GI Physicians Research Articles

1036 Liver Transplant Referral Patterns for Severe Alcoholic Hepatitis With Recent Alcohol Use

INTRODUCTION: Liver transplant is the most effective treatment to optimize survivorship in severe alcoholic hepatitis which has a six month mortality rate of 70%. In recent years, multi-center data demonstrated a drastic mortality benefit of early liver transplant and questions the six month alcohol sobriety requirement at some transplant centers. The purpose of this study is to determine whether or not community gastroenterology (GI) providers are aware of the survival benefits of early liver transplant in severe alcoholic hepatitis and to examine what factors impact their decision to refer. METHODS: This study was designed as a cross sectional survey targeting GI providers and fellows within the Washington, DC area. The surveys were distributed both in paper and electronic form via email and local academic meetings. Data was analyzed using Chi-Squared analysis and two sample T-test to detect statistically significant differences between groups. RESULTS: Forty-five surveys were completed by GI physicians (34 attendings, 11 fellows). There was a wide range in the number of years since completion of academic training (range = 0-45 years, average = 14 years). Overall, 40% (17/42) of all participants stated that an active drinking status made them less likely to refer for transplant. Participants who completed training >10 years ago overestimated the rate of alcohol recidivism compared to their counterparts (P = 0.005); however, there was no statistically significant difference in their likelihood to refer active alcohol users for transplant. Although not statistically significant, participants who were more likely to refer active drinkers for transplant completed their last academic training more recently than their counterparts (10 vs 17 years ago, P = 0.14). Factors associated with a higher tendency to refer active users for liver transplant included working for a liver transplant center (P = 0.007) and awareness that peak mortality occurs within two months of last drink (P = 0.001). CONCLUSION: Despite the survival benefits of early liver transplant in severe alcoholic hepatitis, 40% of gastroenterologists surveyed state they are less likely to refer active alcohol users for liver transplant. Education regarding low recidivism rates and drastic benefits in survival outcomes even in patients with less than six months of alcohol sobriety should be disseminated to community gastroenterologists, especially at non-transplant centers.

413 Assessment of Procedural Performance and Compliance With Standardized Interpretation of High Resolution Esophageal Manometry Studies Post-Quality Improvement Initiative at a Large Community Hospital

INTRODUCTION: Accurate performance of esophageal manometry (EM) is essential for the diagnosis and treatment of esophageal motility disorders. The American Neurogastroenterology and Motility Society (ANMS) proposed minimal quality measures (QMs) for performance and interpretation of EM in 2017. Many community practices are not adhering to standardized guidelines. We previously assessed the compliance to ANMS QMs in terms of procedural performance guidelines and adherence to the Chicago Classification Guidelines for interpretation of studies (Seminara et al (1)). Our aim now is to present our post-quality improvement (QI) initiative results with respect to performance and interpretation of the EMs. METHODS: Motility Nurses were sent to the ANMS Clinical training course with additional weekly training by a GI motility physician with review of standard protocols. A procedural checklist was established and implemented for all subsequent EMs. GI physicians were provided detailed data with articles and books regarding utilizing the Chicago Classification for interpretation of EM results but did not receive 1:1 formal training. Twenty-seven EM studies conducted between January to March 2019 were reviewed since the training. Three main procedural QMs were assessed for compliance: 30 second swallows, 10 attempted wet swallows, and at least 7 evaluable swallows with solids swallows. All 27 studies previously interpreted by community GIs were reread by a motility expert and assessed for: correct diagnosis, missing items based on the Chicago Classification, treatment / referral plan, and the appropriateness of surgery referral. RESULTS: In all three procedural QMs, nursing compliance improved to 100% post QI initiative (n = 27) (see Table 1). For the interpretation segment: 78% (n = 21/27) made an incorrect diagnosis, 92% (25/27) had at least one missing item, 26% (7/27) had no treatment plan, 26% (7/27) were referred to surgery 3 of which was for an incorrect diagnosis. CONCLUSION: This QI initiative effectively increased compliance by nursing staff performing EM up to 100% as assessed by the ANMS validated procedural QMs. However, our study revealed poor data interpretation by physicians despite adequate performance of EMs resulting in a high degree of incorrect diagnoses and possibly treatments. Future QI initiatives should focus on formally improving physician education on the interpretation to increase diagnostic accuracy.

2870 Flexible Endoscopic Diverticultomy: Development of a Community-Based Referral Program and Ways to Improve Efficiency and Outcomes

INTRODUCTION: Until recently Flexible endoscopic diverticulotomy (FED) has not gained momentum among GI endoscopists in USA due to a variety of reasons including new skill set, referral patterns, procedural risks and complexity. Thus far it has been limited to select university hospitals, restricting its availability. We present a case series of FED performed in our community hospital system. METHODS: Retrospective review was performed from the start of the FED program over 3 months in 2018. We established a new multi-disciplinary Advanced GERD & Esophageal Services (PAGES) program through which patients were reviewed and selected. All were performed by a single interventional ESD (endoscopic submucosal dissection) trained endoscopist. RESULTS: Mean age 69yrs; mean Eckardt score (EDS) 5. Prominent symptoms were dysphagia and weight loss. Diagnosis was established by imaging or EGD. ESD knives were used. Clips were placed on the diverticular base. The thickness and length of the cricopharyngeal bar varied from 0.7- 3 cm (mean: 1.8) and 3- 5 cm (mean: 3.6) respectively. Total operative time depended on the length of the septum, thickness, the type of knife used and varied from 25-168 min (mean:62). The transition from other ESD knives to scissor type knives reduced our operative time by 50% (168 down to 40min) (Table 1). Patients were discharged home 6 hrs post-procedure. A routine predischarge esophagogram was obtained to document complete excision of cricopharyngeal bar. One case of intraoperative bleeding was controlled using a coagrasper. No blood transfusions or second endoscopic procedures were required to control bleeding. One patient was readmitted within 24 hrs of discharge for control of N/V. The success of the procedure was measured using 4 week post-operative EDS. Three of five patients achieved complete symptom resolution at week 1. Two patients had occasional dysphagia (EDS:1) and regurgitation (EDS:1) respectively. All were symptom free at the end of week 4 (EDS: 0 -1) (Table 2). CONCLUSION: Transoral FED gives the gastroenterologists the opportunity to be the forerunners in managing ZD. The vast majority of these patients present to GI physicians with a complaint of dysphagia. The development of the multi-disciplinary program to identify and triage patients, scissor type ESD knife, and a fellowship trained advanced endoscopist are the recipe to success for a tertiary community program.

2056 CMV Colitis Superimposed on Ischemic Colitis in an Immunocompetent Individual

INTRODUCTION: Cytomegalovirus (CMV) infections are more commonly seen in individuals with immunosuppressive diseases. We present a unique case of CMV colitis superimposed as ischemic colitis in an immunocompetent individual. CASE DESCRIPTION/METHODS: A 68-year-old man with history of PE (on Xarelto), pneumothorax & COPD presented with 10 weeks of diarrhea, associated with chills, lower abdominal discomfort, poor appetite, and weight loss of 15 pounds. Rectal exam showed dark stool and FOBT was positive Lab data showed elevated ESR and CRP. All stool studies were negative. CT Abdomen reported colonic findings suggestive of colitis with areas of active inflammation. Colonoscopy showed inflammation characterized by congestion (edema), erosions, granularity & ulcerations in a continuous and circumferential pattern from the sigmoid colon to the terminal ileum with sparing of mid & distal sigmoid colon and the rectum (Figures 1 and 2). Preliminary biopsies were suspicious for Crohns Disease. Patient was started on PO Prednisone 60 mgs daily & Pentasa TID and discharged for close follow up with GI. He kept on failing outpatient treatment, and was re-admitted twice with worsening of symptoms. Repeat CT scans showed worsening diffuse colitis. C Diff was checked, which was –ve. He was re-started on IV Abx, IV Steroids and supportive care. His symptoms continued to worsen, so Colorectal Surgery was consulted and, he underwent open subtotal colectomy. Pathology Slides from the Surgical Specimen were diagnostic for Ischemic looking bowel, and showed no features of IBD. So, decision was made to send the slides for second opinion. Meanwhile, he continued to deteriorate, so he was taken for emergent exploratory laparotomy and was found to have diffusely ischemic and distended bowel. Confirmation of pathology was not consistent with IBD. It showed Ischemic ileocolitis with possible superimposed CMV colitis with CMV inclusion bodies (Figure 3). IV Ganciclovir was initiated, steroids were discontinued. He began to improve, diet was advanced and was discharged with GI follow up. DISCUSSION: Suspicion of CMV colitis should be investigated by endoscopic evidence. The typical findings such as owl’s eye inclusion bodies on histology is specific for CMV. This is an unusual case of CMV associated ischemic colitis in an immunocompetent individual. This case report also should sound an alarm to GI physicians on thinking about CMV colitis infections even in immunocompetent individuals.

Promoting Leadership by Women in Gastroenterology—Lessons Learned and Future Directions

Promoting Leadership by Women in Gastroenterology—Lessons Learned and Future Directions

High Burden of GI Disease and Unmet Need in Rwanda: Findings From Rwanda Endoscopy Week

Introduction: Rwanda is an East African country of 12 million people that currently has 8 internists regularly performing diagnostic endoscopy. The country has four public referral hospitals with endoscopic capabilities. The Rwandan Society of Endoscopy (RSE) has a goal of expanding its coverage and increasing skills in therapeutic endoscopy. Prior case series of EGDs in Butare and Kigali have revealed major endoscopic diagnoses (i.e. ulceration, stricture and malignancy) in up to 40% of exams. Rwandan endoscopy week was a collaborative effort between a US gastroenterology team and members of the Rwandan Society of Endoscopy (RSE) who have a longstanding working relationship through a series of international physician exchanges. Methods: Six US GI physicians, two nurses, two technicians and a biomedical engineer worked in collaboration with members of the RSE (15 physicians and 18 nurses) for one week. Combined US/Rwandan teams were deployed to the four referral hospitals with endoscopic capabilities. GI consultation was done on the hundreds of patients referred for endoscopy to ensure appropriateness of the procedure. Patient demographic data, procedural indication and results were collected at the four sites with the Google Forms online tool. Results: Completed procedures included 200 EGDs, 39 colonoscopies and 5 ERCPs. 33% of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), esophageal stenosis (2.5%) and benign-appearing gastric outlet obstruction (2.5%). Interventional procedures included esophageal variceal banding (7), placement of esophageal stents (2), balloon dilation of the esophagus (7), duodenum (1) and pylorus (1). Of those presenting for colonoscopy, the most common indications included hematochezia (41%), abdominal pain (31%) and constipation (28%). Significant findings on colonoscopy included hemorrhoid disease (23%) and suspected colorectal cancer (7.7%). Findings on ERCP included two patients with choledocholithiasis, one with a choledochoduodenal fistula and one with suspected cholangiocarcinoma. Conclusion: Our findings support the presence of a high burden of GI disease in Rwanda. Expanding Rwanda’s current capabilities to address this need is feasible, but will require many more physicians to be trained in diagnostic and therapeutic endoscopy. As the current Rwandan endoscopists are proficient in diagnostic endoscopy, advancement to therapeutic skills is a natural next step.

Introducing ERCP in a Low Income Country: A Case Series From Rwanda Endoscopy Week

Rwanda is an East African country of 12 million people with recent advances in access to diagnostic upper endoscopy. The burden of gastrointestinal disease in Rwanda is great and there is no availability of ERCP. Management of patients with biliary disease currently consists of either medical or surgical interventions. Rwandan endoscopy week was a collaborative effort between a US gastroenterology team and members of the Rwandan Society of Endoscopy (RSE) who have previously established a longstanding working relationship through a series of international physician exchanges. This series illustrates a proposed model for global health endeavors in advanced endoscopy. An advanced therapeutic team of two GI physicians, a nurse, two ERCP technicians and a biomedical engineer from the US worked in collaboration with members of the RSE. The visiting team donated side-viewing endoscopes and therapeutic supplies. The team consulted on patients with biliary pathology to determine which cases were appropriate for ERCP. Procedures were performed in the operating theater under general anesthesia. ERCP was facilitated by fluoroscopy using a C-arm typically used for surgical cases. A Rwandan biliary surgeon was available for surgical backup as needed. Five patients were selected for ERCP and consented to the procedure. Indication for ERCP in 4/5 patients was clinical suspicion for biliary obstruction from gallstone disease; one had suspected biliary obstruction from malignancy. Findings on ERCP included two patients with choledocholithiasis, one with a choledochoduodenal fistula and one with suspected cholangiocarcinoma. ERCP in the patient with biliary malignancy was complicated by perforation during palliative stent placement. Biliary perforation across the tumor was identified on fluoroscopy. The procedure was immediately converted to an open laparotomy and the defect was successfully repaired with a choledochojejunostomy. There were no other complications. The burden of GI disease in Rwanda is great and many patients may benefit from ERCP. This series of five cases were the first ERCPs ever performed in Rwanda. ERCP is possible in an under-resourced setting and would nicely complement the current capabilities in laparoscopic surgery. Challenges include obtaining and maintaining the advanced equipment and training physicians and advanced endoscopy staff. Support from a skilled surgical team is essential given the potential risk of complications.2158 Figure 1 No Caption available.

408 FLUOROSCOPY UTILIZATION IN PEDIATRIC ENDOSCOPY

Fluoroscopy in children requires judicious usage given the risks of ionizing radiation. Fluoroscopy may be utilized during both gastrointestinal (GI; e.g. colonoscopy) and pulmonary (bronchoscopy) endoscopy; however, limited data is available regarding usage and documentation during these pediatric procedures. We completed a retrospective chart review of patients who underwent GI and pulmonary endoscopy with fluoroscopic guidance at a large children’s hospital from January 2016 to September 2017. Patient and procedure characteristics were systematically captured, including fluoroscopy dosage, time, and documentation completion. Statistical analysis, including ANOVA and Student’s t-test, was performed using IBM SPSS 24.0 software. A total of 221 endoscopies (130 GI, 91 pulmonary) were performed among 179 unique patients. GI patient characteristics are listed in Table 1. The most common GI procedure was intestinal dilation (43.1%), followed by endoscopic retrograde cholangiopancreatography (34.6%) and motility catheter placement (21.5%). All pulmonary procedures were bronchoscopies with transbronchial biopsies. Fluoroscopy time was available for 98.5% of GI cases and all bronchoscopies (Table 2). GI fluoroscopy dosage was present in medical records for 66.2% of cases. Of the GI procedures with available data, 82.9% used continuous fluoroscopy exposure, while 17.1% used both continuous and pulsed modes. All pulmonary cases utilized pulsed exposure. Among 8 GI physicians, there was significant inter-provider variation in fluoroscopy time and dose during endoscopic dilation (p<0.004). There was no difference in fluoroscopy time among the 4 pulmonary physicians included in this analysis (p=0.408). Over the 21-month study duration, GI and pulmonary procedures demonstrated a downtrend in fluoroscopy time (Spearman’s correlation: r=0.47 and 0.39; p<0.01). Physician documentation of procedural details included fluoroscopy usage in 97% of both GI and pulmonary cases. Duration of fluoroscopy exposure was reported in GI notes in 55.4% of procedures. Only one case reported an immediate adverse event related to fluoroscopy (aspiration of contrast). Fluoroscopy dosage and duration varied for the same procedure type amongst GI providers. Fluoroscopy time was longer during GI vs. pulmonary cases, though both groups exhibited a decrease in fluoroscopy time over the study duration. Exposure time and dosage are important quality metrics, and should be matched with diagnostic yield from these procedures. Given the variation amongst providers and potential ability to decrease fluoroscopic usage over time, further research into the utilization of fluoroscopy in pediatric endoscopy is integral to improving quality of care and safety.Table 1Gastrointestinal Patient CharacteristicsMeanMedianRangeSex63% maleAge (years)9.180.4-20Weight (kg)38.226.95.4-128.5BSA (m2)1.110.3-2.3ASA2.521-4(BSA=body surface area, ASA=American Society of Anesthesiologists Physical Status classification) Open table in a new tab Table 2Fluoroscopy Usage During EndoscopyGastroenterologyPulmonologyCombinedDose (mGy)Time (sec)Time (sec)Time (sec)Mean11.868.4*33.9*54.1Median556.62135.4Range0.3-130.91.2-412.47.7-133.41.2-412.4Quartile Percentiles25th1.322.3141675th10.799.34877*p Open table in a new tab

Reducing Redundant Anaerobic Therapy Through Spaced Education and Antimicrobial Stewardship Interventions.

Decreasing the use of redundant anaerobic therapy is a key target for antimicrobial stewardship. Education techniques that optimize knowledge retention could be an important component of reducing these regimens. We implemented a quality improvement project that incorporated spaced education to reduce the use of redundant anaerobic therapy. The initial interventions (November through December 2015) included education in a hospital-wide newsletter and review of redundant anaerobic regimens by the antimicrobial stewardship program. A spaced education module was then developed with the gastroenterology (GI) service, which had a relatively high rate of redundant anaerobic therapy use. Ten questions with teaching points were delivered to GI physicians at spaced intervals over 2 to 4 weeks (February through March 2016). Knowledge scores were compared at initial and final question presentation using generalized estimating equations. Interrupted time-series analysis was used to compare the rates of redundant-metronidazole-days per 1000 patient-days among patients in the patients admitted to the GI service and those in the non-GI group before and after the intervention. Of 66 GI physicians, 56 (85%) participated in the spaced education activity. After the intervention, their knowledge scores on all the questions improved, and their mean knowledge score increased from 57% to 86% (P < .001). Nearly all (91%) of the participants were very or generally satisfied with the activity. In the GI group, the rate of redundant-metronidazole-days decreased from 26.2 to 13.0 per 1000 patient-days (relative risk [RR], 0.45 [95% confidence interval (CI), 0.27-0.73]; P = .001). This rate in the non-GI group also decreased from 5.47 to 2.18 per 1000 patient-days (RR, 0.47 [95% CI, 0.36-0.60]; P < .001) after our interventions. Spaced education is an effective approach for teaching antimicrobial stewardship topics. Focused provider education was associated with a sustained reduction in the use of redundant anaerobic therapy.

Superior Mesenteric Thrombosis as the Harbinger of Inflammatory Bowel Disease

Background: Superior Mesenteric vein thrombosis is a rare and potential catastrophic, complication of inflammatory bowel disease (IBD). The purpose of this case report is to describe an unusual presentation where a mesenteric venous thrombosis (MVT) seen on abdominal CT imaging was the heralding sign for the diagnosis of Crohn's Disease. IBD is considered a hypercoagulable state, and the presence of non-specific abdominal complaints and thrombosis on imaging should drive consideration of this etiology. Case presentation: A 58-year-old Caucasian male with no significant past medical history was admitted for evaluation of a one month history of worsening abdominal pain and a ten pound weight loss. Abdominal CT imaging showed a near complete thrombosis of his portal and mesenteric veins, along with wall thickening of the distal ileum and proximal large bowel. His infectious workup was negative. Macroscopic appearance of the luminal mucosa during a subsequent ileo-colonoscopy, along with the supportive histologic findings led to the confirmation of his suspected Crohn's Disease. MRI-enterography also revealed active penetrating Crohn's disease in his small bowel. His medical management consisted of combination therapy with Infliximab and Azathioprine, along with his anticoagulation. On follow-up, the patient reported resolution of his abdominal complaints, and repeat abdominal imaging demonstrated resolution of his MVT. Conclusion: Mesenteric vein thrombosis is a rare and well documented complication of the hypercoagulable nature of IBD. In the context of non-specific abdominal complaints of unclear etiology, it is imperative that GI physicians consider the presence of a MVT as a harbinger of undiagnosed IBD disease.

Variations in the medical treatment of inflammatory bowel disease among gastroenterologists.

Background and aimsWith expanding available treatment options and evolving understanding of the risks and benefits of medical therapies for inflammatory bowel disease (IBD), there is the possibility of significant variations in treatment and outcomes. Little is known about the variation in treatment between IBD specialists and other gastroenterology (GI) physicians. Evaluating possible variations is an important first step to help address standardized care and optimize treatment. We studied the differences in use of biologics and immunomodulators in the management of IBD patients at a tertiary care hospital between IBD-trained physicians and other gastroenterologists.MethodsA total of 325 IBD patients were included in the analysis. Of these, 216 patients received care with an IBD physician and 109 had other GI/non-IBD physicians as their main caregivers.ResultsThe unadjusted use of immunomodulators (35.6% vs 16.5%, p = 0.001), biologics (45.8% vs 22.9%, p =0.001) and dual therapy (biologics and immunomodulator) (14.4% vs 3.7%, p =0.001) was significantly higher in the IBD-physician group. These differences in therapy between the two groups remained after adjusting for patient and disease characteristics.ConclusionThere are significant variations in the treatment of patients with IBD by GI physicians. The use of biologics and immunomodulators is higher in GI physicians with dedicated IBD interest and training.

Is the High Prevalence of IBS in the Morbidly Obese Related to Sleep Disorders?

Introduction: The pandemic of obesity is a global crisis and therefore all GI physicians can see individuals for potential complications of obesity.The prevalence of irritable bowel syndrome (IBS) is reported to be 12% in the general US population. The Manning criteria have been validated in four studies for the diagnosis of IBS and focus on bowel symptoms, rather than on chronic abdominal pain. We have previously reported that 30% of morbidly obese individuals seeking surgery have IBS based on Manning criteria, and that this high prevalence of IBS was not related to diabetes mellitus. Morbidly obese individuals have a high risk of sleep disorders, including obstructive sleep apnea (OSA). The hypothesis of this study is that sleep disorders are associated with IBS in the morbidly obese.Figure 1Figure 2Methods: This is a retrospective study of 203 individuals (81% women and 19% men) in a large, urban community hospital who presented to bariatric gastrointestinal clinic from 2010 to 2013 for evaluation for potential bariatric surgery. The presence of irritable bowel syndrome (IBS) was assessed by asking all patients to complete a preoperative survey of the 6 Manning criteria (a diagnosis of IBS was defined by ≥3 criteria). All patients were screened by usingthe STOPBANG survey. A survey result of 3 or greateris used to supportthe presence of a sleep disorder. Results: The mean[SD] age is 46.7[9.9] years-old with a range of 21 to 73 years-old. The mean[SD] body mass indexis 49.3 kg/m2[10.1] with a range of 37 to 91 kg/m2. There are 56 individuals (28%) with ≥3 Manning criteria, supporting the diagnosis of IBS.Among the 203 patients, 142 (70%) were diagnosed with a sleep disorder.There is no relationship (Chi-Squared 2X2:p=.26) between sleep disorders and IBS. Conclusion: This study confirmed a high prevalence of IBS in morbidly obese individuals prior to bariatric surgery. Sleep disorders are not associated with a high prevalence of IBS in our study. These findings are important for clinical gastroenterologists evaluating chronic gastrointestinal symptoms in morbidly obese individuals. Further translational and prospective studies are required to examine the potential cause and effect association between sleep disorders and IBS.

Subtype Presentation and Prevalence of Subclinical Thiamine Deficiency in Morbidly Obese Individuals Seeking Bariatric Surgery

Introduction: In the past 20 years, the prevalence of obesity has risen to 35% of adults in the US. Preoperative biochemical studies have reported a 6%-29% prevalence of low whole blood thiamine levels in the morbidly obese. In our prior study of individuals seen for GI consultation after gastric bypass surgery, 18% had thiamine deficiency, and 41% of deficient individuals had gastrointestinal manifestations. The hypothesis of this study is that symptoms of subclinical thiamine deficiency are common in morbidly obese individuals seeking bariatric surgery. Methods: This is a retrospective evaluation of morbidly obese individuals with no history of prior bariatric surgery who underwent preoperative GI consultation in a large, urban community teaching hospital from 2013 to 2014. Men with 15 or more drinks (1 drink = 14 g of alcohol) weekly or women with 8 or more drinks weekly were excluded. Patient charts were reviewed to record the symptoms of thiamine deficiencies including gastrointestinal (abdominal pain, nausea/emesis, or constipation), cardiologic (dyspnea on exertion, palpitations, or lower extremity edema), neurologic (blurred vision, nystagmus, ataxia, or paresthesias), or psychiatric (aggressive behavior or psychosis). Patient demographics were also recorded. Thiamine deficiency is defined by consistent clinical symptoms and either: A. a low whole blood thiamine level or B. resolution of an individual's clinical symptoms after receiving oral or intramuscular thiamine. Results: Among the 138 individuals, the mean age was 46 years (range: 18 to 75 years). The mean body mass index was 47.9 kg/m2 (range: 35 to 102); 84% were women and 16% were men. At evaluation, 11% of these individuals were taking a multivitamin supplement. Twenty-three out of 138 individuals (16.7%) fulfilled the dual criteria for thiamine deficiency: 6 patients (26%) had consistent GI symptoms, 17 patients (73%) had cardiac manifestations, 14 patients (61%) had neurological manifestations, and 1 patient (4%) had a psychiatric manifestation. Conclusion: Symptoms of subclinical thiamine deficiency are common in morbidly obese individuals seen for bariatric surgery. The results of this study support prior preoperative biochemical studies of thiamine deficiency in the morbidly obese. Dietary intake may be both an origin for obesity as well as an origin for thiamine deficiency. GI physicians should consider thiamine deficiency when evaluating morbidly obese patients who have consistent gastrointestinal symptoms.

Comparison of a Simplified Colonoscopy Bowel Preparation Scale With the Validated Boston Bowel Preparation Scale

Introduction: A multi-society task force suggests adequate bowel cleansing permit detection of polyps >5mm. We validated a grading scale defining Adequate as enabling detection of polyps > 5mm AND no need to shorten the interval to the next colonoscopy. We aimed to assess intra- and inter-reader agreement between this 2 category scale and the Boston Bowel Preparation Scale (BBPS). Methods: 80 de-identified complete colonoscopies were videotaped. Readers were experienced board certified GI physicians; all attended a pre-study session to review representative videos. Grading was based on optimal cleansing on withdrawal. 8 readers reviewed 40 cases total; each video was read by 4 readers. Reader panels (comprised of a combination of 4 of the 8 readers assigned to each case) were randomized. Readers read assigned cases twice (T1, T2), 4 weeks apart. This study focused on 2 readers who read their 40 assigned cases a third time (T3) using the BBPS after completing on-line training. Agreement (%) and the kappa statistic quantified intra- and inter-reader agreement between readers. Results: For all 8 readers, there were 320 readings at T1 and T2. A rating of Adequate varied between readers for the 2-category scale (range 50%-98%; p = 0.001). Intra-reader agreement ranged from 63% to 98% (median=81%) and kappa from 0.25 to 0.88 (median 0.54). Overall inter-reader kappa= 0.35 for T1 and 0.26 for T2. For the 2 readers assessing T1, T2, and T3, there were 80 readings at each timepoint. An Adequate grade occurred significantly more with the BBPS (80-83%) than the 2-category scale (38-58%) (p-values range 0.001 to 0.004). Intra-reader agreement for the 2-category scale for T1 and T2 was k=0.25 (Reader 1) and k=0.42 (Reader 2). Intra-reader agreement between the 2-category scale and BBPS for Reader 1: T1/BBPS k=0.15, T2/BBPS k=0.34; Reader 2: T1/BBPS k=0.51, T2/BBPS k=0.17. For 18 cases common to both readers, adequacy ratings were also lower with the 2-category scale (44%-67%) compared to the BBPS (67%-83%) (p=NS). Inter-reader agreement for the 2 readers at T1 was k=0.14, T2 was k=0.44, and T3 was k=0.57. Conclusion: Bowel preparation is more likely to be rated Adequate using the BBPS compared to the 2-category scale. Intra- and inter-reader agreement for the 2-category scale was fair to moderate, and agreement between this scale and the BBPS varied greatly, ranging from slight to moderate. The 2-category scale may not be appropriate for clinical practice. Funding by Ferring Pharmaceuticals.

717 Career Prospects and Professional Landscape Post-Advanced Endoscopy Fellowship: a Survey Assessing Graduates From 2009-2013

Advanced endoscopy (AE) has become a popular career choice for graduating GI fellows. We postulate that the number of fellows completing AE fellowship has increased in the past 5 years. Despite this increase, we suspect that the number of AE attending positions has decreased (relative to the number of graduating trainees), with future concerns regarding job market saturation. The aim of this study was to survey practicing GI physicians who completed a 4th year AE fellowship within the past 5 years to assess their current professional status.

Addressing Sexual Function in Patients With IBD: Results of a National Survey of U.S. GI Physicians

Addressing Sexual Function in Patients With IBD: Results of a National Survey of U.S. GI Physicians

Celiac Disease Awareness Among Health Care Providers: Diagnosis and Nutritional and Metabolic Deficiencies: Results of an Anonymous Online Survey

Introduction: Assess the current awareness of celiac disease diagnosis among healthcare providers. Celiac disease (CD) affects an estimated 1/150-1/200. Previous reports reveal that there is limited awareness of the disease among healthcare providers, leading to a delay in diagnosis of up to 10 years after the onset of symptoms. To diagnose CD, current ACG guidelines recommend duodenal biopsy plus celiac serology when pretest probability of the disease is more than 5%, and celiac serology alone when pretest probability is less than 5%. Methods: Online survey was sent to 450 health care providers in the USA. Eighty responses were obtained. Results: Out of 80 responders, 26 (37%) were PCP, 16 (23%) were GI physicians, 29 (36%) had other specialties (DO, NP, OB); 49% had practiced medicine for more than 5 years. Most responders learned about CD in medical school (65%), residency or other postgraduate training (72%), and continuing medical education (29%). Fifty-three percent of responders treat 10 or fewer patients with CD, while 48% treat more than 10. Eighty-nine percent of responders diagnosed these patients with CD. Since starting their careers, 70% of responders feel their awareness of CD has increased, and 78% are now more likely to consider CD when evaluating patients’ symptoms. When responders were asked to define the first tests they order when they strongly suspect CD, 49 (63%) order celiac serology, 15 (19%) order celiac serology and an endoscopy, 12 (15%) refer to GI for work-up, and 7 (9%) refer directly to a nutritionist to start a gluten-free (GF) diet. Asked to state their recommendations after the diagnosis of CD is made, 71 responders (91%) recommend starting a GF diet. Many also refer CD patients to a nutritionist (53 responders, 68%) and a gastroenterologist (49 responders, 63%). While 80% of the responders check calcium, vitamin D, and iron levels, only 58% check vitamin B12 levels; 52% check TSH. Further, only 37% of responders order a bone mineral density scan, and less than 25% check vitamin K and zinc levels. Conclusion: While most healthcare responders feel their awareness of CD has increased in recent years, there is a lack of consensus regarding the methods used for CD diagnosis and which deficiencies should be investigated.Figure 1

Celiac Disease Awareness Among Health Care Providers: Recognizing the Clinical Presentations of the Disease: Results of an Anonymous Online Survey

Introduction: Celiac disease (CD) affects an estimated 1/150-1/200. Despite this high prevalence, previous reports revealed a limited awareness of the disease among healthcare providers, leading to a delay in diagnosis of up to 10 years after onset of symptoms. Atypical presentation is common with CD; this may account in part for the delay in diagnosis. Objective: To assess the current state of awareness of CD manifestations among healthcare providers. Methods: An anonymous online survey was sent to 450 healthcare providers in the USA. Eighty responses were obtained. Participants were asked whether they would consider CD in clinical case scenarios presented as vignettes. Results: Out of 80 responders, 26 (37%) were private practice physicians (PCP), 16 (23%) were GI physicians, 29 (36%) had other subspecialties (DO, NP, OB), and 49% had practiced medicine for more than 5 years. Most responders learned about CD in medical school (65%), residency or other postgraduate training (72%), and continuing medical education (29%). Fifty-three percent of responders estimated they treated 10 or fewer patients with CD, and 48% treated more than 10. Eleven percent of the time, the CD diagnosis was made by another physician. Since starting their professional career, 70% of the responders feel that their awareness of CD has increased, and 78% are now more likely to consider CD when evaluating patients’ symptoms. Up to 77% of responders suspect CD in patients with GI symptoms (suspicion is higher with abdominal pain, diarrhea, and weight loss, and lower for bloating or constipation). Fifty percent suspect CD in patients with Down syndrome and GI symptoms. Less than 45% of responders decided to evaluate for CD in patients with osteoporosis or fractures at a young age. A presentation of dermatitis herpetiformis prompts work-up for CD in 21%-49% of responders, depending on the age/ethnicity of the patient. Between 14-35% of responders opted to evaluate for CD in women with reproductive health issues (early menopause, delayed menarche, infertility, recurrent miscarriage). As for neurological symptoms, 11%, 28%, and 30% of responders desired to look for CD in the work-up of migraine, ataxia, and fatigue, respectively. Finally, up to 48% of responders test for CD in the work-up of iron deficiency, and up to 69% in the work-up of vitamin D or B12 deficiency. Conclusion: While most healthcare providers surveyed feel their awareness of CD has increased in recent years, they continue to suspect CD in patients presenting with GI symptoms or iron and vitamin deficiencies. The atypical manifestations of the disease are not well recognized, potentially delaying the diagnosis and treatment of CD.

How can we improve models of care in inflammatory bowel disease? An international survey of IBD health professionals

Background and aimsFew studies have specifically examined models of care in IBD. This survey was designed to help gather information from health professionals working in IBD services on current care models, and their views on how to best reshape existing models for IBD care worldwide. MethodsAn online mixed-methods survey was conducted with health professionals caring for IBD patients. Recruitment was conducted using the snowballing technique, where members of professional networks of the investigators were invited to participate. Results of the survey were summarised using descriptive statistics. ResultsOf the 135 included respondents, 76 (56%) were female, with a median age of 44 (range: 23–69) years, 50% were GI physicians, 34% nurses, 8% psychologists, 4% dieticians, 2% surgeons, 1% psychiatrists, and 1% physiotherapists. Overall, 73 (54%) respondents considered their IBD service to apply the integrated model of care, and only 5% reported that they worked exclusively using the biomedical care (no recognition of psychosocial factors). The majority of respondents reported including mental health assessment in their standard IBD care (65%), 51% believed that an ideal IBD service should be managed in specialist led clinics, and 64% wanted the service to be publicly funded. Respondents pictured an ideal IBD service as easy-access fully multi-disciplinary, with a significant role for IBD nurses and routine psychological and nutritional assessment and care. ConclusionsHealth care professionals believe that an ideal IBD service should: be fully integrated, involve significant roles of nurses, psychologists and dieticians, run in specialist clinics, be easily accessible to patients and publicly funded.

Tu1047 Assessing Key Barriers to Treatment of Chronic Hepatitis C Virus (HCV) With Next Generation Agents in a Veteran Population

variability was noted in the responses, with some waiting as long as 5 years to repeat screening in the presence of a high-risk adenoma with IBP. Awareness of MSTF recommendations or adherence to these guidelines still remains weak among GI physicians and physician-extenders. Publicity of guidelines and further data to support their recommendations are warranted. REFERENCES 1.Lebwohl B, et al. Gastrointest Endosc 2011;73(6):1207-1214. 2.Neerincx M, et al. Endoscopy 2010;42(9):730-735. 3.Lieberman DA, et al. Gastroenterology 2012;143(3):844-57.