GI Complaints Research Articles

243. IS MUCOSAL CHANGE IN COELIAC DISEASE RESTRICTED TO SMALL BOWEL? STUDY OF OESOPHAGEAL MUCOSAL CHANGES IN CHILDREN WITH COELIAC DISEASE

Abstract Introduction Celiac disease (CeD) may cause changes throughout the gastrointestinal tract. It is not known whether the oesophageal mucosa is involved in CeD. The purpose of this prospective study was to study the mucosal changes in oesophagus in children with CeD. Materials & Methods The mucosal changes in the esophagus was prospectively investigated in 126 children with CeD during 192 upper GI endoscopies performed to obtain duodenal biopsy specimens and was compared with findings in 49 children who underwent endoscopy for upper GI complaints without CeD (non-CeD patients) during one year. Children were diagnosed as cases of CeD based on the modified ESPGHAN criteria and positive serology. Duodenal histologic lesions were classified as proposed by our group. Results The mean age of CeD children (M:F::71:55) at presentation was 6.7 + 3.3 years. 54/126 (42.9%) of CeD and 23/49 (46.9%) of non-CeD patients showed normal oesophageal mucosa. The prevalence of lymphocytic oesophagitis (LyE) was higher in CeD (11.9%) than non-CeD (2.1%) patients. The prevalence of oeosinophilic oesophagitis, follicular oesophagitis, reflux oesophagitis and non-specific oesophageal mucosal changes were similar in both groups. All but one child with LyE showed classic duodenal histologic lesion. Conclusions Our findings showed that the oesophageal mucosa can be damaged in CeD patients and that the prevalence of LyE is higher with CeD. Awareness of potential coexistence of oesophageal lesions in CeD should promote optimal diagnosis of these conditions. Routine oesophageal biopsies may be warranted when investigating for CeD.

Biopsy samples from patients with irritable bowel syndrome, but not from those with mastocytosis or unspecific gastrointestinal complaints reveal unique nerve activation in all gut regions independent of mast cell density, histamine content or specific gastrointestinal symptoms.

We previously showed enteric nerve activation after application of colonic mucosal biopsy supernatants from patients with irritable bowel syndrome (IBS). The question remains whether this is a region-specific or a generalized sensitization. We tested the nerve-activating properties of supernatants from large and small intestinal regions of IBS patients with diarrhea (IBS-D) in comparison to those from mastocytosis patients with diarrhea (MC-D) or non-IBS/non-MC patients with GI-complaints. MC-D patients were included to test samples from patients with an established, severe mast cell disorder, because mast cells are suggested to play a role in IBS. Voltage-sensitive dye imaging was used to record the effects of mucosal biopsy supernatants from IBS-D, MC-D, and non-IBS/non-MC on guinea pig submucous neurons. Mast cell density and histamine concentrations were measured in all samples. The median neuroindex (spike frequency × % responding neurons in Hz × %) was significantly (all p < 0.001) increased for IBS-D (duodenum and colon, proximal and distal each, 49.3; 50.5; 63.7; 71.9, respectively) compared to non-IBS/non-MC (duodenum and colon, proximal and distal each, 8.7; 4.9; 6.9; 5.4, respectively) or MC-D supernatants (duodenum and colon, proximal and distal each, 9.4; 11.9; 0.0; 7.9, respectively). Nerve activation by MC-D and non-IBS/non-MC supernatants was comparable (p>0.05). Mast cell density or histamine concentrations were not different between IBS-D, MC-D, and non-IBS/non-MC samples. Nerve activation by biopsy supernatants is an IBS hallmark that occurs throughout the gut, unrelated to mast cell density or histamine concentration. At least as important is our finding that GI complaints per se were not associated with biopsy supernatant-induced nerve activation, which further stresses the relevance of altered nerve behavior in IBS.

Low Yield of Abdominal Radiographs in Children With GI Complaints

Low Yield of Abdominal Radiographs in Children With GI Complaints

Sonographically Determined Fecal Width: An Objective Indicator of Management of Bladder and Bowel Dysfunction in Children

ObjectivesTo test whether sonographically determined fecal width (SDFW) correlates with symptom improvement in a population of children with Bladder and Bowel Dysfunction (BBD) managed with Standard Urotherapy, even for those patients lacking initial bowel complaints, MethodsWe retrospectively analyzed 200 pediatric BBD patients managed with SU for at least 3 months. Self-reported symptom improvement (complete, partial, no response) following International Children’s Continence Society (ICCS) guidelines was tabulated. Patients with complex urologic diagnoses other than VUR were excluded. Pharmacotherapy choice, physical therapy (PT), UTI occurrence, and VUR status were tabulated. SDFW was recorded. Non-parametric ANOVA and parametric/non-parametric T-testing were used for analysis. ResultsPatients had a mean age of 9.5 years (4-12). 48 patients had no GI complaints at presentation. Urotherapy yielded complete, partial, and no responses in 14% (n=27), 33% (n=67), and 53% (n=106) of patients, respectively. The average SDFW for those patients with complete response (2.6cm) was smaller than the SDFW of those with a partial response (3.1cm) or no response (3.3cm) (p=0.0001). Non-compliance led to greater SDFW compared to compliant patients (3.7cm and 3.1cm respectively, p=0.0001). FW was unaffected by VUR, UTI, PT, or pharmacotherapy. ConclusionsSDFW correlates well with symptom improvement in pediatric patients managed for BBD, confirming our hypothesis. SDFW is reasonable as single objective parameter to identify successful management in patients with BBD, extending to those without bowel complaints at presentation.

Decision regret up to 6years after sleeve gastrectomy.

Sleeve gastrectomy (SG) is one of the most popular types of weight loss surgery today but is neither risk-free nor universally effective. We previously demonstrated that 5% of Roux-en-Y gastric bypass (RYGB) patients and up to 20% of gastric banding patients report overall regret 4years after surgery. This study explores patients' attitudes toward their decision to have SG and decision regret rates up to 6years postoperatively. We surveyed 185 patients who were at least 6months post-SG (response rate 30%). We used a modified version of the Decision Regret Scale developed by Brehaut et al. We converted responses to a 0-100 scale so that higher scores (> 50) reflect greater regret. We characterized patients who expressed having overall decision regret (score > 50) vs. those who did not (≤ 50). Demographic and preoperative clinical information was extracted from the online medical records. Of 185 SG patients, only 13 (7%) reported regret scores > 50 (i.e. high decision regret). Mean time from SG to survey completion was 41months (range 6-76months). Unadjusted comparisons between the two groups revealed that patients with high regret scores had lower mean weight loss (32.1% vs. 48.9% EBMIL), and reported less improvement in quality-of-life (QoL), such as physical health (46.2% vs. 93.5% "somewhat" or "significantly" improved). The two groups were similar in short-term complications, but those reporting overall regret were more likely to report GI complaints such as bloating (61.5% vs. 30.4%). Finally, patients with regret scores > 50 were more likely to be further out from SG (median time since surgery 61.8 vs. 41.1months). In our study, very few patients reported regret (7%) up to 6years postoperatively, in line with prior reports after RYGB. Those with regret reported poorer QoL.

Predictors of care discontinuity in geriatric trauma patients.

Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. Prognostic and Epidemiological; Level IV.

Evaluating and comparing tolerance, nutritional quality and bio-functional activity of bovine-plasma, corn and whey proteins, outcomes of a randomized double blind controlled trial

Important considerations in the choice of future sustainable protein sources for human application are tolerance, nutritional quality, and potential health benefits. We evaluated, in a double-blind cross-over intervention trial, tolerance, nutritional quality, and potential health effects of two sustainable protein sources. Thirty-six apparently healthy older adults (age 62.3 ± 7.2yrs, BMI 25 ± 3 kg/m2) received 40 g/day bovine-plasma protein (BP), corn protein (CP) or, as a benchmark, whey protein (WP) for one week with a washout period of one week in-between. In 12 participants, we also determined postprandial amino acid (PAA) uptake kinetics upon consumption of 20 g BP, CP, or WP. Changes in self-reported gastrointestinal complaints and intestinal permeability assessed using a multi-sugar acetylsalicylic acid test did not differ between the interventions. Clear differences in PAA responses were observed after consumption of the different proteins, but clear essential amino acid responses were observed for all proteins. BP consumption resulted in a small but significant increase in blood pressure outcomes, and CP consumption resulted in a small but significant decrease in insulin levels when compared to the other interventions. In conclusion, alternative protein concentrates and isolates studied here can be consumed in relative high quantities without experiencing unwanted GI complaints or gut barrier dysfunction and they can be a good source of essential amino acids. The rise in blood pressure observed during the BP intervention, potentially linked to the elevated salt content of the BP, constitutes a potential health issue. Future studies with longer intervention periods might however be recommended.

MAST CELL ACTIVATION SYNDROME AND ANTI -IMMUNOGLOBULIN E THERAPY FOR THERAPY-RESISTANT MCAS

<h3>Introduction</h3> Patients with mast cell activation syndrome (MCAS) may present with a variety of symptoms including flushing, urticaria, GI symptoms and headaches. In about 40% of patients, there is a failure of response to the recommended traditional therapy with anti H1/H2 and leukotriene modulating agents (LMAs) and a definitive effective treatment for MCAS has yet to be established. The aim of the current report is to present a medically challenging patient with therapy-resistant MCAS who responded favorably to omalizumab. <h3>Case Description</h3> A 53-year-old white female was evaluated for recurrent episodes of flushing, dermographism, urticaria, headaches, GI complaints and episodes of syncope, symptoms congruent with a diagnosis of MCAS. Our evaluation revealed elevated tryptase serum concentrations of 21.1 mcg per liter and a negative KIT D816 mutation test assay. Since there was no improvement following an initial course of therapy with anti H1/H2 and LMAs, treatment with omalizumab 300 mg SQ q4 weeks was initiated that led to resolution of her flushing, urticaria, GI symptoms and episodes of syncope. <h3>Discussion</h3> MCAS is a disorder that affects multiple systems including the skin, gastrointestinal, cardiovascular and the respiratory system with a small subgroup of patients who do not respond to traditional therapies. Our patient's favorable response to omalizumab, significantly improving her quality of life, should prompt the performance of larger well-controlled studies evaluating its potential use for patients with MCAS resistant to conventional therapies.

S2533 An Unusual Finding Lurking in the Colon

Introduction: Deep Invasive gastrointestinal endometriosis (DIGIE) is rare. Out of all endometriosis cases, 7-12% of cases can have gastrointestinal involvement, ranging from single lesions, to multiple lesions, to full colonic stenosis. Symptoms can include dyspareunia, dysmenorrhea, infertility, dysphasia, diarrhea, constipation, bloating, and rectal bleeding. Here we present a patient who was incidentally found to have endometrioma. Case Description/Methods: A 24-year-old female with a past medical history significant for polycystic ovarian syndrome, HIV and endometriosis, presented to the hospital with chief complaints of fever, dysuria, hematochezia, and lower abdominal pain which had been ongoing for 3-4 days. On admission, the patient was noted to be hemodynamically stable. Abnormal laboratory results included hematocrit 32.6% (reference range 36-46%), hemoglobin 10.2 g/dL (reference range 12-16 g/dL), mean corpuscular volume 72.4 fL (reference range 80-100 fL), ferritin 15.8 ng/mL (reference range 6.3-137 ng/mL), total iron binding capacity 306 mcg/dL (reference range 265-497 mcg/dL), and iron 19 mcg/dL (reference range 37-170 mcg/dL). The following day, she underwent a colonoscopy which showed isolated diverticulosis involving the sigmoid colon. There was an active oozing diverticulum that was successfully treated with endoscopic clip placement. At the rectosigmoid junction, there was a 3 cm submucosal lesion bulging into the lumen. This appeared to have a smooth surface and was without ulceration. Biopsies were taken and the pathology showed submucosal granulation tissue with chronic inflammatory reaction and iron deposition. CD10 specific immunostains were positive, suggesting the diagnosis of an endometrioma (Figure). Discussion: This case highlights an incidental finding of DIGIE. It is important to think about colonic involvement in patients with endometriosis who have GI complaints. Rarely, these lesions can cause obstruction and may require surgery. There are currently no formal guidelines or recommendations, with most of these patients being managed on a personalized basis. Management for these patients includes symptomatic therapies, progresterones, colonic shaving, disc excision, and laparoscopic resection. As for our patient, she pursued conservative symptomatic management with close outpatient Gynecology follow up.Figure 1.: A 3 cm submucosal lesion bulging into the lumen at the rectosigmoid junction.

S206 Clinical Characteristics of Young Patients With Colonic Adenomas

Introduction: The incidence of colonic adenomas and colorectal cancer has been rising among young patients. Studies addressing the prevalence, risk factors, patient characteristics and appropriate surveillance intervals in young patients with adenomas are limited. In this study, we aim at describing the characteristics of young patients (< 50 years of age) with adenomatous polyps and characterizing those polyps. Methods: This was a retrospective chart review of the Department of Gastroenterology database to identify patients < 50 years of age who had polyp(s) on colonoscopy done between 2008 and 2021. Patient demographics, colonoscopy indication, and number, size, location, and pathology of polyps were documented. Timing and findings of follow-up colonoscopies were recorded. Patients with personal history of inflammatory bowel disease, personal or family history of colorectal cancer were excluded. Results: 877 patients were included in the study; mean age 42.4 ± 6.3 years, 62% males, mean BMI 27.7 ± 5.0. Colonoscopy indications were abdominal pain (26%), rectal bleeding (22%), change in bowel habits (17%), and evaluation of abnormal imaging/lab values. Of 877 patients, 610 (70%) had at least one adenoma: 571 (65%) tubular adenomas, 29 (3%) tubulovillous adenomas, 1 villous adenoma and 19 (2%) had sessile serrated adenomas. 267 (31%) patients had only hyperplastic polyps. Of patients with adenomas, 63 had a polyp > 10mm with mean polyp size 11 ± 9mm. 41% of patients had adenomas in the sigmoid, 34% in ascending, 27% in transverse, 24% in descending colon, and 22% in the rectum. Almost half (49%) of patients with adenomas were younger than 45 years and had similar demographic characteristics as patients between 45 and 50 years of age, but they had a larger mean polyp size (Table). Of the 610 patients with adenoma, 156 (26%) had a follow-up colonoscopy after a mean time of 2.9 ± 2.3 years, with 74 (47%) patients developing recurrent adenomas. 38 (6%) patients had a second follow-up after 2.1 ± 1.6 years and 15/38 had adenomas. Conclusion: Patients < 50 years of age with colonic adenomas were mostly males and overweight. Recurrence of adenomas was prevalent over the follow up of 3 years. For patients with GI complaints, colonoscopy should be considered in individuals with high-risk baseline characteristics. High rates of recurrent adenomas and larger polyp size in patients < 45 years of age may warrant more frequent surveillance than is done for patients > 45 years of age. Table 1. - Comparison of Demographics and Polyp Characteristics between Patients Younger than 45 Years of Age and Patients 45 to 50 Years of Age with Adenomatous Polyps Patients Younger than 45 Years of Age (N=299) Patients between 45 and 50 Years of Age (N=311) p-value Mean Age at Colonoscopy 38.27 (n=299) 47.45 (n=311) < 0.001 Males 58.6% (n=299) 63.0% (n=311) 0.256 BMI 26.77 (n=174) 28.20 (n=186) 0.886 Vitamin D Level 20.82 (n=161) 23.28 (n=186) 0.403 Smoking 50.0% (n=270) 51.6% (n=279) 0.705 Mean Size of Polyps 1.21 (n=109) 1.01 (n=97) < 0.001 High Risk Patients* 24.7% (n=299) 30.2% (n=311) 0.130 Follow Up Rate 24.7% (n=299) 26.1% (n=311) 0.713 BMI: Body Mass Index. N: Total number of patients. n: Total number of patients used to calculate a mean or a percentage.*High Risk patients are defined as having three or more adenomatous polyps and/or a villous component on pathology and/or a polyp size >1cm.

S2024 Elderly Patient, Youthful Pathology: Solitary Colonic Juvenile Polyp Found in a 75-Year-Old Male

Introduction: Colonic juvenile polyps are generally found in the pediatric population. Classically, juvenile polyps (JP) are the most common polyp subtype seen in pediatric gastroenterology, accounting for approximately 80-90% of polyps in children. Generally, JP are diagnosed within the first decade of life and most common presentation is painless rectal bleeding. Other terminology used are juvenile hamartomatous polyp or retention polyps. There is no malignant potential for solitary JP and they tend to not recur. Case Description/Methods: We present a 75-year-old male with past medical history of hypertension, diabetes and hyperlipidemia referred to gastroenterology for surveillance colonoscopy due to a history of tubular adenomas. At the pre-procedure visit, the patient was well without GI complaints such as overt bleeding, change in bowel habits or unintentional weight loss. No family history of colon cancer or polyps was reported. Physical exam and vitals were normal at the time of procedure. Colonoscopy revealed a 40mm pedunculated sigmoid colon polyp which was excised using an endoloop at the stalk base followed by hot snare polypectomy ((Figure A). Three other sub-centimeter sessile polyps in the rectosigmoid area were removed by cold snare polypectomy. Histopathological examination of the large pedunculated polyp was consistent with a JP(Figure B). Other polyps were tubular adenomas. Discussion: Our current patient is the oldest reported case of isolated colonic JP. These polyps tend to have a common phenotypical appearance measuring around 10-30mm and roughly 90% of them are considered pedunculated. JP are ultimately defined by their distinctive histopathological features such as edematous lamina propria with inflammatory cells, cystically dilated glands that are bordered by cuboidal or columnar epithelium with reactive changes, and mucus filled glands. Fortunately for our patient, the presence of only a solitary colonic JP generally carries no known malignant potential. Juvenile polyposis syndrome (JPS) on the other hand is a hereditary condition characterized by the presence of hamartomatous polyps in the digestive tract and is known to have an increased risk of digestive tract malignancies. JPS is suspected when a patient has 5 or more juvenile polyps in the gastrointestinal tract or a juvenile polyp and a family history of juvenile polyps. A DNA test to check SMAD4 or BMPR1A gene is helpful.Figure 1.: (a) A 40mm polyp (Paris 0-Ip) located in the in the sigmoid colon. (b) Hamartomatous polyp has ulcerated surface with benign dilated glands.

Effect of Covid on Gaster Intestinal Tract and its Signs and Symptoms

The aim of this descriptive case series was to determine the frequency of various gastrointestinal symptoms of the COVID-19 patients along with the respiratory symptoms. Secondary outcome was to determine the effect of various co-morbid conditions and various sign and symptoms on the length of hospital stay and outcome of disease Material: In this descriptive case series type study, carried out in the COVID ward in the Jinnah Hospital, Lahore, all patients diagnosed with COVID-19 by consultant physician in the out-patient department and ward were included. Written informed consent was taken from all the participants of the study after explaining the primary objective of the study. The study was carried out from 01-07-2019 to 31-12-2019. Primary objective of this study was to determine the various gastrointestinal symptoms of the COVID-19 patients along with the respiratory symptoms Results: Among the 386 patients enrolled in the study, 60% were male and 40% were female. Mean age of the patients was 54.14 SD 16.3 years, with around 71% cases of age above 45 years. Abdominal pain, anosmia and diarrhea were the most common GI complaints. Over all, 26% of the patients of COVID had GI symptoms. Conclusion: GI complaints such as anorexia, nausea, vomiting, diarrhea, and abdominal cramping have been documented in COVID-19 individuals even in the absence of respiratory problems. As a result, COVID-19 disease must be explored in individuals who have mostly GI complaints.

118 A Case Report on Mucinous Adenocarcinoma Colon in a 14-Year-Old

Abstract Pediatric colorectal cancers are rare tumours that carry poor prognosis but none the less the incidence of these tumours is on the rise. Here we present a case of a 14-year-old boy who complained of vague abdominal pain, altered bowel habits and unintentional weight loss for 1 month. On examination a fixed hard mass was palpable on the left side of abdomen and had elevated CEA levels. Open biopsy and immunochemistry confirmed the tumour to be adenocarcinoma of colorectal origin. Patient and guardians denied surgery initially and one month later presented with obstructive symptoms for which left hemicolectomy was done and on histopathological examination mucinous adenocarcinoma stage- T3d N1 M0 was confirmed, the patient was later referred for chemotherapy. The patient showed transient improvement but succumbed to the disease 10 months after the diagnosis. This case highlights the importance of early detection of colorectal malignancy in children by raising awareness of its occurrence and by considering malignancy as a part of the differential diagnosis in pediatric cases with vague GI complaints. Currently colorectal carcinomas in children are being managed in line with the adults due to lack of sufficient evidence and data despite its aggressive nature in the younger age group.

Exocrine pancreatic insufficiency after bariatric surgery: a bariatric surgery center of excellence experience.

Gastrointestinal symptoms such as diarrhea, bloating, abdominal pain, and nausea are common after bariatric surgery (BS) and can lead to significant morbidity. While many diagnoses can explain these symptoms, post-bariatric exocrine pancreatic insufficiency (EPI) is becoming increasingly recognized as contributor to gastrointestinal symptoms. The frequency and outcomes of EPI after BS are not well understood. We investigated the prevalence and outcomes of EPI over 18years at a tertiary bariatric referral center. A retrospective review of patients who underwent primary or revisional BS from 2002 to 2020 was performed. Patients were included if they were suspected of having EPI or underwent fecal elastase testing (FE-1). EPI diagnosis was defined as positive FE-1 testing or improvement with empiric pancreatic enzyme replacement therapy (PERT). EPI was suspected in 261 patients, and 190 were tested via FE-1 (89.5%) or empirically treated (10.5%). EPI was diagnosed in 79 (41.6%) patients and was associated with older age and lower BMI. Therapeutic PERT was given to 65 patients diagnosed with EPI, and 56 (86.2%) patients reported improved symptoms. Patients who underwent RYGB and BPD-DS were more likely to have EPI than those after SG (47.9% and 70.0% vs 17.4%, p < 0.01). EPI diagnosis was associated with a history chronic pancreatitis. While diarrhea and abdominal pain were the most common symptoms prompting FE-1 testing, no symptoms were significantly associated with EPI. EPI was also associated with abnormal fecal fat results and treatment with bile acid sequestrants, but not small intestinal bacterial overgrowth. This study highlights that exocrine pancreatic insufficiency can account to for previously unexplained GI complaints after bariatric surgery. Therefore, bariatric surgery programs should consider this diagnosis in symptomatic patients, especially following RYGB and BPD-DS. Further work to define patient factors that should prompt evaluation, optimal treatment, and prevention is necessary.

A77 IMPLEMENTATION OF GUT LINK-IBS; RESULTS OF A SEMI-STRUCTURED INTERVIEW OF PRIMARY CARE PROVIDERS

BackgroundThe Division of Digestive Care and Endoscopy in Halifax, Nova Scotia has had longstanding challenges with GI referral volume outstripping divisional capacity resulting in limited access to specialist care. Many referrals for functional bowel disorders (FBD) are returned to referring providers. Although this helps rationalize limited system resources, it often impairs access to appropriate and necessary GI care. The co-development and implementation of clinical care pathways across gastroenterology and primary care may help to improve access to high-quality GI care.AimsThe project aimed to engage primary healthcare providers (PHCPs) to identify environmental and behavioral barriers and facilitators for managing undifferentiated lower GI disorders in primary care. Data generated from stakeholder engagement will be used to develop, implement, and evaluate strategies for referral and management of FBD. A real-world, functional clinical care pathway that supports the implementation of evidence-based practices in the diagnosis and management of functional GI conditions within primary care will enhance care and timely access to specialist.MethodsThis is a qualitative study using semi-structured interviews of PHCPs working in Nova Scotia. Interview questions were developed and guided by the evidence-based implementation science frameworks. Physicians were recruited through existing primary care networks. Participants were offered a Zoom™virtual semi-structured interview. A brief intake questionnaire was administered to collect baseline demographics. Interviews were recorded and transcribed for data analysis. Data were categorized into coding schemes and themes were created using an inductive coding approach.ResultsAs of October 2021, 9 interviews have been conducted. Average participant age was 44 years, with the majority identifying practice in a group or collaborative care setting (n=7, 78%). Five worked in urban practice settings and the remainder in rural areas. Preliminary major themes included:1. A lack of satisfaction with access to gastrointestinal care, with most physicians noting it to be worse than access to other specialist services.2. Management of FBDs were felt to be within the scope of primary care practice3. Access to diagnostic tests like fecal calprotectin with appropriate education on its use as a diagnostic tool would be useful.4. PHCP’s suggested care pathways be easy to use, require minimal time, and ideally be implemented within their pre-existing EMR or in paper form.ConclusionsPHCPs acknowledge a significant burden of undifferentiated lower GI complaints in their practice and poor access to gastroenterology services. All participants were open to helping develop and use a clinical care pathway for the investigation and management of undifferentiated lower GI symptoms. Data collection and analysis are ongoing.Funding AgenciesNone

Emergency Department Utilization Is Low After Outpatient Elective Rotator Cuff Repair.

The purpose of this study was to establish emergency department (ED) utilization rate and reasons for presentation to the ED after outpatient rotator cuff repair (RCR) and determine preoperative predictors for these ED visits. Patients who underwent outpatient RCR between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and stratified. Univariate and multivariate analyses were done to identify independent predictors of ED utilization. The 7- and 30-day ED visit rates were 3.2% and 5.0%, respectively. The most common cause for an ED visit after outpatient RCR at 7- and 30-days postoperatively were postoperative pain (29.0%) and GI complaints (16.3%), respectively. African American race (odds ratio [OD], 1.69; P < 0.001), Hispanic race (OD, 1.47; P = 0.005), and comorbid diagnoses of hypertension (OD, 1.51; P < 0.001), diabetes (OD, 1.58; P < 0.001), and/or schizophrenia (OD, 5.14; P < 0.001) were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare (OD, 2.01; P < 0.001) or Medicaid (OD, 2.61; P < 0.001) were more than twice as likely to present to the ED within 30 days than those with private health insurance. ED utilization after outpatient RCR is uncommon with postoperative pain as the most common chief concern for ED visits within the first 7 days and GI issues as the most common reason for ED encounters at up to 30 days postoperatively. Hypertension, diabetes, renal failure, liver disease, rheumatologic diseases, schizophrenia, depression, and Medicare and Medicaid insurance were independent predictors of ED encounters at up to 30 days postoperatively. Procedures done at freestanding surgery centers were protective against ED utilization. Level III, Retrospective Cohort.

P099 READMISSIONS AND EMERGENCY ROOM VISITS FOLLOWING OUTPATIENT AND INPATIENT HERNIORRHAPHIES

Abstract Aim Analysis of all healthcare encounters (readmissions and emergency department visits, EDV) following both inpatient and outpatient abdominal hernia repairs (AHR), with respect to the timeline of such encounters. Material and Methods Patients undergoing AHR were identified in Maryland State Inpatient and State Ambulatory Surgery and Services Databases, 2016-2017, and all their hospital and ED encounters were assembled into a comprehensive database, covering almost 95% of all AHR performed in Maryland. Results Of the total 26,215 patients who underwent AHR (3,333 inpatient and 22,950 outpatient; 48.7% inguinal and 53.0% ventral/umbilical), 5,802 (22.1%) had at least one postoperative encounter (4,186 EDV, 1,415 readmissions, and 248 encounters for mostly outpatient another AHR). 419 (80.4%) post-operative encounters within the first 48 hours were EDV and 98 (18.8%) were readmissions. Fraction of EDV within later encounters was in 69.6–71.1% range. Most frequent reasons for EDV were urinary complaints (24.1%, 10.6% and 4.0% on POD 0–2, 3–7, and 8–30, respectively), followed by pain control issues (18.1%, 24.9%, 14.4%) and delayed return of bowel function or constipation (10.5%, 9.9%, 3.4%). Readmissions mainly occurred for aforementioned GI complaints (15.3%, 19.9%, 6.9% on POD 0–2, 3–7, and 8–30, respectively), local surgical site infections (5.1%, 15.5%, 26.8%), and respiratory complications (8.2%, 6.6%, 4.1%). Conclusions 2.3% of all patients had at least one readmission while 6.4% patients had at least one EDV within 30 days following herniorrhaphy. Early postoperative EDV were mainly caused by urinary complaints, inadequately controlled pain, or delayed bowel function. Factors associated with these largely preventable complications require dedicated analysis.

S1319 The Impact of the COVID-19 Pandemic on Graduating Gastroenterology Trainees and Perceptions of Program Directors

Introduction: Re-allocation of resources and closure of endoscopy units during the COVID-19 pandemic may have lasting impacts on graduating gastroenterology (GI) fellows who rely on their final year in training to refine their skills. We aimed to assess the impact of the pandemic on graduating GI fellows and the perceptions of their program directors (PDs). Methods: We conducted a national survey study of graduating fellows (3rd and 4th year) and program directors (PDs). An initial trainee and a PD survey were administered in 5/2020; a 6-month follow-up trainee survey was administered in 11/2020. The surveys aimed to determine the impact of COVID-19 on: (1) employment; (2) CME; (3) telehealth; (4) clinical practice; and (6) confidence/competency. Initial and follow-up trainee surveys and trainee and PD surveys were compared. Bivariate analyses were performed using either Chi-square or Fisher exact tests. Results: 105 and 43 graduating GI fellows completed the initial and follow-up surveys. 107 PDs were surveyed. 15.2 % of trainees had a change in their employment due to the pandemic. Popular educational resources used were ACG Education Universe (39.1%) and ACG Virtual Grand Rounds (55.4%). A large proportion of fellows were not likely to attend an in-person national conference prior to and 6 months after graduation (34.3 % vs 44.2%, P = 0.58). The risk of COVID-19 transmission was an important factor in the decision to attend a national GI conference both prior to and 6 months after graduation (41.0% vs 46.5%, P = 0.94). For telehealth, lack of training and reimbursement were factors that affected a fellow’s decision to use telehealth. The likelihood of ordering non-invasive testing for common GI complaints decreased significantly with time (P < 0.01). A considerable proportion of fellows believed they needed additional endoscopic training as a result of the pandemic, however, this proportion declined 6 months after graduation (43.8% vs 25.6%, P = 0.04). Compared with trainees, the minority of PD’s believed that graduating fellows needed additional training in endoscopic procedures as a result of the pandemic (43.8 vs 4.7%, P =< 0.001). Conclusion: The COVID-19 pandemic has impacted the employment, educational resources, confidence, telehealth and clinical practice of our graduating GI fellows. Despite the COVID-19 pandemic, PDs were confident in their graduating fellow’s technical abilities and graduating fellows gained confidence in endoscopic skills over time.Table 1.: Impact of the COVID-19 pandemic on graduating GI fellows and perceptions of program directors.

620 GASTRODUODENAL EOSINOPHILIA IS UNDER-APPRECIATED IN EOSINOPHILIC ESOPHAGITIS (EOE) PATIENTS WITH FUNCTIONAL BOWEL SYMPTOMS: A REAL LIFE EXPERIENCE

Abstract Eosinophilic esophagitis (EoE) is currently thought to be the most common Eosinophilic Gastrointestinal Disorder. EoE patients often present with non-esophageal GI symptoms. Presence of EoE increases one’s risk of developing distal eosinophilia, including eosinophilic gastritis (EG) and duodenitis (EoD). A diagnosis of EG/EoD often takes years due to lack of provider awareness and absence of consensus diagnostic guidelines. The aim was to evaluate the prevalence of EG/EoD in patients with EoE and functional abdominal symptoms. Methods 52 EoE patients with extra-esophageal GI symptoms (i.e. abdominal pain, nausea, bloating, irritable bowel) who had stomach and small bowel biopsies interpreted as non-specific inflammation or normal were identified (‘EoE + S’). 15 EoE patients without extra-esophageal complaints who had routine screening stomach and small bowel biopsies at their initial endoscopies were included as a control group (‘EoE-S’). Biopsies taken at initial work up were identified and blocks were cut for H&amp;E staining and assessment by an independent, blinded GI pathologist skilled in eosinophil (eos) assessment. Results 45 EoE + S and 12 EoE-S patients were evaluated (Table 1). Common symptoms were abdominal pain, bloating and nausea. All prior pathology reports were consistent with non-specific inflammation or normal tissue. Upon blinded re-assessment, 8/45 (17.8%) EoE + S patients met criteria for EG (≥30 eos/hpf in ≥5 gastric hpfs). None of the EoE-S patients met criteria for EG. 24/45 (53%) EoE + S patients met criteria for EoD (≥30 eos/hpf in ≥3 duodenal hpfs). 7 patients had concomitant EG + EoD. 3/12 EoE-S patients met criteria for EoD. Peak gastric and duodenal eos counts for the EoE + S group were higher than for the EoE-S group. Conclusion In patients with EoE and extra-esophageal GI complaints, review of gastric and duodenal biopsies previously reported as normal or ‘non-specific inflammation’ demonstrated a high discovery rate of gastroduodenal eosinophilia. These findings suggest that intentional evaluation of gastric and duodenal eos is indicated in patients with EoE and persistent non-esophageal GI symptoms. Increased awareness of EG/EoD and consensus diagnostic criteria may lead to the identification of currently undiagnosed patients with EG/EoD.

Rise of Lower GI Complaints in Young Population: 5 Year Detailed Analysis of Colonoscopic Findings Using ASGE Guidelines in Public Center Hospital of Pakistan

Introduction: Colonoscopy gives detail account of lower gastro intestinal tract pathologies. As the procedure is invasive, operator dependent and associated with few complications, clear indication has to be established.Current study was conducted to evaluate detailed account of clinicopathological findings on colonoscopy that will give idea about the prevalent lower gastrointestinal tract disorders, common complaints, correlation between findings and symptoms, age and gender wise distribution of these pathologies among our population. The study will serve as baseline to construct nationwide guidelines for the procedure. Materials &amp; Methods: This retrospective study was carried out at Gastroenterology Department, Pakistan Institute of Medical Sciences from January 2014 to June 2019. All the patients fulfilling the ASGE criterion or having complaints of lower GI tract for more than 2 months underwent colonoscopy. Patients with inadequate preparation or other undergoing therapeutic procedures were excluded from the study. Total 850 patients fulfilling the criterion were included in the study. Data was recorded and analyzed by SPSSv20. Results: Mean age of the patients was 43.02 ± 18.22. Majority (63.9%) of the patients were males. Majority (n=543, 63.9%) of the patients had some finding on colonoscopy. Most common finding on colonoscopy was hemorrhoid followed by ulceration, mass, inflammation and polyps.Most common complaint was per rectum bleed followed by diarrhea, suspected growth on other modalities andsuspected inflammatory bowel disease.Total 540 patients i.e. 63.52% were below age of 50 years.. Trend of pathologies showed ulceration to be most common finding in patients below 50 years followed by hemorrhoids and mass. Conclusion: The results of our finding shows rise of lower GI pathologies in young male population of Pakistan with ulcerative colitis, hemorrhoids and colorectal cancer being top three diseases. This is an alarming situation and we need to take urgent big steps to control it. Keywords: Colonoscopy, Hemorrhoids, Colorectal Cancer, Per Rectal Bleed, Ulceration