GI Diagnosis Research Articles

Pancreatic necrosis: a scoping review.

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Impact of outpatient gastroenterology consult on pharmacotherapy and management of gastrointestinal symptoms in Parkinson’s Disease

Background & aimsGastrointestinal (GI) symptoms are common in Parkinson’s Disease (PD) patients, and GI dysmotility is thought to induce motor fluctuations, requiring escalation of levodopa therapy. The role of GI consultation in managing such symptoms, however, is unclear. In this study, we investigate the possible association between GI dysmotility symptoms and escalated LEDD therapy, as well as factors associated with GI consultation for PD symptom management. MethodsThis was a retrospective case-study of 248 PD patients evaluated by outpatient neurology at Massachusetts General Brigham Healthcare from 2018 to 2022. Logistic regression, t-test, and Fisher exact tests were performed to identify factors associated with GI consult, change in LEDD with consult, and association of consultation with GI diagnoses and treatments, respectively. ResultsAmong 248 PD patients, 12.9% received GI consultation despite 96.8% having GI symptoms. Bloating was the primary symptom associated with receiving GI consultation (OR 3.59 [95% CI 1.47–8.88], p = 0.005). GI consultation increased the odds of receiving GI-specific medications (78.2% vs 46.3%, p = 0.001) and specialized GI diagnoses like gastroparesis (9.4% vs 0.46%, p < 0.001) and pelvic floor dysfunction (15.6% vs 0%, p < 0.0001). Interestingly, LEDD tended not to change after GI consultation, and dysmotility symptoms, including bloating, did not predict need for higher LEDD. ConclusionsWhile treating symptoms of dysmotility may not ameliorate levodopa-based motor fluctuations as much as previously thought, GI consultations are underutilized in PD, and patients who receive GI consultation are more likely to have changes in GI diagnosis and treatment.

466 Avoidant/Restrictive Food Intake Disorder (ARFID) Among Adult Gastroenterology Behavioral Health Patients: Comparison of ARFID vs. Non-ARFID Patients

INTRODUCTION: Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding disorder characterized by avoidance or restriction of food associated with weight loss, nutritional deficiency, dependence on tube feeds/oral supplements, or significant psychosocial impairment. Emerging evidence has shown 6-19% of gastroenterology (GI) patients have concurrent ARFID; however, these patients have not been characterized. METHODS: Retrospective analysis of 223 adult GI patients seen by a gastroenterologist and GI psychologist at a tertiary care center from 2016 to 2018. ARFID diagnosis was based on chart review by a gastroenterologist and GI psychologist for evidence of DSM-5 ARFID criteria. Demographic, clinical, and questionnaire data were recorded. RESULTS: Of 223 patients, 28 (12.6%) met criteria for ARFID. Concern for ARFID was raised in 0% of cases. There was no difference between ARFID and non-ARFID patient gender, age, educational level, GI diagnosis, GI symptom severity, mean BMI, or frequency of nutrition referral (Table 1). ARFID patients were less likely to be using a psychotropic medication (17.9% vs 50%, P &lt; 0.01). There was no difference in eating disorder history (ARFID 3.6% vs non-ARFID 8.7%, P = 0.12). On the IBS-QOL questionnaire, ARFID patients reported more severe food avoidance concerns, more frustration with not being able to eat what they wanted, and less severe body image concerns (all P&lt; 0.5). Following completion of GI-directed psychological therapies, IBS-QOL scores improved less in ARFID patients (Table 2). There was no difference between groups in Brief Symptoms Inventory scores or sleep quality scores (Table 3). CONCLUSION: This is the first study comparing ARFID vs non-ARFID adult GI behavioral health patients. Of 223 patients, 12.6% met ARFID criteria. ARFID and non-ARFID patients were clinically indistinguishable based on age, gender, BMI, GI diagnosis, or GI symptom severity. Although ARFID is often associated by gastroenterologists with underlying psychiatric or eating disorders, ARFID patients were less likely to be using psychotropic agents, reported lower body image concerns, and reported increased frustration with not being able to eat than non-ARFID patients. ARFID patients had decreased improvement in post-behavioral health therapy IBS-QOL scores. This data demonstrates the need to appropriately screen patients for ARFID and raises concern regarding the need utilize a multidisciplinary treatment approach that takes into account GI, psychological, and nutritional needs.

The Overuse of Empiric Antibiotic Treatment for Enterocolitis Diagnosed by Abdominal CT (OVERACCT)

Introduction: The current ACG guidelines for the management of acute diarrhea discourage the use of empiric antibiotic therapy, unless justified by the clinical presentation, including duration of symptoms, recent traveling, fever or bloody diarrhea. Computed tomography (CT) is a widespread and easily accessible imaging tool for the investigation of abdominal symptoms. However, the incidental finding of nonspecific bowel wall thickening, often results in a radiological diagnosis of enterocolitis, irrespective of the symptoms, with subsequent inappropriate use of antibiotic therapy. Methods: A retrospective, observational, IRB approved study was conducted at an inner-city hospital from July 2015 to July 2017. A total of 184 subjects who experienced gastrointestinal symptoms such as abdominal pain, nausea, vomiting, or diarrhea were identified by the enterocolitis ICD diagnosis code. Patients with comorbidities such as AIDS, cancer, or immunocompromised were excluded from the analysis. Of the remaining subjects, 121 underwent abdominal CT to rule out acute abdominal conditions. Chart review included medical history, recent travel, inflammatory markers and stool studies. Clinical outcomes comprised symptoms resolution, length of hospital stay and final GI diagnosis. Chi-square test was used for data analysis. Results: Among 184 patients identified, 116 (63%) were women with a mean age of 46 ± 26 years. The majority of patients (66%) presented with acute diarrhea, lasting less than 72 hours, without a history of recent travel. A radiological diagnosis of enterocolitis was reached with abdominal CT in 80 patients, of which 71% received antibiotic treatment. There was a significant correlation between positive CT findings and antibiotic use (p=0.005). Surprisingly, 61% of patient with the radiological findings received antibiotic treatment despite the absence of diarrhea (p=0.006). Antibiotic treatment did not impact the clinical outcomes (p=ns). Almost 65% of the patients required only supportive treatment based on ACG guidelines. Conclusion: Patients with CT findings suggestive of enterocolitis were more likely to receive antibiotic therapy, irrespective of the presence or absence of diarrhea. This study highlights the widespread antibiotic misuse for the treatment of enterocolitis based on imaging modalities without adequate clinical correlation. Unwarranted radiological testing and antibiotic therapy were identified in 65% of this cohort, while their clinical outcomes remained unchanged.167_A Figure 1 No Caption available.167_B Figure 2. χ2 Calculations. Two way contingency table.167_C Figure 3. χ2 Calculations. Two way contingency table.

Deep EndoVO: A recurrent convolutional neural network (RCNN) based visual odometry approach for endoscopic capsule robots

Ingestible wireless capsule endoscopy is an emerging minimally invasive diagnostic technology for inspection of the GI tract and diagnosis of a wide range of diseases and pathologies. Medical device companies and many research groups have recently made substantial progresses in converting passive capsule endoscopes to active capsule robots, enabling more accurate, precise, and intuitive detection of the location and size of the diseased areas. Since a reliable real time pose estimation functionality is crucial for actively controlled endoscopic capsule robots, in this study, we propose a monocular visual odometry (VO) method for endoscopic capsule robot operations. Our method lies on the application of the deep Recurrent Convolutional Neural Networks (RCNNs) for the visual odometry task, where Convolutional Neural Networks (CNNs) and Recurrent Neural Networks (RNNs) are used for the feature extraction and inference of dynamics across the frames, respectively. Detailed analyses and evaluations made on a real pig stomach dataset proves that our system achieves high translational and rotational accuracies for different types of endoscopic capsule robot trajectories.

Online Symptom Checker Accuracy for the Complex HIV and Hepatitis C Population: A Real Life Emergency Room Experience

Introduction: We previously analyzed online patient symptom checkers for both diagnostic and triage accuracy for a barrage of GI illnesses using traditional provided clinical vignettes. We now aim to see whether symptom checkers are feasible diagnostic and triage tools for the complex HIV or Hepatitis C patient, using real-life emergency room (ER) patient encounters. Methods: An ER chart analysis from Sept 2013-Sept 2015 for a 10-day block each month was performed on 8363 patients, searching for “HIV” and “Hepatitis C”. No distinction of lab data, treatment regimen, or active disease was made. Patients who came as a direct transfer, sent from clinic, or unable to consciously make a decision were excluded. Eligible patients included: 90 HIV, 67 HepC, 11 Both (Fig. 1). 5 online symptom checkers were utilized for diagnosis, 3 with triage capabilities.Figure: Baseline demographics.Results: When combining HIV and HepC patients, only a mere 6.0%-11.3% of the symptom checkers had the initial diagnosis listed as the Top1 diagnosis. Between 8.9% and 32.1% had the diagnosis listed in the Top10, with only 8.9%-39.3% having the diagnosis listed at all (Fig. 2). Only about half the time was the triage advice correct (44.6%-53.6%). Each checker did display various strengths and weaknesses in triage capabilities (Fig. 2). Whether the diagnosis was considered GI-based did not affect triage ranking as emergent or non-emergent. However, there were varying results for GI versus non-GI diagnosis accuracy. There remained significant inconsistencies between the five symptom checkers in regards to all diagnostic parameters. A model was built to help predict which variables (race, age, gender, HIV or HepC) would aid in predicting triage and diagnostic results. We did find that a higher number of orders in the ER (labs, meds, Rx given, Imaging, Consultant) did positively correlate with the symptom checker triage output as “Emergent” (p=0.034), further justifying the ER visit.Figure: A.) Diagnostic accuracy for initial diagnosis. B). Diagnostic accuracy for discharge diagnosis. C.) Sensitivity: % Emergent among all predicted as Emergent; Specificity: % Non-Emergent among all predicted as Non-Emergent; POS pred value: % Emergent correctly predicted as Emergent; NEG Pred Value: % Non-Emergent correctly predicted as Non-Emergent; Accuracy: % Correct triage (Emergent as Emergent, Non-Emergent as Non-Emergent).Conclusion: Symptom checker diagnostic and triage capability for complex HIV and HepC patients is quite inferior to prior study analysis of the general patient population. In fact, the substandard accuracy may even be at such dangerous levels to where patients are not being triaged to a safe venue. As this is the first study to utilize real-life emergency room data on a large-scale, part of the results may be linked to real-life, non-textbook, complex clinical vignette patient presentations, something prior studies have failed to analyze.

Endoscopic Manifestation in HIV Patients Presenting with Gastrointestinal Symptoms: A Descriptive Study.

Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) due to its varied presentations and multisystem involvement has become a major cause of mortality and morbidity encountered in practice of modern medicine. A large proportion of patients with HIV-AIDS present with a wide spectrum of gastrointestinal symptoms during the course of the disease 1 .Studies on the prevalence of GI symptom, diagnosis, endoscopic findings and management in the Indian population is lacking. Hence we studied the clinical and endoscopic manifestations in HIV infected patients with upper GI symptoms. This is a cross sectional descriptive study of upper endoscopic findings in HIV infected patients presenting with upper gastro-intestinal symptoms to the tertiary center multi-specialty hospital of 1100 beds. We studied 55successive HIV infected patients who underwent Esophagogastroduodenoscopy from 1september 2011 to 31 august 2012. The mean age of the subjects was 43.76 years. There were 37 (67.27%) males and 18 (32.73%) females. In our study, of the 55 patients 30(70.91%) had a CD4 count of<200. While 11(20%) had a CD4 count between 200-499, 5(9.09%) patients had a CD4 count of 500 or less. Dysphagia(26%) was found to be the most commonly appearing symptom followed by vomiting(23%), dyspepsia(19%),nausea(19%) and epigastric pain(12%).Idiopathic oesophageal ulceration was the most common pathology noted followed by CMV, Hiatus hernia, Oesophageal candidiasis and Oesophageal varices .Idiopathic oesophageal ulceration though not being among the opportunistic infections was the most common finding in our study. There was no significant correlation between the presence of an endoscopic finding with CD4 counts. However, in our study, we noted that there was a significant correlation between clinical stage and probability of a positive endoscopic finding. Idiopathic Oesophageal Ulceration was found to be the most common endoscopic finding among patients with HIV presenting with upper GI symptom .This study has noted that oesophageal candidiasis was not the most common endoscopic finding among HIV patients with upper GI symptoms. This could be attributed to empiric treatment with antifungals and early diagnosis and optimal treatment of HIV. Hence even though the prevalence of oesophageal candidiasis might remain the same, it is less often seen during regular endoscopies than before.CMV involvement of the upper GI tract was found to be more common in patients on HAART unlike the rest of the endoscopic findings. This could be attributed to the relatively longer mean duration of the disease and the significantly lower CD4counts in this subset. Treatment failure and progression of the disease could have contributed to this situation. Endoscopic findings increase as the disease progresses.

Abstract 226: Impact of Gastrointestinal Disorders among Nonvalvular Atrial Fibrillation Patients on Healthcare Resource Usage and Costs

Objective: This study evaluated the incremental healthcare burden associated with GI disorders among nonvalvular atrial fibrillation (NVAF) patients. Methods: NVAF patients ≥18 years of age with continuous medical and prescription coverage were identified (1/1/2007-12/31/2009) from the MarketScan ® Commercial and Medicare Research Databases. Patients with at least 1 inpatient or 2 outpatient GI diagnoses within 12 months following any NVAF diagnosis were grouped into the GI cohort, with patients without any GI diagnosis during the entire study period grouped into the non-GI cohort. The date of first GI diagnosis after NVAF diagnosis and a random date within 12 months after NVAF diagnosis date were selected as the index dates for GI and non-GI patients, respectively. Baseline and follow-up periods were each 12 months. Of the overall cohorts, patients were matched (1:1) by key patient characteristics. The GI cohort was further categorized as having a prior history of GI disorders (chronic) or no GI disorders (non-chronic) during the baseline period. Healthcare usage and costs were evaluated and compared during the follow-up period for the matched cohorts. Results: Among NVAF patients 38% were diagnosed with GI disorders, of which 52% had no baseline history of GI disorders. Patient characteristics, including age (non-GI: 71.16 vs. GI: 74.1 years), gender (male: 60.22% vs. 51.9%), Charlson Comorbidity Index (1.34 vs. 2.35) and CHADS 2 score (1.45 vs. 1.76) significantly differed among cohorts. When patients were matched for key patient characteristics including comorbidity, NVAF patients with a GI disorder used healthcare resources (inpatient, outpatient and pharmacy) to a much greater extent than those who did not have a GI disorder, which was reflected in their significantly higher healthcare costs (Table). These results were independent of a prior history of GI disorders in the baseline period. NVAF patients with chronic GI disorders were the least likely to have used warfarin in the follow-up period (non-GI: 59.8%, no history of GI: 53.4%, chronic GI: 48.5%, p&lt;0.001). Conclusions: Greater than a third of NVAF patients have a GI disorder, which is associated with much greater healthcare resource utilization. Warfarin usage appears to be lower among NVAF patients with GI disorders, although further study is needed.

464 A Placebo-Controlled Study of Clonidine on Symptoms in Women With Fecal Incontinence

Abnormalities in rectal compliance have been identified in irritable bowel syndrome (IBS), wherein patients exhibit decreased rectal compliance in response to experimental distention (Kwan CL, et al. Neurogastroenterol Motil 2004; Shroff S, et al. DDW 2012). However, these differences in rectal physiology are not uniformly present in all IBS subjects. We sought to examine whether psychiatric comorbidity (e.g., depression, anxiety) in IBS has mechanistic relevance to rectal compliance. We hypothesized that dysregulation of autonomic tone inherent in mood disorders leads to decreased rectal compliance in IBS patients. Methods: 38 female subjects (43.6 ±11.1 yrs; 22 Rome III IBS/16 healthy controls) were recruited. Measures of mood (Beck Depression and Anxiety Inventories, [BDI, BAI]) and somatization (Patient Health Questionnaire [PHQ-15]) were collected. Both groups underwent 4 series of 6 pseudo-randomized, barostat-controlled rectal distentions using either high pressure (HPD, 50 mmHg) or low pressure (LPD, 25 mmHg) delivery. Dynamic rectal compliances (ΔV/ΔP) were derived from the ascending phase of the distention. Multivariate linear regression was employed to determine whether psychiatric comorbidity independently influenced rectal compliance. Results: Dynamic rectal compliance was significantly lower in IBS vs. controls for both LPD (8.1±1.8 vs. 9.4±1.6 ml/mmHg; p=0.03) and HPD (6.0±1.1 vs. 7.0±1.1 ml/mmHg; p =0.01). High ratings in anxiety (BAI≥16), depression (BDI≥14) and somatization (PHQ-15≥15) were identified in 31.8%, 40.9%, and 50.0% of IBS subjects, respectively. In high anxiety subjects, rectal compliance was significantly diminished with HPD (5.6±0.8 vs. 6.7±1.1 ml/mmHg; p =0.008), and trended lower during LPD (7.9±1.5 vs. 8.8±1.8 ml/ mmHg, P=0.18). High depression scores were also associated with decreased rectal compliance with HPD (5.6±1.0 vs. 6.8±1.2, p=0.02) and trended toward lower compliance during LPD (8.1±1.5 vs. 8.8±1.8 ml/mmHg, P=0.2). In contrast, degree of somatization did not influence rectal compliance with either distention stimulus (P.0.20 for each). Multivariate analyses suggested the effects of anxiety on rectal compliance were independent of IBS during HPD (B=-0.04, p=0.06), but not LPD (B=-0.008, p=0.8). Depression and somatization had no effect on rectal compliance independent of IBS at either pressure level (p .0.15 for each).Conclusions: Decreased dynamic rectal compliance is observed in IBS with both low pressure and high pressure rectal distensions. Mood symptoms common to IBS also are associated with diminished rectal compliance, particularly withmore noxious stimuli. Anxiety appears to influence rectal compliance independent of the functional GI diagnosis itself, an effect potentially mediated by sympathetic autonomic regulation of intestinal motor function.

466 A Novel Portable Device to Measure Anorectal Pressures: Comparison With High Resolution Manometry

Abnormalities in rectal compliance have been identified in irritable bowel syndrome (IBS), wherein patients exhibit decreased rectal compliance in response to experimental distention (Kwan CL, et al. Neurogastroenterol Motil 2004; Shroff S, et al. DDW 2012). However, these differences in rectal physiology are not uniformly present in all IBS subjects. We sought to examine whether psychiatric comorbidity (e.g., depression, anxiety) in IBS has mechanistic relevance to rectal compliance. We hypothesized that dysregulation of autonomic tone inherent in mood disorders leads to decreased rectal compliance in IBS patients. Methods: 38 female subjects (43.6 ±11.1 yrs; 22 Rome III IBS/16 healthy controls) were recruited. Measures of mood (Beck Depression and Anxiety Inventories, [BDI, BAI]) and somatization (Patient Health Questionnaire [PHQ-15]) were collected. Both groups underwent 4 series of 6 pseudo-randomized, barostat-controlled rectal distentions using either high pressure (HPD, 50 mmHg) or low pressure (LPD, 25 mmHg) delivery. Dynamic rectal compliances (ΔV/ΔP) were derived from the ascending phase of the distention. Multivariate linear regression was employed to determine whether psychiatric comorbidity independently influenced rectal compliance. Results: Dynamic rectal compliance was significantly lower in IBS vs. controls for both LPD (8.1±1.8 vs. 9.4±1.6 ml/mmHg; p=0.03) and HPD (6.0±1.1 vs. 7.0±1.1 ml/mmHg; p =0.01). High ratings in anxiety (BAI≥16), depression (BDI≥14) and somatization (PHQ-15≥15) were identified in 31.8%, 40.9%, and 50.0% of IBS subjects, respectively. In high anxiety subjects, rectal compliance was significantly diminished with HPD (5.6±0.8 vs. 6.7±1.1 ml/mmHg; p =0.008), and trended lower during LPD (7.9±1.5 vs. 8.8±1.8 ml/ mmHg, P=0.18). High depression scores were also associated with decreased rectal compliance with HPD (5.6±1.0 vs. 6.8±1.2, p=0.02) and trended toward lower compliance during LPD (8.1±1.5 vs. 8.8±1.8 ml/mmHg, P=0.2). In contrast, degree of somatization did not influence rectal compliance with either distention stimulus (P.0.20 for each). Multivariate analyses suggested the effects of anxiety on rectal compliance were independent of IBS during HPD (B=-0.04, p=0.06), but not LPD (B=-0.008, p=0.8). Depression and somatization had no effect on rectal compliance independent of IBS at either pressure level (p .0.15 for each).Conclusions: Decreased dynamic rectal compliance is observed in IBS with both low pressure and high pressure rectal distensions. Mood symptoms common to IBS also are associated with diminished rectal compliance, particularly withmore noxious stimuli. Anxiety appears to influence rectal compliance independent of the functional GI diagnosis itself, an effect potentially mediated by sympathetic autonomic regulation of intestinal motor function.

PMO-228 Vitamin D deficiency in a cohort of IBD patients treated with anti-TNFα therapy

IntroductionThere is a documented association between low Vitamin D levels and IBD. In addition to the metabolic effects of Vitamin D it also has an immunomodulatory role which includes inhibition...

PTU-263 Is it time for gastroenterology and general medicine to go their separate ways?

IntroductionCurrently most gastroenterologists within the UK are general physicians with a specialist interest in gastroenterology (85%) and most gastroenterology (GI) trainees train for dual accreditation in GI and general internal...

Tu1486 Towards a Wellness Index for Motility Disorders: the use of Desirability Functions to Evaluate Health Status in Patients With Gastroparesis

G A A b st ra ct s research. Oral domperidone has been reported in some cases to prolong the QT interval and predispose to ventricular arrhythmias (Reddymasu et al. Am J Gastro 2007;102:20362045). The aims: 1) To establish an indications and clinical profile of patients receiving domperidone through the limited access protocol 2) to investigate possible side effects of domperidone 3) to analyze ECG reports and the duration of QT intervals. Methods: Study involved a retrospective chart review of 163 patients referred to a single physician at the tertiary GI Motility Center. Patients demographics, GI diagnosis, cardiovascular complain and ECG tracings were obtained. Prolonged QTc were verified if they were longer than 470 ms in females and longer than 450 ms in male patients. Results: Overall 23 out of 163 (13%) patients (15 F; mean age 47, range 18-73) presenting with chief complaints of nausea and vomiting were enrolled in FDA approved protocol and received doses of domperidone ranging from 10 to 30mg QID for at least 6 up to 12 months. 8 (36%) patients were Hispanic, 12 (52%) Caucasian, and 3(12%) African American. A total 16 (60%) of these patients (9F) were diagnosed with GP, 4 females met the criteria for Cyclic Vomiting Syndrome and 3 patients had symptoms of unexplained nausea. 6 (27%) ECG reports showed non-significant sinus arrhythmias, and one male patient had an irregular rhythm. Women had mean heart rates of 82 (range 52-112) and men's average HR was 86 (range 55-105) bpm. Overall the mean value of QTc for all domperidone patients was 427 ms (ranges 383 507 ms). Further analysis of ECGs for females showed, mean QTc duration of 425 (394-507) ms and in males it was 429 (383-469) ms. Two patients (9%), one of each gender, had QTc prolongation above the normal respected value. No patients complained about palpitation or cardiac/ chest pain. Two patients noticed breast discomfort. No other potential adverse events including extra-pyramidal side effects were reported during this investigation. Conclusions:1) Domperidone is legally available in USA under the FDAIND approved protocol and can be prescribed for patients with symptoms of nausea and vomiting related to gastroparesis and other motility disorders 2) No clinically relevant cardiac complaints and ECG changes including QTc prolongations were discovered during this observation 3) Domperidone can be regarded as a safe prokinetic and antiemetic agent.

Tu1487 Progressive Occlusion of Mesenteric Artery Changes Biomagnetic Signature of Intestinal Slow Wave

G A A b st ra ct s research. Oral domperidone has been reported in some cases to prolong the QT interval and predispose to ventricular arrhythmias (Reddymasu et al. Am J Gastro 2007;102:20362045). The aims: 1) To establish an indications and clinical profile of patients receiving domperidone through the limited access protocol 2) to investigate possible side effects of domperidone 3) to analyze ECG reports and the duration of QT intervals. Methods: Study involved a retrospective chart review of 163 patients referred to a single physician at the tertiary GI Motility Center. Patients demographics, GI diagnosis, cardiovascular complain and ECG tracings were obtained. Prolonged QTc were verified if they were longer than 470 ms in females and longer than 450 ms in male patients. Results: Overall 23 out of 163 (13%) patients (15 F; mean age 47, range 18-73) presenting with chief complaints of nausea and vomiting were enrolled in FDA approved protocol and received doses of domperidone ranging from 10 to 30mg QID for at least 6 up to 12 months. 8 (36%) patients were Hispanic, 12 (52%) Caucasian, and 3(12%) African American. A total 16 (60%) of these patients (9F) were diagnosed with GP, 4 females met the criteria for Cyclic Vomiting Syndrome and 3 patients had symptoms of unexplained nausea. 6 (27%) ECG reports showed non-significant sinus arrhythmias, and one male patient had an irregular rhythm. Women had mean heart rates of 82 (range 52-112) and men's average HR was 86 (range 55-105) bpm. Overall the mean value of QTc for all domperidone patients was 427 ms (ranges 383 507 ms). Further analysis of ECGs for females showed, mean QTc duration of 425 (394-507) ms and in males it was 429 (383-469) ms. Two patients (9%), one of each gender, had QTc prolongation above the normal respected value. No patients complained about palpitation or cardiac/ chest pain. Two patients noticed breast discomfort. No other potential adverse events including extra-pyramidal side effects were reported during this investigation. Conclusions:1) Domperidone is legally available in USA under the FDAIND approved protocol and can be prescribed for patients with symptoms of nausea and vomiting related to gastroparesis and other motility disorders 2) No clinically relevant cardiac complaints and ECG changes including QTc prolongations were discovered during this observation 3) Domperidone can be regarded as a safe prokinetic and antiemetic agent.

OC-013 Clinical utility of faecal calprotectin in diagnosing inflammatory bowel disease during first presentation to the gastroenterology clinic: a novel investigative algorithm: Abstract OC-013

Introduction Faecal calprotectin (FC) has been shown to distinguish reliably between functional and inflammatory bowel diseases (IBD) in a number of studies of patients with established gastrointestinal disease. However, it is a poor screening test for colorectal cancer. Presently, diagnostic algorithms incorporating FC at first presentation to the gastroenterology clinic are lacking. Methods This study aimed to determine the optimal use of FC, in conjunction with serum markers, in the initial diagnostic workup of patients aged 16–50 years. Patients >50 years were excluded, as they require colonoscopy to exclude malignancy. Detailed clinical, laboratory, endoscopic and radiological parameters were collected. Patients with a prior GI diagnosis were excluded. All stool samples were analysed in the same laboratory using the same FC assay (Calpro ELISA). ROME III and Lennard-Jones criteria were used. Patients were followed up for a minimum of 12 months. Results The Edinburgh FC Register comprises data on 7512 patients (2005–2008) from across Lothian. 1838/7512 were managed at 2 Edinburgh teaching hospitals, and aged 16–50 years at time of FC; 851 were excluded, mostly due to pre-established diagnosis of IBD. 987 (mean±SD age 33.5±9.0 years; 64.8% female) met the strict inclusion criteria. In patients presenting primarily with bloody diarrhoea (n=68), median FC was 690 μg/g (IQR: 72–2323), in contrast to watery diarrhoea (n=325, FC 30 μg/g (20–90), p 50 μg/g with bloody diarrhoea OR raised CRP/low albumin – combined radiological and endoscopic evaluation. Conclusion In this study, the largest on the clinical utility of FC, we were able to develop clear investigative strategies in adults

The Rome criteria divides, distorts and dilutes the prevalence of irritable bowel syndrome

Functional bowel disorders (FBD) comprise a group of conditions that continue to challenge and defy clear definition and understanding. Patients experience a variable combination of gastrointestinal symptoms for which there is no organic basis that can be identified by routine medical tests. Functional bowel disorders are not life threatening, but its treatment is time consuming. As discussed in the paper from Iran by Sorouri et al, the reported prevalence worldwide is between 12 and 42%, and in Iran, FBDs make up 40% of gastroenterology outpatients.[1] Therefore, it is surprising that in this well conducted study involving 18180 participants from Tehran province, Iran, the prevalence of the irritable bowel syndrome (IBS) (the most well studied of the FBD) was only 1.1%.[1] On the other hand, the prevalence of all FBDs, while modest, was still substantial at 10.9%. These numbers recall the low numbers reported in the study from Israel where the prevalence of IBS was only 2.9% when this was based on the Rome II criteria.[2] Another notable aspect of this new Iranian study was the high degree of overlap between FBD and functional dyspepsia; 83.8% of dyspepsia had FBD, and 68.5% of FBD had dyspepsia.[1] This situation is very similar to what we have observed in the rest of Asia.[3] We have observed that Asian patients may present with upper abdominal symptoms more often than Western population.[3–5] We have identified a number of studies from Asia, where it appeared that subjects with IBS may have been misclassified as suffering from dyspepsia.[3,6,7] In a study from Taiwan, more than half of patients initially classified as suffering from dyspepsia were reclassified as IBS when it was clarified that their upper abdominal pain was exclusively relieved with defecation.[6] How do we make sense of all these numbers? In the study by Sperber et al, it was observed that a simple change in the definition allowing for milder symptoms to qualify for IBS, increased its prevalence almost four times in the same cohort, but the prevalence of FBD remained the same.[8] This suggests that the division of FBD into the various subsets is arbitrary, and in the process, produces distortion in the recognition of IBS. In the current Iranian study, there appears to be a similar distortion by the vagaries of the Rome criteria. Unspecified FBD (U-FBD) comprised the largest group of FBD, suggesting that there is a substantial group of subjects with FBD who just failed to meet the criteria for IBS. In U-FBD, bloating (64.4%) was more common than abdominal pain (46.7%).[1] U-FBD subjects also had the highest overlap with functional dyspepsia. We have argued that bloating should be recognized as one of the major symptoms of IBS, and it should also be recognized that IBS symptoms frequently occur after meals.[3] In a recent major Indian survey, the symptoms of IBS patients were studied unencumbered by the Rome criteria, and it was observed that abdominal fullness (bloating) was as common as abdominal pain (70% of 2785 patients).[4] In their conclusions, the authors of this paper have appropriately highlighted issues with the Rome criteria itself.[1] It is timely that the Rome Foundation takes a more global perspective. To do so, more attention should be paid to the influence of culture on symptom reporting and therein, interpretation of gastrointestinal symptoms, and how this could affect the workup and diagnosis of functional GI diagnosis of FBDs worldwide. While the Rome criteria provide a useful yardstick for pharmaceutical industry and regulatory authorities, in our scientific exploration we should not homogenize for the sake of homogenizing. The underlying risk associated with this is losing potentially valuable clues that can help us to understand FBDs better. However, ultimately, it is still up to researchers in various parts of the world to stand up and be counted, as the authors of this Iranian study and others have recently done.[4]

Irritable bowel syndrome aggregates strongly in families: a family‐based case‐control study

Abstract Irritable bowel syndrome (IBS) runs in families. Prior family studies surveyed patients inquiring about family history without surveying family members. The stigma associated with IBS may lead relatives to not share information with others, resulting in underestimates of familial aggregation of IBS. The aim of the study was to evaluate the accuracy of patient‐report of family history of IBS in cases and controls, and to estimate familial aggregation of IBS using both a case–control and a family‐study design. Fifty cases and 53 controls completed symptom questionnaires and provided contact information for first‐degree relatives. Questionnaires were mailed to relatives. Relatives were considered to have IBS if they met Rome criteria and did not have an alternate GI diagnosis. Cases and controls identified 573 relatives in their families. A total of 202 (51%) of 396 living relatives participated. The kappa statistics between proband‐ and relative‐reported IBS for case‐ and control‐relatives were 0.27 and 0.04. Cases reported 21% of relatives had IBS; relative‐reports showed 37% (P = 0.003). Controls reported 4% of relatives had IBS; relative‐reports showed 16% (P = 0.013). Regardless of whether the proband or the relative themselves were the information source, case‐relatives were threefold as likely to have IBS than control‐relatives (P &lt; 0.05). However, overall rates were higher when data collected from relatives were used. Regardless of approach, strong familial aggregation of IBS was observed. Cases and controls underestimated the frequency of IBS in their relatives and agreement between proband‐ and relative‐report of IBS status was extremely poor, thus emphasizing the need for direct data collection from relatives in IBS family studies.

Irritable bowel syndrome aggregates strongly in families: a family-based case-control study.

Irritable bowel syndrome (IBS) runs in families. Prior family studies surveyed patients inquiring about family history without surveying family members. The stigma associated with IBS may lead relatives to not share information with others,resulting in underestimates of familial aggregation of IBS. The aim of the study was to evaluate the accuracy of patient-report of family history of IBS in cases and controls, and to estimate familial aggregation of IBS using both a case-control and a family-study design. Fifty cases and 53 controls completed symptom questionnaires and provided contact information for first-degree relatives. Questionnaires were mailed to relatives. Relatives were considered to have IBS if they met Rome criteria and did not have an alternate GI diagnosis. Cases and controls identified 573 relatives in their families. A total of 202 (51%) of 396 living relatives participated. The kappa statistics between proband- and relative-reported IBS for case- and control-relatives were 0.27 and 0.04. Cases reported 21%of relatives had IBS; relative-reports showed 37%(P = 0.003). Controls reported 4% of relatives had IBS;relative-reports showed 16% (P = 0.013). Regardless of whether the proband or the relative themselves were the information source, case-relatives were three fold as likely to have IBS than control-relatives (P < 0.05).However, overall rates were higher when data collected from relatives were used. Regardless of approach, strong familial aggregation of IBS was observed. Cases and controls underestimated the frequency of IBS in their relatives and agreement between proband- and relative-report of IBS status was extremely poor, thus emphasizing the need for direct data collection from relatives in IBS family studies.

Is endoscopic screening before major surgical procedures warranted?

Gastroenterologists are frequently requested to perform endoscopic procedures to rule out cancer or other serious GI disease before major surgical operations. To assess whether such requests are warranted. Cost benefit analysis by using decision tree and threshold analysis. Subjects scheduled for liver and kidney transplant or other major surgeries. Costs of medical and surgical procedures. The threshold value is defined as the a priori probability for a GI diagnosis, where the benefit of endoscopy changes from unfavorable to favorable as the diagnostic probability increases. For all types of organ transplants, the threshold probability for diagnosing a GI disease by endoscopy is lower than 1%. Such a low threshold suggests that if a disease cannot be ruled out with certainty before transplant operations or any other major surgical operation, endoscopic screening would be warranted. For lesser interventions, such as percutaneous transluminal coronary angioplasty and coronary bypass grafting, the threshold value varies between 3.2% and 6.5%, which suggests that endoscopic screening may be justified if there are sufficient grounds to suspect a comorbid medical condition that could compromise the success of the planned surgical intervention. The model only considers procedure costs and assumes no endoscopic complications. Endoscopic screening before costly and invasive surgical or other medical interventions is justified.

Gastrointestinal symptoms after pelvic radiotherapy: Role for the gastroenterologist?

To analyze the cause of GI symptoms after pelvic radiotherapy (RT) in a consecutive series of patients with symptoms beginning after RT. A striking lack of evidence is available concerning the optimal treatment for the 50% of patients who develop permanent changes in bowel habits affecting their quality of life after pelvic RT. As a result, in the UK, most such patients are never referred to a gastroenterologist. All diagnoses were prospectively recorded from a consecutive series of patients with symptoms that started after RT and who were referred during a 32-month period to a gastroenterology clinic. Patients either underwent direct access flexible sigmoidoscopy or were investigated in a standard manner by one gastroenterologist after first being seen in the clinic. A total of 265 patients referred from 15 institutions were investigated. They included 90 women (median age, 61.5 years; range, 22-84 years) and 175 men (median age, 70 years; range, 31-85 years). RT had been completed a median of 3 years (range, 0.1-34 years) before the study in the women and 2 years (range, 0-21 years) before in the men. Of the 265 patients, 171 had primary urologic, 78 gynecologic, and 16 GI tumors. The GI symptoms included rectal bleeding in 171, urgency in 82, frequency in 80, tenesmus, discomfort, or pain in 79, fecal incontinence in 79, change in bowel habit in 42, weight loss in 19, vomiting without other obstructive symptoms in 18, steatorrhea in 7, nocturnal defecation in 8, obstructive symptoms in 4, and other in 24. After investigation, significant neoplasia was found in 12%. One-third of all diagnoses were unrelated to the previous RT. More than one-half of the patients had at least two diagnoses. Many of the abnormalities diagnosed were readily treatable. The symptoms were generally unhelpful in predicting the diagnosis, with the exception of pain, which was associated with neoplasia (p < 0.001). The results of our study have shown that radiation enteritis is not a single disease entity. More than one-half of the patients had more than one GI diagnosis contributing to their symptoms. After pelvic RT, specific GI symptoms were not a reliable measure of the underlying diagnoses, and the evaluation of new GI symptoms is worthwhile. An algorithm for this purpose is proposed.