bluuebunny/crossref_metadata_2025 huggingface dataset:
2701 Not Your Usual Gastritis: A Case Report of Pembrolizumab-Induced Lymphocytic Gastritis
Authors: Alkayali Talal , Salem Ahmed I. , Ricardo Juan , Amer Bahaa , Harris Cynthia L.
Published: October 2019

INTRODUCTION:

Pembrolizumab induces immune checkpoint inhibition of programmed cell death protein-1 (PD-1 inhibitors) in various malignancies. Toxicities have been described, including but not limited to, inflammatory reaction in any system, and infusion related side effects. We report a rare case of symptomatic lymphocytic gastritis after pembrolizumab treatment of vocal cord squamous cell carcinoma.

CASE DESCRIPTION/METHODS:

70 year old female with history of right true vocal cord squamous cell carcinoma status post excision and chemoradiation with cisplatin. Recurrence in 1 year to the anterior vocal cord prompted treatment with pembrolizumab. Patient suffered complete esophageal occlusion requiring multiple EGDs with dilatation, gastric tube placement, morphine and transcutaneous fentanyl analgesia. During pembrolizumab treatment she developed new onset nausea and vomiting, intolerance to feeding regimen for 3 weeks, and a 10 pound weight loss in 1 week but no change in bowel movements, melena, abdominal pain, or fever. Physical exam was significant for cachectic female, LUQ G-tube in situ with no erythema/discharge, no abdominal tenderness, rigidity, or organomegaly, normal bowel sounds, and normal rectal exam. Lab work up was not significant. EGD was performed showing diffuse erythematous mucosa in the entire examined stomach. Biopsy showed lymphocytic gastritis negative for metaplasia, dysplasia, or neoplasia with no H-Pylori or other infectious organisms. Patient was started on prednisone 60mg daily with slow taper, metoclopramide, ondansetron PRN, and pembrolizumab was stopped. GI symptoms improved significantly with resolution of emesis.

DISCUSSION:

Lymphocytic gastritis (LG) is a rare subtype linked with H-pylori infection, celiac, lymphoma, and medication side effect. Patient might be asymptomatic or exhibit dyspepsia, nausea, vomiting or weight loss. Work up includes EGD; however, endoscopic appearance can be nonspecific as patients might have erythema, erosions, nodules or normal appearing mucosa. Diagnosis is made when biopsies show intraepithelial lymphocytes with more than 25 in 100 epithelial cells. Recommended treatment is based on etiology and included removing the offending agent, H-pylori eradication and/or gluten free diet. Steroids are not usually considered in the treatment of LG, but they are proposed as first line therapy in treatment of PD-1 inhibitor related side effects (enteritis, colitis, etc). Our patient had good response to steroids as her LG was induced by PD-1 inhibitor.
2732 Signet Ring Cell Carcinoma: A Rare Case Report Masquerading as Digital Infarction
Authors: Gudipally Sindusha , Gowda Vinodhini , Minupuri Arun , Modi Simple , Salas Noain Jesus M. , Thirumaran Rajesh , Nair Jayamohan
Published: October 2019

INTRODUCTION:

Signet Ring Cell Carcinoma (SRCC) is a mucin producing adenocarcinoma, commonly seen in the gastrointestinal tract, also rarely in the urinary bladder, pancreas, breast and gallbladder. Tumor embolism due to slowly evolving disseminated intravascular coagulation (DIC) can manifest as digital infarction and this report highlights its presentation in a case of SRCC.

CASE DESCRIPTION/METHODS:

An 82-year-old African American lady presented with 2 weeks of low back pain, hematuria and purplish discoloration of toes. Physical exam was significant for multiple gangrenous digits but palpable pulses. CT Abdomen and Pelvis revealed diffuse bony metastases and moderate bilateral hydronephrosis. Labs were significant for Hemoglobin of 6.6 gm/dl and Creatinine 1.8. Bone marrow biopsy was consistent with metastatic carcinoma of SRCC. Pathologic staining was positive for AE1/AE3, CK7, CK20, and CDX2, suggestive of gastric tract origin than urinary bladder. Further investigation for the location of the primary tumor was negative. Evaluation for peripheral arterial disease, vasculitis, thrombophilia, and endocarditis for digital infarction was negative. With elevated D-Dimer, prolonged PTT and normal fibrinogen suggestive of slowly evolving DIC, digital infarction from tumor embolism was diagnosed. Ureteral stent placement for hydronephrosis was attempted but was unsuccessful due to multiple clots in the bladder, likely owing to DIC and she further deteriorated to end stage renal disease. Goals of care were discussed with the patient and she was transitioned to hospice care.

DISCUSSION:

Slowly evolving DIC is seen in cancer (mostly adenocarcinoma), liver disease, aneurysm, hemangioma and rarely sepsis. It’s believed that the destruction and production of coagulation factors/platelets are balanced. Diagnostic labs indicate thrombocytopenia, normal to prolonged PT/PTT, normal to low fibrinogen level and elevated D-Dimer. Heparin is the treatment of choice when bleeding is not suspected. Unfortunately, heparin was contra-indicated in our patient who had hematuria.

In conclusion, this case illustrates the aggressive presentation of SRCC, which can present as digital infarction. Identifying tumor embolism and slowly evolving DIC is important as it may indicate poor prognosis. This case is unique in its presentation and cancer should be ruled out in digital infarction when other common causes are not identified.
2757 Gastric Amyloid: The Patient Who Could Not Eat at AL
Authors: Janssens Laurens , Kane Sunanda
Published: October 2019

INTRODUCTION:

Gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction. Diabetes and medication side effects are common causes. AL amyloidosis is a systemic disease due to extracellular fibril deposition that can affect multiple organs. Gastro-intestinal (GI) involvement is less common than in other organ systems but can present in many different ways, including gastroparesis.

CASE DESCRIPTION/METHODS:

A 77 year old non-diabetic man from Mississippi presented with a one year history of intermittent abdominal distention, nausea and bloating. In addition, he had increasing dyspnea on exertion and lower extremity edema. Outside work-up consisted of multiple imaging studies demonstrating marked gastric distention as well as delayed gastric emptying (Figures 1 and 2). Outside colonoscopy was unrevealing and EGD was negative except for a distal esophageal ulcer and focal active duodenitis. He was started on a PPI and trialed on an alternating regimen of metoclopramide and erythromycin, without symptomatic relief. He was referred to our hospital for further diagnostic work-up. Repeat colonoscopy showed congested distal ileal mucosa and friable ascending colonic mucosa. Biopsies from both sites revealed amyloid deposits by Congo red stain (Figure 3). Serum protein electrophoresis noted a monoclonal IgG lambda peak with M-spike of 1.5 g/dL and bone marrow biopsy revealed approximately 70% of marrow cellularity consisting of plasma cells. Echocardiogram confirmed severely increased concentric left ventricular wall thickening consistent with cardiac amyloidosis. Interestingly, neither fat pad biopsy nor bone marrow biopsy showed presence of amyloid. The patient was diagnosed with myeloma and AL amyloidosis with gastro-intestinal and cardiac involvement.

DISCUSSION:

This case highlights the broad differential for gastric distention and dysmotility. When the ‘usual suspects’ such as diabetes, medication, post-surgery and neurological disease have been ruled out, rarer causes like an infiltrative process should be considered. Common manifestations of GI tract amyloidosis include GI bleeding, malabsorption, protein-losing enteropathy and chronic dysmotility. The diagnosis of amyloidosis is based on positive tissue diagnosis. While the combination of a fat pad and a bone marrow biopsy has a high sensitivity (89%) for diagnosing AL amyloidosis, negative results do not rule out amyloid elsewhere and tissue sampling from the affected organ site is essential, as demonstrated in this case.
2775 Intragastric Balloon Hyperinflation: A Rare Cause of a Palpable Abdominal Mass
Authors: Bazarbashi Ahmad Najdat , Smith Benjamin N. , Thompson Christopher C.
Published: October 2019

INTRODUCTION:

Intragastric balloons (IGB) are commonly being used for the treatment of obesity, with increasing data confirming their effectiveness. While usually well tolerated with rare adverse events, IGBs have been associated with complications including visceral perforation, pancreatitis and bowel obstruction. IGB hyperinflation, which occurs due to an abnormal accumulation of gas within IGB is rare. We present a case of a patient with abdominal pain and vomiting after recent IGB placement, found to have a palpable abdominal mass.

CASE DESCRIPTION/METHODS:

A 35-year-old female with class II obesity (BMI: 33 kg/m2) and recently placed adjustable IGB in the Dominican Republic presented to our emergency department with abdominal fullness, vomiting and inability to keep food down. The IGB had been placed for two months with reported 30 lbs weight loss. She denied fevers, dysphagia, hematemesis, melena or altered bowel movements. She was afebrile with normal vital signs. Physical examination revealed a palpable round-like mass in her epigastric region with tenderness to palpation. Laboratory workup, including complete blood count, basic metabolic panel, liver function tests and lipase were normal. CT scan of the abdomen and pelvis revealed a gas-filled hyperinflated IGB within the distal portion of the stomach with dilation proximally representing possible gastric outlet obstruction. There was no evidence of perforation or pneumatosis intestinalis [Figure 1a–c]. Due to her symptoms, and the patient’s wishes to have the balloon removed, endoscopy was performed. Endoscopy revealed a hyperinflated, adjustable IGB occupying two thirds of the gastric body and obstructing the gastric antrum. The balloon appeared mottled suggesting fungal colonization from the outside with food debris. Attention was then placed on balloon removal. Successful removal of 500cc of blue-colored fluid mixed with air was performed resulting in IGB deflation and subsequent retrieval. The patient did well with resolved symptoms and was discharged the next day.

DISCUSSION:

Intragastric balloon hyperinflation should be recognized as a possible complication of IGB placement and may be due to balloon permeability or gas-producing anaerobic bacteria. Patients usually present with nausea, vomiting and inability to tolerate oral intake and if left untreated can result in dire consequences. Imaging may assist with diagnosis. Treatment involves endoscopic IGB removal. In cases of adjustable IGB, deflation and fluid exchange can be considered.
2779 A Case Report of Co-Existing Helicobacter pylori and Clostridium difficile Infections: The Need for Treatment Guidelines
Authors: Bello Fatimah O. , Rivera Arturo Suplee , Herrera Henry R.
Published: October 2019

INTRODUCTION:

Literature is replete with numerous papers reporting Clostridium difficile (C. diff) infection arising as a complication from the management of Helicobacter pylori (H. pylori) infection. However, not much is known about the guidelines for the management of these 2 infections when they occur in the same patient simultaneously. We present a rare case of independent H. pylori and C. diff infections and our treatment modality.

CASE DESCRIPTION/METHODS:

A 56-year-old woman with a history of recent C. diff infection and end stage renal disease presented to the clinic on account of recurrent abdominal pain of about 3 months duration with associated diarrhea, early satiety and subjective unintentional weight loss. Gastrointestinal panel was ordered as part of her diarrhea workup and she was scheduled for an EGD for evaluation of her abdominal pain. Her C.diff returned positive, the third time within the year. She was prescribed oral vancomycin. Her EGD did not reveal any gross abnormalities. However, pathology results returned positive for H.pylori infection. Patient was followed up in clinic after she had completed the vancomycin. She continued to complain of diarrhea and abdominal pain. Her stool sample was re-sent to the laboratory after a few days and it returned positive, for the fourth time. An extensive discussion was held with the patient and she agreed to go ahead with fecal microbiota transplant (FMT) then wait for a month and commence H.pylori eradication regimen using quadruple therapy. Florastor was also added to her regimen and she continues to be under close follow up. Successful treatment of both C diff and H pylori were achieved using this method, without C diff recurrence to date.

DISCUSSION:

About 4.6% of individuals treated for H.pylori infection will develop C. diff infection. This is typically treated using the existing guidelines. However, not much is known about the management of the 2 infections when they co-exist. In the case of our patient, a FMT was performed prior to H.pylori therapy, as the diarrhea appeared to be the chief complaint. Florastor was added to the H. pylori regimen in an effort to reduce the risk of recurrent C. diff infection. There are no guidelines to support our modality of treatment which was decided upon using our best clinical judgement. To the best of our knowledge, there has been no reported case of C.diff and H.pylori co-infection in the context of recurrent C. diff infection. There is a need for treatment guidelines for such clinical scenarios.
2813 Endoscopy and Radiation Oncology Collaboration - The Evolution of Techniques and Applications of EUS-Guided Fiducials for Pancreatic Neoplasm and Beyond: A Tertiary Cancer Institute Experience
Authors: Sharma Neil , Krishnakurup Jay , Rumancik Brad , Kota Sharwani , Gopakumar Harishankar , Zelt Christina , Gupta Saurabh
Published: October 2019

INTRODUCTION:

Stereotactic ablative radiotherapy (SABR) offers improved tumor control, lees number of treatments, and reduced toxicity compared with conventional therapies. The role of SABR continues to expand. Fiducial markers are required to guide SABR.Traditionally CT guided or surgical placement had been used to facilitate the delivery of stereotactic radiotherapy. EUS-guided fiducial marker placement has been introduced as a safe and feasible alternate method. We share our experience with the two types of the fiducial delivery system & evolution of applications & technique. The back loaded fiducial needles (BLFS), which need to be inserted to the needle by hand, is cumbersome, more prone for needle stick injury to the operator, and time consuming. A novel preloaded system (PLFS) delivers 2 fiducials per needle and can be interchanged with the FNB needle enabling biopsies in the same setting. The preloaded system has an automatic safety shield enabling safety during needle exchange. With advance of Endoscopic oncology, a trained advanced endoscopist can implant fiducials in a variety of solid organ tumors accessible by EUS and needing SABR.

METHODS:

We conducted a retrospective review of our experience from 2015-2017. We started using fiducials in late half of 2015 and changed to PLFS in early 2016. We reviewed our experience on the total procedure time (TPT) with the BLFS with PLFS. The PLFS allows for ease of application. After the switch to PLFS, through conversations with radiation oncology, we reviewed the extension of the technology to additional applications outside the pancreas.

RESULTS:

The mean total procedure time TPT with the back loaded system was 31.68 min, while the mean TPT with the preloaded system was 22.68min, a 30% reduction in the total procedural time for pancreatic cases. (Table 1) We then evolved use of the PLFS to place fiducials in other solid tumors such as mediastinal lesions with lung CA, esophagus, cholangiocarcinoma. (Table 2). No migration of fiducials were noted during the mapping for radiotherapy in either cohort, and all patients successfully received SABR. No bleeding or other adverse events were noted.

CONCLUSION:

We believe that the endoscopic interventional community should adopt the use of PLS systems and work with radiation oncology to expand the use of EUS guided fiducial placement to solid malignancies that are accessible through EUS. This will reduce the number of interventions, the lag time to treatment and overall cost.
2830 Bowel Preparation Quality in a Multiethnic Population in a Safety Net Hospital
Authors: Zaki Timothy A. , Williams Renee L. , Lawrence Zoe , Goodman Adam J.
Published: October 2019

INTRODUCTION:

Colonoscopy is the only colorectal cancer screening modality that permits direct visualization of the entire colon and removal of polyps. Low-quality bowel preparation has been associated with lower adenoma detection rates, increased procedure time, and increased hospital cost. An inadequate preparation limits the diagnostic accuracy and overall efficacy of colonoscopy. Factors that contribute to inadequate bowel preparations include age, male sex, inpatient status, low socioeconomic status, low English proficiency, obesity, diabetes, and cirrhosis. We investigated the complex relationship between socioeconomic factors and medical comorbidities on the quality of inpatient colonoscopy preparation.

METHODS:

We conducted a retrospective chart review of inpatient colonoscopies between October 2017 and April 2019. All patients received a single-dose preparation of polyethylene glycol. We collected data including demographics, medical history, indication, and bowel preparation. A Boston Bowel Preparation Score of 6 or above or an Aronchick score of “good” or “excellent” was used to define an adequate preparation.

RESULTS:

A total of 230 patients were included in the final analysis (Table 1). An inadequate bowel preparation was reported in 16.1% of our inpatient colonoscopies. Within the inadequate preparation group, a greater percentage of patients were male (17.3% vs. 12.3%), had low English proficiency (18.3% vs.15.3%), were not diabetic (17.7% vs.12.3%), and did not have prior bowel surgery (16.4% vs. 0.0%). Within the age, race/ethnicity, and insurance subgroups, patients who were age 80+ (21.4%), Asian-American (25%), unreported race/ethnicity (29.4%), uninsured (25%), and prisoners (22.8%) had a greater percentage of inadequate preparation (Table 2). A logistic regression was performed to assess the effects of age, sex, race/ethnicity, insurance, English fluency, diabetes, restricted mobility, and prior surgery on bowel preparation. The logistic regression model was not statistically significant.

CONCLUSION:

No significant socioeconomic or medical predictors of bowel preparation were found in this inpatient population which is in contrast to prior literature. While less than 20% of our patient population had inadequate bowel preparation, this is still significant in the broader context of quality, safety, and healthcare costs. Identifying strategies to increase the quality of bowel preparation still remains at the forefront of our field.
2832 Real Life Impact of Physician Awareness of a Positive Stool DNA Test on Subsequent Colonoscopy Outcome in Colorectal Cancer Screening
Authors: Huq Nadia , Fahed Gracia , Affi Aboud , Fahed Julien
Published: October 2019

INTRODUCTION:

A recent study that included 244 subjects has looked into clinical outcome of colonoscopy based on the physician’s awareness of the positive result. That study showed significant differences in colonoscopy findings. We present a larger real-life study on the impact of physician awareness of a positive stool DNA test on colonoscopy results.

METHODS:

Chart review of 1413 patients who had a positive stool DNA followed by documented subsequent colonoscopy was done. Attention was made to the indication of the procedure in the colonoscopy report. A total of 5 patients were excluded, 3 of them had unknown indication and 2 of them had a finding of “other carcinoma” aside from adenocarcinoma. Index lesions were recorded and patients were divided in 2 groups. Group 1 included patient who had indication of “stool DNA testing” or its equivalent, while group 2 included all the other indications assuming that the provider was not aware of the positive stool DNA testing. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant.

RESULTS:

Out of the 1408 patients included in the analysis, 979 (70%) patients had an indication of “stool DNA testing” or its equivalent while 429 (30%) had another indication. Results of group 1 and group 2 were as follows. “Adenocarcinoma” was found in 1.84% vs. 1.4% respectively (P = 0.56). “Advanced adenoma” was found in 24.82% vs. 21.21% respectively (P = 0.14). “10 mm adenoma” was found in 7.25% vs. 6.99% respectively (P = 0.86). Non advanced adenoma was found in 28.7% vs. 31.24% respectively (P = 0.57). Finally, no adenomas were found in 37.39% vs. 39.16% respectively (P = 0.33).

CONCLUSION:

Following a positive stool DNA test, 1 out of 3 colonoscopies are done without the physician’s awareness of the positive result. Fortunately, there was no difference in the outcome of colonoscopy whether the physician was aware of the positive result or not.
2868 A Single Academic Institution Experience With Caustic Ingestion to the Gastrointestinal Tract
Authors: Argueta Erick A. , Ferreira Kaio , Sukrit Jain , Rupawala Abbas , Bakhit Mena
Published: October 2019

INTRODUCTION:

Patients with caustic ingestion present with a range of gastrointestinal (GI) manifestations. The severity of injury depends on the type of substance ingested, its concentration, and duration of contact with the GI mucosa. Apart from usual supportive care, esophagogastroduodenoscopy (EGD) performed within 24 hours of ingestion is generally recommended. This study reports clinical, endoscopic features and hospital outcomes in patients presenting following ingestion of a caustic agent at a single large academic center.

METHODS:

A retrospective chart review was performed at two academic hospitals between January 2000 and October 2018 in adult patients presenting with caustic ingestion. Demographic data, type of ingestion, endoscopy and computed tomography (CT) findings, in-hospital mortality and length of stay (LOS) was collected. (Table 1).

RESULTS:

A total of 89 patients were included in the study. Suicidal ingestion occurred in 49.4% cases compared to accidental. The mean age was 43 ± 20 years with 50.6% males. Ingestion of alkalis (81.0%) was higher than acids (15.7%). The most common presenting symptom was vomiting (31.5%). Endoscopy was performed in 54 patients (60.7%) with 45 (83.3%) performed within 24 hours. Endoscopic findings are summarized in Table 2. Patients undergoing endoscopy had a longer duration of hospitalization (5.58 vs 1.67 days, P < 0.001). Patients with Zargar grade 0 had shorter hospitalization compared to those with grade IIA-IIB esophagitis (2.87 vs. 7.53 days, P < 0.001). However, there was no difference in LOS when comparing grade II to III esophagitis (8.4 vs. 11.2 days, P = 0.238). All patients with grade IIA-IIIB were started on a PPI during hospitalization. Only 19.1% of patients had a CT with the majority (70.6%) being normal. Death occurred in 3 patients.

CONCLUSION:

In this single center cohort, patients mainly presented with alkali ingestion with varying symptoms. An endoscopy was performed in about 60% patients, most within 24 hours and the majority of patients demonstrated Zagar scores of 0 or 1. Despite recent data suggesting cross-sectional imaging as a triage tool, its utilization in this academic center was limited. Implementing a CT-first strategy prospectively may provide additional data and may minimize the utilization of inpatients endoscopy. To our knowledge, this is one of the largest samples to date on caustic ingestion in the United States.
2875 The Prevalence of Irritable Bowel Syndrome in Patients With Obstructive Sleep Apnea: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Patel Ankit , El Kurdi Bara , Aasen Tyler , Young Mark
Published: October 2019

INTRODUCTION:

Irritable bowel syndrome (IBS) is a common disease that affects between 10-15% of the population globally. A growing body of research is attempting to further understand the underlying pathophysiology of IBS and its association with other extra-intestinal manifestations with reports suggestive of sleep disturbances and obstructive sleep apnea (OSA) being implicated. This study aims to explore the available literature for the prevalence of IBS in OSA patients.

METHODS:

A systematic review was conducted in PudMed, MEDLINE, EMBASE, and Cochrane databases from inception through June 2019 to identify the studies that explored the prevalence of IBS in OSA patients. 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. Effect estimates from the individual studies were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird and a pooled prevalence was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS:

Four studies with a total of 792 patients with OSA were included in this study. The mean age was 52.94 years and 557 (73.09%) patients were men. The pooled event rate of IBS in OSA patients was 23.90% (95% CI: 20.8%-27.3%) (Figure 1). The pooled event rates of IBS in male and female patients with OSA were 26.4% (95% CI: 22.5%-30.8%) and 19.8% (95% CI: 14.6% - 26.2%) respectively (Figures 2 and 3).

CONCLUSION:

These results suggest a higher prevalence of IBS in OSA patients compared to the general population. Further research might be needed to evaluate the prevalence of OSA in IBS patients and whether the treatment of OSA would affect the IBS disease course in these patients. Furthermore, health care providers should also screen patients with OSA for gastrointestinal symptoms.
2917 Rates of Hospitalization Related to Fractures Are Decreasing in Patients With Primary Biliary Cholangitis: Insights From the Nationwide Inpatient Sample
Authors: Shah Ishani , Bhurwal Abhishek , Mehta Harsh , Uppal Surabhi , Reddymasu Savio
Published: October 2019

INTRODUCTION:

Primary Biliary Cholangitis (PBC) is associated with reduced bone density (20-50%) and increased predisposition of developing fractures. Clinical practice guidelines advocate for measures such as calcium and vitamin D supplementation and use of bisphosphonates to prevent development of fractures in this patient population. The purpose of this study was to trend rates of hospitalizations related to fractures in PBC. We also examined fracture-associated morbidity and mortality among patients with PBC.

METHODS:

All adults hospitalized with PBC during the years 2010 to 2014, were identified using the Nationwide Inpatient Sample (NIS). Within this group, temporal analysis of PBC patients with a co-diagnosis of hip, vertebral or wrist fractures (study group) was performed with regards to total number of inpatient admissions, inpatient mortality, length of stay, and total charges associated with hospitalization.

RESULTS:

During the five-year study period, there were 308,753 hospitalizations for PBC. Trends for fracture-related hospitalizations over this period are shown in Figure 1. There has been a significant (P = 0.002) reduction in fracture related admissions in patients with PBC during this study period. Compared with PBC-controls, PBC-fracture patients were older (mean age 73.62 years vs 65.24 years; P < 0.001), more likely to be female (51.92% vs 47.62%; P = 0.24), predominantly White (83.72% vs 69.62%; P = 0.003) and had a higher prevalence of osteoporosis (15.73% vs 4.09%; P < 0.001). Length of stay (10.85 days vs 7.36 days; P < 0.001) was higher in the PBC-fracture group compared to PBC-control group; however, no significant variations in mortality were identified between the two groups (6.6% vs 4.82%; P = 0.26). Total hospitalization charges among the PBC-fracture patients were higher than the control group ($98,444 vs $72,964; P = 0.004) (Table 1).

CONCLUSION:

There has been a steady decline in rate of fracture related hospitalizations in patients with PBC. However, patients with PBC who have fractures have adverse utilization of health care resources compared to their cohort admitted for reasons other than for fracture. Increased adoption of guidelines with regards to bone health in patients with PBC hopefully will lead to continued reduction in rate of fracture related hospitalizations in PBC.
2927 A Prospective Longitudinal Study of Acetaminophen/NSAIDs Effect on Inflammatory Bowel Disease Flares and Activity
Authors: Xu Anthony , Mallepally Niharika , Shapiro Jordan , Hou Jason
Published: October 2019

INTRODUCTION:

It is well established that non-steroidal anti-inflammatory drug (NSAID) users are more likely to have intestinal inflammation/damage. There have been several conflicting studies about the effect of acetaminophen and NSAIDs on inflammatory bowel disease (IBD). We hypothesized that acetaminophen/NSAID use is associated with increased IBD flares and activity. This study was aimed to assess the effect of acetaminophen/NSAIDs on IBD flares and activity.

METHODS:

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

RESULTS:

A total of 132 patients were included in the analysis of which 74 had CD and 58 had UC. 43 patients were acetaminophen users, 43 patients were NSAID users, and IBD flares occurred in 60 patients. No significant associations between Acetaminophen/NSAID usage and IBD flares were observed: Acetaminophen/NSAID users who developed a flare was 41.9% and 55.8% respectively while 54.5% non-users developed a flare. UC patients using acetaminophen/NSAIDs were associated with significant increases in pMayo compared with UC patients not using acetaminophen/NSAIDs (acetaminophen: 1.71- >2.91, P-value = 0.003; NSAIDs: 1.81- >2.60, P-value = 0.034). In patients with UC, acetaminophen use was associated with non-remission status (RR 1.96; 95% CI 1.29-2.97).

CONCLUSION:

Amongst UC patients, acetaminophen/NSAID usage was not associated with interval flare however was associated with increased disease activity and non-remission status. In CD patients, no significant associations between Acetaminophen/NSAID use with flare or activity were observed. Counseling patients on decreasing acetaminophen/NSAID usage may decrease disease severity in patients with UC.
2938 Finding the Needle in the Haystack: A Retrospective Review on the Diagnostic Accuracy of EUS-FNA Needles for Pancreatic Cancer
Authors: Renelus Benjamin D. , Jamorabo Daniel S. , Gurm Hashroop , Bhesania Siddharth , Arya Mukul
Published: October 2019

INTRODUCTION:

Pancreatic cancer is an aggressive malignancy with a dismal five year survival <7%. Early diagnosis and resection can increase this to 15%-25%. Extensive investigation has yet to identify clear diagnostic superiority among needle sizes for EUS-guided FNA. As a result, this topic remains an area of debate heavily based upon institutional practice. The aim of this study is to compare the diagnostic utility of 22G and 25G needles for confirming the presence of pancreatic cancer.

METHODS:

We performed a retrospective review of index pancreatic cancer cases dating from 2010-2017 at our university-affiliated institution. We used Chi-squared testing to compare the diagnostic yield of 22G and 25G needles for EUS-FNA pancreatic tissue sampling.

RESULTS:

We identified 81 pathology confirmed pancreatic cancer cases which underwent EUS-FNA for initial sampling. EUS-FNA with 22G needle provided significantly higher diagnostic yield than did 25G needles (93% vs 50%; P = 0.006). There were no complications or adverse events including blood loss, for both groups.

CONCLUSION:

EUS-FNA with 22G needles provided superior diagnostic yield for pancreatic cancer when compared to 25G needles. This is likely due to the endoscopist familiarity with the needle or former's ability to obtain more tissue for analysis given its wider diameter. Interestingly, there were no differences in adverse events between the two needle sizes. Twenty-two gauge needles may be more helpful in pancreatic cancer diagnosis via EUS-FNA.
2940 Favorable Rates of Post-ERCP Pancreatitis With Endoscopic Sphincterotomy With Delayed Sphincteroplasty Approach
Authors: Malik Fahad , Kim Marina , Mukul Arya , Muhammad Wafa
Published: October 2019

INTRODUCTION:

There are multiple modalities for the management of large bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP). Large bile duct stones, defined as size greater than 15 mm, are a subset of multiple clinical situations associated with difficult bile duct stone extraction. The successful extraction of common bile duct stones typically requires either a sphincterotomy or papillary balloon dilation. Multiple prior studies have shown that endoscopic papillary balloon dilation (EPBD) has less success in stone clearance with more frequent requirement for lithotripsy in addition to carrying a higher risk of post-ERCP pancreatitis. We report the technique of delayed sphincteroplasty to be effective and safe in the management of large bile duct stones.

METHODS:

A retrospective analysis from 2012 to 2018 was obtained from our endoscopy software of all patients who underwent a two-step ERCP with balloon dilation and analyzed in terms of patient demographics, stone size, success of stone extraction, number or procedures required for duct clearance and procedure-related complications. Patients with bile duct strictures, periampullary malignancy or coagulopathy were excluded.

RESULTS:

Seventy five patients had ERCP performed with balloon sphincterotomy at least 30 days after initial ERCP. Twenty seven of them were men. Age ranged from 26 to 101 with an average age of 73. 37.3% of the patients were Caucasian, 33.3% African American, 6.6% Asian, 5.3% Hispanic and 17.3% unknown. The average common bile duct size on imaging prior to ERCP was 14.2 mm. The initial ERCP was performed within an average of 4 days of admission. Total bilirubin was 3.9 on average. Most common indication was proven bile duct stone on imaging, 60.8%. 84% of patients had a plastic stent placed during initial ERCP. 13% had more than 5 stones. Balloon was dilated to an average of 14.6 mm. 97% (73/75) had no immediate complications post procedure. Three patients needed additional lithotripsy.

CONCLUSION:

We present our center's experience with the management of large bile duct stones with the technique using endoscopic sphincterotomy with stent placement for initial drainage and a delayed sphincteroplasty reported decreased rates of post-ERCP pancreatitis and encouraging success rates for stone extraction.
2941 Endoscopic Ultrasound-Guided Gastroenterostomy for the Management of Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis
Authors: Iqbal Umair , Khara Harshit S. , Hu Yirui , Kumar Vikas , Tufail Kashif , Confer Bradley , Diehl David L.
Published: October 2019

INTRODUCTION:

Gastric outlet syndrome (GOO) is characterized by epigastric pain and postprandial vomiting secondary to mechanical obstruction. Management of GOO is usually focused on alleviating the symptoms of obstruction and can be achieved by surgical gastrojejunostomy or enteral stenting. Recent studies have shown success with endoscopic ultrasound guided gastroenterostomy (EUS-GE) in the management of GOO but data is limited. We therefore conducted a meta-analysis to evaluate the safety and efficacy of EUS-GE in the management of GOO.

METHODS:

A comprehensive literature review was conducted by searching the several databases from inception to January 2019 to identify all studies that evaluate the efficacy and safety of EUS-GE in GOO. Our primary outcome was to evaluate technical success and clinical success. Technical success was defined as successful EUS guided deployment luminal apposing stent (LAMS). Clinical success was defined as ability to tolerate oral intake after the procedure. Secondary outcomes were to evaluate need for reintervention and adverse events of the procedure.

RESULTS:

Twelve studies including 285 patients were included in the meta-analysis. Among 12 included studies 3 were case series, 1 prospective and 8 retrospective cohort studies. 7 of the included studies were good quality studies while 5 were of fair quality. EUS-GE was performed in 202 patients with GOO secondary to malignancy while 83 patients had benign etiologies of GOO. Technical success was achieved in 266 patients out 308 patients who underwent EUS-GE with a pooled technical success of 92% [95% CI: 88%-95%]. Clinical success was achieved in 249 patients with a pooled clinical success rate of 90% [95% CI: 85%-94%]. Adverse events occurred in 28 patients with a pooled incidence of 12% [95% CI: 9%-17%]. Recurrence of GOO symptoms and need for unplanned re-intervention was needed in 16 patients with a pooled incidence of 9% [95% CI: 6%-13%]. There was no statistical heterogeneity existed among the included studies (I2 = 0%, P > 0.05). Egger's test indicated no publication bias as the symmetry existed in the funnel plot (P > 0.05).

CONCLUSION:

EUS-GE is safe and efficacious treatment modality for the management of benign and malignant GOO. EUS-GE is also comparable to enteral stenting and may be associated with fewer adverse effects and need for re-intervention compared to enteral stenting. Larger prospective trials are needed to compare the efficacy of EUS-GE with endoscopic duodenal stenting and SGJ in GOO.
2947 Systematic Review and Meta-Analysis of the Association Between H. pylori and Non-Alcoholic Fatty Liver Disease
Authors: Kamal Faisal , Khan Muhammad Ali , Shrestha Shreesh , Tariq Raseen , Reddy Yala , Marella Hemnishil K. , Howden Colin W.
Published: October 2019

INTRODUCTION:

Metabolic syndrome is a risk factor for non-alcoholic fatty liver disease (NAFLD). H. pylori infection has been reported to be associated with the development of metabolic syndrome. Studies evaluating a possible association between H. pylori and NAFLD have reported conflicting results. We conducted a systematic review and meta-analysis to evaluate the possible association between H. pylori and NAFLD.

METHODS:

We searched several databases including Pubmed, Scopus and Web of Science from inception to November 1, 2018 to identify studies evaluating any association between H. pylori and NAFLD. We also searched for abstracts evaluating this association from major conferences including AASLD, DDW and EASL in the past 5 years. Studies reporting odds ratios (ORs) or hazard ratios (HRs) were included. ORs and HRs were pooled using a random effects model; summary data are reported as pooled OR with 95% confidence interval (CI). Heterogeneity was assessed by I2 statistic. To examine for any directionality, studies evaluating the risk of developing NAFLD in H. pylori-infected subjects and studies evaluating the risk of H. pyloriinfection in subjects with NAFLD were also analyzed separately. Sensitivity analysis was done to explore reasons for any heterogeneity.

RESULTS:

15 studies (13 publications and 2 abstracts) were included. Meta-analysis of all studies showed a weak positive association but with substantial heterogeneity (OR 1.21; 95% CI 1.11 to 1.32; I2 = 68%) (Figure 1). Sensitivity analysis excluding two studies reporting extreme effect estimate also showed a weak positive association (OR 1.17; 95% 1.10 to 1.24) although heterogeneity was lower (I2 = 43%). Considering the possible directionality of any association (Figure 2), analysis of studies evaluating the risk of NAFLD in H. pylori-infected subjects showed a weak positive association (OR 1.18; 95% CI 1.09 to 1.26; I2 = 49%). Analysis of studies evaluating the risk of H. pylori in subjects with NAFLD showed a similarly weak positive association (OR 1.39; 95% CI 1.04 to 1.86; I2 = 81%).

CONCLUSION:

H. pylori infection and NAFLD are weakly associated bi-directionally. This is likely to be due to confounding and may be influenced by sociodemographic and ethnic differences among populations in the different studies and/or by shared environmental risk factors.
2952 Liver Transplant in Patients With Budd-Chiari Syndrome: A National Study
Authors: Ghavimi Shima , Hashemipour Reza , Panchal Dayna , Nasir Umair M. , Javidialsaadi Atefeh , Pyrsopoulos Nikolaos T.
Published: October 2019

INTRODUCTION:

Budd-Chiari syndrome (BCS) involves obstruction of hepatic venous outflow tracts at various levels from small hepatic veins to the inferior vena cava and is the result of thrombosis or its fibrous sequelae. The clinical presentation and clinical manifestations are so varied that it should be suspected in any patient with acute or chronic liver dysfunction. Liver transplantation (LT) may be indicated as a rescue treatment or for fulminant cases with promising results. Living donor liver transplantation (LDLT) can also be used for patients with BCS if deceased donor livers are scarce. The Aim of this study is to assess the mortality rate and review the safety of liver transplant in patients with Budd-Chiari Syndrome.

METHODS:

The National Inpatient Sample (NIS) is the largest all-payer inpatient database consisting of approximately 20% of all inpatient admissions to nonfederal hospitals in the United States. We collected and reviewed data records of new liver transplant patients from the NIS database from the year 2009 to 2014. IBM Statistical Package for the Social Sciences (SPSS) version 25 was used for statistical analysis.

RESULTS:

A total of 5,592 patients were discharged between 2009-2014 with a new liver transplant. Of these patients, there were 37 patients (0.66%) with BCS. The overall mortality rate for a new liver transplant was substantially higher for BCS patients (10.8%) when compared to non-BCS patients (4.0%) with an odds ratio (OR) of 2.92 (CI 1.03-8.32). However, liver transplant complications were not significantly higher in BCS patients (27.0%) when compared with non-BCS patients (15.3%) with OR of 2.06 (CI 0.99-4.26). The mean length of stay was higher in BCS patients at 32 days as compared to non-BCS patients at 20 days (P = 0.001). Results of the statistical analysis are presented in Tables 1 and 2.

CONCLUSION:

LT can be indicated as a rescue treatment or for fulminant cases with promising results. LDLT can also be used for patients with BCS, but it involves a difficult procedure particularly regarding venous outflow reconstruction. Our research indicates that liver transplant is riskier in patients with BCS and we encourage more research to be done regarding BCS patients regarding liver transplantation. Limitations of the study are that the NIS is an administrative database which predisposes to errors from coding inaccuracies as well as the inability to distinguish temporal relationships between variables. Future prospective studies can expand on these conclusions.
2971 Correlation Between Markers of Hepatic Inflammation and Novel Magnetic Resonance Elastography Measurements
Authors: Zhou Kali , Ohliger Michael
Published: October 2019

INTRODUCTION:

Non-invasive tools to stage liver fibrosis exist, but a method to evaluate necroinflammation is lacking. A component of MR elastography (MRE) stiffness measurements, termed loss modulus, has shown potential in estimating hepatic inflammation in animal models. We aimed to correlate histologic and laboratory markers of inflammation with this novel MRE marker in patients with chronic liver disease undergoing liver biopsy.

METHODS:

In this prospective, cross-sectional, pilot study, adults over 18 years with a liver biopsy performed for clinical indications were recruited to participate. Those with contraindications to MRI, decompensated cirrhosis or liver cancer were excluded. All participants underwent a 30-minute MRE using a 3T-MRI scanner. MRE measurements (stiffness, storage and loss modulus) were obtained at 30-Hz and 60-Hz. Results were interpreted by a single radiologist following established protocols and blinded to histologic data. Correlation between serum alanine aminotransferase (ALT) and MRE measurements was determined.

RESULTS:

Eleven participants completed the MRE scan: 64% were male with a median age of 53 years (IQR 32-61). Indication for liver biopsy was fibrosis staging in 4 (36%), elevated liver enzymes in 3 (27%) and evaluation for non-alcoholic steatohepatitis in 4 (36%). The median time from liver biopsy to MRE was 93 days (34-139). Median ALT was 42 U/L (26-85). Adequate MRE results were obtained on 9 of 11 participants. Four (44%), 2 (22%) and 3 (33%) had F0, F0-1, and F1 fibrosis on histology, respectively. Two (22%) had grade 0-1 inflammation and 7 (88%) had grade 1 inflammation. At 60-Hz, median stiffness was 1.85 kPa (1.66-2.30) and loss modulus was 0.23 (0.19-0.28). At 30-Hz, median stiffness was 1.21 kPa (1.03-1.24) and loss modulus was 0.11 (0.06-0.14). Measurements by fibrosis stage and inflammation grade are presented in the Table. There was very weak correlation between ALT and stiffness at both 60-Hz and 30-Hz (r = 0.05 and 0.16, respectively) (see Figure 1). Correlation was moderate between ALT and loss modulus at 60-Hz (r = 0.39) and strong between ALT and loss modulus at 30-Hz (r = 0.62).

CONCLUSION:

In this small cohort of patients with minimal liver fibrosis and mild inflammation on histology, ALT correlated better with MRE measurements of loss modulus compared to stiffness, particularly at 30-Hz, suggesting that loss modulus may approximate hepatic inflammation. Larger studies are needed to validate and optimize the diagnostic performance of this novel tool.