Prior GI Research Articles

A121 CROSS-SECTIONAL STUDY OF RESIDENT PHYSICIAN KNOWLEDGE AND PERCEPTIONS REGARDING NON-ALCOHOLIC FATTY LIVER DISEASE IN CANADA

Abstract Background Non-alcoholic Fatty Liver Disease (NAFLD) is a prevalent condition affecting approximately 25% of the Canadian population and is projected to continue increasing. Given the increasing prevalence and complications of NAFLD, it is imperative for future primary care physicians to possess a thorough understanding of NAFLD to enhance patient care. Aims To assess the knowledge and perceptions of primary care resident physicians in Canada concerning NAFLD. Methods We conducted a nationwide cross-sectional survey of resident physicians in primary care specialties to assess their knowledge of NAFLD. Additionally, we evaluated resident perceptions regarding the importance of NAFLD and their exposure and familiarity with the condition. "Reasonable knowledge" was defined as correctly answering more than 50% of the questions. We assessed associations using χ2 testing and multiple logistic regression analysis. Results We received 413 responses, with 252 (61%) from family medicine residents and 161 (39%) from internal medicine residents. Among the respondents, 90% considered NAFLD an important public health issue, but only 7% felt they had adequate exposure to the condition, and 94% expressed a need for more teaching. 59% indicated that they were only slightly familiar or unfamiliar with NAFLD. The majority of respondents correctly identified diabetes (90%), dyslipidemia (96%), and obesity (97%) as risk factors for NAFLD, while fewer recognized obstructive sleep apnea (53%), hypothyroidism (27%) and hypopituitarism (14%) as risk factors. Cardiovascular disease and cirrhosis were reported as the most common causes of mortality from NAFLD by 37% and 35% of respondents, respectively. Up to 59% of respondents reported that non-alcoholic steatohepatitis can be diagnosed through imaging or a blood test. Respondents demonstrated a strong understanding of nonpharmacologic therapies, but only 11% recognized that there are no approved medications for NAFLD. Overall, 35% of the respondents displayed a reasonable knowledge of NAFLD. In univariate analysis, factors associated with greater NAFLD knowledge included internal medicine residency (P=0.001), higher post-graduate year (P=0.003), prior GI or hepatology rotations (P=0.003), and subjective familiarity with NAFLD (Pampersand:003C0.001). However, only higher post-graduate year (P=0.048) and subjective familiarity (P=0.003) remained statistically significant in multivariate analysis. Conclusions Resident physicians perceive NAFLD as an important health issue but significantly lack exposure and knowledge about the condition. Further emphasis and education are needed to bridge these knowledge gaps and improve patient outcomes. Funding Agencies None Endoscopy, Technology & Imaging

Impact of proton pump inhibitor on quality of anticoagulant control and outcomes in atrial fibrillation patients treated with an oral anticoagulant in the COOL-AF registry

Abstract Introduction Proton pump inhibitor (PPI) is commonly prescribed in patients treated with antithrombotic therapy, assuming it will reduce bleeding risk irrespective of the risk of bleeding. Although PPI may reduce the risk of gastrointestinal bleeding in those treated with an oral anticoagulant, PPI may increase INR by accelerating warfarin absorption, thereby increasing the risk of bleeding. We aimed to assess the impact of PPI use on outcomes and quality of anticoagulant control in AF patients treated with OAC. Methods The COOL-AF registry was a nationwide prospective observational study enrolling AF patients from 27 hospitals in Thailand between 2014 and 2017. The registry aimed to evaluate antithrombotic patterns, quality of OAC control, and clinical outcomes. Clinical information of patients was collected every six months and until three years. Patients treated with oral anticoagulants (either warfarin or non-vitamin K antagonist OAC (NOAC)) were included in the present analysis. Patients receiving any PPI type and dosage at the registry entry were counted as PPI users. Poor anticoagulant control was defined as time to therapeutic range (TTR) less than 65%. The association between PPI use and outcomes, including GI bleeding, overall bleeding, all-cause mortality, and ischemic stroke or systemic embolization, were assessed in the Cox model adjusted for age, prior GI bleeding, chronic alcohol use, chronic kidney disease, liver disease, smoking, and baseline anemia. Subgroup analyses were performed in patients at high bleeding risk (HAS-BLED score ≥ 3), and in patients concomitantly treated with antiplatelet. Results Of 3,402 patients in the registry, 2568 (75.5%) were treated with OAC at baseline. The prevalence of females was 43.4%, with a mean age of 68.4 years. The majority of patients (91.1%) received warfarin. The incidence of major bleeding was 2.11 (1.79–2.48) per 100 person-years. PPI was used at baseline in 707 patients (20.8%). Compared with their counterpart, PPI was more frequently used in high-bleeding risk patients (27.3% vs. 18.1%, p < 0.001) and in those with concomitant antiplatelet therapy (37.5% vs. 17.1%, p < 0.001). The mean TTR was similar between PPI and non-PPI users (52.5% vs. 53.8%, p 0.37). PPI use was not associated with poor anticoagulant control (adjusted OR 1.12, 95% 0.89-1.40). The risk of GI bleeding in PPI users was similar to non-user (adjusted HR 1.01, 95%CI 0.59-1.75). The risk of all-cause mortality, ischemic stroke or systemic embolization, and overall bleeding was not different between PPI and non-PPI users. There was no significant interaction between PPI use and bleeding risk or concomitant antiplatelet therapy on adverse outcomes. Conclusion PPI use has no impact on major outcomes, including bleeding in AF patients treated with OAC. The practice of concomitant prescribing of PPI in patients treated with OAC is needed to be re-examined, given the potentially high impact of health care costs.PPI use and outcomes

S1653 Identification of Trends in Post COVID-19 Infection Gastroenterology Clinic Referrals

Introduction: Post-viral gastrointestinal symptoms are well recognized. Over 50% of patients hospitalized with COVID-19 experienced at least one GI symptom. Here we aim to look at longer-lasting sequelae of COVID infections on the digestive system by identifying trends in patients after the resolution of acute COVID symptoms. Methods: A retrospective chart review was performed on all patients referred to the Northwestern Medicine post-COVID GI clinic from November 2020 - June 2021. For each patient, data regarding demographics and hospitalization/ICU stays during their COVID infection, psychiatric comorbidities, and GI history/medications were reviewed. EMR was reviewed to determine if they had changes in bowel habits, loss of appetite, nausea, GE reflux, abdominal pain, and/or bloody stools. Results: 45 patients were referred to the clinic during this 8 month period; however, 6 missed their appointments and thus a total of 39 patients were evaluated. There were 10 males and 29 females (avg age 42). Five of these patients were hospitalized during their COVID infection (3 were in the ICU). The most common reported symptoms were change in bowel habits (85%), abdominal pain (69%), nausea (51%), GE reflux (38%), loss of appetite (31%), and/or bloody stools (15%). Of the 85% of patients who endorsed change in bowel habits, 8/33 reported constipation, 19/33 reported diarrhea, and 6/33 had a mixed picture. 51% of patients had a psychiatric comorbidity of anxiety or depression. 62% of patients had a prior GI history, of which GERD and IBS were the most common. 74% of patients were noted to be on a prior GI medication, of which a PPI or H2 blocker were most common. Conclusion: The majority of patients seen in the post-COVID GI clinic reported a change in bowel habits (primarily diarrhea). A large percentage of patients were also noted to have concomitant psychiatric comorbidities of depression and/or anxiety. As with other GI tract diseases (e.g. IBS, IBD), it is not unexpected that pre-existing psychiatric comorbidities contribute to a heightened GI sensitivity or reporting of GI symptoms. As SARS-CoV-2 binds to ACE-2 receptors located along the GI tract, and viral RNA is shed into feces, it is also possible that the infection can impact GI tract motility and/or gut flora leading to prolonged symptoms after the resolution of respiratory symptoms. Future longitudinal studies are anticipated to determine whether the impacts on GI function are transient or long-lasting.

S2711 Biologic Therapies for Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease

Introduction: Isolated complex perianal fistulas are abnormal connections between the epithelial surfaces of the anal canal and the perianal skin, meeting criteria for complex perianal fistula but without evidence of inflammatory bowel disease (IBD). While over half of patients with Crohn’s disease (CD) have perianal fistulas, isolated perianal CD is rare. Here we discuss five cases of patients presenting with isolated recurrent complex perianal fistula, and we describe their diagnostic evaluation, attempted therapies, and outcomes. Case Description/Methods: Five adults (3 women, 2 men; mean age 38 years old) with no prior GI symptoms/diseases initially presented with perianal pain (3/5), perirectal mass (2/5), diarrhea (1/5), and abdominal pain (1/5) (Table). All patents underwent exam under anesthesia (EUA) with incision and drainage (I&D) of perirectal abscesses, and setons were placed in perianal/rectal fistulas in 4/5 cases. Each patient had colonoscopy without evidence of inflammation on endoscopy or histology. Radiographic imaging (MRIs, MREs, and CT) revealed fistulas and abscesses but no evidence of luminal inflammation. All patients were treated with antibiotics and 4/5 received biologic therapy (Adalimumab, Infliximab, or Ustekinumab). Despite surgical and medical management, complex perianal fistulas were persistent in all patients at follow-up after an average of 45 months. Discussion: For patients who develop recurrent complex fistulas, a presumptive diagnosis of CD is often made. However, patients who present with complex perianal fistulas in the absence of the luminal inflammation characteristically found in CD are said to have isolated perianal disease (IPD). It is unclear whether IPD represents truly isolated severe cryptoglandular fistulas or early presentation of undiagnosed CD, which renders the best treatment approach a clinical dilemma. IPD is classically treated with antibiotics and local surgical intervention, whereas perianal CD treatment is more complex, incorporating the use of immunosuppressive therapy. The cases described in our cohort reveal the importance of a multimodal approach when treating IPD in the absence of luminal findings of CD. While classic medications for CD are unlikely to succeed when used alone for IPD, their incorporation into the treatment regimen may be critical in achieving eventual resolution of perianal disease. Given the similarity in management, it is important to consider CD in the differential for IPD patients even in the absence of luminal findings. Table 1. - Patient Summary PT # Initial Presentation Diagnostic Evaluations Subsequent Diagnosis Medical Therapies Attempted Surgical Procedures Ultimate Diagnosis and Plan (1) 39F Painful perianal mass, presumed to be an abscess or hemorrhoids Flexible sigmoidoscopyColonoscopy with bxMRIEUA Refractory perirectal and rectovaginal fistula with abscess IBD medications: AdalimumabMethotrexate Non-IBD medical therapies: CiprofloxacinMetronidazoleAmoxicillin-Clavulanic acidPrednisone I&DSeton placementFistulectomy with sphincterotomyDiverting sigmoid colostomyFistulotomy Non-healing cryptoglandular anal fistula complicated by surgery Discontinue IBD therapySurgical f/u with consideration for clinical trial of stem cell injection or transperitoneal repair (2) 34M Abdominal pain, diagnosed with sigmoid diverticulitis Colonoscopy with bxMRIMRECT scanEUA Refractory perianal fistula with abscess IBD medications: InfliximabUstekinumabTacrolimusAzathioprine Non-IBD medical therapies: MetronidazoleCiprofloxacin I&DSeton placement Isolated perianal disease in the setting of presumed CD Chronic treatment with chronic, cyclical abx (Ciprofloxacin or Amoxicillin-Clavulanic acidIBD-directed therapy (Azathioprine + Infliximab; will consider Upadacitinib once approved by the FDA)Planning for surgical f/u (3) 43M Painful perianal mass, presumed to be a rectal abscess Colonoscopy with bxMRIEUA Refractory perianal abscess Non-IBD medical therapies: Amoxicillin-Clavulanic acid I&D Isolated cryptoglandular abscess with potential hemorrhoids No need for chronic antibioticsSitz baths and PrepH as neededIf symptoms worsen will plan for EUA and surgical f/u (4) 24F Perianal pain, diagnosed as perianal abscess with fistula Colonoscopy with bxMRIEUA Refractory perianal abscess, inflammatory arthropathy IBD medications: AdalimumabInfliximabAzathioprine Non-IBD medical therapies: CiprofloxacinMetronidazole I&DSeton placement Presumed CD with perianal disease and inflammatory arthropathy IBD-directed therapy (Azathioprine + Infliximab)Planning for surgical f/u (5) 50F Diarrhea and rectal ulcers, presumed to have CD Colonoscopy with bxMRICTEUA Refractory perianal fistula with abscess IBD medications: Infliximab Non-IBD medical therapies: ColchicinePrednisone I&DSeton placementPerineal debridementLay open fistulotomy Presumed CD with perianal disease IBD-directed therapy (Infliximab) Abbreviations: Bx = biopsies. CD = Crohn’s disease. EUA = exam under anesthesia. F = female. F/U = follow up. I&D = incision and drainage. IBD = inflammatory bowel disease. M = male. MRE = magnetic resonance elastography. MRI = magnetic resonance imaging

Role of endoscopic evaluation prior to diagnostic transesophageal echocardiography: Is it necessary?

Background and AimEsophagogastroduodenoscopy (EGD) is often performed prior to transesophageal echocardiogram (TEE) to evaluate for esophageal pathologies. Although TEE is a safe procedure, some contraindications exist, such as esophageal varices. The incidence of bleeding with TEE is <0.01%, which questions the need for this routine invasive procedure prior to TEE. We sought to characterize patients in whom pre‐TEE endoscopy was requested to determine its clinical utility and identify those that would most benefit.MethodsWe retrospectively studied patients who underwent EGD for TEE clearance between January 2014 and October 2019. We assessed how often EGD changed management and complications after TEE in those with EGD abnormalities.ResultsEighty‐three patients were included. Twenty‐three percent had prior GI bleed, 63% had cirrhosis, 18% had known varices, and 7% had prior variceal bleed. The most common EGD findings were varices (33%). Eighty‐one percent proceeded with TEE. Reasons for TEE deferral included varices (12.5%), high‐risk bleeding lesion (12.5%), and mechanical abnormality (12.5%). In the majority (37.5%), TEE was deemed no longer indicated. No patient undergoing TEE had significant hemoglobin drop or overt bleeding. The most common reason for not performing TEE was unrelated to EGD findings: lack of ongoing indication for TEE.ConclusionBased on our study, EGD is likely not needed for TEE clearance in patients with varices or prior GI bleed. Given that data are limited in patients with abnormalities such as strictures, EGD may still be warranted for these patients. Further studies to identify which patients will benefit from pre‐TEE endoscopy are warranted.

A135 DO VISCOUS SWALLOWS IMPROVE THE DIAGNOSTIC YIELD OF HIGH-RESOLUTION MANOMETRY?

BackgroundEsophageal motility disorders are diagnosed using high-resolution esophageal manometry (HR-EMS) using the Chicago Classification (CC V4.0) which is based on a series of 10 normal saline swallows (LS). Viscous swallows (VS; thickened liquid/applesauce) are often performed during esophageal manometry; however, they were not included within the framework of CC V4.0. Previous literature has suggested inconsistency between LS and VS in up to 25% of studies, yet it remains unclear whether routine use of VS offers any benefit to LS alone in diagnosing manometric abnormalities according to the CC V4.0.AimsTo determine if the routine use of VS improves the diagnostic yield in HR-EMSMethodsA retrospective analysis of all HR-EMS studies performed between December 2020 and July 2021 at Kingston Health Sciences Centre was completed. Demographic information including age, sex, indication for HR-EMS, surgical history, and chronic narcotic use was documented. Each study (consisting of 10 LS and 10 VS) was reviewed independently by a Gastroenterology Fellow and Neurogastroenterologist. A manometric diagnosis using CC V4.0 was made for both LS and VS. Descriptive statistics were performed.ResultsA total of 101 HR-EMS studies were reviewed (33 male, 68 female, age range 26 to 90 years). The most common indication for HR-EMS was dysphagia (87/101) with 23/101 having 2 indications, 30/101 having 3 indications, and 43/101 patients having >3 indications. Prior upper GI tract surgery and chronic narcotic use was recorded in 9/101 and 8/101 patients, respectively. Two HR-EMS studies were excluded due to incomplete protocol. In total, 38.4% (38/99) had normal HR-EMS for both LS and VS. LS and VS that resulted in a CC V4.0 diagnosis were concordant in 37.4%(37/99) and discordant in 24.2% (24/99). Of the 24 discordant studies, 6 had a CC V4.0 diagnosis for LS (4 esophagogastric outflow obstruction (EGJOO), 1 ineffective esophageal motility (IEM), 1 diffuse esophageal spasm) and normal VS. Ten studies had normal LS and a CC V4.0 diagnosis for VS (9 IEM, 1 EGJOO). Eight had differing CC V4.0 diagnoses for LS and VS.ConclusionsLS and VS resulted in concordant diagnoses in the majority of cases. However, there were discordant results in approximately 25% of cases. In nearly half of these studies, the LS was within normal limits whereas VS yielded a diagnosis of an esophageal motility disorder which may be of clinical significance to the patient’s management. The addition of VS to HR-EMS protocol may increase diagnostic yield in symptomatic patients.Funding AgenciesNone

GOBLET: A phase 1/2 multiple-indication biomarker, safety, and efficacy study in advanced or metastatic gastrointestinal cancers exploring treatment combinations with pelareorep and atezolizumab.

TPS216 Background: Checkpoint blockade therapy only benefits a small subset of GI cancer patients (approximately 4%) with microsatellite instability-high (MSI-H) tumors, which are characterized as immunologically ‘hot’ (Bonneville et al., 2017). Most GI cancers, however, have microsatellite stable (MSS) tumors, which have an immunologically “cold” phenotype with fewer genetic mutations, reduced immune cell infiltration, and downregulated immune checkpoint proteins. These attributes make MSS tumors resistant to conventional immunotherapy including checkpoint blockade therapy (Ooki et al., 2021). Pelareorep is a naturally occurring, non-genetically modified reovirus. Upon intravenous administration, pelareorep selectively kills tumor cells and promotes several immunologic effects that prime tumors to respond to checkpoint blockade. These include the stimulation of tumor-directed innate and adaptive immune responses, increased T cell infiltration, expansion of new T cell clones, and increased PD-L1 expression in tumors (Samson et al., 2018, Manso et al. 2021 AACR). Given its expected synergy with checkpoint blockade, as well as its encouraging efficacy in prior GI cancer studies (Mahalingam et al. 2020), the GOBLET study is designed to evaluate pelareorep plus atezolizumab in multiple GI cancer indications. Methods: GOBLET is an open-label, non-randomized, multiple-cohort, phase 1/2 study in patients with advanced or metastatic GI cancers. This study employs a Simon two-stage design. Stage 1 comprises four treatment groups: Cohort 1 – First-line pancreatic cancer treated with pelareorep plus atezolizumab and chemotherapy (gemcitabine and nab-paclitaxel) (N = 12); Cohort 2 – First-line MSI-H colorectal cancer (CRC) treated with pelareorep plus atezolizumab (N = 19); Cohort 3 – Third-line CRC treated with pelareorep plus atezolizumab and chemotherapy (trifluridine/tipiracil) (N = 14); and Cohort 4 – Second-line or later squamous cell carcinoma of the anal canal treated with pelareorep plus atezolizumab (N = 10). The first 3-6 patients enrolled into the chemotherapy-containing cohorts (Cohorts 1 and 3) comprise a safety run-in that must be successfully concluded prior to enrolling additional patients into these cohorts. The primary objectives are safety and efficacy based on objective response rate (ORR) at week 16. Any cohort showing a promising ORR in Stage 1, based on pre-specified criteria, may be advanced to Stage 2 and enroll additional patients. Clinical trial information: 2020-003996-16.

S1294 Implementation of an Electronic Medical Record Based Transition of Care Program From the Emergency Room to Gastroenterology Clinics Improves Followup

Introduction: Patients discharged from the emergency department (ED) requiring outpatient follow-up are at risk for increased rates of adverse events, return visits to the ED, and hospitalization when they do not follow-up. This highlights preliminary results from a pilot GI Transitionof- Care (GI TOC) program. Methods: A retrospective single center cohort study was performed. ED patients referred for outpatient GI follow-up were examined from before and after implementation of the GI TOC program. The GI TOC program at Stony Brook University Hospital (initiated July 2019) involved a message generated by ED referral orders to GI clinic. This message pool was reviewed by a Gastroenterologist who triaged each patient for urgency and directed patients to appropriate GI subspecialty clinics. The GI office then called patients to facilitate appointment scheduling. Patients discharged from the ED prior GI TOC were simply given the GI office phone number. Primary outcome: percentage of patients discharged from the ED for GI follow-up who successfully completed a follow-up GI appointment. Secondary outcomes included rates of appointment scheduling and percent of diagnostic testing and therapeutic GI procedures generated as a result. Results: There were 233 GI TOC patients during the 5-month period from August-December 2020. 942 ED patients were referred to GI over a 5-month period from February-June 2019. These time periods were chosen to minimize the bias introduced by the COVID19 pandemic. GI TOC patients were statistically more likely to schedule GI appointments (48.93% vs 21.97%, p<0.01) and show up (37.77% vs 20.91%, p<0.01) when compared to pre-GI TOC patients. Of the patients who showed up to appointments, pre-GI TOC patients were more likely to have additional diagnostic testing (e.g. labs and imaging) when compared to GI TOC patients (80.71% vs 64.77%, p<0.01). However, GI TOC patients had a higher percentage of endoscopic procedures ordered when compared to pre-GI TOC patients (85.96% vs 64.41%, p<0.01). Conclusion: Patient navigation through a GI TOC program can result in improved outpatient GI follow-up. Expediting patient care, GI TOC programs can decrease repeat ED visits and costly hospitalizations. GI provider review of consults for urgency and appropriate subspecialty clinics can introduce increased efficiency in patient care. GI TOC can also result in increased downstream revenue for the GI practice through procedure generation..

Comparative Effectiveness of Machine Learning Approaches for Predicting Gastrointestinal Bleeds in Patients Receiving Antithrombotic Treatment

Anticipating the risk of gastrointestinal bleeding (GIB) when initiating antithrombotic treatment (oral antiplatelets or anticoagulants) is limited by existing risk prediction models. Machine learning algorithms may result in superior predictive models to aid in clinical decision-making. To compare the performance of 3 machine learning approaches with the commonly used HAS-BLED (hypertension, abnormal kidney and liver function, stroke, bleeding, labile international normalized ratio, older age, and drug or alcohol use) risk score in predicting antithrombotic-related GIB. This retrospective cross-sectional study used data from the OptumLabs Data Warehouse, which contains medical and pharmacy claims on privately insured patients and Medicare Advantage enrollees in the US. The study cohort included patients 18 years or older with a history of atrial fibrillation, ischemic heart disease, or venous thromboembolism who were prescribed oral anticoagulant and/or thienopyridine antiplatelet agents between January 1, 2016, and December 31, 2019. A cohort of patients prescribed oral anticoagulant and thienopyridine antiplatelet agents was divided into development and validation cohorts based on date of index prescription. The development cohort was used to train 3 machine learning models to predict GIB at 6 and 12 months: regularized Cox proportional hazards regression (RegCox), random survival forests (RSF), and extreme gradient boosting (XGBoost). The performance of the models for predicting GIB in the validation cohort, evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, and prediction density plots. Relative importance scores were used to identify the variables that were most influential in the top-performing machine learning model. In the entire study cohort of 306 463 patients, 166 177 (54.2%) were male, 193 648 (63.2%) were White, the mean (SD) age was 69.0 (12.6) years, and 12 322 (4.0%) had experienced a GIB. In the validation data set, the HAS-BLED model had an AUC of 0.60 for predicting GIB at 6 months and 0.59 at 12 months. The RegCox model performed the best in the validation set, with an AUC of 0.67 at 6 months and 0.66 at 12 months. XGBoost was similar, with AUCs of 0.67 at 6 months and 0.66 at 12 months, whereas for RSF, AUCs were 0.62 at 6 months and 0.60 at 12 months. The variables with the highest importance scores in the RegCox model were prior GI bleed (importance score, 0.72); atrial fibrillation, ischemic heart disease, and venous thromboembolism combined (importance score, 0.38); and use of gastroprotective agents (importance score, 0.32). In this cross-sectional study, the machine learning models examined showed similar performance in identifying patients at high risk for GIB after being prescribed antithrombotic agents. Two models (RegCox and XGBoost) performed modestly better than the HAS-BLED score. A prospective evaluation of the RegCox model compared with HAS-BLED may provide a better understanding of the clinical impact of improved performance.

Depression in individuals who subsequently develop inflammatory bowel disease: a population-based nested case–control study

ObjectiveDepression is a potential risk factor for developing IBD. This association may be related to GI symptoms occurring before diagnosis. We aimed to determine whether depression, adjusted for pre-existing GI...

Thiamine deficiency in the outpatient psychiatric oncology setting: A case series.

B vitamins are essential for the functioning of the nervous system. Vitamin B1 (thiamine) deficiency is associated with neuropsychiatric syndromes such as Wernicke's encephalopathy (WE), which, if untreated, has an estimated mortality of 17-20%. Although the prevalence of thiamine deficiency in the general population is difficult to estimate, it is being increasingly recognized in oncology, especially in the inpatient setting. We describe three cases of thiamine deficiency (TD) in the outpatient psychiatric oncology setting. Retrospective chart review of three adult patients, who were seen in the psychiatric oncology clinic and found to have TD on laboratory testing, was done. Patient, disease, and thiamine treatment-related information were obtained, and descriptive statistics were used to analyze the data. The average age was 59 years, mean body mass index (BMI) was 22.00 ± 4.58 (mean ± SD), and mean thiamine level was 59.10 ± 7.69 that ranged from 45 to 68 nmol/L (normal thiamine level reference: 70-180 nmol/L). None of the patients had brain imaging nor cerebrospinal fluid analysis. Risk factors such as unbalanced nutrition, prior GI surgery, renal disease, and chemotherapy were noted. TD can have a multifactorial etiology in oncology. Identification of TD in both inpatient and outpatient setting is important. Our report highlights how early identification of TD in the outpatient setting can help prevent further clinical progression.

S2864 A Rare Presentation of Immunoproliferative Small Intestinal Disease

INTRODUCTION: Immunoproliferative small intestinal disease (IPSID), is a form of extra-nodal marginal zone B-cell lymphoma, seen in young adults in the Mediterranean basin and Southeast Asia. It characterized by the production of monoclonal heavy chain without light chains that are deposited in the lamina propria, culminating in blunting of intestinal villi, malabsorption, and protein-losing enteropathy. It manifests as colicky abdominal pain, persistent diarrhea, malabsorption, weight loss and failure to thrive. IPSID is associated with chronic Campylobacter jejuni infection and has a range of presentation from lymphoid infiltration to malignant diffuse large-B-cell lymphoma, early stages of which are completely responsive to antibiotics. CASE DESCRIPTION/METHODS: A 50-year-old woman presented after syncope and a two-week history of persistent watery diarrhea and thirty-pound weight loss over six months (Table A). Four months prior, she was hospitalized in Nigeria for similar symptoms. She was ill-appearing and malnourished with a diffusely tender abdomen. Computed tomography revealed diffuse mesenteric lymphadenopathy. An extensive infectious (Table A) and non-infectious (Table B) was negative except for a positive Campylobacter stool antigen. Endoscopy revealed moderate gastritis and colitis, duodenal biopsy revealed blunted villi and lymphocytic infiltration (Figure A). Her diarrhea improved with antibiotics and she was discharged.One month after discharge, she presented with recurrence of symptoms. An extensive workup yielded the same results as before. Biopsy of mesenteric lymph nodes revealed reactive lymphadenitis. One year later, the patient presented to the hospital again, now with neck pain and dysphagia in addition to the prior GI symptoms. She was found to have cervical lymphadenopathy biopsy of which revealed lymphoma. She was diagnosed with IPSID Stage C initiated on chemotherapy. However, she succumbed to her disease. DISCUSSION: IPSID should be considered in all patients from endemic regions after other causes of infectious and non-infectious diarrhea and mesenteric lymphadenopathy are ruled out. Early diagnosis and treatment, at a stage responsive to antibiotics, may lead to resolution of the disease. In the case of our patient, Campylobacter stool antigen was persistently positive even after she had left an endemic region (West Africa) and received multiple courses of antibiotics, underscoring the puzzling nature of the source of her recurrent bacterial infection.Table 2.: Diarrhea and mesenteric lymphadenopathy can be caused by a multitude of pathology, which should be considered and ruled out because a diagnosis of IPSID is madeTable 1.: Initial presentation versus one month later versus one year laterFigure 1.: 4x magnification, Low power view of the small intestinal mucosa with marked villous blunting and expansion of lamina propria by small, mature lymphoid cells. Figure 2: 40x magnification, High power view of the small intestinal mucosa showing sheets of predominantly mature lymphoid cells with scattered plasma cells and eosinophils.

Safety of palbociclib concurrent with palliative pelvic radiotherapy: discussion of a case of increased toxicity and brief review of literature.

Several cyclin‐dependent kinase 4/6 (CDK4/6) inhibitors are indicated in the treatment of metastatic hormone receptor‐positive (HR)/ human epidermal growth factor receptor 2 (HER2) negative breast cancer which includes palbociclib, ribociclib and abemaciclib. Pelvic radiation therapy (RT) is often indicated for symptomatic or progressive bone metastasis. There are limited data on concurrent use of CDK4/6 inhibitors with pelvic RT with few retrospective studies in the literature involving a small number of patients. The major side effects of these agents include haematological toxicities, while non‐haematological toxicities are less severe. There are concerns for an increased possibility of synergistic toxicity with concurrent use of CDK4/6 inhibitors with pelvic RT. Here we describe an instance of acute grade 3 gastrointestinal toxicity and discuss the relevant literature. A 77‐year‐old lady treated with palliative conventional RT 30 Gy/ 10 fractions concurrently with palbociclib to left hemipelvis and proximal femur, developed severe pancolitis starting 5 days from last RT. She needed inpatient care for 3 weeks and recovered with mesalamine and supportive care. We also postulate a few strategies that can be adopted in patients receiving palliative RT in such a scenario. The agents should be stopped 1 week before, during and for a time (1 week minimally) after RT. A shorter course of 5 fractions (and ablative RT as indicated) can be considered to minimise treatment gaps. Highly conformal techniques (intensity‐modulated radiotherapy/ volumetric‐modulated arc therapy) can significantly reduce bowel dose and should be considered in patients with pre‐existing GI comorbidities or prior GI toxicity with these agents.

264-OR: Characterizing the Distinct Glycemic Patterns Of Postbariatric Hypoglycemia (PBH)

While bariatric surgery can promote remission of type 2 diabetes (T2D), it can also result in severe hypoglycemia, termed post-bariatric hypoglycemia (PBH). Hypoglycemia is most often recognized after meals, but also can occur after activity or during mid-nocturnal hours and can yield unawareness and disabling neuroglycopenia. We used blinded CGM (Dexcom G4) to characterize glycemia, glycemic variability (GV), and severity and length of hypoglycemia in patients with PBH with prior roux-en-Y gastric bypass (PBH, n=40). We compared results to those of individuals with reactive hypoglycemia with no prior GI surgery (Hypo, no-GS, n=20) and to publicly available Dexcom G4 data from 3 additional groups: healthy controls (HC, n=38), prediabetes (Pre-DM, n=14), and T2D (n=5). Metrics were assessed over 24 hours as well as during daytime (6 AM to midnight) and nighttime (midnight to 6 AM) independently. Mean and median sensor glucose (SG) were similar for PBH and HC (mean: 99.8±18.6 vs. 96.9±10.2 mg/dL; median: 93.0±14.8 vs. 94.5±7.4 mg/dL, p&amp;gt;0.05 for both). By contrast, PBH had higher coefficient of variation (27.3±6.8 vs. 17.9±2.4%, p&amp;lt;0.0001) and a wider range and IQR of SG values (range: 154.5±50.4 vs. 112.0±26.7 mg/dL; IQR: 28.0±7.4 vs. 20.0±4.4, p&amp;lt;0.0001 for both). Nadir SG was lowest in PBH (42.5± 3.7 mg/dL vs. other groups, p&amp;lt;0.0001) with statistical significance vs. HC (49.0±11.9 mg/dL, p=0.0046). PBH had greater percentage of time with SG&amp;lt;70 mg/dL vs. HC (7.7±8.4 vs. 3.2±4.1%, p&amp;lt;0.002); these differences were greater at night (12.6±16.9 vs. 1.0±1.5%, p&amp;lt;0.0001). Also, the frequency of severe hypoglycemic episodes (&amp;lt;54 mg/dL, duration ≥ 15 minutes) per day was higher for PBH group vs. HC (0.5 vs. 0.1, p&amp;lt;0.002). In summary, patients with PBH experience higher GV and greater severity and frequency of hypoglycemia compared to HC, especially at night. Future studies should explore the potential of CGM technology in assisting PBH patients to recognize early hypoglycemia and prevent severe hypoglycemia. Disclosure D. Lee: None. J. Dreyfuss: None. C.M. Mulla: None. M. Patti: Consultant; Self; Fractyl Laboratories, Inc. Research Support; Self; Dexcom, Inc., Xeris Pharmaceuticals, Inc. Other Relationship; Self; Academy of Nutrition and Dietetics, American Diabetes Association, American Society of Metabolic and Bariatric Surgery, Endocrine Society, Insulet Corporation, King Abdullah International Medical Research Center, SUNY Downstate. Funding National Institutes of Health (R01DK121995); National Institute of Diabetes and Digestive and Kidney Diseases (T32DK007260)

1627 Segmental Colitis Associated With Diverticulosis: An Emerging Entity Among the Non-Specific Colitis

INTRODUCTION: An 86 y/o male with diverticulosis and hypertension, arrived at the ER due to intermittent episodes of bright rectal bleeding associated with lower quadrant abdominal pain since 3 weeks ago. Laboratories without anemia, leukocytosis, eosinophilia or any other abnormality. CT abd/pelvic revealed a segmental area of concentric mural thickening and narrowing of the lumen of the sigmoid colon, concerning for a mass. No prior colonoscopies or GI alarming features. GI service consulted for diagnostic endoscopic procedure. CASE DESCRIPTION/METHODS: Sigmoidoscopy was remarkable for severe diverticular disease of the rectal mucosa with associated significant erythema, exudative material and loss of vascular pattern consistent with an inflammatory process. At 20 cm from the anal verge, a luminal narrowing covering &gt; 90% of the lumen extended up to 27 cm. Pathology report from the area of obstruction showed acute over chronic inflammation without granulomas, microorganisms or dysplasia. He was started on rectal mesalamine and a 14-day course of oral antibiotics (metronidazole and ciprofloxacin). Surgery service consulted which agreed with medical management. Within two weeks after completion of antibiotics, colonoscopy was performed revealing marked improvement of the luminal narrowing evidenced in the previous colonoscopy at 20cm, including less degree of inflammation and fewer loss of vascular pattern among the segmental area within multiple diverticuli. Biopsies taken from the same narrowing were remarkable for chronic inflammation without dysplasia. All findings were consistent with segmental colitis associated with diverticulosis (SCAD). DISCUSSION: SCAD is an inflammatory process that affects colonic luminal mucosa in areas that are affected by diverticulosis. The prevalence is 1.5 – 11.4% among those with diverticular disease. The pathogenesis of SCAD is unclear. The clinical presentation is not specific and thus similar to other pathologies, including inflammatory bowel disease, for which makes this condition difficult to diagnose. There are currently no guidelines for its management. It is frequently based on the administration of salicylates, antibiotics and surgical intervention for refractory cases. Currently it is unclear if SCAD is in fact a spectrum of IBD or if it is itself a separate entity. The rarity of SCAD supports the claim that further research is needed to better understand the disease and thus improve its management and clinical outcomes.

2354 Massive Hematochezia Due to Bleeding Cecal Varices in a 35-Year-Old

INTRODUCTION: Bleeding from cecal varices is a rare complication of portal hypertension. We present a case of bleeding cecal varices manifesting as massive hematochezia in a 35 year-old woman with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 35yo woman with chronic alcoholism presented with hematochezia, hypotension, and syncope. She endorsed a 15-year history of heavy alcohol intake, with no known liver disease or prior GI bleeding. Vital signs included HR 112 bpm and BP 83/48 mmHg. Labs indicated hemoglobin 6.6 g/dL, platelet count 58 K/uL, BUN 12 mg/dL, INR 1.5. Upper endoscopy showed no esophageal varices or blood. Colonoscopy showed red blood in the entire colon causing impaired visualization of underlying mucosa. The patient had continued hematochezia and hypotension requiring massive transfusion. CT angiography revealed active bleeding in the cecum and proximal ascending colon with abnormal surrounding vascularity, consistent with bleeding cecal varices (Figure 1). Arteriography demonstrated rectal, splenic, gastric, and small esophageal varices. The patient underwent transhepatic intravenous portosystemic shunt (TIPS) with an associated portosystemic gradient decrease from 24mmHg to 14mmHg. She had no further bleeding and was started on Nadolol for further reduction in portosystemic pressure. The patient was discharged in stable condition. DISCUSSION: Bleeding colonic varices are an uncommon manifestation of portal hypertension, with an incidence of 0.07%. Specifically, bleeding cecal varices are far more rare, and have been reported in less than 20 cases in the literature. This report describes a case of bleeding cecal varices in a 35 year-old with alcoholic cirrhosis; there is only one other report of bleeding cecal varices in a younger patient. Hemorrhage from these lesions is life threatening and requires robust knowledge of diagnostic and therapeutic options. Diagnosis is often attempted with colonoscopy, however can be difficult due to visual obscuration by bleeding. Mesenteric angiography is most effective in diagnosis. Endoscopic and radiologic interventions include cyanoacrylate injection, endoscopic variceal ligation, coil embolization, balloon occluded retrograde transverse obliteration (BRTO), and TIPS. In our case, the decision to pursue TIPS was made due to complicated superior mesenteric artery anatomy precluding coil embolization. Aggressive resuscitation and collaboration between gastroenterology, surgery, and radiology made for a successful outcome for this young patient.

Barriers to Colonoscopy in an Uninsured Patient Population—A Quality Improvement Project

Colorectal cancer remains common, with the "80 per cent by 2018" initiative proposed by the National Colorectal Cancer Roundtable. This study was designed to examine obstacles for patients who did not receive their scheduled colonoscopy, focusing on the impact of insurance status. Retrospective chart review was carried out on patients who did not complete their colonoscopy as scheduled from January 2013 to June 2017. The control group consisted of patients who completed their scheduled colonoscopy. One hundred and seventy five patients missed 200 colonoscopies. The most common reasons for cancellation were patient illness (16%), no-show (14%), no prep carried out (13%), inadequate prep (10%), and no transportation (11%). The canceled patients were significantly more likely to have the combination of no insurance and no Primary Care Provider (PCP) (13% vs 4%, P = 0.008), personal history of cancer (22% vs 12%, P = 0.02), and higher rates of prior GI issues (78% vs 50%, P < 0.001). The canceled group had a significantly lower history of colon polyps (37% vs 53%, P = 0.006). Difficulty with the bowel prep in addition to lack of insurance and poverty likely does create a barrier, even in a system that has a safety net, atop other issues such as transportation and inability to miss work playing a role.

Role of Pre-LVAD Endoscopic Screening and Assessment of Risk Factors Associated With Post-LVAD Implantation Gastrointestinal Bleeding

Introduction: Left Ventricular Assist Devices (LVAD) occupy a key place in treatment for end-stage heart failure. However, around 20 - 30 % of the patients present with post-implant gastrointestinal bleed (GIB). To effectively manage the GIB in this patient population, it is vital to understand the associated risk factors and demographic parameters. Hence, we conducted this study to assess the role of pre-LVAD endoscopic screening in this population and to identify the risk factors associated with post-LVAD GIB. Methods: We performed a retrospective study at a single academic tertiary care referral center in patients who had Heart Mate IITM LVAD placed between 2010 and 2017. Various parameters, including patient demographic data, pre-LVAD endoscopic findings, history of prior GI bleed, time between LVAD implantation and admission for GIB, LVAD settings, laboratory data during admission, and endoscopic intervention utilized were analyzed. The statistical analysis was conducted using SAS v9.4. Results: 68 patients had LVAD implanted between 2011 and 2017. 25/68 patients (36.7%) had at least one admission for a GIB. Both groups (bleeders vs. non-bleeders) were similar in their demographics, pre-LVAD endoscopic screening procedures and findings (Table 1). However, those that presented with GIB were more likely to have a history of GIB prior to the implantation (p = 0.037) and an increased LVAD power (p= 0.05) (Table 1). 68% of the patients with GIB presented to the hospital within 1 year of implantation and 88% were managed in the non-ICU setting. EGD was performed in 67 % of the GIB patients and 77% of the endoscopic procedures were done within 2 days of admission. Of the patients that presented with GIB, 36% had multiple readmissions (Table 2). Compared to patients with a single GIB, the patients with multiple GIB had an increased LVAD power (p=0.036) and lower admission hemoglobin (p=0.006) (Table 2). Further, analysis revealed that patients with 3 or more readmissions for GIB had a significantly higher percentage of their first admission within 90 days of LVAD implantation (p=0.012) (Table 3). Conclusion: No significant association was seen between pre-LVAD endoscopic screening and post-LVAD admission for GIB was noted. History of prior GIB increases the risk of GIB in LVAD patients. A higher LVAD power and shorter median time between LVAD implantation and first admission (< 90 days) for GIB are significantly associated with recurrent GIB hospitalizations.567_A Figure 1 No Caption available.567_B Figure 2 No Caption available.567_C Figure 3 No Caption available.

Examining Individuals’ Decision Making Surrounding Bowel Preps for Colonoscopy: Insights From a Conjoint Analysis Survey

Introduction: Bowel cleansing is a critical factor in determining the quality of colonoscopic exams. There are 11 bowel preps available for clinical use, and it can be difficult for patients to navigate the different options and to select their preferred prep. In this study, we examined individual decision making surrounding bowel preps using conjoint analysis, a form of tradeoff analysis that determines how participants make complex decisions by presenting them with competing prep profiles. Methods: We performed a conjoint analysis survey that quantified the relative importance of 8 bowel prep attributes (Figure) in the decision-making process. We partnered with Cint, a survey research firm, to recruit Americans ≥ 18 y.o to complete the choice exercise. The conjoint analysis software determined each individual’s preferences by calculating importance factors (part-worth utilities) for each prep attribute (higher part-worth utility=more important factor in decision-making process). We also conducted regression analysis to determine if patient demographics and clinical characteristics (e.g prior colonoscopy, comorbidities, etc.) predicted importance of tested attributes. Results: 628 individuals completed the survey and the determinants of decision-making are shown in the Figure. Out-of-pocket cost, prep effectiveness, and risk for belly pain were the most important factors in the decision-making process. Prep characteristics such as form of bowel prep (liquid vs pill-based vs edible), flavor, and amount of liquid needed to ingest were less important. In regression analyses, demographic and clinical factors largely did not predict part-worth utilities for the tested attributes, save for a few exceptions (Table). Those with prior GI surgery were more likely to value prep characteristics. Individuals from high income households prioritized the prep’s bowel cleansing effectiveness in the decision-making process. Non-Hispanic blacks and Asians deemed avoidance of side effects as the most important factor when selecting among the preps.153_A Figure 1. Average bowel prep attribute importance scores (N=628). The average importance of each bowel prep attribute is based on conjoint analysis part-worth utilities. The leading factor in bowel prep decision making was out-of-pocket cost at 34.4%, followed by chances of incomplete bowel cleansing, belly pain, nausea, and vomiting. Conversely, prep characteristics such total liquid ingested, flavor, and form of prep were less valued in the decision-making process.153_B Figure 2. Odds ratios for reporting prep characteristics, prep cost, prep effectiveness, or prep side effect profile as the most important factor in the decision-making process.Conclusion: The determinants of decision-making surrounding bowel preps for colonoscopy are largely driven by out-of-pocket costs while prep characteristics (i.e. form, flavor, amount of liquid) were less important. Moreover, demographics and clinical characteristics poorly predicted decision making; this calls for the need of online decision tools to support patients when choosing among the available prep options for colonoscopy.

Small Bowel Transit Time Index Demonstrates Good Agreement and Accuracy in Predicting Best Approach for Double Balloon Enteroscopy

Introduction: Advances in capsule endoscopy (CE) have brought enhanced visualization in small bowel mucosa; however, it is limited by its inability to localize and intervene on abnormalities. Double balloon enteroscopy (DBE) allows for tissue acquisition, therapeutic intervention, and improved visualization. A negative procedure often requires repeat procedure from an alternate approach. When performed prior to DBE, CE can help decide the appropriate endoscopic route and reduce unnecessary procedures. The objective of our study was to evaluate the agreement and accuracy of using a small bowel transit time (SBTT) index value of 0.6 in determining the best approach for DBE. Methods: We performed a retrospective analysis of 71 patients with positive findings on CE who underwent DBE at our hospital. Incomplete CE studies or patients with prior GI surgery were excluded. CE was analyzed for transit time to duodenum, culprit lesion, and ileocecal valve. SBTT index was calculated as the time from the duodenum to index lesion divided by the total SBTT (time from duodenum to ileocecal valve). SBTT index of less than 0.6 was chosen to suggest anterograde approach and a value of greater than 0.6 was used to suggest retrograde approach. Cohen's kappa, which accounts for the possibility of the agreement occurring by chance, was used to measure agreement between suggested and actual DBE results. For example, if the lesion was detected on anterograde DBE and SBTT index was less than 0.6, agreement was suggested. Accuracy was calculated as a proportion of correct suggestions. Results: 71 patients (mean age 65, 49% male) with positive findings on CE were included (Table 1). Of these, 53 had SBTT index < 0.6, suggesting that the lesion might be best detected on anterograde approach. The lesion was found in 48 of the 53 patients with the method suggested by SBTT. 18 patients had SBTT index >0.6. 13 of these patients underwent retrograde endoscopy with lesions identified. Cohen's Kappa for the level of agreement between suggested DBE based on SBTT index and actual DBE was 0.63 (0.35, 0.82). The level of accuracy for the suggestion of anterograde compared to retrograde approach was 0.86 (95%CI 0.75, 0.93).Table: Table. Summary of the findings on double-balloon enteroscopy (DBE) with suspected findings on capsule endoscopy (CE)Conclusion: There is good agreement between suggested DBE based on SBTT index of 0.6 and actual DBE results as judged by this study. The accuracy of the SBTT index in choosing the correct route for DBE is 0.86. A SBTT index of 0.6 can reliably be used to predict the best insertion route for DBE.