bluuebunny/crossref_metadata_2025_split huggingface dataset:
571 Diagnostic Accuracy of Narrow Band Imaging on Endoscopy in Detection of Duodenal Villous Atrophy Using Histopathology as a Gold Standard in Patients Presenting With Chronic Diarrhea
Authors: Kumar Sanjay Kirshan , Sham Sunder , Lail Ghulamullah , Mandhwani Rajesh , Hanif Farina , Luck Nasir Hassan , Samejo Khadim Hussain , Ul Haque Muhammad Manzoor , Devi Asha 
Published: October 2019

INTRODUCTION:
Celiac disease and tropical sprue are common causes of chronic diarrhea & duodenal villous atrophy (DVA). Narrow band imaging (NBI) is chromoendoscopic technique which facilitates detailed visualization of the mucosal surface & allows targeted biopsy and thus increases the diagnostic yield of the biopsy specimen. Hence, we aimed to determine the diagnostic accuracy of NBI in detection of DVA using histopathology as a gold standard in chronic diarrhea patients.

METHODS:
All patients with diarrhea for >4weeks were enrolled. Endoscopy was performed in all the patients to take duodenal biopsy and simultaneously NBI villous pattern was noted. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and diagnostic accuracy of NBI were calculated comparing histopathology.

RESULTS:
Baseline characteristics are shown in Table 1. NBI findings of total patients were finger shaped (normal villi), gyriform (partial villi atrophy) and flat surface (complete villous atrophy) mucosa as 22.6%, 59.7% and 17.7% respectively. NBI has sensitivity, specificity; PPV, NPV, and diagnostic accuracy were 84.9%, 45.2%, 82.3%, 50.0%, and 75% respectively for the detection of DVA as depicted in Table 2.

CONCLUSION:
This study showed 93 (75%) of participants had DVA in contrast to another study from Pakistan which revealed DVA in 49.8% of patients. This disparity is likely due to difference in study population. Our patients had normal villi, partial and complete villous atrophy in 31 (25%), 72 (58.1%) & 21 (16.9%) respectively with P value 0.001. Dutta AK et al. found that NBI has sensitivity 81-87%, specificity 93%, NPV 96% and PPV 68-77% to detect DVA. We found sensitivity 85%, specificity 45%, NPV 50% & PPV 82.3%. In our study specificity & NPV were lower than in others as we included mild villous atrophy while most of the studies had a greater proportion of patients with moderate to severe villous atrophy. We found that duration of diarrhea is associated with presence of villous atrophy, as disease duration of >5 months had sensitivity 92.1% and specificity 60% while 5 months had sensitivity & specificity 80% & 31.3% respectively. This association was not observed in previous studies. So we conclude NBI is a promising technique for assessment of duodenal mucosal details in patients with longstanding chronic diarrhea.
581 Factors Associated With In-Hospital Mortality in Acute Variceal Bleeding
Authors: Alimirah Maryam , Sadiq Omar , Venkat Deepak 
Published: October 2019

INTRODUCTION:
Risk stratification scoring systems for upper gastrointestinal bleeds, including the Glasgow Blatchford and Rockall scores, don't accurately predict outcomes in acute variceal bleeds (AVB). Similarly, the Child–Pugh score has poor prognostic value in AVB, likely due to its subjective parameters. The goal of this retrospective study was to identify factors that predict in-hospital mortality in patients presenting with AVB.

METHODS:
Data was obtained through the Medical Information Mart for Intensive Care III (MIMICIII), which is a large, freely available database comprised of patients admitted to Beth Israel Deaconess Medical Center. 236 patients were included in this study who were admitted to the ICU from 2001 to 2012 with an ICD code of cirrhosis and variceal bleed. After excluding 136 patients who did not undergo esophagogastroduodenoscopy (EGD) during admission, 100 patients remained and were analyzed. Factors such as transfusion requirements, number of EGDs, demographics, and laboratory values were collected using postgresql queries. Statistical analysis was done using R 3.5.1.

RESULTS:
19 of the 100 patients died during admission (mortality rate of 19%). There were no significant differences between the deceased and survival groups with regards to age, sex, race and insurance type. There were significant differences between both groups regarding hemoglobin nadir (P = .0001), MELD-Na score (P < .0001), MELD score (P < .0001), INR (P < .0001) and bilirubin (P = .005). Other factors analyzed included number of EGDs during admission, length of admission and blood product requirements. Compared with the survival group, the deceased group received a larger number of red blood cell transfusions (P = .02) and fresh frozen plasma (P = .007). The number of cryoprecipitate and platelet transfusions between both groups was not statistically significant (P = 0.14 and P = 0.07) respectively. The number of EGDs in the deceased group was higher, compared with the survival group (P = 0.008).

CONCLUSION:
We were able to identify several risk factors of mortality in variceal bleeders admitted to the intensive care unit. We found the MELD-Na score, INR as well as hemoglobin nadir to have the strongest association with mortality. Number of EGDs was also associated with increased mortality suggesting that in-hospital rebleeding is a strong predictor of outcome. The MELD score was as strongly associated with mortality as the MELD-Na score, contrary to previous studies of mortality in cirrhosis.
591 Trend Analysis of Lower Gastrointestinal Bleeding 2002-2017: A Population-Based Study
Authors: Suresh Kumar Vishnu Charan , Elangovan Abbinaya , Waghray Nisheet 
Published: October 2019

INTRODUCTION:
Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database.

METHODS:
Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016.

RESULTS:
Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies.

CONCLUSION:
The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.
592 Comparison of Endoscopic Placement versus Oral Ingestion of Small Bowel Video Capsule for Evaluation of Inpatients With Small Intestinal Bleeding
Authors: Chen Brendan , Farrakhan Kanhai , Sukrit Jain , Akerman Paul , Rupawala Abbas 
Published: October 2019

INTRODUCTION:
Wireless small bowel video capsule endoscopy (VCE) is used to evaluate small intestinal bleeding after upper endoscopy and colonoscopy fail to identify a source of bleeding. The majority of patients swallow the capsule but endoscopic placement in the duodenum is an option. Limited data suggests higher rate of gastric retention of capsule in inpatients due to a variety of reasons, resulting in an incomplete exam. Hypothetically, endoscopic placement should increase likelihood of complete small bowel evaluation but there is little data comparing the two approaches. We aimed to compare completion rates and outcomes of capsule studies via endoscopic placement (CS-EP) versus oral ingestion (CS-OI) in inpatients undergoing VCE.

METHODS:
Patients who had VCE studies performed inpatient for gastrointestinal bleeding at Rhode Island Hospital between April 2015 and July 2016 were identified retrospectively. Baseline patient demographics, time intervals between reported bleed, date of admission and date of discharge, capsule study, indications for capsule study, completion rates and detection of small bowel bleeding were collected. Statistical tests were done using student's t-test and chi square test.

RESULTS:
Data was available for 83 patients between April 2015 and July 2016. The most common indications were for obscure bleed (92%) followed by anemia (86%). 29 (35%) patients had small bowel capsule studies that were endoscopically placed. Majority of patients underwent endoscopic placement due to provider preference. CS-EP had a higher proportion of men than CS-OI (66% vs. 44%, P = .06). The mean duration from bleeding episode to capsule study was 8.4 days for both groups. Small bowel bleeding was more likely to be detected by CS-EP than CS-OI (34% vs. 13%, P = 0.02), however completion rates were similar between both studies (69% vs. 76%, P = 0.5). CS-EP had a longer time from study to discharge (days: 7.1 vs. 3.7, P = 0.1) and longer length of stay at the hospital (days: 11.45 vs. 7.47, P = 0.1) compared to CS-OI.

CONCLUSION:
Based on this single center study, although endoscopic placement of VCE was more likely to detect small bowel bleeding compared to oral ingestion, there was no difference in study completion rates and CS-EP group in fact had a longer length of stay. Investigation into potential causes of longer length of stay and cost of care associated with endoscopic placement are ongoing. Additional data is also being collected for capsule studies performed over several more years.
594 Weekend Admissions Do Not Affect Management of Lower GI Bleeding
Authors: Li Brian , Schwartz Jeffrey , Lipcsey Megan , Stein Daniel J. , Feuerstein Joseph 
Published: October 2019

INTRODUCTION:
Lower gastrointestinal bleeding (LGIB) is a common condition requiring GI consultation and management. Current ACG guideline recommends colonoscopy within 24 hours of LGIB. However, while colonoscopy is the most common intervention, it may not be readily available at all hospitals on the weekend when many endoscopy units are closed. Previous work has found that in non-variceal upper GI hemorrhage, patients admitted on weekends had lower total endoscopy rates and high hospitalization charges. We explored these outcomes in LGIB.

METHODS:
This national inpatient sample (NIS) from 2016 was queried for all cases of confirmed lower GI bleeding as the primary diagnosis code based on ICD-10. This included bleeding AVMs, diverticular hemorrhage, rectal ulcers, radiation proctitis and other anal/rectal hemorrhage. Outcomes for patients admitted on a weekend (Saturday/Sunday) were compared to weekday admissions using survey-adjusted Chi-square and correlation for comparisons and logistic/linear regression to examine mortality, length of stay, and hospitalization costs. Adjustment was made for the Elixhauser mortality score (a validated measure of comorbidities), colonoscopy, and transfusion in the regression.

RESULTS:
In 2016, 92,065 patients were admitted for LGIB overall. Of these, 23,070 (25%) were admitted on a weekend. See table 1 for causes of bleeding. For weekend admissions, mortality (0.8% vs 0.9%, P = 0.626), transfusion rate (28.8% vs 30.1%, P = 0.113), colonoscopy rate (58.4% vs 58.1%, P = 0.749), angiography rate (3.3% vs 3.3%, P = 0.894), mean days to colonoscopy (1.8 vs 1.8, P = 0.157), length of stay (4.1 vs 4.2 days, P = 0.068), and charges ($40,552 vs $40,604, P = 0.956) were all similar to weekday admissions. In the multivariable regression, colonoscopy (OR=2.7, P < 0.001) and Elixhauser score (OR=1.09, P < 0.001) but not weekday admission (OR=1.13, P = 0.535) or freedom from transfusion (OR=0.78, P = 0.140) predicted mortality. Length of stay (0.1 day difference, P = 0.053) and charges ($14 difference, P = 0.987) were also not affected by weekend admission after adjustment for the same covariates.

CONCLUSION:
In this estimate of all U.S. lower GI bleeding admissions from 2016, weekend admission did not affect outcomes including mortality, length of stay or total charges. Time to colonoscopy was similar. Undergoing colonoscopy was associated with a 2.7 times lower odds of mortality.
605 Independent Risk Factors for Severity and Mortality in Lower Gastrointestinal Bleeding and Proposal of New Prognosis Score
Authors: Bellido Alvaro , Espinoza-Ríos Jorge , Pinto Jose , Bravo Eduar , Gomez Paul , Tagle Martin 
Published: October 2019

INTRODUCTION:
Risk stratification is key in the assessement and management of patients with lower gastrointestinal bleeding (LGIB). AIM: To identity risk factors for mortality and severity, namely: critical care requirement, prolonged hospitalization, rebleeding, blood transfusions, re-admissions or surgery in a cohort of patients with LGIB in a hospital in Peru.

METHODS:
Analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. The sample size (80 Patients) was calculated considering an incidence of 0.3% with a confidence level of 95%. Data was collected during the hospitalization, including sex, age, comorbidities, medication, etiology, time to colonoscopy, vital signs, laboratory and the outcomes. The independent factors were determined using binomial logistic regression, these factors were used to developed a score. Thirty – day survival was calculated using a Kaplan-Meier curve.

RESULTS:
A total of 98 patients were included, of which 13 patients (13, 3%) died, and 56 (57, 1%) met severity criteria. Sixty-two patients (63, 3%) were male, the average age was 54.89 ± 19.37 years. The most frequent etiologies were hemorrhoids (20.4%), colorectal cancer (19.4%), and diverticulosis (13.3%). Thirteen patients died and the most frequent cause of death was pneumonia in twelve (92.3%). The independent risks factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg and albumin lower than 2, 8 g/dL. With these factors the score SGA (S systolic, G Glasgow, and A albumin) was developed. An area under Receiving Operator Curve (AUC ROC) of 87.5% with a P < 0.000, the value of 2 or more predicted mortality with a sensitivity of 90.9% and a specificity of 69.7%, positive predictive value 33.7%, negative predictive value 97.9%. The value 2 or more predicted severity with a sensitivity of 59.6% and a specificity of 93.3%, positive predictive value 93.3%, negative predictive value 59.6%. The survival curve with the kaplan meier test is statistically significant, when comparing the value 0 or 1 versus the value 2 or 3.

CONCLUSION:
We found a high mortality rate and frequent severity parameters in our population with LGIB, the main risk factors being systolic blood pressure under 100 mm Hg, Glasgow score lower than 15, and albumin lower than 2.8 g/dL. Early identification of these associated factors would improve the management of LGB in the emergency room.
608 Prevalence of Acid Suppressive Prophylaxis in Hospitalized Patients for Peptic Ulcer Disease and Complications: Retrospective Study
Authors: Kaddourah Osama , Elkafrawy Ahmed A. , Noman Anas , Abuamr Khalil 
Published: October 2019

INTRODUCTION:
An NSAID is present in about 8% of all prescriptions written by primary care physicians. Among GI-related adverse drug events, 23.5% were related to NSAIDs, 45% were considered avoidable. Risk factors associated with peptic ulcer disease include: History of peptic ulcer or ulcer bleeding, positive status of H Pylori, age (>65 years), Concomitant use of warfarin, steroids, anti-platelets. Study in France, showed that gastroprotection was not prescribed in 16% of patients on NSAIDs and risk factors for GI toxicity. Misoprostol and PPI therapy are proved to reduce the risk of GI toxicity. Current guidelines recommend that high risk patients should be prescribed COX2 selective agents by itself or non-selective agents with gastroprotection.

METHODS:
We performed a retrospective chart review of patients at Truman Medical Center Hospital Hill, Missouri who were hospitalized for NSAID-related peptic ulcer disease from the time period of January 2013 till September 2018. We further included only patients with risk factors of peptic ulcer disease and should have been on gastroprotective agents prior to presentation.

RESULTS:
Our sample included 81 patients hospitalized for NSAID-related peptic disease with risk factors for peptic ulcer disease. Mean age was 58.2 years old. More than half of patients were male (56.8%). Around 47% were smokers and 41% were alcohol current users. Around third of patients were taking aspirin daily and only 13% were on anticoagulation. More than half of patient had History of peptic ulcer (52%) and 38% had history of bleeding ulcer. Only 44.4% of our patients were on gastroprotective agents prior to presentation. Significant portion of our sample presented with ulcer complication (i.e., bleeding, perforation) at 74.1% (60/81). About 60% of patient were anemic at presentation. 31% of patients presented with significant bleeding requiring more than 2 units of packed RBC. Gastroprotective agent prescription prior to presentation was significantly associated with aspirin use (P-value 0.038), anticoagulation (P-value 0.023), Hx coronary artery disease (P-value 0.023), history of peptic ulcer in the past (P-value 0.002) and anemia (P-value 0.003).

CONCLUSION:
Significant portion of patients who were hospitalized with peptic ulcer disease complications were not on gastroprotective agents although indicated. Risk stratification and PPI prescription when appropriate should be implemented more aggressively in outpatient setting.
609  The Unseen Bleed: Does the Degree of Anemia Mirror Hiatal Hernia Size?
Authors: Lorio Eric , Wisnewski Nicole , Vizuete John A. 
Published: October 2019

INTRODUCTION:
Multiple studies have established a relationship between esophageal hiatal hernias (HH) and iron deficiency anemia (IDA), often attributed to presence of Cameron lesions. Small hernias are often detected incidentally, and most do not lead to anemia. This study is designed to evaluate if size of hernia directly correlates with degree of anemia, particularly in very large hernias, a finding that could provide insight into the management of these patients in the future.

METHODS:
Electronic medical records from 5/2016 to 5/2019 were retrospectively reviewed. Patients with a diagnosis of iron deficiency anemia with complete endoscopic workup including EGD, colonoscopy, and complete small bowel capsule were included. Exclusion criteria included an alternative source for anemia such as celiac disease, peptic ulcer, or significant small bowel AVMs. Collected information included standard demographics, size of hiatal hernia, nadir hemoglobin (Hgb) during visit, presence or absence of Cameron lesions, and other capsule endoscopy findings. Analysis of associations between hernia size at the time of capsule endoscopy and nadir Hgb was formulated using Pearson's correlation testing. Graphic representation of results was depicted via linear regression modeling. Two-score T testing was also utilized to examine whether significant differences in degree of anemia exist between small (<5 cm) and large (≥5 cm) hiatal hernias.

RESULTS:
45 patients were included in the final dataset (78% women, 22% men). Only 7% (3/45) had visible Cameron lesions on upper endoscopy. Overall, degree of anemia did not correlate to size of hiatal hernia as Pearson's correlation testing identified an r = -0.234 (P = 0.136). However, when controlling for hiatal hernias ≥5 cm, a statistically significant inverse relationship was noted between nadir hemoglobin levels and size of hiatal hernia, r = -0.362 (P = 0.041). Figure 1 summarizes these results. 2 score T-testing identified no significant difference in the mean nadir hemoglobin between small and large hiatal hernias, t = -0.029 (P = 0.488).

CONCLUSION:
A linear relationship between hernia size and degree of anemia appears to exist when esophageal hiatal hernias are 5 cm or larger, but even 3-4 cm hernias can result in significant iron loss. Clinicians should also be aware that Cameron lesions are not required to develop profound IDA. Our study is limited by sample size but offers some evidence that hernias larger than 5 cm should be considered for surgical repair.
617 Outcomes of Patients With Small Bowel Angiodysplasia Treated With a Small Bowel Radiofrequency Ablation Catheter: A Multicenter Case Series
Authors: Lara Luis , Silva Rogelio , Thakkar Shyam , Stanich Peter P. , Samarasena Jason 
Published: October 2019

INTRODUCTION:
Small bowel angioectasia (SBA) are the most common cause of small bowel GI bleeding, usually treated with argon plasma coagulation (APC). Bleeding recurs in >40%. The outcomes of patients with SBA treated with a dedicated radiofrequency ablation catheter was reported.

METHODS:
Patients were treated using a commercially available small bowel radiofrequency ablation catheter (SBRFA) during enteroscopy which is 25 mm wide, 260 cm long, and the treatment paddle is 7.5 mm wide deployed, and 10 mm long. The paddle was advanced to the lesion, and gentle pressure was applied delivering 10 J/cm2 with each application. The same area could be treated twice. Patient demographics, pre and post treatment hemoglobin, time to recurrent bleeding, and need for repeated therapy were reported.

RESULTS:
20 subjects were treated from March to October 2018: 6 females (age 68; SD 11.1) and 14 males (age 73; SD 10.4). Three subjects had a left ventricular assist device (LVAD). 19 (95%) had at least one previous EGD (total at least 43, range 1 to >10), and at least one previous colonoscopy (total 42, range 1 to >10). 14 subjects (70%) had an abnormal video capsule endoscopy; 14 (70%) had previous APC. Median hemoglobin before treatment was 8.3 g/dL (5.1-14.4), and 13 subjects (65%) had a mean of 4 (SD 2.1) units of blood transfused. A median of 23 SBA were treated (2 to 99 total). No other treatments such as APC were used. Median follow-up was 195 days (30-240). The most recent median hemoglobin in 15 subjects (75%) was 9.4 g/dL (5 to 13) (P = 0.04). Repeat endoscopy rate was 20%; once in 2 subjects (at 45 and 210 days after SBRFA), and twice in one subject (60 days after SBRFA treatment). One subject with LVAD had a repeat upper endoscopy and no treatment, one subject with GAVE had a push enteroscopy and no treatment, and the third subject with LVAD had two assisted enteroscopies: SBA were re-treated with APC once, and no treatment was needed the last time. One patient with an LVAD had overt ileum bleeding and underwent embolization. 2 subjects (10%) required repeat blood transfusion (2 units each). Two deaths at 60 and 180 days were unrelated to GIB.

CONCLUSION:
In this series of SBRFA therapy of SBA up to 240 days of follow up 3/20 subjects (15%) required repeat endoscopy. Repeated endotherapy was necessary in 1 subject. All subjects with LVAD had repeat procedures. 2 subjects required more blood transfusions. The data compares favorably to historical SBA outcomes but comparative studies are needed.