bluuebunny/crossref_metadata_2025_split huggingface dataset:
1178 Accuracy of Glucose Breath Testing for Small Intestine Bacterial Overgrowth (SIBO) Using Endoscopy Aspirate Cultures as a Reference Standard: A Meta-Analysis
Authors: Jones Mitchell L. , Chuang Emil , Wahl Chris , Lee Shaoying N. , Kelly Colleen , Styli Jack 
Published: October 2019

INTRODUCTION:
Small Intestinal Bacterial Overgrowth (SIBO) is associated with abnormally high bacterial counts in the small intestine. SIBO is under-diagnosed and there are significant limitations with currently available testing methods.

METHODS:
Two research databases (Google Scholar and Web of Science) were used to find relevant published literature using keywords including glucose breath test accuracy, endoscopy aspirate culture and small intestine bacterial overgrowth. Eleven studies with data on patients tested with both a glucose breath test and endoscopy aspirate culture were found. Fixed-effects and random-effects models were fit to the eleven studies’ data using the Metafor (Meta-Analysis Package for R). The mean positive and negative percent agreement across studies is estimated as the weighted average of each study’s percent agreement, where the weights are the inverse of the standard errors, squared, plus the variance of the random study effects.

RESULTS:
The homogeneity of effects across studies was tested with a Chi-square test and homogeneity of effects was rejected for both positive and negative percent agreement (c2 = 91.5 and 107.5, respectively, df = 10, P-value < 0.0001) (Table 1). The mean percent agreement across studies was estimated with both the fixed-effects and the random-effects models (Table 2). Figure 1 presents each study’s estimate of the positive and negative percent agreement, respectively, and their associated 95% confidence intervals, as well as the overall estimate and its 95% confidence interval.

CONCLUSION:
Heterogeneity was found in the study designs and the implementation of breath tests such as the differences in dose of the substrate (50g or 75-100g) and the duration of the breath test (120∼240min). Meanwhile, the endoscopy aspirate culture is also not completely standardized, as the amount of liquid collected, the site of collection and the technical details of the microbiological tests may differ. This heterogeneity in practice of the two tests certainly contributes to the heterogeneity in positive and negative percentage agreement observed between the two tests. The random effects models’ estimates of 54% positive agreement and 76% negative agreement indicate moderate to poor agreement between the breath test and endoscopy aspirate culture. Given these limitations, there is an unmet need for novel tools to evaluate patients suspected of SIBO.
1180 Novel Capillary Catheter System Is Superior to Conventional Small Bowel Aspiration Catheter: An Important Development for Small Bowel Microbiome Assessment
Authors: Sedighi Rashin , Pimental Mark , Mathur Ruchi , Gaddam Srinivas , Parodi Gonzalo , Lo Simon , Gupta Kapil , Jamil Laith H. , Rezaie Ali 
Published: October 2019

INTRODUCTION:
The small intestine is an understudied frontier of microbiome research. While aspiration during endoscopy is considered the gold standard to assess small bowel bacteria, the tools for sterile retrieval are primitive and poorly validated. Moreover, endoscopic aspiration is time consuming and prone to contamination. Inspired by plants’ ability to draw water via capillary action, a novel multi-capillary sterile system was designed. We examined the suctioning time and volume capabilities of this catheter using various liquids compared to conventional aspiration catheters.

METHODS:
Liquids with varying viscosities (water, 25% glucose solution and povidone iodine 10%) were used to assess the aspiration efficiency of the capillary catheter (MicroLotus, Hobbs Medical Inc.) ex-vivo as compared to a conventional small bowel aspiration catheter (Hobbs Medical Inc.) (Figure 1). Viscosity ranged between 0.89 mPa*s for water to 18 mPa*s for povidone. In the first experiment, 8 ml of each liquid was placed in a test tube. Catheters were completely submerged in the liquid and suction was applied using a standardized suctioning technique (Alliance™ II Integrated Inflation device). Next, the same four liquids were placed in a petri dish to mimic the flat mucosal surface. The technique was repeated with 3mL (typical volume of small bowel aspirate). Each experiment was repeated 10 times.

RESULTS:
The conventional catheter suffered from air entering the catheter when not completely submerged which is typical of the small bowel surface. In terms of speed of aspiration, the capillary catheter was at least 10 times faster than the conventional catheter for all fluid viscosities (Figure 2). Capillary catheter demonstrated increasing superiority with increasing viscosity (R = 0.96). When comparing aspiration on a flat surface, aspiration times were 4.67 + 1.35, 9.65 + 2.03 and 23.52 + 3.30 seconds for water, glucose and povidone for the capillary catheter, and too long to measure for the conventional due to concomitant superfluous air entry due to catheter design.

CONCLUSION:
The capillary aspiration catheter system is superior to conventional aspiration catheter in suctioning liquids with various viscosities. This new system may improve aspiration time and quality for small bowel aspiration. Overall, this new system could save between 1 and 6 minutes in endoscopy time to obtain aspirates depending upon the viscosity of the aspirating fluid. Future in-vivo studies are needed to further assess the capillary catheter.
1182 Small Intestinal Bacterial Overgrowth (SIBO) Is Common in Patients With Ehlers-Danlos Syndrome (EDS)
Authors: Xiong Tingting , Baker Jason , Chey William D. , Nojkov Borko 
Published: October 2019

INTRODUCTION:
EDS is a group of rare connective tissue disorders caused by defects in collagen synthesis. EDS patients frequently have chronic gastrointestinal (GI) symptoms. Delayed gastric emptying and colonic transit time are common in EDS, suggesting underlying GI dysmotility. The relationship between SIBO and EDS has not been studied. In this study, we aimed to assess the prevalence of SIBO by glucose hydrogen breath test (GBT) in EDS patients with GI symptoms. We also characterized the risk factors for SIBO in these patients.

METHODS:
This was a retrospective cohort study of adults with EDS from specialty clinics at University of Michigan (2000-2019) who completed GBT for suspected SIBO. Demographics, history, medications, and GBT findings were reviewed. Patients with documented structural disease (eg. neoplasm) were excluded. GI symptoms were prospectively collected from all patients at their GBT. A priori variables associated with SIBO were analyzed including: presence of diabetes, GERD, and gastroparesis; history of small bowel surgery or gastric bypass; use of opioids or proton pump inhibitors. Positive GBT for SIBO was defined as breath H2 rise ≥20 ppm within 90 min and/or CH4 rise ≥10 ppm at any time after glucose ingestion. Statistical methods included chi-square and t test. Univariate regression analysis assessed the relationship between tested variables and GBT outcome.

RESULTS:
A total of 600 EDS patients were identified and 327 (54.5%) had at least one GI symptom. GBT was performed in 39 patients (mean age 37.6 ± 12.9; 94.8% female; 92.3% Caucasian) for suspected SIBO. Common symptomatic indications in these patients are shown in Table 1. 15 patients (38.5%) had positive GBT by either H2 (n = 11; 28.2%) and/or CH4 (n = 7; 17.9%). There were no significant differences in demographic factors between EDS patients with positive and negative GBT. Symptomatically, the presence of bloating was associated with a positive GBT (P = 0.04) but there was no significant association between any other GI symptom and the GBT outcome. Diagnosis of GERD was significantly associated with a positive GBT (P = 0.04) and there was a trend towards significant association between IBS and positive GBT (P = 0.07). None of other tested variables predicted the GBT outcome.

CONCLUSION:
SIBO diagnosed by GBT is common in EDS patients with chronic GI symptoms. Our preliminary results suggest that SIBO should be particularly considered in EDS patients with bloating and GERD. Further study is needed to delineate this relationship.
1184 Durability of Rifaximin in the Treatment of Small Intestine Bacterial Overgrowth
Authors: Martinez Nicholas , Randall Charles W. , Vizuete John A. 
Published: October 2019

INTRODUCTION:
Multiple antibiotics have been evaluated in the treatment of small intestinal bacterial overgrowth (SIBO). Although the response rates vary by treatment, the overall duration of response has not been clearly defined. Rifaximin (Xifaxan, Salix, Bridgewater, New Jersey, USA) has demonstrated potent activity against numerous pathogenic bacteria. We report our clinical experience with Rifaximin as a durable treatment option for SIBO.

METHODS:
205 records from 9 physicians at a single center were reviewed retrospectively. Chart review was performed from January 2010 through present. Patients underwent hydrogen breath testing in accordance with current consensus recommendations. Patients who were treated with Rifaximin were included for review. Patients less than 18 years old or those with incomplete follow up data were excluded. Patient demographics, antibiotic regimen, response to therapy, and duration of follow up were recorded. Clinical response was defined as patient reported response to underlying symptom (bloating, flatulence, pain, diarrhea) and physician assessment. Duration of response was defined as time to recurrence of initial symptoms from date of antibiotic treatment. Adverse events were defined as patient reported symptoms during treatment. Data were summarized and analyzed using Microsoft Excel v14.7.2. Chi-squared analysis was performed where appropriate.

RESULTS:
156 patients met criteria for review. One hundred twenty-two (78%) were women and 34 (22%) were men. The average age was 52 +/- 19 years. Most patients were treated with 550mg twice daily dosing (n = 108, 69%) with 10 days being the most common duration (n = 68, 44%). Forty-eight patients (31%) were treated with TID dosing for 7,10, or 14 days duration. Symptom relief was observed in 77% of all patients (n = 120). The median duration of symptom relief was 6 months (range 1-96), with a mean follow up time of 14 months. Response was not significantly different when stratified by gender (79% vs 67% for women and men, respectively; P = 0.15). BID dosing was associated with symptom improvement compared to TID dosing (83% vs 63%, P = 0.004). Side effects included: nausea (1.9%), diarrhea (1.3%), oral thrush (1.3%) and abdominal pain (0.6%).

CONCLUSION:
Treatment with Rifaximin resulted in clinical improvement in the majority of patients with SIBO. The median duration of symptom relief with Rifaximin treatment was 6 months. Further prospective data is needed to identify the optimal dosing regimen to maximize durability.
1186 Clostridioides difficile Infection in Patients With Celiac Disease
Authors: Kroner Paul T. , Kesler Alex M. , Jimenez Xavier A. , Simons-Linares Roberto , Raimondo Massimo 
Published: October 2019

INTRODUCTION:
Patients with Celiac disease (CD) are at increased risk of infections, as evidenced by increased prevalence of tuberculosis, influenza, and sepsis. Alterations in immunity and microbiota can contribute to this predisposition. Although the prevalence of Clostridium difficile infection (CDI) continues to increase in the US, there is little data on the association and outcomes in patients with CD. The aim of this study was to assess inpatient prevalence, outcomes and resource utilization of patients with CD and CDI in the US in the past decade.

METHODS:
Retrospective cohort study using the NIS 2007 to 2016. All patients with CD were included using ICD9-10CM codes. Cohorts were stratified for CDI coexistence. None were excluded. The primary outcome was determining the association of CD with CDI. Secondary outcomes were determining the CDI inpatient prevalence trend in the CD patients, as well as mortality, morbidity, length of hospital stay (LOS), total hospital charges and costs, which were adjusted for inflation using the Consumer Price Index. Multivariate regression was used to adjust for age, gender, income in patient zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status.

RESULTS:
A total of 337,201 patients with CD were identified, of which 5,500 had associated CDI. Mean age was 55 years and 71% were female. The inpatient prevalence of CDI in patients with CD increased from 0.9/100,000 admissions in 2007 to 1.65/100,000 admissions in 2016. Patients with CD displayed increased adjusted odds (aOR:1.56, P < 0.01) of coexisting CDI compared to patients without CD. Patients with CD had lower odds of mortality, ICU, shock, multiorgan failure, hospital costs, charges, and LOS but increased odds of requiring TPN compared to the general population admitted population with CDI.

CONCLUSION:
Patients with CD had higher odds of CDI compared to non-CD patients, which could be attributed to CD-related gut mucosal integrity, immunological or microbiome alterations. The inpatient prevalence of CDI in patients with CD increased from 2007 to 2016. This may be a reflection of the general increase of CDI cases in the inpatient population and with improved CD diagnostic modalities. Patients with CD and CDI did show decreased morbidity/mortality and resource utilization, suggesting that the clinical course is less severe. Further studies should further assess the gut immunological and microbiome changes in CD to clarify potential factors associated with CDI.
1193 Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis (FAP): Risks, Benefits, and Changes in Management
Authors: Mehta Neal , Shah Ravi , Yoon Ji Yoon , O'Malley Margaret , LaGuardia Lisa , Mankaney Gautam , Bhatt Amit , Burke Carol A. 
Published: October 2019

INTRODUCTION:
Nearly all patients with FAP will develop duodenal adenomas. Ampullary/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 system. Guidelines recommend upper endoscopic surveillance with forward and side-viewing scopes to evaluate the duodenum and visualize the papilla. There is no consensus whether the papilla should be routinely biopsied or included in Spigelman staging. Some endoscopists refrain from biopsy of the papilla due to a theoretical risk of pancreatitis. No data is available to support this risk. We aim to identify the incidence of pancreatitis after biopsy of the papilla in FAP patients and the effect of biopsy on Spigelman stage.

METHODS:
This retrospective cohort study identified consecutive FAP patients at the Cleveland Clinic between 1/2011-12/2018. FAP patients with ≥1 endoscopy with biopsy of the duodenal papilla were included. Patients with history of foregut surgery were excluded. Medical records determined demographics, endoscopic data, and Spigelman staging with/without biopsy. Post-procedural pancreatitis was defined as 2/3 of typical symptoms, lipase 3 times upper limit of normal, or radiography consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD).

RESULTS:
273 FAP patients (52.4% male) with 792 EGDs with biopsy of the papilla were identified (Table 1). Cumulative times that the papilla was biopsied over the study period ranged from 1-8/patient. 2 patients developed pancreatitis. Of all EGDs with ampullary biopsy, 0.34% (3/792) developed post-procedural pancreatitis. The papilla appeared normal in 546/792 exams and 1 patient developed pancreatitis with biopsy of normal papilla. This patient was admitted for 4 days with mild acute pancreatitis (BISAP 1). The papilla was abnormal in 226 exams and 2 episodes of pancreatitis occurred in the same patient. This patient had a history of chronic pancreatitis due to alcohol abuse. Hospitalization wasn’t necessary for mild acute pancreatitis (BISAP 1). Biopsy of normal papilla increased Spigelman stage in 15 patients, one upstaged from Spigelman III to IV and had a pancreas-sparing duodenectomy.

CONCLUSION:
Pancreatitis after biopsy of the duodenal papilla is rare, especially in patients without a history of pancreatitis. Biopsy of normal papilla in FAP changes patient management. Physicians managing FAP should understand risks/benefits of biopsy of the papilla and include it in Spigelman staging.
1194 Small Intestinal Bacterial Overgrowth Is Common in Mast Cell Activation Syndrome
Authors: Weinstock Leonard B. , Brook Jill , Kaleem Zahid , Afrin Lawrence , Molderings Gerhart 
Published: October 2019

INTRODUCTION:
Mast cell activation syndrome (MCAS) often presents with symptoms of irritable bowel syndrome (IBS). MCAS is a multi-systemic disorder caused by inappropriate mast cell (MC) activation causing inflammatory and allergic symptoms. IBS can be associated with small intestinal bacterial overgrowth (SIBO). This study determined the prevalence of SIBO in MCAS.

METHODS:
Patients with refractory gastrointestinal (GI) symptoms were evaluated for MCAS and SIBO. MCAS was diagnosed if there were typical symptoms of mast cell (MC) activation in 2 or more organ systems plus 1 or more of the following: elevation of MC chemical mediator(s), clinical improvement with MC-directed therapy, and/or increased intestinal MC density. SIBO diagnosis was based on a lactulose breath test (LBT) with ≥20 ppm hydrogen rise from baseline within 90 minutes. These LBT results were compared to our prior study of healthy controls. The effect of co-morbid syndromes and medication use was analyzed. Antibiotic therapy effects were a secondary aim. This study was IRB approved.

RESULTS:
There were 139 MCAS subjects (116 F, 23 M, 46.6 ± 16.9 years) and 30 controls (19 F, 11 M, 44 ± 14.0 years). GI symptoms preceded other MCAS symptoms in 66.2%. Symptoms included abdominal pain (87.1%), bloating (74.8%), constipation (66.9%), diarrhea (63.3%), nausea (61.9%), heartburn (54.0%), and dysphagia (29.5%). In these MCAS patients Rome 4 criteria for IBS-mixed (39.6%), IBS-constipation (22.3%), and IBS-diarrhea (18.7%) were met. SIBO was present in 30.9% MCAS subjects vs. 10% in controls (P = 0.023). Methane excretion in a plateau pattern was common in MCAS: 10.1% had levels ≥10 ppm and 24.5% had levels 3-9 ppm. Higher methane levels were associated with IBS-constipation compared to SIBO positive subjects: 42.9% vs. 9.3% (P = 0.02). Postural orthostatic tachycardia syndrome, hypermobile Ehlers-Danlos syndrome, MC density and mediators, proton pump inhibitors, thyroid supplements, and statins were not associated with LBT changes. Antibiotics were prescribed for 74 subjects: 67.6% had marked improvement, 5.4% had partial improvement, and 21.6% had no improvement in GI symptoms. Adverse events led to cessation of antibiotics in 9.5%.

CONCLUSION:
SIBO with hydrogen and methane plateau patterns are common in MCAS subjects. MCAS could cause SIBO due to alterations of the GI immune system or altered motility by local release of MC mediators. Antibiotic therapy appears to improve GI symptoms in MCAS patients.
1202 Long Term Outcomes Following Surgical Resection of 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:
Gastric neuroendocrine tumors vary in propensity for lymph node metastases, and this principle has guided management towards endoscopic, surgical or pharmacologic therapy. However, no consensus on optimal type of gastric surgery for gastric carcinoid and rate of recurrence or survival has been reached in North America. The goal of our study is to determine mortality and incidence of tumor recurrence among different surgical interventions for gastric neuroendocrine tumors.

METHODS:
All consecutive patients encountered at a tertiary referral center who underwent gastric surgery or endoscopic submucosal dissection (ESD) for biopsy proven gastric neuroendocrine tumor from April 1988 to January 2019 were entered into the study. Patients were categorized by proximal/wedge, distal/subtotal, total gastric resection, and ESD as well as by lymphadenectomy: none (D0), D1, or D2. Tumor grading was characterized as high (poorly differentiated, WHO 3) or low (well differentiated, WHO 1 & 2) as some patients preceded WHO classification. Recurrence and lymph node metastases were based on biopsy. Patient follow-up was determined by most recent encounter with gastroenterology or oncology provider within our health system. Date of decease was determined by Social Security Death Index query of all patients.

RESULTS:
Thirty patients were enrolled. Mean age of diagnosis was 63.9 ± 12.3 years old. Lymph node dissection practices were provider dependent but at least 62% did not have any lymphadenectomy. Mean follow up after surgery was 42.8 ± 12.8 months. Of those who underwent distal gastrectomy and ESD, no evidence of recurrence was noted. Two of 3 patients with recurrence had low grade tumors without lymphadenectomy. Mortality did not significantly vary with lymphadenectomy status (Figure 2). One 78-year-old patient did not survive post operatively after distal/subtotal gastrectomy with D1 lymphadenectomy due to sudden cardiac arrest 9 days after surgery.

CONCLUSION:
In our cohort, fewer gastric resections for GNETS include lymphadnectomy. Interestingly, recurrence was not statistically significantly associated with positive and negative lymph nodes or performance of lymphadenectomy. One limitation of this study is the scarcity of lymph node positive GNET.