bluuebunny/crossref_metadata_2025_split huggingface dataset:
343 Bilateral Metal Stent ERCP Through an Endoscopic Ultrasound-Guided Gastrojejunal Lumen-Apposing Stent
Authors: Hashimoto Rintaro , El Hage Chehade Nabil , Samarasena Jason 
Published: October 2019

INTRODUCTION:
ERCP in patients with altered anatomy due to malignant obstruction is consistently a challenge. EUS-guided gastroenterostomy using lumen-apposing metal stents (LAMS) have been shown to be effective and safe for the relief of gastric and intestinal obstruction. We report a successful case of ERCP performed through a recently placed EUS-guided Gastroenterostomy in a patient with both malignant biliary and gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 64-year-old male with a history of metastatic gallbladder cancer status-post placement of an internal-external biliary drain and percutaneous cholecystostomy was admitted to our institution with nausea, vomiting, and jaundice with concern for gastric outlet obstruction and worsening biliary obstruction on CT imaging. To relieve the gastric outlet obstruction, the decision was made to perform EUS guided gastroenterostomy with a LAMS using the “double-scope method.” An ultraslim upper endoscope traversed the stricture into the second portion of the duodenum. Water filling of the intestinal lumen was achieved with this scope while a therapeutic linear echoendoscope was simultaneously passed through the mouth into the stomach and visualized the water-distended distal duodenum and proximal jejunum. EUS-guided gastroenterostomy was performed using a 15 mm electrocautery enhanced LAMS. Balloon dilation of the stent lumen up to 15 mm was performed. The patient enjoyed a regular diet that evening. On the next day, ERCP was performed. A double channel therapeutic endoscope was advanced into the duodenum through the LAMS and bilateral metal stenting of the right and left biliary systems was performed. On follow-up, patient was able to tolerate a regular diet and jaundice improved

DISCUSSION:
In this case, we successfully performed bilateral metal stent placement ERCP via EUS-guided gastroenterostomy to relieve gastric outlet obstruction and biliary obstruction. The diameter of the lumen apposing metallic stent was sufficient to insert a double-channel therapeutic scope, which facilitated bilateral metal stenting. Of note, care must be taken when performing endoscopic procedures through a newly created gastrenterostomy.
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351 Intrinsic Sex-Specific Differences in Inflammatory and Fibrotic Gene Expression and Remodeling Contribute to Male Disease Predisposition in Eosinophilic Esophagitis
Authors: Nhu Quan M. , Duong Loan D. , Rawson Renee M. , Newbury Robert O. , Kurten Richard C. , Dohil Ranjan , Aceves Seema S. 
Published: October 2019

INTRODUCTION:
Eosinophilic esophagitis (EoE) is a chronic allergic disease characterized by esophageal inflammation and fibrosis with a higher disease prevalence in males than females (3:1). The underlying mechanisms behind this sexual dimorphism remain unclear.

METHODS:
Primary human fibroblasts from males and females with active EoE were isolated from esophageal biopsies. Normal fibroblasts were isolated from donor esophageal explants. Fibroblasts were treated with recombinant IL-4, IL-13, or TGFβ1 and analyzed for inflammatory and fibrotic gene expression by qPCR. Esophageal biopsy specimens from active disease patients were scored using a standardized histology score.

RESULTS:
IL-4 or IL-13 induced significantly more eotaxin-3/ccl26 mRNA expression in esophageal fibroblasts from males as compared with females (P < 0.001). This trend was observed in fibroblasts derived from adults or children, consistent with increased EoE onset in males of all ages. TGFβ1 induced significantly higher levels of collagen-1, α-smooth muscle actin, fibronectin, and serpinE1 (P < 0.03) mRNA in male (n = 5) EoE esophageal fibroblasts as compared with females (n = 3). Hematoxylin and eosin staining of EoE esophageal biopsies (n = 153, 125 males and 28 females) revealed that while overall eosinophil count correlated with epithelial remodeling score (r = 0.3550, P < 0.0001) within the distal esophagus, this correlation was distinctly stronger in the male patients (r = 0.4062, P < 0.0001) than within the female patients (r = 0.1546, P = 0.4323). The same pattern was found in the middle (male r = 0.6080, P < 0.0001; female r = 0.4723, P = 0.013) and proximal esophageal levels (male r = 0.8504, P < 0.0001; female r = 0.5235, P = 0.006). Immunohistochemical staining of EoE esophageal biopsies showed significantly more TGFβ1-positive cells in female than male patients (P < 0.001) but no differences in Smad2/3 phosphorylation.

CONCLUSION:
Male esophageal fibroblasts have a more robust response to Th2 interleukins and TGFβ1 as compared with female fibroblasts in adults and children and during the normal and active disease states, suggesting an intrinsic sexual dimorphism in esophageal cells. Epithelial histologic disease severity in males also correlates more strongly with elevated eosinophil counts than in females, suggesting that the male esophagus may have more profound responses to cytokines or antigens as compared to females. These data support a potential mechanism for the sex biased disease expression of EoE.
357 Trends and Per-Patient Expenditures Associated With Proton Pump Inhibitor Use Among the Elderly in the United States: A 10-Year Analysis of the Medical Expenditure Panel Survey
Authors: Alayo Quazim A. , Akanbi Olalekan , Nnanna Onyema , Adejumo Adeyinka C. , Okafor Philip N. 
Published: October 2019

INTRODUCTION:
Multiple observational studies have reported associations between long-term PPI use and adverse events particularly in the elderly leading to increased morbidity and healthcare utilization. We examined the trend, per-patient expenditures and healthcare resource utilization associated with PPI use in non-institutionalized elderly in the United States (US).

METHODS:
We conducted a cross-sectional study using data from the Medical Expenditure Panel Survey (MEPS) from 2006 to 2015. A Cochrane Armitage trend analysis was performed on elderly (>65 years old) participants in the US self-reporting PPI use during this period. Trend in PPI use were compared by race, socioeconomic, and educational status of participants. Weighted logistic regression was used to explore the association between PPI use, healthcare utilization and expenditures, adjusted for relevant sociodemographic factors and comorbidities.

RESULTS:
We identified 32 790 elderly participants with data on PPI use representing ≅38.8 million US elderly population. Trend in PPI use increased from 20.6% (95% CI, 19.2%-22.1%) in the 2006-07 cohort to 22.7% (95% CI, 20.7%-24.4%) in the 2014-15 cohort (P = 0.07, Figure 1). Women reported higher rates of PPI use compared to men (22.5% vs 19.8%, P < 0.001). Interestingly, PPI use significantly increased in Hispanics in the study period (Figure 1). Hispanic participants had the highest rates of PPI use (22.9%), followed by non-Hispanic Whites (21.7%), African-Americans (19.7%) and lowest in Asians (16.7%) (P < 0.001). PPI use was most prevalent in elderly residing in the Southern US (P = 0.006), and significantly higher in very low-income earners (P < 0.001), and those with less than high school education (P < 0001) [Table 1]. Over the 10-year period, we found an increasing trend in PPI use among these subpopulations (Figure 1). Participants reporting PPI use were more likely to have ER visits (AOR: 1.76; 95% CI, 1.55-2.01) and hospitalizations (AOR: 1.86; 95% CI, 1.49-1.77) compared to non-PPI users even after adjusting for potential confounders (Table 2). Expectedly, this increased resource utilization among PPI users resulted in higher health-related costs with an excess of $3,483 (95% CI, $2815-$4151) in mean total annual healthcare expenditures compared to non-PPI user.

CONCLUSION:
Despite reports of adverse events associated with PPI use especially in the elderly, trend in PPI use is increasing particularly among elderly Hispanic patients, low-income earners, and those with less than a high school education.
358 Clinical Features of Reflux Esophagitis in a Predominantly Hispanic Population at a Large Safety-Net Hospital
Authors: Haghighat Shida , Horwich Brian H. , Liu Yao , Idos Gregory , Shaker Anisa 
Published: October 2019

INTRODUCTION:
There are many variables whose role remains undefined in predicting esophagitis severity. This is particularly true for female and non-white populations for whom existing data is limited. Our aim was to determine clinical and endoscopic characteristics of reflux esophagitis in the predominantly Hispanic population of a large, safety-net hospital.

METHODS:
We performed a retrospective electronic medical record review of patients identified with mild (Los Angeles Grade A/B) and severe (Los Angeles Grade C/D) esophagitis between January 2017 to December 2018. Demographic, clinical, and endoscopic data were recorded. Continuous and categorical data was analyzed using a two tailed T-test and/or chi-square test or Fisher’s Exact test.

RESULTS:
Reflux esophagitis was identified in 382 patients; 56.5% (n = 216) males, 79.8% (n = 305) Hispanic, 8.4% (n = 32) Caucasian, 5.8% (n = 22) African American, and 6.0% (n = 23) other. Among the cohort, 59% (n = 225) had mild esophagitis and 41% (n = 157) had severe esophagitis with median ages 56 and 58 years, respectively (P = 0.05). Patients with mild esophagitis had a higher body mass index (BMI) as compared to those with severe esophagitis [median 28.4 (25.5, 33.7) vs. 26.3 (21.9, 29.6); P < 0.01], were more frequently female (P = 0.03), diagnosed in the outpatient setting vs. inpatient (P < 0.01), and had higher rates of cirrhosis (P = 0.03). Gastroparesis (P = 0.02) and immunosuppression (P = 0.01) were more common in severe vs. mild esophagitis. Hiatal hernia (P < 0.01) and esophageal strictures (P = 0.01) were more frequent in severe esophagitis. Gastrointestinal bleed (P < 0.01), dysphagia (P < 0.01) and nausea/vomiting (P = 0.02) were more frequently the indication for endoscopy in severe vs. mild esophagitis. Esophagitis severity was not associated with tobacco or alcohol use.

CONCLUSION:
In this predominantly Hispanic cohort, patients with severe esophagitis were more frequently male, hospitalized, and had lower BMI compared to those with mild esophagitis. Ongoing multivariate analysis is underway to determine whether these variables are independent risk factors for severity of esophagitis in this unique population after adjustment for age, BMI, and hospitalization status.
360 Gender and Racial Disparities in Incidence Rates of Esophageal Adenocarcinoma
Authors: Bhagat Vicky , Kahaleh Michel 
Published: October 2019

INTRODUCTION:
Adenocarcinoma is more common in the US than squamous cell cancer of the esophagus. The purpose of this study is to investigate the impact of gender, and race/ethnicity on the incidence of esophageal adenocarcinoma cancer from 2000-2016 using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS:
Patients diagnosed with esophageal adenocarcinoma from 2000-2016 were identified from the SEER Registry. We retrospectively evaluated gender-specific, and race/ethnicity variations in age-adjusted annual percent changes in incidence rates during 2000-2016 for people above the age above 20. A secondary analysis was also done in regards to stage distribution for disease from 2007-2016.

RESULTS:
Based on the SEER 21 areas data sets, the annual percent change of incidence for esophageal adenocarcinoma was 2.3% from 2000-2007 and -0.8% from 2007-2016 for both males and females. The annual percent change for females was 2.0% from 2000-2008, -5.7% from 2008-2011, and 3.5% from 2011-2016. For males, the annual percent change was 2.3 from 2000-2007 and -1.1 from 2007-2016. There was an increase in the annual percent change incidence for females from 2011-2016. Annual percentage of incidence rates by race/ethnicity can be seen in Table 1. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution was evaluated by gender. Males had the highest percent of incidence cases for distant spread at 39.4, and regional spread at 32.5. Females had the highest percent of incidence cases for localized spread at 23.8. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution for race/ethnicity can be seen in Table 2. For distant spread, the highest percent of cases was seen with American Indian/Alaska Natives at 46.5.

CONCLUSION:
Esophageal adenocarcinoma can be prevented. Our study shows that there has been an increase in the annual percent change of incidence for females in the last decade. In addition, males had the highest incidence cases for distant spread and regional spread. This study shows that American Indian/Alaskan Native and Non-Hispanic White and White (including Hispanics) had the highest percentage of cases for distant and regional spread, respectively. This may support interventions to inform certain gender and race/ethnic populations about the importance of screening for esophageal adenocarcinoma.
364 Shorter Esophageal Length Is Associated With Increased Proximal Reflux and Symptom Severity in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms
Authors: Sikavi Daniel R. , Cai Jennifer X. , Carroll Thomas L. , Chan Walter W. 
Published: October 2019

INTRODUCTION:
Laryngopharyngeal reflux (LPR) is a heterogeneous condition with various underlying pathologies. The effect of esophageal anatomy on LPR is unclear. Shorter distance between lower esophageal sphincter (LES) and upper esophageal sphincter (UES) may allow refluxate to more easily reach the pharynx. We aimed to examine the effect of esophageal length on reflux parameters and symptoms.

METHODS:
115 consecutive patients (64% female, mean age 53.9 yrs) with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019 were enrolled. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index (RSI) and 12-item short-form health survey (SF-12) for health-related quality of life (HRQOL). Esophageal length was measured from the distal margin of UES to the proximal margin of LES on HRM. Univariate analyses were performed with Pearson correlation or Student’s t-test. Generalized linear regression was used for multivariate analysis.

RESULTS:
Mean esophageal length on HRM was 20.4 cm (SD = 2.2). Esophageal length was significantly shorter among patients with a hiatal hernia ≥2 cm (19.2 cm vs 20.6 cm, P = 0.01), but did not correlate with any primary motility disorder per Chicago classification v3.0. Shorter esophageal length was significantly associated with higher acid exposure time and proximal reflux events on impedance, with a trend toward more total reflux events (Table 1). Esophageal length was also shorter among patients with pharyngeal reflux events on HEMII-pH compared to those without (20.0 cm vs 20.9 cm, P = 0.04). Even after controlling for hiatal hernia size, esophageal length remained independently predictive of reflux severity and pharyngeal reflux events. There was a correlation between shorter esophageal length and more severe symptoms on the heartburn/chest pain/indigestion subscore of RSI, but not total RSI or throat symptom subscores (Table 2). Shorter esophageal length was associated with lower physical health scores on SF-12 for HRQOL (Figure 1).

CONCLUSION:
Shorter esophageal length is independently associated with increased reflux severity, proximal reflux, and pharyngeal reflux, even after controlling for hiatal hernia size. It also correlates with more severe typical reflux symptoms and physical HRQOL. Decreased esophageal length may play a role in the pathophysiology of reflux in patients with LPR symptoms.
365 The Prevalence and Clinical Significance of Esophageal Motility Disorders in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms
Authors: Sikavi Daniel R. , Cai Jennifer X. , Carroll Thomas L. , Chan Walter W. 
Published: October 2019

INTRODUCTION:
Esophageal motor dysfunction may underlie impaired bolus and refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of co-existing esophageal dysmotility and correlation with reflux parameters and symptoms in LPR is unknown.

METHODS:
We conducted a retrospective study of consecutive patients with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019. Validated symptom surveys were prospectively collected at the time of testing, including Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Questionnaire (GERD-Q), and 12-item short-form health survey (SF-12). HRM findings were categorized using the Chicago Classification v3.0. Statistical analyses were performed using ANOVA or Fisher’s exact test.

RESULTS:
113 patients (64% female, mean age 54.9 years) were included, with 52 (46%) having abnormal findings on HRM. The most common diagnosis was ineffective esophageal motility (IEM) [n = 37 (32.7%)]. 19 (16.8%) patients were found to have either a disorder of esophagogastric junction (EGJ) outflow or a major disorder of peristalsis, of which EGJ outflow obstruction (EGJOO) was the most prevalent diagnosis [n = 11 (9.7%)] (Table 1). With the exception of increased distal acid exposure time (AET) among patients with hypercontractile motility disorders (9% vs 2% in patients with normal HRM, P = 0.03), there were no differences in pharyngeal bolus reflux events, total bolus reflux events on impedance, and AET across HRM findings. Reporting throat symptoms as a primary complaint on presentation was associated with greater odds of having abnormal HRM compared to esophageal symptoms alone (OR 5.5, P = 0.005) (Figure 1). However, the presence and specific type of motility disorder were not associated with symptom severity as measured on RSI, GERD-Q, or health-related quality of life on the SF-12.

CONCLUSION:
Esophageal motility disorders are prevalent among patients with suspected LPR symptoms, including up to one of six with either a disorder of EGJ outflow or major disorder of peristalsis. Patients with these conditions are more likely to report throat symptoms as a primary complaint. However, there was no correlation between HRM findings and symptom severity. The role of esophageal motor dysfunction in patients with LPR symptoms remains to be further defined.
366 Safety and Efficacy of Cryoablation Balloon for the Treatment of Barrett’s Associated Neoplasia: A Meta-Analysis
Authors: Westerveld Donevan , Nguyen Khaai , Banerjee Debdeep , Jacobs Chelsea , Kadle Nikhil , Draganov Peter V. , Yang Dennis 
Published: October 2019

INTRODUCTION:
The Cryoballoon Focal Ablation System (CbFAS) (CryoBalloon; Pentax Medical, Redwood City, California, USA), a novel device that permits the conversion of liquid nitrous oxide into its gaseous form within a contact balloon system, was recently introduced for the endoscopic ablation of Barrett’s esophagus (BE) associated neoplasia. We performed a meta-analysis to assess the feasibility, efficacy, and safety of the CbFAS for the treatment of BE neoplasia.

METHODS:
Several databases were searched for relevant articles (PubMed, Web of Science, Google Scholar, EMBASE) as well as abstracts of recent gastroenterology meetings. Studies included at least 5 patients with BE treated with cryotherapy via cryoballoon device and data extraction, which was performed by two investigators using standardized forms, included age, gender, length of BE segment, treatments prior to CbFAS, procedural time and number ablation sessions, technical feasibility, adverse events, and eradication rates of intestinal metaplasia (CE-IM) and dysplasia (CE-D) at follow-up. Quality of the studies was performed using a modified Newcastle Ottawa Scale. Random effects model was used in the presence of heterogeneity.

RESULTS:
Seven studies (4 full-length publications, 3 abstracts) met inclusion criteria for a total of 548 ablation sessions in 272 patients. In aggregate, the most common histopathology reported prior to cryoballoon ablation was high-grade dysplasia (n = 131), followed by low-grade dysplasia (n = 75), and intramucosal adenocarcinoma (n = 52). The pooled rate for technical feasibility, defined as completion of cryoablation as intended was 95.8% (95% CI: 93.6-97.5%; I2 = 13.2%; P = 0.3) (Figure 1a). The pooled rates of CE-IM and CE-D were 85.8% (95% CI: 77.8-92.2%, I2 = 55.5%; P = 0.04) and 93.8% (95% CI: 85.5-98.7%, I2 = 74.2%; P = 0.001) (Figure 1b,c), respectively. Funnel plots did not show substantial publication bias (Figure 2). The overall adverse event rate was 12.5% (34 out of 272 patients), of which stricture formation was the most common (5.8%), followed by mucosal laceration (0.7%), perforation (0.4%), and bleeding (0.4%). All adverse events were successfully managed endoscopically.

CONCLUSION:
This meta-analysis suggests that CbFAS has a comparable safety profile to radiofrequency ablation with a 12.5% adverse event rate. Furthermore, this study demonstrated that CbFAS is associated with high rates of CE-IM (88%) and CE-D (94%). Future prospective comparative trials are needed to corroborate these initial findings.
368 Comparison of Budesonide and Fluticasone in the Treatment of Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis
Authors: Numan Laith , Hamdeh Shadi , Kalot Mohamad , Jajeh Muhammad Omar , Tarakji Ahmad G. , Olyaee Mojtaba 
Published: October 2019

INTRODUCTION:
Steroids are the first line treatment of choice in patients with eosinophilic esophagitis (EOE) who failed proton pump inhibitors (PPIs). Fluticasone and budesonide are the two main steroid medications used in EOE treatment, but current guidelines do not recommend one agent over the other. In our study, we aim to conduct a meta-analysis to compare both agents and determine whether if one agent is associated with better outcomes.

METHODS:
A comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus was performed from each database’s inception to June, 1st, 2019. Two independent reviewers systematically identified trials that compared the effect of budesonide versus fluticasone in the management of EOE. A meta-analysis was performed using a fixed effects model. The main outcome was the histologic response (defined as eosinophils count < 15/HPF), and therefore response to treatment.

RESULTS:
Three studies met our inclusion criteria and included in the analysis, with a total of 272 patients. All studies were done in the United States, with one RCT. Our meta-analysis showed no statistically significant difference with the use of budesonide compared to fluticasone in achieving histologic response (total of eosionphils count < 15/hpf) (OR: 1.29, 95% CI: 0.77-2.14, P = 0.34, heterogeneity I2: 0%).

CONCLUSION:
Our systematic review and meta-analysis indicated no difference in budesonide and fluticasone in achieving histologic response in patients with eosinophilic esophagitis.