Repeat Endoscopy Research Articles

Small Bowel Hemolymphangioma Treated by Polypectomy in a Pediatric Patient with Cystic Fibrosis

Small Bowel Hemolymphangioma Treated by Polypectomy in a Pediatric Patient with Cystic Fibrosis

Esophagitis Dissecans Superficialis in Children.

Esophagitis dissecans superficialis (EDS) is a desquamative disorder of the superficial esophageal epithelium with variable clinical characteristics. Endoscopically, there is an appearance of superficial peeling of sheets of epithelium. Histologically there is 2-toned epithelium with coagulative necrosis of the superficial epithelium. Currently, there is paucity of data regarding this condition in children. A 10-year retrospective search of the pathology information system was performed for cases with a pathologic diagnosis of EDS in a tertiary care pediatric center. Demographic data, clinical history, endoscopic findings, and histopathologic reports were reviewed. Thirteen patients (9 girls; ages 3-18 years), were identified with histologic findings of EDS. Esophageal food impaction, dysphagia, vomiting, and abdominal pain were the most common presenting symptoms. Sixty-nine percentage of the patients had underlying comorbidities and 76% were on at least 1 medication chronically. Eosinophilic esophagitis (23%), inflammatory bowel disease (23%), and gastroesophageal reflux disease (GERD) (15%) were the most common associated diagnoses. Of the 13 patients, 5 had repeat endoscopies showing complete resolution of EDS with no complications. EDS is an under-recognized entity that endoscopists should be familiar with. In our series, the most prevalent associations were with food impaction and eosinophilic esophagitis (EoE). Contact injury and/or inflammation may precede the development of EDS. Pediatric EDS appears to be an incidental finding without significant morbidity or mortality.

Inhalation and ingestion of magnetic foreign bodies in a toddler with persistent cough—a case report

: Inhalation and ingestion of foreign bodies are common emergency presentations in paediatric otolaryngology. Here we present a case of an incidental finding of simultaneous ingestion and inhalation of small magnets in a 21-month-old following a history of worsening cough. The initial diagnosis was thought to be a viral upper respiratory tract infection, however, due to the persistence of symptoms, a chest x-ray was obtained, which revealed two foreign bodies in the location of the left main bronchus. The first attempt at endoscopic removal of foreign bodies using laryngoscopy, bronchoscopy and oesophagoscopy (LBO) was unsuccessful due to a complete occlusion of the left main bronchus by a significant mass of friable granulation tissue precluding visualisation of the foreign bodies. An urgent computed tomography (CT) scan was obtained to further delineate the location of the foreign bodies; this, unfortunately, was limited by streak artefacts but raised the possibility of the foreign bodies being in both the airway and the oesophagus. Given the potential of a fistula and the close proximity of the objects to the carina, median sternotomy with cardiopulmonary bypass was planned for retrieval and reconstruction if endoscopic retrieval failed. Repeat endoscopy successfully retrieved two magnetic ball-bearings measuring 6mm in diameter each. One was located in the left main bronchus and the other in the oesophagus. To our knowledge, this is the first case in Australia described of two foreign bodies entering the airway and digestive tract at the same time. We discuss the presentation, diagnosis and management of this case including the diagnostic dilemma encountered and the involvement of multidisciplinary teams. This case highlights the importance of having a high clinical suspicion of foreign body inhalation/ingestion in paediatric patients presenting with prolonged unexplained respiratory symptoms and no resolution with standard treatment.

A199 SEVERE COLITIS FOLLOWING PELVIC RADIOTHERAPY: CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background Mild-to-moderate proctocolitis is a well-known complication of pelvic radiation therapy, occurring in 43% and 6% of patients following external beam radiotherapy (EBRT) and brachytherapy (BT), respectively. This typically presents as recurrent painless rectal bleeding, diarrhea, urgency, and/or iron-deficiency anemia. Severe ulcerating proctocolitis is a less common complication of pelvic radiotherapy and is rare following BT. We report two cases of severe ulcerating proctocolitis mimicking inflammatory bowel disease (IBD) following pelvic radiotherapy in patients without known IBD, including an elderly male undergoing EBRT, and an elderly female undergoing vaginal vault BT. Aims To describe two cases of severe ulcerating proctocolitis, mimicking IBD, following pelvic radiotherapy. Methods Case descriptions and literature review. Results A 71-year-old male without antecedent gastrointestinal disease developed bloody diarrhea 3 months following EBRT for treatment of prostate cancer. Infectious work-up was negative. Blood work showed anemia and an elevated CRP. CT scan showed distal large bowel inflammation concerning for proctocolitis. Flexible sigmoidoscopy revealed severe proctosigmoiditis with circumferential thickening and nodularity of the mucosa and multiple ulcers. Biopsies showed ulcer tissue with fibrinopurulent exudate. He was treated with systemic corticosteroids and symptoms gradually resolved. Repeat colonoscopy 8 months later showed healed inflammation with scarring and residual radiation proctosigmoiditis. A 74-year-old female without antecedent gastrointestinal disease developed watery diarrhea 2 weeks after initiating low dose vaginal vault BT for treatment of endometrial cancer. Infectious work-up was negative. Blood work showed an elevated CRP and CT scan revealed proctocolitis extending to the descending colon. Flexible sigmoidoscopy revealed severe ulcerating proctosigmoiditis with tram tracks of denuded mucosa. Biopsies showed moderate diffuse chronic active colitis with crypt abscesses and apoptotic bodies. She was treated with systemic corticosteroids followed by infliximab and methotrexate, with mild symptomatic improvement. However, repeat endoscopy revealed persistent severe ulceration. Unfortunately, she developed a sigmoid perforation with pelvic abscess, leading to bacteremia and fungemia, and subsequently passed. Conclusions While rare, severe ulcerating proctocolitis mimicking IBD can occur following pelvic radiotherapy, including BT. The decision to manage these patients as IBD using immunosuppressive therapy should be weighed against the risks of these therapies, considering a patient’s age and underlying health, and in collaboration with a patient’s health care team. Careful assessment for risk factors and pathological findings from biopsy specimens may help in predicting the likelihood of IBD in such patients. Funding Agencies None

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE.

Abstract Background Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated. Aims To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE. Methods An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020. Results 62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of >50 new patients per year; 9/16 centres have >100 patients in follow-up. An EoE Clinic is present in 5 centres. Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1). Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings. Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children <10 and >10 years, respectively. Conclusions The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research. Funding Agencies None

Clinical Practice Survey of Repeat Endoscopy in Pediatric Inflammatory Bowel Disease in North America.

Endoscopic remission has become a standard treatment target in inflammatory bowel disease (IBD). It is unclear how widely this practice has been adopted amongst pediatric gastroenterology providers. This study determines the frequency of repeat endoscopy in pediatric IBD and evaluates for predictive baseline characteristics of providers. We developed a cross-sectional survey, which was distributed via 3 national email listservs to pediatric gastroenterology providers. We obtained baseline characteristics of respondents and assessed motivations and barriers for the practice of repeat endoscopy compared with none. Two hundred and thirty-eight unique respondents completed the online survey. Response rate was 11% (238 of 2300 possible participants). The majority practice in an academic setting (77%) and reported participation in ImproveCareNow (63%). Overall, 65% of respondents perform repeat endoscopy to assess for endoscopic remission in pediatric IBD as part of routine clinical practice. Fifty-six percent reported repeat endoscopy as individuals in the absence of a departmental protocol. "Symptoms are not sufficient to follow IBD patients" was reported by 82% of those who repeat endoscopy; conversely, "I perform endoscopy based on clinical, biomarker, and/or imaging trends" was reported by 81% of those who do not repeat endoscopy. The establishment of a pediatric-specific guideline was most commonly reported to change current practice, based on rank-order scoring. A majority of representative providers repeat endoscopy to assess for endoscopic remission in pediatric IBD. Fewer years in practice favored repeating endoscopy. The need for North American pediatric guidelines with pediatric-specific evidence to support the long-term benefits of endoscopic remission are highlighted in this study.

Sudden Chest Pain Due to Esophageal Intramural Dissection

Sudden Chest Pain Due to Esophageal Intramural Dissection

Fecal calprotectin as a noninvasive test to predict deep remission in patients with ulcerative colitis.

Mucosal healing (MH) has become a major target in the management of ulcerative colitis (UC). Because repeat endoscopy is expensive and invasive, we aimed to evaluate fecal calprotectin (FC) as an alternative marker to predict MH in UC.Eighty patients with UC in clinical remission were consecutively included in a prospective observational study. FC was measured using a quantitative enzyme-linked immunosorbent assay. The colonic mucosa was assessed for endoscopic and histological measures of inflammatory status. Endoscopic and histological remission were defined according to the Mayo endoscopic subscore (MES) and Geboes score (GS), respectively. Deep remission was defined as a combination of the MES and GS. FC performance and cutoff values for identifying MH and deep remission were determined using contingency tables and receiver operator characteristic (ROC) and area under the curve (AUC) analysis.The median FC concentration in patients who met the criteria for deep remission (MES ≤1 and GS < 3.1) was 65.5 μg/g, while that in patients with disease activity was 389.6 μg/g (P = .025). A FC cutoff value of 100 μg/g, determined by the ROC analysis, resulted in sensitivity and specificity of 91.7% and 57.1%, respectively, for histological remission, and 82.4% and 60.9%, respectively, for deep mucosal remission. Positive correlations were detected between FC concentrations with the histologic (CC: 0.435; P < .001) and the combined endoscopic and histologic (CC: 0.413; P < .001) scores.FC can be used confidently as a noninvasive biomarker to predict deep remission in patients with UC in clinical remission when concentrations are below 100 μg/g.

Endoscopic resection is more effective than biopsy or EUS to detect residual rectal neuroendocrine tumor

Background and study aims Rectal neuroendocrine tumors (NETs) are often discovered incidentally and may be misidentified as adenomatous polyps. This can result in a partial resection at the index procedure, and lesions are often referred for staging or evaluation for residual disease at the resection site. The aim of this study was to identify the ideal method to confirm complete excision of small rectal NETs. Patients and methods Data from patients with a previously resected rectal NET referred for follow-up endoscopy or endoscopic ultrasound (EUS) were retrospectively reviewed. Univariate analysis was performed on categorical data using the Chi-squared test. Results Forty-nine patients with rectal NETs were identified by pathology specimens. Of those, 39 underwent follow-up endoscopy or EUS and were included. Baseline characteristics included gender (71 % F, 29 % M), age (57.2 ± 13.4 yrs) lesion size (7.3 ± 4.2 mm) and location. The prior resection site was identified in 37/39 patients who underwent tissue sampling. Residual NET was found histologically in 14/37 lesions. All residual disease was found during salvage endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) and 43 % had a normal-appearing scar. Every patient undergoing EUS had an unremarkable exam. Initial cold biopsy polypectomy ( P = 0.006), visible lesions ( P = 0.001) and EMR/ESD of the prior resection site ( P = 0.01) correlated with residual NET. Conclusions Localized rectal NETs may be incompletely removed with standard polypectomy. If an advanced resection is not performed initially, repeat endoscopy with salvage EMR or ESD of the scar should be considered. For small rectal NETs, biopsy may miss residual disease when there is no visible lesion and EUS appears to have no benefit.

Patient Perspective on Safety of Elective Gastrointestinal Endoscopy During the COVID-19 Pandemic

BackgroundPatients’ perception regarding the risks of COVID-19 infection with gastrointestinal (GI) and the preventive measures taken in GI endoscopy units to mitigate infection risk remains unclear. We aimed to assess patients’ perception regarding risks of COVID-19 with GI endoscopy and the changes in the endoscopy unit as a result of the ongoing pandemic. MethodsOutpatients undergoing GI endoscopy at our institution were categorized into those scheduled to undergo GI endoscopy (preprocedure) and those who had recently undergone GI endoscopy during the pandemic (postprocedure). Two separate but similar survey instruments were designed. Patients were asked to respond on a 5-point Likert scale. Responses were stratified as “low,” “neutral,” and “high” for analysis. ResultsA total of 150 and 355 respondents completed the preprocedure and postprocedure surveys, with a combined response rate of 82.5%. Non-white ethnicity was associated with reporting a “high” level of concern for endoscopy related COVID-19 exposure in both the preprocedure (OR 4.09, 95% CI 1.54-10.82) and postprocedure cohorts (OR 2.11, 95% CI 1.04-4.29). 42% of patients in the preprocedure cohort and 11.8% in the postprocedure cohort reported their level of concern for COVID exposure as “high.” Among the postprocedure cohort, 88% of the patients were likely to undergo repeat endoscopy during the pandemic if recommended. ConclusionPatients are willing to undergo GI endoscopy during the COVID-19 pandemic. Non-white and older patients, and those undergoing screening examinations were more concerned with the GI endoscopy related COVID-19 transmission risk.

Can COVID-19 Trigger De Novo Inflammatory Bowel Disease?

Question: On March, 2020 an otherwise young female never smoker presented to the emergency department with a seven-day episode of fever up to 38°C, sore throat, myalgia, dyspnea, and bloodless watery diarrhea (6–7 stools per day). Laboratory tests showed a leucocyte count of 14,000/μL, lymphocyte count of 1200/μL, C-reactive protein of 26.8 mg/dL, d-dimer of 1769 ng/mL, and lactate dehydrogenase of 670 U/L; other laboratory results were unremarkable. A nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A chest radiograph showed bilateral infiltrates and the patient was admitted. During hospitalization, the patient was treated with hydroxychloroquine, lopinavir/ritonavir, and azithromycin. Her symptoms improved significantly, and peripheral oxygen saturation while breathing ambient air was 98%. Markers of systemic inflammation dropped progressively, and lymphocyte count increased. On day 7 a new nasopharyngeal reverse transcriptase polymerase chain reaction swab was negative, and she was discharged from hospital. Between April and June, watery diarrhea (3–4 stools per day) persisted, with no other common symptoms of coronavirus disease-2019 (COVID-19). In July, her diarrhea worsened, with blood in all bowel movements. A chest radiograph and laboratory tests were normal, with IgG positive and IgM negative SARS-CoV-2 antibodies. Stool cultures ruled out common pathogens, including Clostridium difficile. Fecal calprotectin concentration was elevated (460 μg/g). In August, after a negative nasopharyngeal reverse transcriptase polymerase chain reaction swab, an ileocolonoscopy showed confluent colonic involvement extending for 35 cm from the anal verge, with granularity, edema, friability, and ulcers (Figure A). The rest of the colon and 5 cm of terminal ileum were normal. Histopathology showed widespread crypt architectural distortion, superficial erosions, a diffuse transmucosal inflammatory infiltrate, cryptitis, and mucin depletion (Figure B, stain: hematoxylin and eosin; original magnification ×4 large picture, ×40 small picture; courtesy of Dr. María Suárez). Immunohistochemistry excluded cytomegalovirus infection. Given this history, clinical presentation, and endoscopic and histology findings, what is your diagnostic suspicion? Look on page 1030 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Treatment with oral and topical mesalamine was started. On day 10, the patient achieved remission (partial Mayo score of 0). Based on clinical data, endoscopic, and histology findings, incident ulcerative colitis (UC) was diagnosed in a patient with no prior gastrointestinal symptoms. Because there is no pathognomonic feature for diagnosis of a first flare of UC, we consider the presence of a second flare with repeat endoscopy necessary to confirm the diagnosis. The exact etiology of UC is unknown, although the disease is thought to be triggered by an interaction between genetic and environmental factors. Infectious gastroenteritis (GE) has been associated with an increased risk of incident inflammatory bowel disease (IBD).1García Rodríguez L.A. Ruigómez A. Panés J. Acute gastroenteritis is followed by an increased risk of inflammatory bowel disease.Gastroenterology. 2006; 130: 1588-1594Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar The observation that the incidence rate of IBD after a documented bacterial GE was similar to the incidence after episodes of GE with negative stool culture, in which a significant proportion of cases are probably of viral origin, suggests the possibility that both bacterial and viral infections can trigger IBD. However, no specific bacterial or viral pathogens have been confirmed as a cause of IBD as per Koch’s postulates. Available evidence indicates that IBD patients are not at a greater risk of acquiring COVID-19,2Taxonera C. et al.Gastroenterology. 2020 Jul 17; ([Epub ahead of print])Google Scholar but data on SARS-CoV-2 infection in triggering IBD are lacking. Initial intestinal inflammation may arise owing to SARS-CoV2 infection. This response overshoot or defective down-regulation of mucosal immune response could lead to chronic intestinal inflammation. A case of incident UC during SARS-CoV-2 infection has been reported, but unlike our patient, COVID-19 and UC were diagnosed simultaneously, making it difficult to determine whether endoscopic and histologic alterations were related to UC or to SARS-CoV2 by itself.3Calabrese E. Zorzi F. Monteleone G. Del Vecchio Blanco G. Onset of ulcerative colitis during SARS-CoV-2 infection.Dig Liver Dis. 2020; 52: 1228-1229Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In our case, it is not possible to rule out that the patient had UC at the time of diagnosis of the SARS-CoV-2 infection, but the absence of previous gastrointestinal symptoms and the appearance within hours of watery diarrhea as a presenting symptom of COVID -19 makes this possibility highly unlikely. In conclusion, in clinical practice, we should be vigilant to the possibility that COVID-19 may trigger de novo UC, although large population studies would be necessary to confirm a causal link.

Experience with the use of a hemostatic powder in 152 patients undergoing urgent endoscopy for gastrointestinal bleeding

Background and study aimsIn the recent years, topical hemostatic powders have been used for the management of upper gastrointestinal bleeding. The aim of this study was to report on the use of an hemostatic powder (Hemospray®), outside regular hours, by on-call endoscopists during urgent endoscopic procedures. Material and methodsIn this retrospective multicenter cohort study, consecutive patients having undergone an urgent endoscopy with the use of Hemospray® from November 2015 to December 2018 in the Paris and suburbs area were included. We collected clinical, biological and endoscopic variables. The outcomes such as the recurrence, repeat endoscopy and hemostatic treatment need, complications and survival were also collected. ResultsA total of 152 patients (mean 65 years old, 70.4% male) were included. Amongst the 31 endoscopists, 11 were “more experienced”, and performed 48% of the endoscopies. The most common causes of bleeding were peptic ulcer (47.7%), malignancy (22.2%) and esophagitis (12.4%). Most bleedings originated from the upper GI tract (95.0%). Hemospray® was used as a salvage therapy in 60.8% of cases. Other hemostatic techniques were used in 52.9% of cases. Immediate bleeding cessation was noted in 79.0% of cases, recurrence in 39.9% of cases, and 26.4% of patients benefited from a repeat endoscopic hemostasis. 34 (23.0%) patients required a non-endoscopic treatment. At day 30, the survival rate was 71.6%. One complication was reported (perforation). ConclusionsHemostatic powder application by on-call endoscopists outside regular hours is technically feasible, but comes with a high risk of rebleeding in severely ill patients.

Reduced gastric injury with a novel, liquid lipid-aspirin formulation: results from a pooled, patient level analysis of two randomized endoscopy studies In healthy volunteers

Abstract Background Gastrointestinal (GI) toxicity from aspirin is high at the time of initiation of therapy. Objective The current analysis aimed to determine rates of endoscopically detected gastroduodenal erosions and ulcers after 7 days of either immediate release aspirin (IR-ASA) or a novel, pharmaceutical lipid-aspirin complex (PL-ASA) liquid formulation that has an antiplatelet effect similar to IR-ASA. Methods Two randomized, single blind, multicenter active control studies comparing upper GI damage after 7 days of 325 mg PL-ASA or IR-ASA in healthy volunteers not taking a gastroprotectant and who had a negative baseline endoscopy were pooled at the patient level. The primary outcome was the composite of &amp;gt;5 erosions and/or ≥1 ulcer (≥3 mm deep) assessed by a treatment-blinded reviewer at repeat endoscopy on day 7. Results Out of 451 randomized subjects (mean age 57 years, 47% males), 441 completed the 7-day endoscopy and represent the full analysis set. PL-ASA significantly reduced the primary outcome by 34% compared with IR-ASA (25.7% vs. 39%, p=0.0032) (figure). Notably, for ulcers there was a 61% reduction with PL-ASA (6.0% vs. 14.8%, p=0.0018) (Figure 1). The mean number of gastric erosions per patient was also reduced with PL-ASA (2.8±7.3 vs. 4.2±7.5, p&amp;lt;0.0001), while erosions in the duodenum were not different (1.4±7.1 vs. 0.9±2.3, p=0.45). Conclusion The novel PL-ASA liquid capsules reduced rates of GI injury compared with IR-ASA tablets. The combination of reliable platelet inhibition with less GI injury makes PL-ASA an attractive new aspirin therapy option. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): PLx Pharma

Magnet-assist endoscopic augmentation of the lower esophageal sphincter for treatment of gastroesophageal reflux disease: cadaveric and survival studies in a porcine model (with video).

Augmentation of the lower esophageal sphincter (LES) is the primary goal of both surgical and endoscopic therapies for gastroesophageal reflux disease (GERD). The feasibility, efficacy, safety, and reversibility of a newly developed endotherapy for GERD using intraluminal magnets referred to as a magnet closure device (MCD) were evaluated. This study involved nine cadaveric and six survival pigs. The MCD consisted of a ring neodymium magnet attached to a 2-0 polypropylene suture and suture anchor. The MCD was deployed onto the esophageal wall at the region of the LES using an endoscopic suturing device. Two to three MCDs were placed on opposing walls to induce closure of the esophageal lumen. LES pressures were measured using high-resolution manometry at the index procedure (baseline and immediately post-MCD placement) and at survival endoscopy. Endoscopic removal of the devices was performed followed by necropsy at week 2. MCDs were successfully deployed in all cadaveric (n = 22) and survival animals (n = 12). In cadavers, 20/22 (91%) sutures were full-thickness with no adjacent organ injury. In survival animals, mean LES pressure increased from 8.4mmHg (baseline) to 32.4mmHg immediately post-procedure (p < 0.01). No clinically significant adverse events occurred. Repeat endoscopy at two weeks showed intact MCDs in 4/6 (67%) animals with significant increase in median LES pressure (n = 4, 24.0mmHg versus 7.4mmHg [baseline], p < 0.05). Endoscopic removal of MCDs was successfully achieved. Endoscopic augmentation of the LES using a new MCD was feasible, safe and reversible with significantly increased LES pressures recorded. Future studies are needed to enhance durability. These preliminary results on a reversible technique are promising and may represent an attractive alternative to endoluminal GERD therapy.

S3174 Examining Endoscopic Evaluation of Acute Gastrointestinal Bleeding

INTRODUCTION: Gastrointestinal bleeding (GIB) is a common medical problem encountered by physicians. GIB is divided into upper or lower GIB based on location in relation to the ligament of Treitz. The incidence of annual upper GIB is estimated to be 50-150 per 100,000. Lower GIB has an annual incidence of approximately 20-35.7 per 100, 000 with a mortality rate. The average cost associated with an upper GIB in the US is ∼$2500 and ∼ $9,700 for lower GIB. The aim of our study was to analyze if the number endoscopies being performed are justified by examining the incidence of acute findings. METHODS: Single institution retrospective observational study conducted from 2014-2016. All patients that presented with GIB were included. Main outcome: incidence of a positive endoscopic finding for an active GIB. Secondary outcome: reason for GIB, association with antiplatelet (AP) or anticoagulants (AC), and if repeat endoscopy was performed. Statistical methods used included: Chi-square/Fisher’s exact test, Mann-Whitney U test, and univariate/multivariate analyses. A P< 0.05 was used to determine statistical significance. RESULTS: 730 observations were collected. 223/730 subjects had a reason for GIB (table 1). EGD, repeat endoscopy and taking AC were statistically significant. The highest reported reason for GIB was diverticulitis/diverticulosis (table 2). When the reason for GIB were listed for colonoscopy and EGD overall and compared between the two groups, the highest findings were diverticular, normal, or adenoma/polyp for colonoscopy overall and normal, gastritis, and hiatal hernia for EGD (table 3). Logistic regression analysis (table 4) was used and using no as a reference group for each variable we found those who used AC were less likely to have a reason found for bleeding than those who did not have use AC (OR = 0.65, 95% CI = 0.42, 1.01). When using yes as the reference group for each variable we found those who did not use AC were more likely to have a reason found for bleeding than those who used AC (OR = 1.53, 95% CI = 0.99, 2.38). Lastly we examined AP and AC use by repeat endoscopy status and found no significant differences in AP or AC use between those who has a repeat endoscopy and those who did not. CONCLUSION: Due to the high cost of GIB we examined if the number of endoscopies being performed were justified by finding the reason for GIB. This is a complex task, we found over a 3-year period, only 30.55% of subjects were found to have a reason for GIB.Table 1.: Characteristics of patientsTable 2: and Table 3.Table 4: and Table 5.

S2933 Vanishing Polyps: Can Switching From a PPI to an H2 Blocker Cause Regression of Fundic Gland Polyps?

INTRODUCTION: Fundic gland polyps (FGPs) are identified as a sequalae of prolonged acid suppression. Though some studies show that acid suppression with a proton pump inhibitor (PPI) or Histamine 2 receptor blockers (H2RB) may cause FGPs, stronger evidence supports PPIs as a culprit. Studies have shown improvement of FGPs with cessation of acid suppression, but few studies investigated the effect of changing therapy to an H2RB. This case demonstrates a reduction of polyp size and number upon transition to an H2RB in a patient who developed FGPs as a result of long-term PPI use. CASE DESCRIPTION/METHODS: An 85-year-old female with rheumatoid arthritis on methotrexate and prednisone and on chronic PPI for 15 years for acid reflux presented to the gastroenterology clinic for possible gastritis. Upper endoscopy was performed and showed multiple 5–50 mm pedunculated and sessile polyps throughout the entire stomach. A majority of the polyps were about 3–5 cm. A hot snare and a Roth net were used to remove polyps to confirm histopathology (Figure 1). Gastric biopsies revealed FGPs without evidence of H. pylori, intestinal metaplasia, dysplasia or malignancy. Despite concern for FAP, malignancy, or high-grade dysplasia, the patient elected for continued endoscopic surveillance. She transitioned from a PPI to an H2RB. Serial endoscopies showed marked improvement in the size and number of gastric polyps at 6-months (Figure 2) and at 1-year (Figure 3). DISCUSSION: Some studies have shown a 4 fold increased risk of FGP formation in patients on chronic PPI. These polyps likely form as a response to low acid production causing increased parietal cell growth due to increased gastrin and chromogranin-A circulation causing gland proliferation. Few case reports demonstrate improvement of polyp size and number with transitioning therapy from PPI to H2RB and no large trials support changing therapy to H2RB. Still, H2RBs may be an ideal alternative since studies have shown an improvement in polyp size with cessation of PPI. Though FGPs are benign, PPI may increase the risk of adenomatous polyps and biopsy is necessary to differentiate these, particularly in patients with FAP. Our case demonstrates that discontinuing PPI for H2RB may lead to a sheer reduction in both number of polyps and polyp size, making lesions more amenable to continued resection and sampling and, therefore decreasing and minimizing risk of malignancy.Figure 1.: Initial endoscopy showing multiple large Fundic Gland Polyps in patient on chronic PPI for 15 years.Figure 2.: Repeat Endoscopy 6 months after transitioning from PPI to H2RB and showing smaller and fewer number of Fundic Gland Polyps.Figure 3.: Repeat Endoscopy 1 year after transitioning to H2RB and demonstrating continued, marked improvement in the size and number of Fundic Gland Polyps.

S1937 Development of Eosinophilic Esophagitis in a Patient With Radiation-Induced Esophageal Strictures: A Case Report

INTRODUCTION: Radiation therapy for head, neck, and esophageal cancer often results in difficult to manage esophageal strictures. These strictures often require repeat dilation to improve dysphagia symptoms. Eosinophilic esophagitis (EOE) can present with similar symptoms of malnutrition and dysphagia and can lead to strictures. We present the unique case of a female with suspected radiation strictures found to have associated eosinophilic esophagitis with improvement in dysphagia with anti-reflux therapy. CASE DESCRIPTION/METHODS: A 49 year old female with history of tongue cancer status post hemiglossectomy and multiple radiation treatments developed worsening chronic oropharyngeal dysphagia and regurgitation. Patient underwent a barium esophagram which showed esophageal narrowing. She then had an upper endoscopy which revealed a cervical esophageal stricture and underwent bougie dilation. Patient was diagnosed with a post-radiation stricture. On repeat endoscopy one month later, patient was found to have a similar esophageal stricture but noted to have associated linear furrows with upper esophageal biopsies showing 110 eosinophils per high power field. She was dilated at that time and also started on anti-reflux therapy daily. On repeat endoscopy, patient was noted to have significant improvement in her symptoms with no subsequent dilations required and improved nutritional performance. DISCUSSION: Upper esophageal strictures can be challenging to treat. Strictures in patients with EOE can often escape detection during endoscopy. Our patient demonstrates a unique case with simultaneous radiation and eosinophilic stricture causing dysphagia. Her symptoms responded significantly better after initiation of proton pump therapy, highlighting the importance of considering dual etiology for esophageal strictures. In patients who do not respond to multiple dilations for radiation strictures, co-existing pathology such as EOE should be considered. Patients with refractory radiation esophagitis warrant careful endoscopic evaluation for associated EOE. Treatment for patients with radiation strictures and dysphagia often requires dilation, which may place patients at higher risks for complications with underlying EOE. Patients with radiation esophagitis with suspicion for EOE should undergo cautious dilation. This case propagates the role for empiric anti-reflux therapy in patients with a high pre-test probability of EOE complicating radiation and other benign esophageal strictures.Figure 1.: Proximal Esophagus Stricture.Figure 2.: Linear Furrows in Upper Esophagus.

S2039 “Black Esophagus”: A Rare Complication of Diabetic Ketoacidosis

INTRODUCTION: Acute esophageal necrosis (AEN), also known as “black esophagus”, is a rare presentation of severe esophageal injury. Most cases occur in patients with cardiovascular comorbidities and alcohol use. Injury results from a combination of ischemic injury and gastroesophageal acid reflux-mediated mucosal damage. Hallmark endoscopic findings are a circumferential black mucosal discoloration which abruptly stops at the gastroesophageal junction. We report a case of black esophagus in a patient who presented with diabetic ketoacidosis (DKA). CASE DESCRIPTION/METHODS: A 62 year old male with poorly controlled diabetes mellitus presented with altered mental status after being found down with a reported episode of coffee-ground emesis. He was hypotensive on admission and was oriented only to self. Labs were significant for leukocytosis and multiple metabolic derangements including hyponatremia, hyperkalemia, acidosis, acute kidney injury, and hyperglycemia with a blood glucose of 1,878 mg/dL. He was admitted for hypovolemic shock secondary to DKA and was treated with vasopressors briefly, fluid resuscitation, and insulin. After resolution of DKA, he reported persistent dysphagia, epigastric pain, and nausea. Upper endoscopy was performed which showed friable circumferential black mucosal discoloration throughout the entire esophagus that spared the gastroesophageal junction. He was diagnosed with AEN and continued on a proton-pump inhibitor and sucralfate with improvement in symptoms. Repeat upper endoscopy was performed four weeks after discharge at which time the patient was endorsing recurrent dysphagia, epigastric pain and nausea. Upper endoscopy revealed a tight stricture in the mid esophagus requiring dilation. DISCUSSION: AEN is a rare clinical entity, with an estimated incidence of 0.01%. Our patient developed AEN likely due to profound hemodynamic compromise in the setting of DKA. Due to its relatively limited blood supply, the distal esophagus is preferentially affected, while findings of pan-esophageal involvement is less common. AEN carries a mortality rate of 23-35% and can be complicated by superimposed infection, esophageal rupture, and stricture formation. While data is limited, the mainstay of therapy involves identifying and treating the underlying disease and supportive care to allow for mucosal healing. Given its high mortality rate, AEN must be considered and accurately diagnosed. Repeat endoscopy should be done to demonstrate healing due to the risk of complications.Figure 1.: Endoscopic evidence of “black” mucosa with associated esophagitis.Figure 2.: Endoscopic image showing mucosal sparing of the GE junction.Figure 3.: Repeat endoscopy 4 weeks later with tight stricture in mid-esophagus.

S1965 Progression of Esophageal Intramural Pseudodiverticulosis in the Setting of Candida

INTRODUCTION: Esophageal intramural pseudodiverticulosis (EIPD) is a rare disorder characterized by the appearance of multiple small flask-shaped lesions of the esophageal wall. Inflammation of the submucosal glands can cause fibrosis and eventual stricture formation. Here we review a case of EIPD due to recurrent candida esophagitis complicated by esophageal lumenal narrowing. CASE DESCRIPTION/METHODS: The patient is a 48 year old woman who was admitted for hematemesis. She has a complicated medical history of untreated hepatitis C, HIV/AIDS, thrombocytopenia secondary to HIV, recurrent esophageal candidiasis, severe esophagitis and gastritis. She had a history of noncompliance with medications. On admission she had a hemoglobin 4.4, MCV 67.9, platelets 8, WBC 6.7. She received appropriate transfusions and underwent endoscopy. Diffuse white plaques were seen throughout the esophagus along with severe esophagitis (Figure 1), and a benign appearing intrinsic stricture was found at 16cm from the incisors measuring 9 mm in diameter which required downsizing of scope to traverse. This stricture was dilated up to 36Fr. Esophageal biopsies were consistent with Candida esophagitis. Repeat endoscopy for re-treatment was completed 2 days later and diffuse severe mucosal changes consistent with pseudo-diverticulosis were found (Figure 2). The esophageal stricture (Figure 3) was found again and dilation was performed to 45Fr. She completed a 1 month course of fluconazole. Repeat endoscopy one month later showed candida esophagitis and EIPD, but resolution of stenosis. DISCUSSION: Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition with unclear etiology and pathogenesis, although some theorize that chronic inflammation or motility issues may contribute. It has been associated with diabetes mellitus, HIV, alcoholism, gastroesophageal reflux, candidiasis, infectious esophagitis, achalasia, and other motor disorders. Diagnosis is often made during endoscopy or found on imaging such as barium esophageal studies. Stricture development particularly in upper or mid esophagus can occur in up to 50% of patients. Risk of squamous cell carcinoma has also been reported. Conservative management is the treatment of choice, although endoscopic therapy with bougienage dilation is sometimes required, often with repeat dilation. This case highlights a common complication in an uncommon condition. This patient required repeat bougienage dilation, but it is important to remember treatment of underlying etiology is key.Figure 1.: Esophagus with diffuse white plaques of Candida.Figure 2.: Esophagus showing multiple diverticuli of EIPD.Figure 3.: Esophagus with numerous psuedodiverticuli and stricture with EIPD.

S3458 A Tale of Two Dieulafoy’s: Massive GI Hemorrhage from Synchronous Dieulafoy Lesions

INTRODUCTION: Dieulafoy lesions (DL) are an elusive source of gastrointestinal hemorrhage accounting for 5% of all cases. They consist of large aberrant submucosal arterioles that erode through overlying epithelium. Patients present with hematemesis, melenic stools, and/or hemodynamic instability. Bleeding is from a single lesion in the stomach (64%), small intestine (20%), colon (10%), or esophagus (2%). Diagnosis is difficult in the absence of overt bleeding and repeat endoscopy is often required. Management includes epinephrine injection, thermal ablation, hemoclips, or resection. Unfortunately, recurrence can be seen in 5-10% of cases. We report an exceedingly rare case of two synchronous DL actively bleeding during one hospitalization. CASE DESCRIPTION/METHODS: A 61 year old male with ESRD, CAD status-post bypass grafting, atrial fibrillation, and heart failure status-post mitral valve replacement presented with four weeks of melena. Index endoscopy demonstrated duodenal bulb and cecal angioectasias that were ablated with snare polypectomy of four polyps. Bleeding persisted so capsule endoscopy was pursued showing fresh blood in the jejunum and distal ileum. Upper double balloon-assisted enterography (DBE) showed an actively bleeding DL in the mid-distal jejunum that was treated with APC, hemoclips and marked with India Ink. Melena and transfusion-dependent anemia persisted and repeat upper DBE showed oozing from prior DL ablation, thus retreated with APC. Bleeding continued but IR angiogram was unrevealing, so resection was pursued. Unfortunately, despite resection, video capsule, and two colonoscopies with hemoclip placement at polypectomy sites, bleeding continued. A lower DBE revealed an actively bleeding DL 50cm proximal to the ileocecal valve that was treated with APC and hemoclips. Hemostasis was achieved and the patient was discharged. DISCUSSION: Despite endoscopy and small bowel series, the source is not found in up to 5% of overt GI hemorrhages. While DL account for only 5% of GI bleeding cases, they are important due to their propensity to cause significant hemorrhage. DL are typically solitary; only two cases of synchronous DL have been reported in literature, and were isolated to the stomach or stomach and small bowel. This is an unusual case of persistent GI bleeding caused by two active small bowel DL (distal jejunum and ileum) which were synchronously bleeding during one hospital admission. As far as we know, this is the only reported case of two actively bleeding DL in the small bowel.Figure 1.: Initially identified DL in mid-distal jejunum treated with APC & hemoclips.Figure 2.: Synchronous DL 50cm from ICV.