bluuebunny/crossref_metadata_2025_split huggingface dataset:
A84 LINITIS PLASTICA FROM A NON-GASTROINTESTINAL PRIMARY TUMOR: A CASE REPORT
Authors: Ghaith J , Alhafid I , Habal F 
Published: February 2020

Abstract

Background
Infiltrative malignancies to the stomach are unusual and are difficult to detect. Linitis Plastic is a syndrome caused by submucosal invasion of the gastric wall. It represents Bormann type III or IV of gastric adenocarcinoma. Uncommonly, the latter can be a manifestation of lobular breast cancer.

Aims
To present a case report of lobular breast cancer that manifested primarily as Linitis Plastica (LP). We review the literature of LP as a clinical syndrome and the diagnostic challenges associated with this condition. We aim to increase the awareness of LP as a non-gastric tumor and its endoscopic features.

Methods
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Results
A seventy-two-year-old female patient, previously healthy, presented with general deconditioning and distended abdomen. Basic laboratory testing such as complete blood count, electrolytes and kidney function were normal. Computed tomography of the abdomen and pelvis revealed moderately sized peritoneal carcinomatosis deposits on the abdominal wall. Her family history was non-contributary for any gastrointestinal or gynecological malignancies. On review of system, the patient noted a history of successful eradication of Helicobacter pylori infection remotely. Additionally, no preceding age-appropriate malignancy screening tests were reported. A gastroscopy was done looking for a primary gastrointestinal tumor exhibited abnormally stiff gastric wall, erythematous thickened mucosal folds, and non-distensible stomach. No clear lesions, submucosal masses or ulcers were visualized. The duodenal mucosa was noted to be normal. Twelve deep random biopsies were retrieved from the mucosal body and fundus. Following immunohistochemistry, the histological diagnosis revealed lobular adenocarcinoma of the breast.

Conclusions
Linitis Plastica (leather bottle stomach) or Brinton disease is a rare entity of diffuse gastric mucosa infiltrating tumor. LP depicts 3–10% of primary gastric carcinoma, whilst less than 10% are secondary breast cancer. Endoscopically, breast cancer-related LP can be divided into two morphologies: nodular pattern with ulceration, which is the typical presentation of ductal breast carcinoma and diffuse mural pattern in lobular breast carcinoma. LP is a unique condition with challenging diagnostic features. Many biopsies can result in negative histopathological diagnoses. This can be explained partially by 1. The scirrhous and fibrous stroma that forms LP tumors. 2. The deep location in the submucosa and muscular layer of the gastric wall. 3. Inability to identify this entity endoscopically. In one case report, Endoscopic Ultrasound-Fine Needle Aspirate (EUS-FNA) was incorporated after negative obtained biopsies. There are no standardized diagnostic approaches for LP. Further studies inquiring rates of missed malignant diagnoses and optimum diagnostic assessments in the setting of LP are needed.

Funding Agencies
None
A95 DO BENIGN LIVER TUMOURS ALWAYS STAY BENIGN? A CASE REPORT OF HEPATIC INFLAMMATORY PSEUDOTUMOR AND SUBSEQUENT CHOLANGIOCARCINOMA
Authors: Onizuka K , Schell M , Tsoi K 
Published: February 2020

Abstract

Background
Hepatic inflammatory pseudotumors (HIPTs) are rare, benign lesions of unclear etiology which can be challenging to diagnose and differentiate from malignant processes. The optimal treatment and follow up of these lesions is controversial, and literature exists to support both surgical resection as well as conservative medical management. The natural history of HIPTs is generally benign, however there are some reports of disease recurrence, and two reports of malignant transformation to lymphoma.

Aims
To describe a case of HIPT with progression to malignancy.

Methods
Case report and review of the literature.

Results
A 53-year-old male presented to St. Joseph’s Healthcare Hamilton in August 2019 with a three-week history of abdominal pain and distention. He had a previous diagnosis of HIPT, incidentally found on ultrasound four years earlier. CT in January 2016 reported two well-marginated focal liver masses with peripheral rim enhancement and central hypodensity, 3.9 x 3.9cm in segment 2, and a 6 x 4.6cm central lesion, as well as diffuse fatty infiltration of the liver. Bloodwork showed a mildly elevated Ca19-9 626 kU/L, and normal CEA and AFP.
Two biopsies were performed in 2016, both demonstrating dense fibrous tissue and abundant chronic inflammatory cell infiltrate composed of lymphocytes, histiocytes, eosinophils, and plasma cells, with some areas of bland spindle cell proliferation. No malignant cells, and histology was felt to be consistent with HIPT.
MRI in September 2017 showed progression of disease, prompting Rheumatology to initiate immunosuppressive medications, however serial imaging continued to show increase in the size and number of lesions.
Upon presentation to hospital in August 2019 ultrasound showed new ascites, with ascitic fluid analysis reporting highly atypical cells with prominent nucleoli of uncertain origin. CT showed extensive intrahepatic lesions throughout both lobes of the liver, and tumor markers were elevated with Ca19-9 16,581 kU/L, CEA 10 ug/L, Ca125 511 kU/L, and normal AFP.
Repeat liver biopsy reported adenocarcinoma, likely cholangiocarcinoma, with background cirrhosis. Medical oncology did not feel he would tolerate chemotherapy, and he was thus discharged home with palliative supports.

Conclusions
HIPTs are benign lesions that are often initially misdiagnosed as malignancy, however this is the first case reporting progression of HIPT to cholangiocarcinoma. It is unclear if HIPT itself has premalignant potential, or whether its presence delays diagnosis of subsequent de novo malignancies. Given these uncertainties, as well as the lack of clarity on optimal management of HIPT, this case illustrates the importance of long-term clinical and radiographic follow up of these uncommon lesions, with consideration of repeat biopsy if the disease is not following the expected clinical course.

Funding Agencies
None
A98 EXCITATION OF LUMBAR SPLANCHNIC AFFERENT NERVES BY FECAL SUPERNATANTS FROM INFLAMMATORY BOWEL DISEASE PATIENTS
Authors: Abu Omar A A , Reed D E , Lomax A E 
Published: February 2020

Abstract

Background
Increased excitability of extrinsic afferent nerves has emerged as an important cause of visceral pain during inflammatory bowel disease (IBD). However, little is understood regarding what role, if any, the intestinal microbiota plays in pain development during IBD. Therefore, we aimed to determine the effects of fecal supernatants (FS) from patients with IBD on lumbar splanchnic afferent nerves (LSN).

Aims
We aimed to determine the effects of fecal supernatants (FS) from patients with IBD on lumbar splanchnic afferent nerves (LSN).

Methods
Fecal samples from 8 patients with active IBD (4 Crohn’s disease (CD) patients and 4 ulcerative colitis (UC) patients) and 6 healthy volunteers (HV) were suspended in normal saline solution at 0.5gm/4 ml. In vitro extracellular recordings of action potential discharge were obtained from LSN of the distal colon from control mice. LSN afferents were classified based on their responses to colonic distention into low threshold (LT), high threshold (HT), wide dynamic range (WDR) and mechanically insensitive (MIS) units. FS was applied intraluminally for 20 min after which afferent nerve sensitivity for colonic distension was re-assessed.

Results
FS from IBD patients increased the basal firing frequency of afferent nerves compared to vehicle control (P value &lt;0.0001 in both CD and UC experiments). Furthermore, FS from CD augmented the mechanosensitivity of the overall activity of the units with 35% increase in the units’ discharge compared to vehicle control with a significant effect on HT and MIS units. Conversely, FS from HV decreased the basal firing frequency of afferent nerves compared to vehicle control (P value &lt; 0.01). Moreover, FS from HV induced 60% reduction in the mechanosensitivity of the overall activity of the units with a significant effect on HT and WDR units.

Conclusions
These results suggest that FS from IBD patients contain mediators that can activate LSN. These changes would lead to an increased afferent input to the CNS, which could exacerbate pain. On the other hand, control FS from HV contain mediators that suppress the activity of LSN. Further characterization these mediators has the potential to lead to new targets for pain management in IBD.

Funding Agencies
CCC, CIHR
A99 IMPACT OF OSMOTIC PERTURBATIONS ON THE GUT MICROBIOTA AND HOST HEALTH
Authors: Pepin D M , Tropini C 
Published: February 2020

Abstract

Background
Osmotic diarrhea is a prevalent condition concurrent with diverse pathologies such as Crohn’s disease and is due to unabsorbed solutes in the gastrointestinal contents inhibiting normal water absorption. Osmotic laxatives such as polyethylene glycol (PEG) take advantage of this process to counteract constipation. However, short-term PEG treatment impacts the gut microbial community, and in humanized and conventional mice leads to disappearance of the abundant and prevalent bacterial family S24-7, while increasing the relative abundance of a related family, Bacteroidaceae. Excitingly, despite community re-equilibration over weeks, S24-7 is capable of superseding other bacterial members and reach its original levels when reintroduced into the environment. My central hypothesis is that the depletion of S24-7 during osmotic diarrhea is due to its deficiency of stress response pathways required to counteract increased osmolality. However, in the absence of this stress, S24-7 is capable of exploiting a unique interaction with the immune system to successfully recolonize.

Aims
To shed light on this, I will pursue the following two aims: Aim 1: Compare the growth, survival and expression profiles of S24-7 and B. thetaiotaomicron in a bi-colonized gnotobiotic mouse model before, during and after osmotic perturbation to identify candidate genes involved in response to osmotic perturbation. Aim 2: Identify changes in S24-7 gene expression during recolonization and evaluate the host immune response.

Methods
Gnotobiotic mice were first colonized with S24-7 and then B. thetaiotaomicron, treated with PEG for 6 days and monitored during recovery and recolonization for 20 days. Fecal pellets were used to quantify bacterial abundances via qPCR and bacterial gene expression analysis through metatranscriptomics. Mouse serum was used for ELISA immunoassays to compare adaptive immune responses through serum IgG as well as to quantify glycine betaine levels.

Results
During PEG treatment S24-7 became undetectable and recolonized to pre-treatment levels during recovery. Using genomic and metagenomic annotation we have identified that S24-7 isolates do not possess the glycine betaine transport system, which is present in B. thetaiotaomicron (Figure 1). B. thetaiotaomicron reduced host serum glycine betaine levels, unlike S24-7. In S24-7 mono-colonized mice, S24-7 specific serum IgG was not detectable. However, once mice were co-colonized with B. thetaiotaomicron, both S24-7 and B. thetaiotaomicron specific IgG is detected, identifying an interesting relationship between S24-7 and the adaptive immune system that may shed light on its unique recolonization.

Conclusions
By studying S24-7 sensitivity to osmotic stress and its robust colonization abilities we are shedding light on the mechanisms of microbiota response to perturbations that are commonly experienced by the human gut.

Funding Agencies
None
A107 PATIENT PERSPECTIVES ON THE LONG-TERM MANAGEMENT OF CELIAC DISEASE
Authors: Elias E , Silvester J , Graff L A , Bernstein C N , Rigaux L , Duerksen D 
Published: February 2020

Abstract

Background
Celiac disease (CD) is a common chronic gastrointestinal illness with a range of manifestations. The only available treatment is strict gluten avoidance, therefore patients are effectively self-managed. Despite the critical role patients play in their treatment, patient perspectives on long-term CD care have not been formally assessed and are therefore not represented in current clinical guidelines.

Aims
To determine the opinions of CD patients on the need for long-term CD follow-up, the utility of various aspects of CD follow-up, and the areas in which further information is desired.

Methods
The Manitoba Celiac Disease Cohort includes newly diagnosed adults with elevated TTG and/or EMA antibodies and Marsh III histology. At the 24-month follow-up visit, participants were asked to rate the utility of various aspects of CD care from 1–5 (low-high) and their desire for further information on CD-related issues from 1–6 (low-high).

Results
A total of 213 patients were recruited and 137 participants completed the online survey (median age 41 [interquartile range 29–57] years; 68% female). Adherence to a gluten free diet was variable, with 29% of patients having TTG antibodies above the upper limit of normal.
Two-thirds of participants felt they should be seen regularly for their celiac disease, while 79.8% of those who wished to be followed felt they should be seen every 6–12 months. Blood tests were the most highly rated component of CD care (scored ≥4 by 78% of respondents). Celiac symptom review, information on research in celiac disease, and the opportunity to ask questions about vitamins and supplements were also positively regarded. Diet review was not generally considered helpful. 79% of patients desired further information on research in CD, while approximately 60% desired information on the long-term complications of CD and the risk of nutritional deficiencies.

Conclusions
The majority of CD patients find regular specialist follow-up helpful, particularly for biochemical assessment of disease activity and its complications. Further information on CD research and the long-term complications of CD should be addressed in follow-up visits. These aspects of follow-up care should be reflected in future guidelines.

Funding Agencies
None
A137 COLONOSCOPY RELATED ADVERSE EVENTS IN A POPULATION-BASED COLON SCREENING PROGRAM
Authors: Tomaszewski M , Sanders D , Enns R A , Gentile L , Nash C , Cowie S , Petrunia D , Mullins P , Azari-Razm N , Bykov D , Telford J J 
Published: February 2020

Abstract

Background
The British Columbia Colon Screening Program (BCCSP) is a population-based program enrolling 50–74 year old individuals for biennial FIT (OC-Sensor, cut-off 10 mcg/g) with follow-up colonoscopy for positive FIT. The neoplasia detection rate is 50–55% and over 75% of colonoscopies have a specimen taken. Previously reported colonoscopy adverse event rates for FIT based screening programs vary widely: 0.03–6.2% and 0–2.7% for bleeding and perforation, respectively. Mortality as a result of colonoscopy is rare but has been reported in 0.0004%-0.0074% of colonoscopies. The rate of colonoscopy related adverse events in BCCSP participants is unknown.

Aims
To determine the rate of colonoscopy related serious adverse events within the BCCSP.

Methods
This is a retrospective cohort study of all participants undergoing colonoscopy in BCCSP from November 15, 2013 to December 31, 2017. BCCSP contacts screening participants by phone 14 days post colonoscopy to determine unplanned medical visits the day prior (during bowel preparation) or following the colonoscopy. Unplanned events underwent chart review if the event was a perforation, cardiovascular or respiratory event, or resulted in death, hospitalization, or significant intervention including repeat colonoscopy, interventional radiology, surgery, blood transfusion, cardioversion, casting of a fracture or suturing of a laceration. Chart review was conducted by a Colonoscopy Lead and reviewed by BCCSP Quality Committee. Unplanned events were defined as serious adverse events (SAE) if they resulted in death, hospitalization or significant intervention and further classified as probably, possibly, or unlikely related to the colonoscopy.

Results
A total of 108,004 colonoscopies were performed. Unplanned events were reported in 1753 participants, of which 586 met criteria for review. Of these, 578 were confirmed unplanned events and 409 were SAEs of which 367 (89.7%) were probably, 22 (5.4%) possibly and 20 (4.9%) unlikely associated with colonoscopy. 36/10,000 colonoscopies were associated with a SAE that was probably or possibly related: perforation in 5/10,000, bleeding 22/10,000. Three deaths occurred in the 14 days following colonoscopy that were probably (2 perforations) or possibly related to the colonoscopy (0.3/10,000).

Conclusions
The BCCSP has a colonoscopy SAE rate in keeping with previous publications, particularly in the context of a very high proportion of procedures associated with polypectomy, a known risk factor for perforation and bleeding. This study will help inform screening participants about the risks of colonoscopy in the BC program. Future studies are required to confirm these rates using hospital admission data.

Funding Agencies
None
A148 EFFICIENCY IN THE ENDOSCOPY UNIT: CAN WE ‘TURN AROUND’ ROOM TURNOVER?
Authors: Tan C M , Tinmouth J , Bernstein M 
Published: February 2020

Abstract

Background
Endoscopy units across Canada are being challenged to meet the growing demand for procedures despite limited resources, highlighting the need to optimize endoscopy unit efficiency. Earlier studies have found that non-procedural factors, such as room turnover, represent an ideal target to improve efficiency.

Aims
The objective of this research project was to identify practices that will improve efficiency for routine outpatient gastrointestinal (GI) procedures at Sunnybrook Health Sciences Centre (SHSC). There were 2 sub-aims: 1) to understand practices at Toronto hospitals that shorten room turnover time and 2) to describe the variation in room turnover time at SHSC.

Methods
Sub-aim #1: A survey of endoscopy units at five other Toronto hospitals was completed. Questions were designed to gain a better understanding of routine practices and any initiatives undertaken to improve room turnover efficiency.
Sub-aim #2: Median room turnover time from April 2018 to March 2019, defined as ‘patient out’ to ‘patient in’, was reported in an anonymized fashion for the following categories: 1) by endoscopist, 2) by nurse, and 3) by unique endoscopist-nurse pair. Only data from routine outpatient endoscopic procedures (e.g. colonoscopy, gastroscopy, flexible sigmoidoscopy) were included. In order to evaluate turnover times by endoscopist-nurse pair, consecutive cases not performed by the same pair were excluded. Procedures affected by patient- and transportation-related delays were also excluded.

Results
Of the five centers surveyed, three allocated 5 minutes for turnover and two allocated 10 minutes. All centers reported tracking turnover time and four centers reported undertaking initiatives to decrease turnover time such as involving a flow team, hiring team attendants, and sharing performance data.
Over the 12-month period, 2504 routine outpatient GI endoscopic procedures were performed at SHSC, with 803 cases meeting inclusion criteria. Median turnover time for the unit was 6 minutes, ranging from 5 to 9 minutes across endoscopists, 5 to 7 minutes across nurses, and 3 to 10 minutes across unique endoscopist-nurse pairs (Figure 1). Efficiency of endoscopist-nurse pairs did not correlate with the number of cases performed as a pair over the 12-month period.

Conclusions
Endoscopy room turnover times at SHSC are similar to those reported by other local centers, with important variation across endoscopists and nurses. The next phase of this study will involve directly observing each of the most and least efficient individuals and pairs and recording common practices. It is anticipated that these findings will enable us to identify efficient practices that should be incorporated into standard operating procedures and training for endoscopy room personnel.

Funding Agencies
None
A164 UPTAKE OF FECAL CALPROTECTIN IN PRACTICE: PATTERNS IN A TERTIARY GI REFERRAL CENTRE
Authors: Kundra A , Ritchie T , Ropeleski M 
Published: February 2020

Abstract

Background
Fecal Calprotectin (FC) is helpful in distinguishing functional from organic bowel disease. Also, it has proven useful in monitoring disease activity in inflammatory bowel disease (IBD). The uptake of its use in clinical practice has increased considerably, though access varies significantly. Studies exploring current practice patterns among GI specialists and how to optimize its use are limited. In 2017, Kingston Health Sciences Centre (KHSC) began funding FC testing at no cost to patients.

Aims
We aimed to better understand practice patterns of gastroenterologists in IBD patients where there is in house access to FC assays, and to generate hypotheses regarding its optimal use in IBD monitoring. We hypothesize that FC is not being used in a regular manner for monitoring of IBD patients.

Methods
A retrospective chart audit study was done on all KHSC patients who had FC testing completed from 2017–2018. Qualitative data was gathered from dictated reports using rigorous set definitions regarding indication for the test, change in clinical decision making, and frequency patterns of testing. Specifically, change in use for colonoscopy or in medical therapy was coded only if the dictated note was clear that a decision hinged largely on the FC result. Frequency of testing was based on test order date. Reactive testing was coded as tests ordered to confirm a clinical flare. Variable testing was coded where monitoring tests that varied in intervals greater than 3 months and crossed over the other set frequency codes. Quantitative data regarding FC test values, and dates were also collected. This data was then analyzed using descriptive statistics.

Results
Of the 834 patients in our study, 7 were under 18 years old and excluded. 562(67.34%) of these patients had a pre-existing diagnosis of IBD; 193 (34%) with Ulcerative Colitis (UC), 369 (66%) with Crohn’s Disease (CD). FC testing changed the clinician’s decision for medical therapy in 12.82% of cases and use for colonoscopy 13.06% of the time for all comers. Of the FC tests, 79.8% were sent in a variable frequency pattern and 2.68% with reactive intent. The remaining 17.5% were monitored with a regular pattern, with 8.57% patients having their FC monitored at regular intervals greater than 6 months, 7.68% every 6 months, and 1.25% less than 6 months. The average FC level of patients with UC was 356.2ug/ml and 330.6 ug/ml for CD. The mean time interval from 1st to 2nd test was 189.6 days.

Conclusions
FC testing changed clinical decisions regarding medical therapy and use for colonoscopy about 13% of the time. FC testing was done variably 79.8% of the time, where as 17.5% of patients had a regular FC monitoring schedule. An optimal monitoring interval for IBD flares using FC for maximal clinical benefit has yet to be determined. Large scale studies will be required to answer this question.

Funding Agencies
None