were no significant changes in other medications (Table 1). Overall, 59% required hospitalizations after the diagnosis of SBS, but only 15% had CD-exacerbation. There was no significant association between endoscopic disease activity and intestinal length before and after the diagnosis of SBS (Figure 1a,b).

CONCLUSION:

Our study suggests that contrary to common belief of less medication requirement in CD after SBS, some patient might need aggressive medical therapy as there is no significant co-relation between endoscopic disease activity and bowel length. Further studies with longer follow-up are required to confirm these findings.