bluuebunny/crossref_metadata_2025_split huggingface dataset:
A173 RECOGNIZING RARE PRESENTATIONS OF POLYPOSIS SYNDROMES AND THEIR ASSOCIATED MALIGNANCIES IN PEDIATRIC PATIENTS
Authors: Reitzel N E , Sherlock M , Zachos M , Arredondo J , Ratcliffe E 
Published: February 2020

Abstract

Background
There is a range of polyposis syndromes and presentations in pediatrics. There are also associated extra-colonic malignancies of which to be cognizant when orchestrating the initial work-up of the various polyposis syndromes.

Aims
To use case review to highlight the importance of recognizing the breadth of presentations of polyposis syndromes in pediatrics.

Methods
Two recent pediatric presentations of polyposis with extra-intestinal manifestations were identified, chart review completed, and compared with newly published ESPGHAN guidelines.

Results
Two patients with intestinal polyposis are presented, in which extra-colonic malignancies and genetic mutations were identified.
The first patient presented at age 16 with a history of fatigue and abdominal pain, and was found to have pancytopenia and splenomegaly. Initial work up included a bone marrow biopsy that was normal. The patient then underwent upper and lower endoscopic evaluation for increasing abdominal pain and persistent anemia and was found to have polymorphic polyps in the duodenum, sigmoid and rectum. On pathology, polyps were mostly inflammatory, but one was found to be hamartomatous. Additional screening revealed a thyroid nodule, found to be follicular carcinoma, requiring hemithyroidectomy. The patient was confirmed to have a PTEN mutation and was diagnosed with Cowden syndrome; following this diagnosis proceeded with a prophylactic bilateral mastectomy.
The second patient was referred at age 15 with a strong family history of APC-associated FAP. At the time of consultation she was asymptomatic and she remained so throughout her work-up. Screening endoscopy revealed 70–90 recto-sigmoid adenomatous polyps as well as scattered gastric and duodenal polyps. Her initial work-up also uncovered an early papillary thyroid carcinoma. Her treatment included a total thyroidectomy and total proctocolectomy with J-pouch and ileoanal anastomosis. Follow-up endoscopy continues for surveillance of numerous gastric adenomas which to this point have not progressed to high-grade dysplasia or malignancy.

Conclusions
These 2 cases highlight the importance of recognizing that neoplastic conditions typically diagnosed in adulthood can also present in the pediatric age group. Ideally, further guidelines in pediatrics would be beneficial to ensure a consistent approach to investigating polyposis and associated malignancies. Pertaining to our specific patients, each had identification of a thyroid malignancy before the recommended screening age of 18 as per the currently accepted guideline, and neither were symptomatic. More cases are needed to establish if this earlier recognition of disease is meaningful in postulating potential mortality associated with a later diagnosis.

Funding Agencies
None
A175 RECURRENT GASTROINTESTINAL BLEED – A LATE MANIFESTATION OF COLONIC TUBERCULOSIS TREATED CONSERVATIVELY
Authors: Tan J , Hejazifar N , Vantomme E , Tsoi K 
Published: February 2020

Abstract

Background
The incidence of active tuberculosis (TB) in Canada is 4.8 per 100000 persons. Globally, gastrointestinal (GI) TB is rare and accounts for 5% of all extra-pulmonary cases. Clinical manifestations of intestinal TB include weight loss (75%), abdominal pain (54%), and changes in bowel habits (50%). GI bleeding has been observed in 5–15% of confirmed cases of colorectal TB. The cecum is the most common site of involvement, with the most common gross finding on colonoscopy being ulcerations (88%), and the least common being polypoid lesions (10%). Intestinal TB is treated the same as pulmonary TB, with endoscopic healing observed in the majority of cases following 9 months of anti-TB therapy. Surgery is entertained in cases of non-resolving obstruction, perforation, or fistula formation.

Aims
Management of stable, recurrent, large volume GI bleeding in TB colitis is not well established. We report such a case that resolved solely by anti-TB regimen.

Methods
Case report

Results
A 56 year old man with chronic kidney disease presented with cachexia and 40 pound weight loss over 6 months after return from India. He underwent computerized tomography scan of his chest, abdomen and pelvis. Multiple, large, cavitary lesions in the right upper lung lobe were seen, and confirmed to be TB by bronchoalveolar lavage. Abdominal imaging identified moderate circumferential wall thickening at the cecum concerning for intestinal TB. These findings were also retrospectively noted on a review of an abdominal MRI 4 months prior.
His course was complicated by episodes of large, alternating bright red blood per rectum and melena stools starting 5 days after initiation of anti-TB therapy. Colonoscopy revealed polypoid lesions in the cecum as well as blood throughout the colon, with no active source of bleeding. Surgery was considered for ongoing bleeding, however, because biopsies were negative for malignancy and positive on acid-fast stain, he continued conservative management with blood transfusions and anti-TB therapy. GI bleeding decreased significantly within the first 2 weeks, and resolved by day 25. He completed 1 year of anti-TB therapy, with no signs of colitis detected radiographically at the 6-month mark.

Conclusions
To our knowledge, this is the first report of GI bleeding as a very late manifestation of colonic TB, resolved with anti-TB therapy alone. Time from initial evidence of intestinal TB on imaging to the first bleed was 159 days, and time from initial symptoms was 6 months. As polypoid lesions are the least common gross finding on colonoscopy, a high degree of suspicion should be held in the right clinical setting. Surgical management should be considered only after conventional anti-TB therapy has failed.

Funding Agencies
None
A182 LAST RESORT – RESOLVING REFRACTORY UPPER GI BLEEDS WITH ENDOSCOPIC APPLICATION OF FIBRIN GLUE
Authors: Enns C J , Dhalla S , Corcoran M 
Published: February 2020

Abstract

Background
Endoscopic assessment of gastric bleeding is essential for timely investigation and evaluation in attempting to resolve bleeds. Increasingly, endotherapy is used to stop bleeds to prevent the patient from progressing to surgery. The tools available for the endoscopist can be broadly broke into injection sclerotherapy, mechanical tamponade, thermal methods and Hemospray©. Each method has their own inherent advantages and disadvantages with indications for use.

Aims
Unfortunately, patients fail despite standard endotherapy and would then be subjected to surgical procedures. Fibrin glue injection has been selectively described in case reports to resolve recalcitrant bleeds. We have reviewed endotherapy cases by one surgeon where fibrin glue was used to resolve recalcitrant upper gastrointestinal bleeding in a variety of clinical presentations. The goal was to show that endotherapy application of fibrin glue can be used to resolve challenging GI bleeds.

Methods
A retrospective review was made from one surgeon records of endoscopic bleed resolution with fibrin glue from 2010 to 2018. Indications for the procedure were gastric bleeds in hospital, emergency department, or undergoing endoscopic procedures that resulted in a heavy bleed. Patients were categorized as high risk using the Rockall score and those with known ulcers ertr graded as Forest Ia. The patients were of a variety of ages, sex, and had differing co-morbid medical conditions. The fibrin product used was Tisseel which is a two-component fibrin sealant and was deployed using a standard endoscopic Injection sclerotherapy needle.

Results
In all but one of the patients, hemostasis had been reached by delivering fibrin glue by endoscopy. The patient that failed treatment had multiple co-morbidities and the bleeding source was a gastric bed of venous malformations. Patients were followed up with next day scoping to confirm bleed hemostasis. No adverse reactions were noted.

Conclusions
Studies have shown in the past that fibrin glue has worked in achieving hemostasis and had a lower rate of re-bleeding. There are several advantages to using the biological process of the clotting system. The fibrin mat will stay localized and not spread into the lesion. Fibrin injection also creates the natural meshwork of normal biological healing. This naturally compress the mat meshwork along the wound and promote hemostasis. Fibrin glue can also be re-applied in the case of a site re-bleed. Treating endoscopically can beneficial in that patients may not need to progress to the risks and recovery times of surgery. Utilizing the biological process of the body allows for natural repair and degradation of the clot. The procedure is well tolerated and had showed no side effects in this review. Our findings support the use of fibrin glue injection endotherapy as a last resort before surgical intervention.

Funding Agencies
None
A183 UPPER GASTROINTESTINAL CAUSTIC INJURIES: A SINGLE CENTRE CASE SERIES
Authors: Monachese M , Griller N , Yong E 
Published: February 2020

Abstract

Background
Caustic esophageal and gastric injury is a rare, but potentially lethal event. The 2017 American Association of Poison Control reported only 193,000 cases of caustic ingestion (1). Caustic agents are acidic or alkaline. The pH of the ingested substance dictates the type of injury and the area of the gastrointestinal track most at risk. The most common culprit agents are alkaline including, for example, bleaches, drain openers and dishwashing detergents. Due to the rarity and natural history of this disease there are very few high-quality studies for clinicians to refer to when managing these patients.

Aims
We present three cases of caustic ingestion and provide a review of current best practice standards.

Methods
Between August and September 2019, three patients were admitted to Sunnybrook Health Sciences Centre at the University of Toronto for caustic injury. All three patients were referred to the gastroenterology service and underwent an esophagogastroduodenoscopy (EGD) to assess the degree of esophageal and gastric injury. Patients were followed both in hospital and in the outpatient setting for ongoing surveillance and repeated endoscopic evaluation. Patient demographics, treatment, endoscopic findings and outcomes were collected.

Results
Three patients intentionally ingested caustic agents, were admitted to hospital and managed by the gastroenterology service. Patients were a mix of ages, genders and ethnicities. All ingestions were strong alkali agents including sodium hydroxide and sodium hypochlorite. All patients underwent an EGD within 24 hours of presentation and caustic injury was graded using the Zargar classification (2). All patients were started on intravenous proton pump inhibitor therapy. All patients were initially made nothing per mouth and ability to resume feeds was assessed based on symptoms. Patient 1, Zargar grade 1, was able to resume oral intake within 48 hours and progressed to a regular diet without complications. Patient 2, Zargar grade 2a, required 5 days of TPN and bowel rest after which a liquid diet was initiated and advanced without complications. The third patient, had a severe injury (Zargar grade 3b), requiring a prolonged hospital stay. He was on TPN for three weeks before transitioned to tube feeds.

Conclusions
Caustic mucosal injuries are an infrequent, but potentially lethal event requiring urgent assessment and management by a team including gastroenterologists, thoracic and abdominal surgeons, dieticians and intensivists. High-quality evidence to guide management of caustic injuries remains limited. In our case series, there was a wide spectrum of degree of mucosal injury. All 3 patients were managed in a consistent fashion based on current recommendations. Two of three cases had a rapid recovery with the ability to resume oral intake and return home. The third patient remains in hospital, requiring a high level of supportive care.

Funding Agencies
None
A188 COMPARING THE PERFORMANCE OF FIBROSIS-4 (FIB-4) AND NON-ALCOHOLIC FATTY LIVER DISEASE FIBROSIS SCORE (NFS) WITH FIBROSCAN SCORES IN NON-ALCOHOLIC FATTY LIVER DISEASE
Authors: Cox B D , Trasolini R , Galts C , Yoshida E M , Marquez V 
Published: February 2020

Abstract

Background
With the rates of non-alcoholic fatty liver disease (NAFLD) on the rise, the necessity of identifying patients at risk of cirrhosis and its complications is becoming ever more important. Liver biopsy remains the gold standard for assessing fibrosis, although the costs, risks, and availability prohibit its widespread use for at-risk patients. Fibroscan has proven to be a non-invasive and accurate way of assessing fibrosis, although the availability of this modality is often limited in the primary care setting. The Fibrosis-4 (FIB-4) and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) are scoring systems which incorporate commonly measured lab parameters and BMI to predict fibrosis. In this study, we compared FIB-4 and NFS values to fibroscan scores to assess the accuracy of these inexpensive and readily available scoring systems for detecting fibrosis.

Aims
The aim of this study was to determine if non-invasive and inexpensive scoring systems (FIB-4 and NFS) can be used to rule out fibrosis in non-alcoholic fatty liver disease with comparable efficacy to fibroscan. Ultimately, we aim to demonstrate that these scoring systems can be used as an alternative to fibroscan in some patients.

Methods
Data was collected from 317 patient charts from the Vancouver General Hepatology Clinic. 93 patients were removed from the study due to insufficient data (missing Fibroscan score or lab work necessary for FIB-4/NFS). For the remaining 224 patients, FIB-4 and NFS were calculated and compared to fibrosis scores both independently and in combination.
Results:
Using a NFS score cut-off of -1.455 and a fibroscan score cut-off of ≥8.7kPa, the NFS had a sensitivity of 71.9%, a specificity of 75%, and a negative predictive value of 94.1%. For a fibroscan score cut-off of ≥8.0kPa, the NFS had a sensitivity of 66.7%, a specificity of 75.7%, and a negative predictive value of 91.5%.
Using a fibroscan score cut-off of ≥8.7kPa, the FIB-4 score had a sensitivity of 53.1%, specificity of 84.9%, and a negative predictive value of 91.6%. For a cut-off of ≥8.0kPa, it had a sensitivity of 51.3%, and 85.9%, and a negative predictive value of 89.3%.
Conclusions:
The NFS and FIB-4 are non-invasive scoring systems that have high sensitivity and negative predictive value for fibrosis when compared to fibroscan scores. These findings suggest that the NFS and FIB-4 can provide adequate reassurance to rule-out fibrosis in select patients, and has promising use in the primary care setting where fibroscan access is often limited.

Funding Agencies
None
A193 GLUTEN-FREE DIET IMPROVES DYSPEPSIA-LIKE SYMPTOMS IN A PILOT STUDY OF PATIENTS WITH TYPE 1 DIABETES MELLITUS
Authors: Miranda P M , Rueda G H , Calo N , Seiler C , Punthakee Z , Pinto-Sanchez M I , Bercik P 
Published: February 2020

Abstract

Background
Patients with type 1 Diabetes Mellitus (T1DM) often suffer with gastrointestinal (GI) symptoms, such as abdominal pain, bloating, early satiety, nausea and vomiting. T1DM patients are at a higher risk to develop celiac disease, and those patient with both disorders benefit from a gluten-free diet (GFD). However, it is unknown whether GFD has any benefit in patients with T1DM without celiac disease who present with upper GI symptoms.

Aims
To investigate the role of GFD in the management of moderate to severe dyspeptic symptoms in non-celiac patients with T1DM.

Methods
We enrolled adult T1DM patients, in whom celiac disease was ruled out by serology and/or endoscopy, suffering with two or more of upper GI symptoms. The patients were instructed to undergo a strict GFD for a period of 1 month, under supervision of a dietitian. Glycemic levels were monitored by a continuous glucose monitoring device (CGM) for 2 weeks before, and for 2 weeks at the end of the GFD period. Upper GI symptoms, general quality of life, anxiety and depression were assessed using standardized questionnaires. Blood samples were collected to assess glycaemia (Hb1Ac) and lipid profiles. Scintigraphy and videofluoroscopy were used to assess gastric emptying.

Results
Seven patients finished the study so far. They reported a significant improvement in nausea (p&lt;0.05), sensation of fullness (p&lt;0.01), bloating (p&lt;0.01), feeling of excessive fullness after meals (p&lt;0.01) and having stomach visibly larger after meals (p&lt;0.01). 5 out of the 7 patients reported an improvement in general quality of life, based on PAGI-QOL (Patient Assessment of Upper Gastrointestinal Disorders – Quality of Life), and decreased anxiety levels (HADS, Hospital Anxiety and Depression Score). There was no significant change in mean glucose level, time in target, glucose variance and HbA1c levels after GFD. However, there was a trend for less time spent in hypoglycemia, namely in those patients who experienced frequent hypoglycemia prior to GFD. Overall, there was no change in serum lipid profile or gastric emptying.

Conclusions
One month of GFD improved dyspepsia-like symptoms, general quality of life and anxiety levels in T1D patients without concomitant celiac disease. GFD also improved the blood glucose management of patients with frequent hypoglycemia. Thus, this dietary intervention appears to improve upper GI symptoms in T1D patients but the results need to be replicated in a larger patient cohort.

Funding Agencies
CIHR
A195 THE CANADIAN POEM EXPERIENCE. THE FIRST 50 PATIENTS
Authors: Rai M , Woo M , Bechara R 
Published: February 2020

Abstract

Background
Achalasia is a disorder of esophageal motility characterized by a loss of enteric neurons resulting in impaired relaxation of the lower esophageal sphincter and absence of esophageal peristalsis. There are no current treatments that allow for regeneration of the enteric neurons. Interventions focus primarily on lowering the LES pressure to provide symptom relief and improve quality of life. Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia.

Aims
This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center.

Methods
All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤ 3 at ≥ 3 months. Adverse events were recorded according to the Clavien-Dindo grading system.

Results
A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6±29.6 minutes. Post-POEM Eckardt scores of ≤ 3 at ≥ 3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day (range 1–2 days). No major adverse events occurred.

Conclusions
POEM is a safe and effective procedure for the treatment of achalasia. At a median follow up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤ 3).

Stages of POEM. a) Injection and mucosal incision, b) submucosal tunneling c) completed tunnel, view from just above the lower esophageal sphincter (main), gastric side (right upper) and esophageal side (right lower) d) myotomy e[i]) completed myotomy f) closure with hemostatic clips.

Funding Agencies
None
A197 MEDICAL INTERVENTIONS IN EOSINOPHILIC ESOPHAGITIS (EOE): A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS (RCTS)
Authors: Someili A , Alshammari K , Yuan Y , Alhazzani W 
Published: February 2020

Abstract

Background
Eosinophilic esophagitis (EoE) is a chronic, allergic/immune condition of esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.

Aims
Despite different drugs were studied for the treatment of EoE, there is no consensus on what the most effective medical interventions. We performed a systematic review and meta-analysis of RCTs to compare the efficacy of medical interventions in patients with EoE.

Methods
We searched MEDLINE, EMBASE and the Cochrane CENTRAL (via OvidSP) published from inception to November 01, 2018, to identify RCTs assessing the efficacy of medications (PPIs, steroids, anti-IL5 agents, anti-IL13 agents, anti-IL-4Rα agents and mast cell stabilizers) in patients with EoE. Outcomes were symptoms improvement and histology improvement. Studies that only reported continuous scores were excluded. Pooled risk ratios (RR) with 95% confidence intervals (CI), using a random effects model, were calculated.

Results
Among 1311 citations, 19 RCTs (n=1239 EoE cases) were included. 11 RCTs compared steroids vs placebo, two compared PPIs vs steroids, two compared anti- IL-13 vs placebo, two compared anti-IL-5 vs placebo, one compared anti-IL-4Rα vs placebo, and one compared mast cell stabilizer vs placebo. Steroids demonstrated significant improved in histology (63.3% vs 2.9%; RR 10.12, 95% CI 4.56–22.46) and improved EOE symptoms (39.6% vs 20.0%; RR =1.91, 1.16,3.14) compared to placebo. No difference was seen between oral and inhale steroids. No significant difference was seen between PPI vs prednisone either in symptom (RR 1.33, 0.36, 4.97) or in histology improvement (RR 1.83,0.76,4.40). Limited data suggest there is no significant difference between anti-IL-13 vs placebo; and anti-IL5 vs placebo; anti-IL-4Rα dupilumab but not mast cell stabilizer cromolyn may significantly improve histology compared to placebo. No substantial heterogeneity was seen in all analyses.

Conclusions
Current evidence suggests steroids significantly improve histology as well as symptoms in patients with EoE in compared to placebo. There is no significant difference between steroids and PPI. Data relate to other newer agents are limited. This meta-analysis highlights the variability in the interventions of EoE and the need for further studies to determine the optimal intervention.

Funding Agencies
None