Postprandial Pain Research Articles

A CASE OF TRANSMESENTERIC HERNIA WITH SMALL BOWEL GANGRENE

Transmesentric hernia involves herniation through a gap in the mesentry.We have case report of a 51 M with complaints of diffuse abdomen pain for 1 day and 1 episode of non bilious vomiting.Patient had history of postprandial abdomen pain and loss of weight in the past 10 months CT abdomen and pelvis showed clumping of jejunal loops in right side with hypoenhancement of the bowel wall with moderate ascites in abdomen.Laprotomy done it was found to be transmesentric herniation of small bowel.The jejunal loops were reduced and foun

Systematic hybrid laparoscopic and endovascular treatment of median arcuate ligament syndrome: A single-center experience.

Median arcuate ligament syndrome (MALS) is caused by celiac trunk (CT) compression by the median arcuate ligament. Clinically, this pathology varies from postprandial pain (Dunbar syndrome) to a life-threatening hemorrhage because of a rupture of a gastroduodenal artery aneurysm (GAA). Due to the low prevalence of this disease, there is no standard management for MALS. This was a single-center, retrospective study of 13 patients. Two groups were identified on the basis of the initial clinical presentation: those operated for a GAA rupture (bleeding group-BG) and those operated electively for Dunbar syndrome (Dunbar syndrome group-DG). The primary endpoint was 30-day postoperative complications of a systematic laparoscopic release of the median arcuate ligament and stenting during the same procedure. Seven patients (54%) underwent elective surgery. Six patients (46%) underwent semiurgent repair under elective conditions post-embolization for GAA bleeding. The total operative time was longer in the BG (p = 0.06). Two patients in the BG suffered early major complications and needed reintervention, and those in the DG had a lower comprehensive complication index. No mortality was reported at 30 days. Overall median length of stay was 5 days (IQR: 3.5-15.3). Patients in the DG had a significantly shorter length of stay (p = 0.02). At 6 months, the primary and secondary CT stent patencies were 82% and 100%, respectively. There were no high-flow GAA recurrences. A combined approach of laparoscopic release of the median arcuate ligament and stenting during the same procedure is feasible and safe, and this approach must be systematically discussed in symptomatic patients.

Reconsideration of the Gastroparetic Syndrome.

Gastroparesis is a chronic disorder characterized by a constellation of foregut symptoms, including postprandial nausea, vomiting, distension, epigastric pain, and regurgitation in the absence of gastric outlet obstruction. Despite considerable research over the past decades, there remains to be only nominal understanding of disease classification, diagnostic criteria, pathogenesis, and preferred therapy. We critically reassess current approaches for disease identification and stratification, theories of causation, and treatment for gastroparesis. Gastric scintigraphy, long considered a diagnostic standard, has been re-evaluated in light of evidence showing low sensitivity, whereas newer testing modalities are incompletely validated. Present concepts of pathogenesis do not provide a unified model linking biological impairments with clinical manifestations, whereas available pharmacological and anatomical treatments lack explicit selection criteria or evidence for sustained effectiveness. We propose a disease model that embodies the re-programming of distributed neuro-immune interactions in the gastric wall by inflammatory perturbants. These interactions, combined with effects on the foregut hormonal milieu and brain-gut axis, are postulated to generate the syndromic attributes characteristically linked with gastroparesis. Research linking models of immunopathogenesis with diagnostic and therapeutic paradigms will lead to reclassifications of gastroparesis that guide future trials and technological developments. • The term gastroparesis embodies a heterogenous array of symptoms and clinical findings based on a complex assimilation of afferent and efferent mechanisms, gastrointestinal locations, and pathologies. • There currently exists no single test or group of tests with sufficient capacity to be termed a definitional standard for gastroparesis. • Present research regarding pathogenesis suggests the importance of immune regulation of intrinsic oscillatory activity involving myenteric nerves, interstitial cells of Cajal, and smooth muscle cells. • Prokinetic pharmaceuticals remain the mainstay of management, although novel treatments are being studied that are directed to alternative muscle/nerve receptors, electromodulation of the brain-gut axis, and anatomical (endoscopic, surgical) interventions.

Resolution of Celiac Artery Compression Syndrome Following Spinal Cord Stimulation: A Case Report

BACKGROUND: Celiac artery compression syndrome is characterized by postprandial epigastric pain, weight loss, and occasional epigastric bruit, and can be difficult to treat because there are no definitive guidelines. We present a case of a 47-year-old man who had postprandial pain, weight loss, and chronic diarrhea for 5 years, which was resolved with spinal cord stimulation (SCS). CASE REPORT: After extensive workup, a diagnosis of celiac artery compression syndrome was confirmed. Due to previous treatment failures, repeat celiac plexus blocks becoming less efficacious, and surgical unsuitability, the patient underwent an SCS trial. They continued having pain relief, so a permanent spinal cord stimulator lead was implanted. CONCLUSION: We highlight complete resolution of celiac artery compression syndrome using SCS. KEY WORDS: Case report, celiac artery compression syndrome, celiac plexus block, median arcuate ligament syndrome, spinal cord stimulation

Food, Dietary Patterns, or Is Eating Behavior to Blame? Analyzing the Nutritional Aspects of Functional Dyspepsia.

Functional dyspepsia is a gastrointestinal disorder characterized by postprandial fullness, early satiation, epigastric pain, and epigastric burning. The pathophysiology of the disease is not fully elucidated and there is no permanent cure, although some therapies (drugs or herbal remedies) try to reduce the symptoms. Diet plays a critical role in either the reduction or the exacerbation of functional dyspepsia symptoms; therefore dietary management is considered to be of high importance. Several foods have been suggested to be associated with worsening functional dyspepsia, such as fatty and spicy foods, soft drinks, and others, and other foods are thought to alleviate symptoms, such as apples, rice, bread, olive oil, yogurt, and others. Although an association between functional dyspepsia and irregular eating habits (abnormal meal frequency, skipping meals, late-night snacking, dining out, etc.) has been established, not many dietary patterns have been reported as potential factors that influence the severity of functional dyspepsia. A higher adherence to Western diets and a lower adherence to FODMAPs diets and healthy patterns, such as the Mediterranean diet, can contribute to the worsening of symptoms. More research is needed on the role of specific foods, dietary patterns, or specific eating habits in the management of functional dyspepsia.

Outcomes of Median Arcuate Ligament Release: A Single Institution Retrospective Review

Median arcuate ligament syndrome (MALS) is an uncommon diagnosis that is often associated with variable clinical presentation and inconsistent response to treatment. Due to the nature of MALS, the optimal treatment modality and predictors of outcomes remain unclear. A retrospective review was performed of all median arcuate ligament release (MALR) procedures at a single academic institution between 2000 and 2020. Variables examined included patient demographics, symptom characteristics, operative technique (open, robotic, laparoscopic), patient symptoms before release, symptom relief within 1year, and recurrence of symptoms between release and last clinical follow-up. During the study period, 47 patients (75% female, mean age 42.1years) underwent MALR with 19 (36%) robotic, 18 (34%) open, 14 (26%) laparoscopic, and 2 (4%) laparoscopic converted to open procedures. Abdominal pain, weight loss, and nausea and vomiting were the most common symptoms. Postoperatively, 19 (40%) had complete symptom relief within 1year, 18 (38%) had partial relief, and 10 (21%) had no symptom improvement. 6 were excluded due to loss of follow-up. Laparoscopic and open procedures had the highest rate of complete symptom relief by year 1 with 7 (58%) and 8 (50%) respectively. Twenty-one (57%) patients had recurrence with the greatest rate of recurrence seen among laparoscopic (80%), compared to robotic (57%) and open (38%). Patients reporting a weight loss of 20 pounds or more before surgery were more likely to have partial or complete symptom relief after 1year compared to those reporting less than 20-pound weight loss (92% vs. 64%). Furthermore, 84% of patients younger than 60years old reported partial or complete symptom relief compared to only 56% of those older than60. MALS continues to be a rare disorder with widely variable surgical outcomes, requiring further study. While our patients presented with several gastrointestinal symptoms, the most common was postprandial pain. Our center employed laparoscopic, open, and robotic operative techniques with varying success rates, in terms of symptom relief and recurrence. Consistent with current literature, our study found greater surgical success among patients younger than 60years regardless of operative technique. This suggests the need for better predictors to determine which patients are the most likely to have complete or prolonged remission of symptoms following MALR.

An uncommon cause of pancreatitis with obstructive jaundice

A 56-year-old man with a history of diabetes mellitus poorly controlled recently (HbA1c: 7.5%, <6%) presented with a 3-month history of postprandial epigastric pain, 10-kg weight loss, steatorrhea, tea-colored urine, and clay-colored stool. Physical examination revealed yellowish skin and icteric sclera but no peripheral stigmata of cirrhosis. Laboratory investigation was significant for elevated aspartate aminotransferase (289 IU/L, 8-31 IU/L), alanine aminotransferase (613 IU/L, 0-41 IU/L), alkaline phosphatase (595 U/L, 34-104 U/L), γ-glutamyl transferase (758 U/L, 0-26 U/L), total and direct bilirubin (8.0/6.1 mg/dL, 0.3-1/0.03-0.18 mg/dL), and carbohydrate antigen 19-9 (289 U/mL, <37 U/mL). Contrast-enhanced computed tomography revealed diffuse enlargement of the pancreas (arrow) and dilatation of the common bile duct (CBD) without identifiable stone or a mass lesion (arrowhead; Figure 1A). Endoscopic ultrasound (EUS) demonstrated hyperechoic foci and strands in the enlarged pancreas (arrow) and layer-by-layer whole wall thickening with a hyper-hypo-hyperechoic series (sandwich pattern) of CBD (arrowhead) as well as gallbladder (star; Figure 1B). Magnetic resonance cholangiopancreatography (MRCP) showed dilated CBD with distal tapering near the pancreatic head (arrow; Figure 1C). The diagnosis of autoimmune pancreatitis was confirmed by serologic immunoglobulin G4 (IgG 4) elevation (IgG 4: 2880 mg/dL, 3-201 mg/dL) and favored type I according to nonductal Level 1/Level 2 criteria of international consensus diagnostic criteria.1 The patient recovered from jaundice and gained weight after treatment of prednisone 40 mg/d for 4 weeks, then taper by 5 mg/wk. The 8-week follow-up EUS demonstrated normalization of pancreatic size (arrow) and CBD morphology (arrowhead; Figure 2).2 Autoimmune pancreatitis mimicking pancreatic cancer is a rare cause of obstructive jaundice with an estimated incidence of 1 per 100 000.3 In summary, we demonstrated a case of autoimmune pancreatitis diagnosed by complement image study and elevating serum IgG 4, which achieved successful medical treatment of obstructive jaundice without further invasive procedures.1 The authors declare no conflict of interest. This report was approved by the Research Ethical Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (No. CR111-08).

A COMPARATIVE EVALUATION OF EFFECTIVENESS OF ACOTIAMIDE WITH RABEPRAZOLE VS MOSAPRIDE WITH RABEPRAZOLE IN PATIENTS WITH FUNCTIONAL DYSPEPSIA POST H.PYLORI ERADICATION

Background: Functional Dyspepsia is well dened when a patient had one or more of these symptoms with duration of three months or longer like post-prandial fullness, early satiation, epigastric pain and burning, bloating, nausea, vomiting and belching. Functional dyspepsia, consisting of epigastric pain syndrome and postprandial distress syndrome, is a prevalent functional gastrointestinal disorder. To date, only limited treatment options are available and conicting results in terms of efcacy have been reported. This was a prospective, com Methods: parative study carried out for a period of six months. Patient data were extracted from their medical records. Treatment outcome was evaluated based on the resolving of Symptoms using Gastrointestinal Symptom Rating Scale (GSRS), and (Hospital anxiety and depression scale) HADS scales. Descriptive statistics were used to summarize patient characteristics. Unpaired t-test and Mann Whitney test were used wherever appropriate. A total of 100 patients with conrmed funct Results: ional dyspepsia after H. pylori eradication were included.They were randomized into two study Groups namely Group 1 &amp; 2. Each Group consists of 50 patients. Patients in Group 1 treated with Acotiamide and Rabeprazole. Group 2 patients treated with Mosapride and Rabeprazole. Patients with two different treatments have shown signicant improvement in gastrointestinal symptoms. The major risk factors are consumption of junk food, tea and spicy food. Our study shows that FD is predominant in Females than Males. Minor ADRS were reported which includes Nausea, Headache, dizziness and Constipation. study till date revealed that effects of both gastroprokinetic drugs help in enhancing Gastric emptying Rate (GER) , Gastric Accommodation Rate (GAR) and helps in acceleration of intestinal transit which ultimately results in preventing relaxation peristaltic movements respectively. Our study demonstrated that Mosapride and Acotiamide were both effective and well t Conclusion: olerated in FD patients without serious side effects. We found that effectiveness of Mosapride is 86% and Acotiamide is 84% thus Mosapride offers good alternative to Acotiamide in treating post H.pylori FD patients. Further investigations with increased sample are required in order to conrm the results in depth

Type 2 and type 17 effector cells are increased in the duodenal mucosa but not peripheral blood of patients with functional dyspepsia.

Functional dyspepsia is characterised by chronic symptoms of post-prandial distress or epigastric pain not associated with defined structural pathology. Increased peripheral gut-homing T cells have been previously identified in patients. To date, it is unknown if these T cells were antigen-experienced, or if a specific phenotype was associated with FD. This study aimed to characterise T cell populations in the blood and duodenal mucosa of FD patients that may be implicated in disease pathophysiology. We identified duodenal T cell populations from 23 controls and 49 Rome III FD patients by flow cytometry using a surface marker antibody panel. We also analysed T cell populations in peripheral blood from 37 controls and 61 patients. Where available, we examined the number of duodenal eosinophils in patients and controls. There was a shift in the duodenal T helper cell balance in FD patients compared to controls. For example, patients had increased duodenal mucosal Th2 populations in the effector (13.03 ± 16.11, 19.84 ± 15.51, p=0.038), central memory (23.75 ± 18.97, 37.52 ± 17.51, p=0.007) and effector memory (9.80±10.50 vs 20.53±14.15, p=0.001) populations. Th17 populations were also increased in the effector (31.74±24.73 vs 45.57±23.75, p=0.03) and effector memory (11.95±8.42 vs 18.44±15.63, p=0.027) subsets. Peripheral T cell populations were unchanged between FD and control. Our findings identify an association between lymphocyte populations and FD, specifically a Th2 and Th17 signature in the duodenal mucosa. The presence of effector and memory cells suggest that the microinflammation in FD is antigen driven.

Updates in Gastroenterology: Acotiamide for Treatment of Functional Dyspepsia

Functional dyspepsia (FD) comprises of two types, the postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). Acotiamide is a new prokinetic agent that acts by increased release of acetylcholine and is used in the treatment of FD-postprandial distress syndrome (FD-PDS). The drug initially launched in Japan is the world’s first approved treatment for FD. It exerts its activity via muscarinic receptor inhibition, which enhances acetylcholine (ACh) release, and via inhibition of acetylcholinesterase (AChE) activity in the stomach. It increases the availability of ACh on postsynaptic receptors in the enteric nervous system. The gastroprokinetic activity of acotiamide does not cause prolongation of the QT interval. Long-term studies of 48 weeks have shown a favorable clinical course with acotiamide in FD.

Laparoscopic duodeno jejunostomy a minimaly invasive surgery in the management of Wilkie syndrome a case report cas clinique

The superior mesenteric artery syndrome (SMAS), also known as Wilkie’s syndrome, is a duodenal obstruction caused by the compression of the third part of the duodenum between the superior mesenteric artery (SMA) and the aorta. This condition often arises due to the disappearance of perivascular fatty tissue, as well as advanced stages of malnutrition and weight loss. Patients typically experience symptoms such as vomiting, fullness, and postprandial epigastric pain. While initial management involves conservative measures, surgery becomes necessary if symptoms do not improve. Here, we present the case of a 25-year-old man diagnosed with SMAS. Despite undergoing conservative management for three months, the symptoms did not regress. Subsequently, a laparoscopic duodeno-jejunostomy was performed, resulting in an uneventful postoperative period, disappearance of vomiting and epigastric pain, and a weight gain of 14 kg after one year.

Lactobacillus rhamnosus GG supplementation on eradication rate and dyspepsia in Helicobacter pylori infection treated with three-in-one bismuth quadruple therapy.

Helicobacter pylori (Hp)-related dyspepsia has been related to gastroduodenal dysbiosis. The role of probiotic supplementation in the clinical management of Hp infection has been the object of several studies in terms of improvement of efficacy and tolerability of eradication treatments but data on their effects on the outcomes of post-eradication dyspepsia are lacking. The aim of the present study was to evaluate the influence of Lactobacillus rhamnosus GG (LGG) supplementation on bismuth quadruple therapy (BQT) in the clinical management of Hp-related infection both in terms of efficacy and tolerability and persistence of post-treatment dyspepsia. A total of 164 (121 women) Hp-positive adult patients were enrolled in this pilot study and assigned to two different treatment regimens: group A received BQT for 10 days (three capsules qid, IPP bid) and group B received BQT for 10 days in combination with 6 × 109CFU LGG (ATCC53103) taken for 24 days (7 days before, 10 days during, and 7 days after therapy). Eradication was assessed after 45 days using the 13C-urea breath test (13C-UBT). Dyspepsia, distinguished into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS), was assessed at the time of enrollment and 6 months after eradication. Approximately 98 patients were enrolled in group A and 66 patients in group B. At the enrollment, dyspepsia was present in 76.5% of group A and 86.5% of group B. No significant differences were observed in eradication rate between the 2 groups, both in intention-to-treat (ITT) analysis (82.3 vs. 75.0%) and per-protocol (PP) analysis (95 vs. 96%), and in the presence of side effects during the treatment (70.6 vs. 65.4%). At 6 months after eradication of Hp infection, the persistence of dyspepsia was statistically higher in patients of group A than in group B (38.8 vs. 16.1%; p = 0.032). The positive influence of LGG supplementation in improving post-eradication dyspepsia resulted in statistically more effectiveness in PDS dyspepsia, whose remission was 41.7% in group A and 84% in group B patients (p = 0.011). In conclusion, LGG supplementation during Hp eradication therapy, even if not affecting eradication rates and therapy-related side effects, significantly impacts the remission of dyspepsia.

S68 Concurrent Esophageal Crohn’s Disease and Superior Mesenteric Artery Syndrome in a Pediatric Patient

Case: A previously healthy 12-year-old female with 4-month history of malaise, dizziness, headaches, anorexia (20-pound weight loss). A month prior, she developed daily non-bilious, non-bloody emesis and early satiety. Denied abdominal pain, diarrhea, hematochezia, constipation, oral ulcers, rash or fever. Family history was negative for gastrointestinal illness. Physical exam showed thin stature, epigastric tenderness, weight 37.7 kg (27th percentile) and BMI 14.36 kg/m2 (2nd percentile). Initial labs: Hgb 13 g/dL, MCV 74.4 fL, albumin 2.5 g/dL, platelet 497,000/uL, CRP 16.6 mg/L, ESR 24 mm/hr and fecal calprotectin 2500 mcg/g with remainder unremarkable. Upper GI demonstrated mucosal irregularity/fold thickening and narrowing at the third portion of the duodenum. Superior mesenteric artery (SMA) ultrasound showed aortomesenteric angle EGD revealed esophagitis, gastritis and bulbar duodenitis. She received intravenous pantoprazole and NJ tube placed for enteral nutrition. Biopsy with chronic lymphocytic esophagitis, chronic active gastritis negative for Helicobacter Pylori or CMV, and chronic peptic duodenitis. MRE demonstrated a 1-2 cm segment of bowel wall thickening and hyperenhancement 10-20 cm proximal to the terminal ileum. Colonoscopy found terminal ileitis, unremarkable colon, and perianal disease consisting of a skin tag with small fissure. Biopsies revealed mixed inflammatory infiltrate consistent with chronic active ileitis. Discharged with NJ feeds for 4-6 weeks, and pantoprazole. Given first dose of adalimumab prior to discharge. Introduction: SMA syndrome is characterized by compression of the third portion of the duodenum between the SMA and the aorta. In pediatrics, the major cause is rapid weight loss leading to loss of the intervening mesenteric fat pad. Symptoms include postprandial epigastric pain and early satiety. Those with advanced obstructions may have severe nausea, bilious emesis and weight loss. The incidence ranges between 0.013 and 0.3%. Treatment is typically successful with enteral nutrition, with surgical intervention reserved for patient’s refractory to refeeding. Crohn’s disease (CD) is a chronic inflammatory disease that can affect any part of the GI tract. CD of the esophagus is less common, affecting 7.6-17.6% of pediatric patients. Most cases of esophageal CD present with symptoms similar to gastroesophageal reflux disease (GERD) with chest pain, heartburn and regurgitation and more advanced cases with odynophagia, vomiting, and weight loss. The mean time to diagnosis of CD and esophageal involvement is up to 3 years. Upper GI involvement of CD is more common in pediatric than adult population, but still less prevalent than lower GI involvement. Discussion: This is an atypical case of CD primarily involving the esophagus that led to the development of SMA syndrome. Though weight loss due to CD is common (57%) there is limited literature describing CD associated with SMA syndrome and only a few reported cases of SMA syndrome as the presenting sign of CD with nonspecific symptoms (vomiting, abdominal pain). There is an even smaller number of cases reported in the pediatric literature. Thus, it is important to highlight that esophageal CD, often presenting with nonspecific symptoms (vomiting, weight loss), is severe and can lead to SMA syndrome.

S3613 Gastric Spindle Cell Leiomyosarcoma Is Associated With Chronic Helicobacter pylori Infection

Introduction: Chronic Helicobacter pylori (HP) infection has been shown to be strongly associated with development of gastric malignancies, mostly gastric adenocarcinomas and lymphomas. We present a case of primary gastric leiomyosarcoma in a patient with persistent epigastric pain and HP infection. Case Description/Methods: A 59-year-old female presented to clinic with persistent, postprandial epigastric pain. Cardiopulmonary workup was negative. She had a history of esophageal leiomyoma resected endoscopically with negative margins 10 years ago. She was treated in the past for HP infection but never had repeat testing to confirm eradication. Abdominal computed tomography showed focal hepatic infiltration. She was advised to have a repeat upper endoscopy for surveillance but was lost to follow-up due to psychiatric comorbidities. She presented 6 years later with epigastric pain. Repeat CT abdomen showed a new 2.8 cm hypoattenuating lesion in the lesser curvature of the stomach. Patient did not follow up due to psychosocial issues. Two years later, she returned to clinic for epigastric pain and underwent repeat upper endoscopy and endoscopic ultrasound (EUS) with fine needle aspiration (FNA). EGD showed sub-gastric nodule attached gastric wall, about 30 mm in maximal dimension and gastric biopsy confirmed active HP infection. The EUS showed a 31.7x23.5 mm hypoechoic homogeneous gastric mass along the lesser gastric curvature. Cytology showed cellular spindle cell neoplasia with myogenic differentiation concerning for possible leiomyoma or leiomyosarcoma. Abdominal magnetic resonance imaging and chest computed tomography revealed no evidence of abdominal or thoracic metastasis. Subsequently, partial underwent sleeve gastrectomy. Pathology revealed Grade 1 myxoid leiomyosarcoma with negative margins. (Figure) Discussion: Prior studies demonstrated associations between HP infection and gastric malignancies - typically gastric adenocarcinoma or lymphomas. Few studies investigated the relationship between HP infection and gastric leiomyosarcomas.4,5 Importantly, this patient never had clearance of HP infection and may have allowed a leiomyosarcoma to develop. It is imperative that clinicians confirm eradication of HP infection given risk of leiomyosarcoma development in addition to other malignancies HP infections are known to cause.Figure 1.: Endoscopic and histologic examination of gastric leiomyosarcoma. (A) Endoscopic ultrasound visualization demonstrating tumor within lesser curvature of stomach. (B) Upper endoscopy revealing tumor approximately 4 cm from gastroesophageal junction. (C) Hematoxylin and eosin (H&E) stain of gastric tumor biopsy demonstrating spindle cell proliferation in a myxoid background with significant nuclear atypia and pleomorphism consistent with myxoid leiomyosarcoma. Magnification x400. (D) Immunohistochemical staining of gastric lesion biopsy demonstrating strong immunoreactivity to desmin. Not shown are positive stains for smooth muscle actin (SMA) as well as negative stains for Cytokeratin AE1/AE3, Myogenin, MyoD1, DOG-1, CD117, S100, SOX10, CD34, ALK-1 and ER. Positive and negative controls stained appropriately but are not included.

S575 Rate and Reasons for Non-Elective 30-Day Readmissions for Functional Dyspepsia in the U.S.

Introduction: Functional dyspepsia (FD), a diagnosis of exclusion, has a 10–20% prevalence(1,2). The pathophysiology is unclear, often multifactorial, and involves treatment with a detailed education about its benign nature. Tricyclic antidepressants and psychotherapy are warranted if functional dyspepsia (FD) is refractory or severe (1). Functional dyspepsia (FD) can present with postprandial distress (70% of FD cases) or epigastric pain syndrome (30% of FD cases) (3). FD can decrease quality of life and place a significant cost burden on healthcare services. Our study sought to determine the rate and reasons for 30-day all-cause readmissions for FD to help identify potentially modifiable factors and decrease the burden of readmissions. Methods: From the NRD, we identified all adults discharged with a principal diagnosis of FD after hospitalization from 2016 to 2019. Then, we identified any readmission of the same patient within 30-days for FD, excluding elective and traumatic encounters. Outcomes assessed included 30-day all-cause readmissions, top principal diagnosis for the readmitted patients, comparison of mortality, length of stay (LOS), and total hospital charges (THC) following readmission. Results: 4 917 patients with FD during index admissions were identified. The 30-day all-cause readmission rate was 19.3%. The Kaplan-Meier curve for 30-day all-cause readmissions was split by sex (Figure). There was no significant difference in age and sex distribution between patients with initial hospitalizations and those with readmissions. The most common reasons for readmissions in patients with FD were gastroparesis (5.9%), FD (5.8%), sepsis unspecified (5.2%), unspecified nausea and vomiting (3.1%), unspecified abdominal pain (2.1%), and acute renal failure (2.0%). Readmission was associated with higher odds of mortality (2.8% vs. < 0.01%, p< 0.001), longer LOS (6.0 vs. 5.0 days, p< 0.001), and higher THC. Over the period, readmissions for FD accounted for a cumulative 5.694 days of hospitalization, costing over $14 million. Conclusion: 1 in 4 patients was readmitted with FD within 30 days. Gastroparesis contributed more to readmissions than a primary diagnosis of FD. Higher rates of poorer outcomes were found with 30-days readmissions. Cohort studies are needed to validate these results.Figure 1.: Survival estimates for 30-day all-cause readmissions in male and Female patients with functional dyspepsia

S352 Presidential Poster Award Light at the End of the Tunnel: Pipeline to the Jejunum

Introduction: Small intestinal strictures that are distal to the duodenum, particularly the jejunum, are uniquely complicated to manage. Adult endoscopes are often too short or too rigid to reach this region of the small bowel. Furthermore, duodenal stents are not flexible enough and are uncovered. In this case, we were able to place several esophageal stents in the proximal jejunum using a pediatric colonoscope that could not be placed previously. Case Description/Methods: A 56 year-old woman with hypertension, obstructive lung disease, and a prior ischemic stroke presented to the hospital for four days of postprandial emesis, abdominal distention, epigastric pain, and constipation. She previously underwent appendectomy and hysterectomy, and had no prior endoscopic studies. Computed tomography (CT) was performed demonstrating mural thickening of the distal duodenum and partial occlusion of the small bowel with regional lymphadenopathy, and a large left adrenal mass. Esophagogastroduodenoscopy (EGD) showed an intrinsic severe stenosis in the distal duodenum. After biopsies were taken, the tissue was found to be a primitive neuroectodermal tumor. Because of the presence of mesenteric adhesion and extensive stenosis, it was decided to correct the stricture endoscopically rather than with surgical intervention. Using a pediatric colonoscope and fluoroscopic guidance, three stents were placed sequentially and telescoping each other from the proximal jejunum to the distal duodenum: a fully covered 20 mm x 120 mm esophageal stent, a partially covered 18 mm x 97 mm esophageal stent, and a fully covered 20 mm x 60 mm esophageal stent (Figure). There were no immediate complications with the procedure and repeat imaging demonstrated luminal patency. Due to the expansion of the stents through a tight stricture, the abdominal pain and pressure was present despite no evidence of perforation on CT. Discussion: This demonstrates the feasibility of utilizing multiple esophageal stents to help relieve more distal gastrointestinal obstructions that were not feasible in the past. The covered esophageal stents are extremely useful when there is discontinuity in the lumen of the small bowel to keep the natural flow of food and help prevent surgical interventions. Watch the video at https://tinyurl.com/ACGAbstractS352Figure 1.: (A) Coronal CT image of a large abdominal mass involving loops of bowel and jejunum. (B) Abdominal x-ray showing interval placement of stents from the distal duodenum to the proximal jejunum.

S3041 Hepatic Artery Dissection – A Case Report

Introduction: Visceral artery aneurysms are rare pathologies with reported incidence rates between 0.01% to 0.2%; even rarer are hepatic artery dissections (HAD). Most aneurysms rupture or are incidentally found on autopsy, but imaging advancements has enabled earlier identification of aneurysms; in this case, a HAD. Case Description/Methods: A 77-year-old female with medical history pertinent for sickle cell trait, acquired factor VIII inhibitor coagulopathy, history of type 2 thoracic aortic dissection, and hypertension presented to the emergency room with a week of mild fatigue, postprandial epigastric burning pain, and intermittent stabbing right upper quadrant pain. Right upper quadrant ultrasound demonstrated a hypervascularized right hepatic lobe mass with large tortuous internal vessels. CT abdomen & pelvis without contrast showed a large hypodensity in the right liver with curvilinear density. MRI demonstrated large arteriovenous malformation (AVM) within the right hepatic lobe and focal hepatic parenchymal hemorrhage centered within AVM nidus. Gastroenterology was consulted and CT angiogram findings were suspicious for common HAD, proper hepatic & intrahepatic pseudoaneurysms, and intrahepatic rupture. Interventional radiology was consulted. Hepatic angiogram showed a large defect in the proximal hepatic artery with brisk opacification, thought to represent a pseudoaneurysm. This prompted framing coil placement across the large defect and coils extending from the proper hepatic artery to the common hepatic artery with significant reduction in forward flow & pseudoaneurysm opacification. Per hepatobiliary & vascular surgery, no need for additional surgical intervention. Postoperative course was complicated by fever & leukocytosis, worsening kidney injury, and anemia; attributed to the procedure and resolved with supportive care. Patient discharged on postoperative day 8 with outpatient follow-up. (Figure) Discussion: This case highlights the importance of imaging for earlier detection of hepatic artery aneurysms (HAA) in minimizing risk of catastrophic hemorrhage. HAA are rare but clinically important given they are associated with high incidence of rupture and mortality up to 20%. Although surgery is preferred for extrahepatic findings, endovascular interventions are favored for intrahepatic findings depending on size and presence of pseudoaneurysms, such as this case. They have led to more favorable short & longer-term outcomes and lower mortality & morbidity rates, particularly in poor surgical candidates.Figure 1.: Hepatic angiography and embolization was performed. A large defect with brisk opacification of the proper and common hepatic arteries were seen (A), prompting deploy of a framing coil. (B) Embolization was then performed on the hepatic artery with three coils (5mm, 6mm, & 8mm). Coils were examined from proper hepatic artery to the common hepatic artery. (C) Following placement of the coils, significant reduction in flow and opacification of the pseudoaneurysm was seen.

S3439 Lemmel Syndrome Due to Periampullary Diverticular Food Impaction

Introduction: Lemmel Syndrome is a rare cause of mechanical biliary obstruction attributed to periampullary duodenal diverticula (PAD). It was first described in 1934 as obstructive jaundice in the absence of biliary stones or malignancy. The majority of PAD are asymptomatic, however, about 5% have symptomatic disease. We present a symptomatic case. Case Description/Methods: An 80-year-old woman with history of cholecystectomy, coronary artery disease, hypertension, and diabetes was transferred from a free-standing emergency room for acute pancreatitis. She had a one day history of postprandial epigastric pain with radiation to the back. Labs on presentation included lipase above 4000 U/L, BUN 27 mg/dL, AST 316 U/L, ALT 422 U/L, ALP 292 IU/L, total bilirubin 0.6 mg/dL. Abdominal ultrasound revealed 12mm common bile duct (CBD) with intrahepatic ductal dilatation. MRCP showed intra and extrahepatic biliary ductal dilatation with dilated pancreatic duct and a 3.6 cm fluid filled periampullary diverticulum. ERCP showed a large periampullary duodenal diverticulum with food impaction causing obstruction of the ampullary orifice which was removed with forceps. Cholangiogram revealed dilation of pancreatic, common bile, and intrahepatic ducts without any filling defects. Patient improved and was discharged home. (Figure) Discussion: The incidence of duodenal diverticula is approximately 17% with PAD being the most common type. PADs are pseudo-diverticula most commonly found in the second part of the duodenum and they pose a cannulation challenge during ERCP with an increased risk of complications. PAD in the setting of biliary obstruction is known as Lemmel Syndrome. It can cause biliary obstruction by sphincter of Oddi dysfunction, direct obstruction, or via external compression by fluid or material-filled PAD. In our case, there was biliary compression due to a food-filled PAD. Cross sectional imaging is critical for diagnosis, however, ERCP is the gold standard. Several therapeutic modalities including endoscopic extraction of entrapped food or stones, extracorporeal shock wave lithotripsy, and laparoscopic diverticulectomy have been used. Our case required endoscopic extraction of diverticular food debris and adds to the limited published cases to date. Lemmel Syndrome requires a high index of suspicion when a PAD is found in the setting of biliary obstruction.Figure 1.: A. MRCP image showing a large periampullary diverticulum packed with debris. B. ERCP image of food impacted inside periampullary diverticulum. C. MRCP image demonstrating a dilated common bile duct in absence of choledocholithiasis.

S3487 Superior Mesentery Artery Syndrome Presenting in an Otherwise Healthy Female

Introduction: Superior Mesentery Artery (SMA) Syndrome is a rare gastrovascular disorder due to narrowing of the space between the aorta and superior mesenteric artery, also known as aortomesenteric angle, which can compress the third part of the duodenum. Clinically, SMA syndrome in adults is associated with conditions, such a malignancy, trauma, extreme weight loss, or corrective spinal surgeries. We report a case of SMA syndrome in a patient without comorbidities to alert clinicians of the non-specific manifestations of this rare phenomenon. Case Description/Methods: A 41-year-old female presented with a 30-year-history of post-prandial epigastric pain and acid reflux. She also reported early satiety, frequent belching, nausea, and constipation. She denied vomiting, diarrhea, hematochezia, and weight loss. Physical examination revealed epigastric tenderness to palpation. Laboratory studies were unremarkable. Upper endoscopy showed patchy erythema and few erosions in the antrum consistent with gastritis. Colonoscopy, gastric emptying study, and abdominal ultrasound were unremarkable. CT abdomen and pelvis showed nondilated bowels without thickening. Magnetic resonance angiography abdomen showed narrowing of the aortomesenteric distance at 5 mm, decreased aortomesenteric angle at 23 degrees, and mild narrowing of the left renal vein as it passes between the aorta and superior mesenteric artery (Figure). SMA syndrome was diagnosed. She was started on metoclopramide 5mg twice a day with subsequent improvement of her acid reflux by 90 percent and resolution of her epigastric pain. Discussion: SMA Syndrome may present with insidious non-specific signs and symptoms, which can lead to delayed diagnosis. When diagnosis is delayed, it can result in significant morbidity and mortality. Diagnosis is challenging. Gastric emptying studies may be falsely negative when the duodenum obstruction is relieved by positional changes. CT or magnetic resonance angiography allows visualization of the vascular compression. In mild cases without small bowel obstruction, prokinetic pharmacotherapy may help decrease symptoms. Surgical correction may be needed. Clinicians should consider SMA syndrome in select patients who present with symptoms suggestive of small bowel obstruction when gastrointestinal studies are unrevealing.Figure 1.: Decreased aortomesenteric angle of 23 degrees. A. Sagittal view. B. 3-dimensional reconstruction view.

S2871 Successful Treatment of “Candy Cane” Syndrome Through Endoscopic Gastrojejunal Anastomosis Revision

Introduction: “Candy cane” syndrome is a post-surgical Roux-en-Y gastric bypass (RYGB) complication associated with a markedly long, surgically-created blind end of the afferent Roux limb distal to the gastrojejunostomy. Gradual filling of this long blind limb with food can result in symptoms, including postprandial epigastric pain, nausea, vomiting, or regurgitation. Treatment of candy cane syndrome traditionally consists of laparoscopic resection of the redundant blind afferent limb. We present the first case of successful treatment of candy cane syndrome through endoscopic revision of the gastrojejunal (GJ) anastomosis. Case Description/Methods: A 40-year-old female presented for evaluation of intractable acid reflux, nausea, and weight recidivism eight years post RYGB. Esophagogastroduodenoscopy revealed evidence of prior RYGB, a healthy-appearing GJ anastomosis, a direct path across the GJ anastomosis into the blind afferent limb, and the enteral efferent limb located at a more angulated orientation toward the 4:00 position. An upper gastrointestinal series revealed an exaggerated blind afferent limb with pooling of contrast in the afferent blind limb before spilling to progress down the Roux limb. This finding suggested the reflux likely stemmed from the excessively long blind afferent limb. The patient wished to avoid surgery and a novel endoscopic suturing technique was performed that narrowed the GJ anastomosis and oriented flow towards the enteral efferent limb. This resulted in 1) limiting acid reflux 2) assisting with weight loss and 3) redirecting flow of contents more toward the enteral efferent limb. Post-procedure our patient had no additional weight gain and her acid reflux and nausea resolved. (Figure) Discussion: Candy cane syndrome is an underappreciated complication reported following RYGB. It results from an excessively long blind afferent Roux limb at the gastrojejunostomy that can lead to food accumulation. Patients often present with nausea, vomiting, food intolerance, acid reflux, and abdominal pain. Many patients remain undiagnosed due to vague gastrointestinal symptoms, delayed presentation, and physician unawareness. Historically, treatment has required surgical revision. Endoscopic suturing revision of the GJ anastomosis can provide an alternative less invasive and possibly safer treatment option that address the reflux symptoms, weight regain, and aberrant flow of contents into the blind limb.Figure 1.: Figure: Endoscopic view of direct access into the blind afferent limb A, the acute angle of the enteral efferent limb B, and dilated gastrojejunal anastomosis C.