bluuebunny/crossref_metadata_2025_split huggingface dataset:
1172 Low Diagnostic Yield of Dudodenal Biopsy of Celiac Disease in Patients With Iron Deficiency Anemia and Malabsorption Symptoms
Authors: Kwon Alvin Guyun , Yoo Heesoo , Nam Myungwoo , Nguyen Nghia , Barsky Maria , Kalmaz Denise 
Published: October 2019

INTRODUCTION:
Iron deficiency anemia (IDA) is the most common form of anemia worldwide and can present with malabsorption symptoms. Current guidelines recommend performing both upper and lower endoscopies with biopsies for patients with iron deficiency anemia. Studies show that for celiac disease pooled diagnostic yield of duodenal biopsies in IDA is around 1.15%. The primary aim of this study is to determine the diagnostic yield of routine duodenal biopsies for celiac disease in patients with IDA and malabsorprtion symptoms.

METHODS:
A retrospective chart review was performed of patients undergoing EGD with duodenal biopsy as work up of IDA. All duodenal biopsies were performed from 1/1/2011-4/26/2019 at an academic tertiary referral center. Inclusion criteria was ferritin < / = 45ng/mL within 1 year prior to EGD. If ferritin data was unavailable, physician records were reviewed for diagnosis of iron deficiency anemia in patients who had proven serum MCV < 80 um3 within 1 year prior to EGD. Charts were then reviewed for reported malabsorption symptoms, n = 166. Malabsorption symptoms included abdominal pain and bloating. Patients with rectal bleeding, history of Crohn’s disease, Ulcerative colitis, gastrointestinal cancer, lymphoma or abdominal surgery leading to malabsorption were excluded. A diagnosis of celiac disease was defined as a Marsh type 2 or greater on tissue biopsy. Data on patients that had tissue transglutaminase IgA was (TTG-IGA) was also collected. Diagnostic yield for celiac disease was determined for patients who reported malabsorption symptoms.

RESULTS:
The median age of patients was 57.5 ± 16.8, of whom 25% were female. Symptoms included abdominal pain (22%), bloating (6%), diarrhea (11%) or weight loss (13%). 54% of the sample was white, 20% were Hispanic and 13% were black. Average Hgb was 9.3 ± 2.1, MCV was 76.1 ± 8.5 and ferritin was 22.9 ± 45.9. 31% of the sample had DM2, 10% had CAD, 11% had CKD, 8% had atrial fibrillation and 5% had cirrhosis. The diagnostic yield of duodenal biopsy in respect to celiac disease was 4.2%. The overall diagnostic yield in symptomatic patients with positive TTG IGA was 17%.

CONCLUSION:
Diagnostic yield of routine duodenal biopsies for identifying patients with celiac disease in setting of IDA is low. In patients with malabsorption symptoms, the diagnostic yield of routine duodenal biopsies remains less than 5%. These results suggest that alternative diagnoses should be considered in these patients.
1175 Ileal Carcinoid Tumors Detected During Screening versus Diagnostic Colonoscopy: Comparison of Tumor Characteristics
Authors: Narayani Raj I. , Narayani Kaden R. 
Published: October 2019

INTRODUCTION:
Small intestinal carcinoid tumors are the most common type of small bowel malignancy observed. Most are indolent and incidentally found in asymptomatic patients undergoing ileal intubation during routine colonoscopy. Our aim was to survey all patients diagnosed with ileal carcinoid and to compare tumor characteristics for those discovered during screening or diagnostic colonoscopy.

METHODS:
We reviewed all ileal carcinoid tumor cases from 2005-2018. For each case, we recorded patient age, colonoscopy indication at diagnosis, timing of prior colonoscopy (if ever performed), coexistence of adenomatous polyps in the colon, carcinoid tumor size and stage after resection, and disease-free survival.

RESULTS:
Twenty-nine (29) cases of ileal carcinoid tumor were identified. Mean patient age at diagnosis was 64. In 5 cases, the tumor was initially identified during urgent surgical evaluation of obstructive symptoms and not during colonoscopy. In the remaining 24 cases, tumors were initially detected during colonoscopy with ileal intubation. Of these, 13 were having initial screening or surveillance. The remaining 11 were having diagnostic evaluation of symptoms, abnormal findings on CT imaging, or both. Table 1 compares carcinoid features for cases detected during screening versus diagnostic colonoscopy. A prior colonoscopy was performed within the preceding 10-year period in 11 cases, and of these, only 3 included terminal ileum intubation. Adenomatous colon polyps were found in 11 of 24 patients, with advanced adenomas identified in 3. Tumor size ranged from 0.5 to 3.7 cm (mean 1.8 cm). Lymph nodes were involved in 21 of 24 patients. In the 3 patients without lymph node involvement, tumors were small (0.5, 0.5, 0.6 cm). At diagnosis, only 1 patient had distant metastases and eventually died from tumor complications 42 months later. Another patient died from an unrelated cause at 99 months after diagnosis. Mean survival-to-date for the remaining 22 patients is 57 months with a range of 2-172 months.

CONCLUSION:
In our series, most patients with ileal carcinoid tumors were initially diagnosed during colonoscopy rather than during urgent surgery. Nearly all carcinoids discovered during colonoscopy were associated with lymph node involvement at the time of diagnosis. Most, however, did not have or develop distant metastases and have enjoyed prolonged survival. No significant differences in carcinoid tumor size or stage were observed between patients having screening versus diagnostic colonoscopy.
1176 A Sex-Based Comparison of Initial Presentation and Disease Severity of Celiac Disease
Authors: Cao Christopher , Block Peter , Russell Madeline , Parikh Devayu , Robbins Justin , Kumar Priyanka , David Allison , DiMarino Anthony J. , Moleski Stephanie 
Published: October 2019

INTRODUCTION:
The presenting symptoms of Celiac Disease (CD) in females were initially described as more severe and rapid in comparison to males1. However, a recent study implied these differences may not be as significant as once believed2. The primary objective of this study is to assess for sex differences in CD.

METHODS:
This study is a single center retrospective chart review of adult patients diagnosed with CD at an urban, tertiary hospital. Patients without clear documentation of initial presentation were excluded. Outcomes included age at diagnosis, demographic data, presenting symptoms, relevant clinical values, mode of diagnosis, and adherence to diet.

RESULTS:
We included 194 patients (77% females, n = 150) diagnosed between 1999 – 2017. Ethnicity was similar between sexes. Female patients had a lower mean age (38.7 yr in females; 42.0 yr in males) and lower hemoglobin at presentation (13.5 in females; 14.3 in males; P = 0.0019). Female patients on presentation had similar BMI but higher total cholesterol. Both sexes had similar presentation at time of diagnosis, most commonly GI symptoms and neurologic symptoms. More females presented with symptoms of anemia (9.3% of females; 2.3% of males). The majority of patients in each group were diagnosed by both biopsy and serology. Both sexes presented with a similar distribution of Marsh Classification and were similarly adherent to a gluten free diet.

CONCLUSION:
This study compared the presentation of CD between sexes. In support of recent literature, our study found that male and female patients have similar clinical presentations of CD. However, a few notable differences were noted. Namely, females presented at a younger age and more frequently presented with symptomatic anemia. Both sexes had similar marsh classification on initial diagnosis and had similar adherence to a gluten free diet. While more females carry the diagnosis of CD, clinicians should have a high index of suspicion for CD in both male and female populations.
1191 Use of Artificial Intelligence for Identification of Celiac and Vascular Lesions on Capsule Endoscopy
Authors: Sethi Sajiv , Singh Arush , Morera Hunter H. , Edwards Jade , Goldgof Dmitry , Vidyarthi Gitanjali 
Published: October 2019

INTRODUCTION:
Capsule endoscopy is an important tool for noninvasive identification of gastrointestinal pathology. It requires a physician to review images which can be tedious and time consuming. The use of artificial intelligence has increased in popularity for colonoscopy for identification of polyps and vascular lesions. We aim to use computer-assisted image analysis using convolutional neural networks (CNNs) for the identification of inflammatory and vascular lesions on capsule endoscopy.

METHODS:
We examined a total of 2371 publicly available wireless capsule endoscopy (WCE) images obtained using MiroCam® (IntroMedic Co, Seoul, Korea) capsule endoscopes. The capsule images illustrated normal and assorted small bowel findings including polypoid, vascular and, inflammatory lesions and were notated with each finding. Images were divided into “normal” (725 images), “inflammatory” (225 images), and “vascular” (300 images) for the purposes of this analysis. Pre-processing was performed on these images. Augmentation of the image was performed by flipping and rotating the image to obtain multiple views of pathologic and normal images. The machine learning algorithm was trained on the original and augmented images, testing was only performed on original images.

RESULTS:
Using this machine learning architecture, a total testing accuracy of 73.7% was able to be achieved for the differentiation of normal versus inflammatory and a total testing accuracy of 70.2% was able to be achieved for the differentiation of normal versus vascular capsule endoscopy images. In a set of 2371 capsule endoscopy images, the CNN identified both vascular and inflammatory images using a 5-Fold Cross validation with an accuracy of 73.7% for normal compared to inflammatory images (Figure 1) and 70.20% for normal versus vascular images. The area under the receiver operating characteristic curve (ROC) for identification of inflammatory images was 0.70 (95% CI 0.664-0.736) compared to 0.68 (95% CI 0.646-0.714) for vascular lesions.

CONCLUSION:
This system demonstrates that AI can be used to find more subtle inflammatory and vascular lesions. The CNN system detected and localized polyps well within real-time constraints using an ordinary desktop machine with a contemporary graphics-processing unit. It can increase the findings of pathology and decrease time needed to review capsule endoscopy studies, but requires further validation in large multicenter trials.
1192 The Safety, Efficacy, and Outcomes for the Endoscopic Resection of Large Non-Ampullary Duodenal Polyps in Familial Adenomatous Polyposis (FAP)
Authors: Mehta Neal , Shah Ravi , Yoon Ji Yoon , O'Malley Margaret , LaGuardia Lisa , Mankaney Gautam , Cruise Michael , Kalady Matthew F. , Church James M. , Walsh R. Matthew , Burke Carol A. , Bhatt Amit 
Published: October 2019

INTRODUCTION:
Nearly all patients with FAP will develop duodenal adenomas. Duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging (SS) system. Endoscopic resection (ER) of larger duodenal polyps is technically challenging because of the duodenum’s thin wall, narrow lumen, multiple folds, and increased vascularity. However, successful removal of these large duodenal lesions can potentially avoid foregut surgery by downstaging the SS. We evaluated the safety, feasibility, and outcomes, including the effect on SS, for the ER of large duodenal polyps in FAP.

METHODS:
This is a single-center retrospective cohort study including consecutive FAP patients who underwent ER of large (defined as >1.5 cm) duodenal polyps between 4/2016-2/2019. Resection techniques used included injection-assisted endoscopic mucosal resection (EMR) and hybrid EMR-Endoscopic submucosal dissection (ESD) by an advanced endoscopist specialized in endoscopic resection. Primary aim was to determine safety of the technique, particularly perforation, immediate (>2-gram hemoglobin drop < 48 hrs after procedure) and delayed (active bleeding from a post-resection ulcer diagnosed by emergency or planned follow-up endoscopy) bleeding. SS before and after resection was calculated.

RESULTS:
35 unique FAP patients (48.6% male; age 47.7 years) with 55 large duodenal polyps were identified. All 35 underwent endoscopic resection (54 EMR, 1 ESD/EMR hybrid) of at least one large duodenal polyp [Table 1]. 7 polyps were resected from the duodenal bulb, 33 in D2, 10 in D3/D4, and 2 in the neoduodenum. Median lesion size is 2.4 cm [25-75 IQR:1.65-3], median procedure time 49 min[30-60], and median resection speed 0.16 cm2/min [0.073-0.208]. No duodenal perforations or delayed bleeding occurred. 1 case of immediate bleeding was managed endoscopically. 53/55 polyps were completely resected endoscopically. The 2 incomplete resections were poorly-lifting lesions, preventing safe resection. Of the 35 patients included, 25 had adequate endoscopic surveillance over the study period. 11/25 started at SS IV and 8 were downstaged to SS III (73%) with endoscopic resection, avoiding surgery (Figures 1 and 2).

CONCLUSION:
Endoscopic resection of large duodenal polyps in FAP is safe when performed with adequate expertise. Endoscopic resection of large polyps allows downstaging of advanced SS in many of these patients. Long-term benefit of downstaging needs to be further evaluated.
1201 Clinical and Pathologic Risk Factors for Lymph Node Metastases in Gastric Neuroendocrine Tumors
Authors: Ragheb Jonathan , Bahdi Firas , Mehta Neal , Butler Robert , Chahal Prabhleen , Stevens Tyler , Cruise Michael , Augustin Toms , McNamara Michael , Walsh R. Matthew , Bhatt Amit 
Published: October 2019

INTRODUCTION:
Among gastric neuroendocrine tumors (GNETs), type III is believed to have higher risk of lymph node (LN) metastases than type I or II; however, few studies have explored the clinical history and pathologic attributes correlating with LN metastases. With advances in endoscopic resection techniques like endoscopic submucosal dissection and endoscopic full thickness resection allowing endoscopic removal of these tumors, it is important to understand which lesions are at risk of LN metastases and not candidates for endoscopic resection. Our study aims to determine clinical and pathologic risk factors associated with GNET LN metastases in the US.

METHODS:
This single center retrospective study evaluated consecutive patients at a large tertiary referral center undergoing surgical resection of biopsy proven GNET from April 1988 to January 2019. Demographics, past medical history, and serum studies (gastrin, B12, chromogranin) were included as available. Endoscopic and pathologic tumor features, such as size, number of lesions, depth of invasion, and lymphovascular invasion were studied. Tumor grading was characterized as high (poorly differentiated/WHO 3) or low (well differentiated/WHO 1 & 2) as some patients preceded WHO classification. If unreported, GNET type was based on presence of atrophic gastritis and/or gastrin levels. LN metastases were defined by positive nodes on surgical resection.

RESULTS:
Thirty patients underwent gastric surgical resection for GNET. There were 14 type 1, 8 type 3, and 8 unclassified GNETs (insufficient serum and/or pathology description for classification); no type 2 GNETs were identified based on documented history (Table 1). Of the 37.9% of patients who underwent LN dissection, 3 patients (27%) had positive LN on pathology. No patients that did not have LN dissection developed evidence of LN metastasis on surveillance imaging. Of the endoscopic and pathologic factors in Table 2, high tumor grade (P = 0.093) and deep invasion (P = 0.058) were statistically associated with LN metastasis, as with 1 high grade type 3 GNET invading the subserosa.

CONCLUSION:
High grade or deeply invading GNETs are associated with LN metastases; endoscopic resection should be avoided in these patients. In our case series, low grade type 3 GNETs were not associated with LN metastasis. Endoscopic resection with close surveillance may be considered in small, low grade type 3 GNET, especially if patients are poor surgical candidates. Further studies are needed to confirm these findings.
1209 Effect of Secretin on Gastric Accommodation, Emptying, and Symptoms in Functional Dyspepsia and Health: A Randomized, Controlled, Cross-Over Trial
Authors: Brandler Justin , Miller Laurence J. , Wang Xiao Jing , Vijayvargiya Priya , Arndt Kayla , Busciglio Irene , Burton Duane , Harmsen William S. , Acosta Andres , Camilleri Michael 
Published: October 2019

INTRODUCTION:
Reduced gastric accommodation (GA) or accelerated or delayed gastric emptying (GE) contributes to pathophysiology in functional dyspepsia (FD). Secretin is an endogenous hormone secreted postprandially from the duodenal mucosa. Our objective was to determine the effects of secretin in human gastric motor functions and satiation in health and FD.

METHODS:
We conducted a double-blind, randomized, placebo-controlled, cross-over trial in 10 healthy participants and 10 patients with FD by Rome IV criteria. Subjects were randomized to IV secretin or normal saline with a 1-4 week washout period. We measured GA using validated 99mTc-single photon emission computed tomography with a standardized 300 mL meal of 111In radiolabeled Ensure®. We measured GE using scintigraphy of the same meal and symptoms 30 minutes post meal based on 100 mm visualized analog scale (VAS). To measure volume to fullness (VTF) and maximum tolerated volume (MTV), we performed Ensure® nutrient drink test (NDT) and recorded symptoms 30 min post-MTV. Wilcoxon Signed-Rank Test was used for comparison within healthy and FD groups and ANCOVA modeling was used for intention to treat comparison between groups, adjusting for age, sex, and treatment arm (secretin vs. placebo). Study drug was provided by ChiroClin, Inc.

RESULTS:
The median age for healthy volunteers (HV) was 45.0 years [IQR: 38.0, 49.0 (80% female)] and for FD was 50.5 years [42.0, 55.0 (70% female)]. There was no statistical difference in either group for secretin vs. placebo for GA. Secretin delayed GE in both HV and FD (Table 1). There was decrease in GE for secretin vs. placebo in HV at 20 minutes [-10% (-13, -7), P = 0.008] and 30 minutes [-11% (-16, -4), P = 0.004]. This finding was also seen in the FD group for GE at 25 minutes [-5% (-9, 0), P = 0.047] and 30 minutes [-8% (-9, 0), P = 0.03]. There were no statistically significant differences between treatment arms for VTF or MTV in either HV or FD. On ANCOVA analysis, there were statistically significant increases in nausea at 30 minutes (P = 0.0016) and fullness at 30 minutes (P = 0.0002) for secretin vs. placebo in FD compared to HV.

CONCLUSION:
Secretin delayed GE in both healthy volunteers and FD without significantly altering GA, VTF, or MTV. Secretin receptor stimulation deserves further study in FD patients with accelerated GE.
1220 Clinical Epidemiology of Gastric Signet Ring Cell Carcinoma in a Safety Net County Setting
Authors: Fung Brian M. , Patel Mital , Patel Neha , Brown Arleen F. , Ostrzega Nora L. , Miller Jeffrey M. , Tabibian James H. 
Published: October 2019

INTRODUCTION:
Signet ring cell carcinoma is a rare but increasingly incident histotype of gastric cancer. Historically, this histotype (GSRC) has been known for its dismal prognosis; however, studies evaluating the clinical features and natural history of GSRC, particularly in the United States (US) and in minority populations, have been lacking. Thus, we examined the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmarked them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.

METHODS:
We identified all biopsy-proven GSRC cases at our Los Angeles County hospital (Olive View-UCLA Medical Center) between 2004-2017 through a retrospective histopathology database and prospective endoscopic repository. Pertinent data were collected from medical records with a standardized abstraction sheet and examined using descriptive statistics. Survival (measured as time to death or initiation of hospice) was calculated using the Kaplan-Meier method and compared with the log-rank test. Where applicable, cohort data were compared to SEER data.

RESULTS:
A total of 63 patients with GSRC were identified, of which 81% were Hispanic. Compared with SEER data, patients in this cohort were younger (mean age at diagnosis 52.6 vs 63.5 years), majority female (57% vs 45%), had higher T staging (T3 and T4 stage in 76.7% vs 60.7%), and more frequent lymph node involvement (89.2% vs 48.5%). Longer survival was seen in patients with lower tumor stage (P = 0.001), H. pylori infection (P = 0.017), and surgical intervention (P < 0.001). Overall median survival was slightly longer in this cohort compared to SEER (12.6 vs 10.0 months).

CONCLUSION:
Patients with GSRC in this safety net hospital cohort have different clinical characteristics compared to what has been reported in SEER. Patients in our cohort were younger and more often female, and despite having more advanced disease, did not have shorter survival. Further study is needed and underway to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.
1223 7 Years' Retrospective Study of Helicobacter pylori Therapy Prescription Patterns in an Urban Academic Medical Center in the United States
Authors: Lin Christina , Lee Salina 
Published: October 2019

INTRODUCTION:

H. pylori is a significant cause of gastrointestinal (GI) morbidity and highly associated with gastric cancer. Combined with rising antibiotic resistance rates, prescribing effective treatment is important. Infection is not only managed by gastroenterologists, so discrepancies in prescribing patterns between GI and non-GI practitioners would be expected. Despite new ACG guidelines recommending that clarithromycin triple therapy (Tx) is no longer first line, non-GI providers may still be prescribing it over more effective therapies.

METHODS:
The data of 808 H. pylori positive adult patients, treated a variety of regimens in an urban academic medical center in the United States from 2011 to 2017 was collected and stratified by year. Positivity was determined by urea breath test, serology, stool antigen testing, or pathology. Therapies were categorized by departments, either GI (GI, pediatrics GI, hepatology, or digestive diseases) or non-GI related. Microsoft Excel was used for statistical analysis. T-tests significance level was set to α = 0.05.

RESULTS:
GI providers (68.4%) prescribed 660 therapies (315 triple, 208 quadruple, 33 sequential, 52 concomitant, & 52 hybrid). Non-GI providers (31.6%) prescribed 286 therapies (226 triple, 39 quadruple, 5 sequential, 4 concomitant, & 12 hybrid). Overall, significant differences were seen in triple (-31.3%), quadruple (17.9%), sequential (3.3%), concomitant (6.5%), and hybrid (3.7%) Tx between the groups. Significant differences between them in triple and quadruple Tx were seen in 2012-2017 and 2012 & 2014-2017, respectively. Differences in sequential, concomitant, and hybrid Tx were significant in 2015 & 2017, 2016-2017, and 2011 & 2013 & 2015, respectively. Amongst GI prescribers, a significant increase (27.9%) in concomitant Tx from 2016 to 2017 and decrease in triple Tx (15.1%) from 2015 to 2016 was observed. After 2016, triple Tx was exceeded by quadruple and concomitant Tx in the GI group, but remained the most prescribed in non-GI group.

CONCLUSION:
Triple therapy most likely decreased due to new guidelines, but it remains most prescribed by non-GI practitioners, suggesting more resources should be invested in outreach. Consistent decrease of triple therapy in the GI group, juxtaposed to the non-GI group, strongly reinforces the guideline's impact on prescription patterns. Thus, further studies to determine changes in non-GI prescribing patterns would be warranted.