bluuebunny/crossref_metadata_2025_split huggingface dataset:
A202 A CASE OF MYCOBACTERIUM WOLINSKYI PULMONARY INFECTION SECONDARY TO LONG-STANDING ACHALASIA IN AN IMMUNOCOMPETENT PATIENT
Authors: Bowron J C , Sadowski D C 
Published: February 2024

Abstract

Background
Achalasia is an esophageal motility disorder resulting in chronic esophageal obstruction and stasis. Rapidly growing mycobacterium (RGM) pulmonary infections have been previously observed in individuals with underlying gastro-esophageal motility disorders. To date, pulmonary Mycobacterium wolinskyi infection (MWI) in the setting of achalasia has not previously been reported.

Aims
Our aim is to present a novel case of M. wolinskyi pneumonia in a patient with achalasia. We also searched the medical literature to identify previously reported associations between achalasia, chronic regurgitation symptoms and MWI. M. wolinskyi is an emerging clinical concern among RGMs. While primarily associated with post-operative, prosthetic joint and skin and soft tissue infections, M. wolinskyi pulmonary infections have not been documented to date in an immunocompetent patient.

Methods
We present a retrospective clinical case description of our case. We carried out a literature review from 1999 to Oct 2023, with the keywords "M. wolinskyi and infection.

Results
A 34-year-old male presented with a several-month history of productive cough, exertional dyspnea, fatigue, and unintentional weight loss of 17 kg over the past 6 months. Despite multiple courses of oral and intravenous antibiotics, there was no clinical improvement. His medical history included long-standing achalasia requiring previous pneumatic dilations. On admission, his chest X-ray revealed bilateral interstitial and alveolar infiltrates with consolidation. Routine microbiology and viral panels were negative. CT scan showed widespread bilateral consolidation and a dilated and fluid-filled esophagus. A timed barium swallow demonstrated dilated esophagus with irregular tertiary contractions and limited GE-J opening.
Sputum cultures were positive for MWI on day 8 of admission (BACTEC MGIT). This was confirmed with lung biopsy demonstrating MWI with necrotizing granulomatous inflammation. The patient was prescribed a 12-month course of doxycycline, trimethoprim-sulfamethoxazole, and ciprofloxacin. Inpatient pneumatic dilation to 35 mm was performed. At discharge, his swallowing was subjectively improved, and a follow-up swallowing study noted improvement with no evidence of regurgitation.

Conclusions
Chronic esophageal obstruction provides an ideal lipid-rich environment for RGM infections. Related mycobacterial species have been isolated in pulmonary infections have been linked to chronic esophageal obstruction. To date, no cases of M. wolinskyi pulmonary infection with achalasia have been reported. We present a unique case of M. wolinskyi pulmonary infection in an immunocompetent patient with chronic achalasia, adding to our understanding of this emerging clinical concern.

Funding Agencies
None
A211 INCREASED RATES OF PPI DEPRESCRIPTION OVER TIME IN PATIENTS WITH UPPER GI BLEEDS
Authors: Kecskemeti K , Borgaonkar M , Mcgrath J 
Published: February 2024

Abstract

Background
Proton Pump Inhibitors (PPIs) are commonly used for various indications, including prophylaxis of upper GI bleeding. We aimed to assess if there has been more PPI deprescription in recent years in patients treated for Upper GI Bleeds (UGIB).

Aims
Our study aimed to assess the frequency of PPI deprescription in patients treated with endoscopic therapy for UGIBs. We hypothesized that there was a higher rate of PPI deprescription in recent years.

Methods
This retrospective cohort study analyzed patients who received endoscopic treatment for UGIB between the years 2015-2022. All patients who were treated with endoscopic therapy for an UGIB from two academic GI practices were included. PPI deprescription was defined as a 50% dose reduction, frequency reduction or complete medication discontinuation in the past 3 months or longer in established PPI users. To assess trends, the cohort was divided into group 1 (2015-2018) and group 2 (2019-2022). Data were analysed using SPSS and chi-squared testing was used to compare categorical variables.

Results
Data were collected from 301 UGIB treated endoscopically. The mean age was 66.4 ± 13.5 years with 64% males and 36% females. Patients from group 1 had a deprescription rate of 2% (2/101 cases). Patients from group 2 (2019-2022) had a deprescription rate of 16% (32/200 cases) (pampersand:003C0.001).

Conclusions
There was a higher rate of PPI deprescription in patients treated for UGIB in the second time period. Reasons for the increased rate of PPI deprescription require further investigation.
Chi-Squared of PPI Deprescription for entire cohort
Fisher Exact test: P value ampersand:003C0.001

Funding Agencies
None
A214 AGE, SEX AND POSITION INFLUENCE UPPER ESOPHAGEAL SPHINCTER PRESSURES
Authors: Pokraka K , Woo M , Randall D 
Published: February 2024

Abstract

Background
Upper esophageal sphincter (UES) function may be evaluated using high resolution manometry (HRM) to measure manometric parameters specific to the UES. The UES parameters are not well established however there is evidence suggesting a relationship between the UES parameters and esophageal motility disorders as well as UES parameters and symptoms including dysphagia, globus sensation and reflux. The Esophageal Symptom Questionnaire (ESQ-30) is a validated tool in the assessment of esophageal symptoms and measures the frequency and severity of dysphagia, reflux and globus through three separate sub-scales (ESQ-D, ESQ-R, ESQ-G respectively).

Aims
We aimed to identify the relationship between UES manometric variables and patient demographic variables (age, sex) as well as patient symptoms including broad categories of globus sensation, dysphagia and reflux.

Methods
Retrospective analysis of consecutive reports from HRM studies performed between October 2021 – March 2023 who provided consent for inclusion in the motility databank and completed ESQ-30 questionnaires. All values expressed as median (IQR: 25-75-centile). Values were compared with the non-parametric Mann-Whitney U test. Relationships between manometric diagnosis, UES pressures and symptomatology were explored.

Results
681 patients underwent esophageal manometry and completed the ESQ-30 questionnaire. These patients were 442 (65%) female (mean age 54.6 +/- 14.8 years). Over the study period, 318 patients underwent esophageal HRM in the upright position and were diagnosed according to CCv3 and 361 patients underwent HRM in the supine position and were diagnosed by CCv4 manometric criteria.
UES mean basal pressure was significantly higher in females than males (64.6 [42.3-89.1] vs 68.4 [48.4-96.1], p = .015) as well as in the supine position (77.5 [55.9-101.0] vs. 56.0 [38.7-80.3]. UES mean basal pressure was negatively correlated with age (R2 -.28 p ampersand:003C .001).
In terms of esophageal symptomatology, dysphagia scores (ESQ-D) were negatively correlated with UES mean basal pressure (R2 -.15, p ampersand:003C .001).

Conclusions
Age, sex and position may influence UES manometric pressures. The finding of higher UES pressures in the supine position may reflect a mechanism for decreasing proximal reflux. The decreased UES basal pressure with age is possibly related to changes in the integrity of the neuromuscular system. Having a better understanding of the poorly understood normal UES dynamics and how this changes in motility disorders may allow us to more specifically target areas for treatment.

Funding Agencies
None
A218 TRADING ONE PROBLEM FOR ANOTHER? THE EMERGENCE OF LYMPHOCYTIC ESOPHAGITIS IN A PEDIATRIC PATIENT WITH EOSINOPHILIC ESOPHAGITIS AFTER TREATMENT WITH DUPILUMAB
Authors: Strauss J , Brundler M , McKenzie L S 
Published: February 2024

Abstract

Background
Eosinophilic esophagitis (EoE) is a Th2 driven chronic, inflammatory disorder defined by esophageal dysfunction and a peak eosinophil count (PEC) ≧ 15 eosinophils/high-power field on biopsy. Dupilumab, a human monoclonal antibody that inhibits IL-4 and IL-13 signaling was recently approved for use in Canada in children with EoE. There is limited data on the histologic abnormalities found with reintroduction of dietary triggers on dupilumab.

Aims
To describe emergence of lymphocytic esophagitis without eosinophilia observed during food reintroduction in a pediatric patient with EoE on dupilumab.

Methods
Case report and literature review.

Results
We present a 14-year-old boy with extensive food allergies, eczema, asthma and treatment refractory EoE. After failing to improve with proton-pump inhibitor (PPI), food elimination diet and topical steroids, he was started on an elemental formula with concomitant PPI. This resulted in symptomatic and histologic remission, however food restriction led to poor quality of life.
The patient was started on dupilumab 200 mg every 2 weeks and had a dramatic improvement in his disease course. Over 2 years on treatment, several allergic foods were reintroduced with normal histologic biopsies. However, two dietary challenges led to the emergence of lymphocytic esophagitis with basal zone hyperplasia (BZH) and dilated intercellular spaces (DIS), but no eosinophilia. Subsequent removal of the dietary antigen and endoscopic reassessment led to normal biopsies, without lymphocytic or eosinophilic infiltration.
Lymphocytic esophagitis is rare in children and the etiology is unknown; it is characterized by increased intraepithelial lymphocytes without eosinophils or neutrophils, and associated spongiosis. The emergence of lymphocytic esophagitis was unexpected and subsequent normalization of histology with removal of an antigen suggests that the lymphocytic pattern observed was driven by the allergic food. This may indicate that IL-4/IL-13 antagonism by dupilumab affects other immune signaling pathways, resulting in a lymphocytic-predominant inflammatory response upon exposure to allergic food antigens.

Conclusions
Dupilumab is a promising new medication in the management of pediatric EoE, particularly in the extremely atopic patient. In our case, the use of dupilumab led to improved antigen tolerance and quality of life. However, the emergence of lymphocytic esophagitis was unexpected, and the natural history and prognosis of this condition is not well defined. This is the first case to describe the emergence of lymphocytic esophagitis in a patient treated for eosinophilic esophagitis with dupilumab, and its subsequent resolution with dietary exclusion.

Funding Agencies
None
A219 EARLY CANADIAN EXPERIENCE WITH BALLOON CRYOTHERAPY FOR BARRETT’S ESOPHAGUS
Authors: Sullivan R , Fazal A , Gupta M , Belletrutti P , Wong C 
Published: February 2024

Abstract

Background
Balloon Cryotherapy (bCr) is a novel endoscopic treatment modality for Barrett’s esophagus (BE) associated dysplasia. Cryotherapy offers an additional approach, particularly in cases refractory to or with an anatomical impediment to radiofrequency ablation (RFA), currently first line in endoscopic eradiation therapy (EET). The use of bCr is new in Canada and it was introduced in Alberta in February 2023.

Aims
To present the early experience of bCr use for BE from a provincial Canadian cohort.

Methods
An Alberta health technology assessment approved bCr, which was then incorporated into the provincial BE treatment algorithm. Indications for bCr include: 1) RFA-refractory, 2) anatomical impediment to RFA, 3) need for concomitant biopsy/EMR, and 4) pain with RFA. All patients who underwent bCr for BE in Alberta from February to September 2023 at two tertiary care centers were included. Data on demographics, BE lesion characteristics, prior BE treatments, and bCr use are presented.

Results
During the 8-month period, 22 patients underwent a total of 32 bCr treatments. The median age was 68, with 77% of patients being male. At baseline, 81% had long-segment BE (≥3 cm), with a median maximal BE length of 7cm. The majority had baseline histology of high-grade dysplasia (HGD) (n=11, 50%), followed by low-grade dysplasia (LGD) (n=5, 22%), T1a (n=4, 18%), T1b (n=1, 4.5%), and intestinal metaplasia (IM) (n=1, 4.5%). All patients had previously received EET, with 77% undergoing a combination of EMR, RFA, APC, and/or ESD. Most had received RFA (n=18, 81%, median sessions=5) and EMR (n=13, 59%, median sessions=2). Some had prior APC (n=10, 45%, median sessions=1) and one had ESD. Prior to bCr, most patients had converted to short-segment (ampersand:003C3cm) BE (n=16, 72%), and histology was predominately IM (31%), followed by visible BE though no biopsy (27%), HGD (22%), T1a (13%), and LGD (4.5%). The primary indication for bCr was RFA-refractory BE (n=17, 77%), followed by anatomical impediment to RFA (n=4, 18%), and concomitant EMR (n=1, 4%). No procedures were aborted due to technical difficulties and there were no major adverse events such as perforation, bleeding, or pain requiring hospitalization. Among those with follow-up after a bCr session (n=19, 59%), one reported pain, two reported self-limited dysphagia, and one had a stricture requiring dilation. Of the 7 patients with post-bCr endoscopy, all had no dysplasia on the first set of biopsies (no IM, n=4; IM, n=2; indefinite for dysplasia, n=1).

Conclusions
Our early experience with bCr demonstrates there is a need for additional EET for BE. Cryotherapy, in accordance with gastroenterology society guidelines, is a promising next step in the BE algorithm. In our provincial cohort, bCr has shown technical success, and preliminary data suggests that it is safe and effective in ablating resistant BE segments.

Funding Agencies
None
A222 CLINICAL EFFECTIVENESS AND SAFETY OF USTEKINUMAB IN YOUTH WITH REFRACTORY INFLAMMATORY BOWEL DISEASE IN SAUDI ARABIA: A RETROSPECTIVE COHORT STUDY
Authors: Alhadab A A , Almarhoon A , AlAlwan A , Hammo A 
Published: February 2024

Abstract

Background
Inflammatory bowel disease (IBD) incidence and prevalence have been increasing worldwide with higher disease severity observed in pediatrics. Limited data exists on the effectiveness of ustekinumab (UST) in children.

Aims
To describe the effectiveness and safety of UST in pediatric patients with IBD.

Methods
A retrospective, single-center cohort study was conducted between January 2017 and February 2022. The study included patients ≤16 years of age who were treated with off-label UST and followed up for a minimum of one year. Clinical remission was defined as a decrease in the score on the Pediatric Crohn's Disease (CD) and Pediatric Ulcerative Colitis (UC) Activity Indices to ≤10 at week 52.

Results
A total of 13 patients who had failed anti-TNFα therapy were included, 8 (61.5%) with CD and 5 (38.5%) with UC. The median age of the patients was 13y (IQR: 11.5 to 14). UST treatment was initiated at a median of 3y (IQR: 2.3 to 7) after diagnosis. Ten patients (76.9%) achieved clinical remission. There were no statistically significant differences in baseline characteristics between patients who achieved and did not achieve clinical remission. Biochemical remission was achieved in 6 patients (46.2%). C-reactive protein levels decreased significantly in the remission group and insignificantly in the non-remission group. No significant changes were observed in erythrocyte sedimentation rate, albumin, or hemoglobin. BMI improved (Fig 1) and the need for corticosteroids significantly decreased after UST therapy in the remission group (P = 0.014). Endoscopy conducted post-treatment in 7 patients confirmed remission in 6 patients, with one patient showing clinical remission but not endoscopic remission. Adverse events included two instances of infection and once case of headache.

Conclusions
UST was effective as a secondary biologic therapy for the induction and maintenance of remission in patients with anti-TNFα refractory IBD. At one year, 84% of patients remained on UST with no severe adverse reactions reported. Future prospective large-scale studies are necessary to assess the therapeutic positioning and optimal dosing regimens of UST in pediatric IBD.

Figure 1. Change in BMI Z-score throughout the study (P value of interaction = 0.049).

Funding Agencies
None
A223 DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE AND PRIMARY SCLEROSING CHOLANGITIS AT THE OTTAWA HOSPITAL
Authors: Alrifae Y , Sambhi G , Benchimol E I , Ricciuto A , Murthy S 
Published: February 2024

Abstract

Background
Primary sclerosing cholangitis (PSC) is present in up to 8% of individuals with inflammatory bowel disease (IBD). Characteristics of this population are unique and data are limited.

Aims
To describe the demographic and clinical characteristics of all individuals with PSC-IBD managed at The Ottawa Hospital (TOH).

Methods
A chart review was performed for 132 patients with PSC-IBD followed at TOH between January 1998 and July 2023.

Results
Of 132 individuals with PSC-IBD identified at TOH, 26.5% had Crohn’s disease (CD), 68.2% had ulcerative colitis (UC) and 5.3% had IBD-unclassified. Median age at diagnosis were 25.3 (IQR 20.94) for IBD and 33.84 (IQR 23.98) for PSC, and 66.7% of all patients were male. More than 17% had a co-morbid autoimmune disease other than IBD or PSC. Of those with CD, roughly 15% had fibrostenotic or penetrating complications and 17% had perianal disease at the time of IBD diagnosis. Only 28% ever had a liver biopsy, whereas the majority were diagnosed with PSC by cholangiography. PSC distribution was isolated intrahepatic in 47%, isolated extra-hepatic in 5.1% and mixed intra/extra-hepatic in 38.5%. Clinically significant portal hypertension was present in 11.5% at PSC diagnosis, while 27.3% and 16.7% developed cirrhosis and liver decompensation, respectively by last follow-up. 17.4% underwent liver transplant, of which 30.4% developed PSC recurrence post-transplant.

Conclusions
Our study showed that the majority of PSC-IBD patients are young males with UC. Co-morbid autoimmune diseases are common while isolated extra-hepatic PSC is uncommon. Cirrhosis, liver decompensation and liver transplant are frequent occurrences in this population. PSC recurrence post-transplant is observed in more than 30% of patients.

Funding Agencies
None
A224 CHARACTERIZATION OF VERY-EARLY-ONSET INFLAMMATORY BOWEL DISEASE IN CHILDREN ampersand:003C6 YEARS OF AGE: A SINGLE CENTER EXPERIENCE
Authors: Alsaedi K S , Sant'Anna A , Ahmed N 
Published: February 2024

Abstract

Background
Very-early-onset inflammatory bowel disease (VEO-IBD), diagnosed before the age of six years old, presents a distinct subtype of pediatric inflammatory bowel disease (IBD). This chronic inflammatory condition is believed to result from an abnormal immune response triggered by environmental factors including the gut microbiota, in genetically susceptible individuals.

Aims
This study aims to analyze the clinical characteristics and management of VEO-IBD patients in a tertiary medical center, evaluating disease presentation, localization and treatment strategies.

Methods
A retrospective descriptive study was conducted of 28 VEO-IBD patients diagnosed between January 2001 and January 2019 at our institution. Data was abstracted including patient demographics, clinical features, laboratory and histological parameters, treatment, and disease classification based on the revised Porto Criteria.

Results
Among the 28 patients, Crohn’s disease (CD) was the predominant diagnosis (89%) with predominantly colonic involvement. Thiry-two percent of patients had isolated colitis whereas the upper gastrointestinal (UGI) tract was involved in 57% of the cohort, approximately one third had involvement of the small bowel. The most common presenting symptoms were rectal bleeding and diarrhea, both occurred in 65% of the patients. Patients were followed for a mean duration of 115 months. Despite prior assumptions of its severity, VEO-IBD patients in this cohort responded well to conventional treatments in which 64% were induced with steroid therapy, 25% received biologics and 35% received immunomodulators. Surgical interventions were relatively infrequent. Only 2 patients out the 28 VEO-IBD patients underwent surgery for refractory colitis, one of them in the 1st 2 years of life. There were limited genetic testing results which made it difficult to know our incidence of monogenic IBD. However, only 5 of our patients had full genetic workup done in other centers for research purposes with 1 patient being diagnosed with monogenic IBD consistent IPEX syndrome.

Conclusions
This study highlights the unique clinical profile of VEO-IBD, with CD being the prevalent diagnosis in this age group in our population. Our cohort did not have a more severe phenotype, emphasizing that there is significant variation within this group Understanding the predictors of response is needed in individual patients with VEO-IBD is vital for tailored management and improved outcomes in this young population.

Funding Agencies
None
A225 ASSESSMENT OF BEDSIDE INTESTINAL ULTRASOUND IN MONITORING CROHN’S DISEASE ACTIVITY
Authors: Ashrafinia N , Guzowski T , Fowler S 
Published: February 2024

Abstract

Background
Bedside intestinal ultrasound (IUS) is an evolving modality in monitoring disease activity and assessing complications in inflammatory bowel disease (IBD). The easy-tolerability and immediate accessibility to results for expedited clinical decision-making contribute to the growing global attraction of IUS integration into IBD care. Fecal calprotectin (FC) is a known, non-invasive tool to assess disease activity in IBD. However, it comes with limitations.

Aims
To assess the efficacy of IUS in monitoring Crohn’s Disease (CD) compared to FC level.

Methods
We conducted a retrospective observational study in patients with confirmed CD at a certified IUS gastroenterologist’s outpatient clinic in Saskatoon. Patients’ charts undergoing IUS between February 2022 and April 2023 were reviewed. Patients with CD and available FC results within a month of IUS performance were identified. Age, gender, disease character, clinical symptoms (Harvey-Bradshaw Index (HBI)), FC levels, and IUS bowel wall thickening (BWT) were collected. The cut-off for FC levels and BWT for disease activity were ampersand:003E250 μg/g and ampersand:003E3 mm, respectively. The correlation between IUS BWT and FC levels was analyzed based on the Pearson correlation.

Results
Among a total of 178 chart reviews, 71 patients were identified. The median age was 49 years, 52.1% were males and 47.8% were females. 35 (49.3%) ileal CD, 35 (49.3%) ileocolonic and 1 (1.4%) colonic CD were identified. The HBI score verified 67.6% mild disease, 19.7% moderate, 11.2% in remission, and 1.4% severe disease. The Pearson correlation coefficient (r) between FC levels and BWT findings on IUS was r = 0.29 (P ampersand:003C0.0001), indicating a weak positive correlation.

Conclusions
A positive but weak correlation exists between bowel wall thickening in IUS and FC level in monitoring CD. Recognizing FC limitations, future multi-center, larger cohort studies need to be done to investigate this correlation further.

Funding Agencies
None