Repeat Endoscopy Research Articles

S2173 An Unusual Case of Dysphagia: Tuberculous Bronchoesophageal Fistula

Introduction: A tuberculous bronchoesophageal fistula (BEF) is a rare cause of dysphagia, with only a handful of cases in the literature, and a lack of consensus on its diagnosis and appropriate management. Case Description/Methods: A 30-year-old male presented with weight loss, worsening dysphagia, and cough on swallowing for 4 months. He also reported having pleuritic chest pain, malaise, and low-grade fever in the week before presentation. He was on immunosuppressive therapy for a renal transplant due to chronic renal failure and had a history of bariatric surgery for morbid obesity. Laboratory testing revealed normocytic anemia, normal white blood cell count, and significantly elevated erythrocyte sedimentation rates as well as C-reactive protein. A purified protein derivative skin test performed 3 months prior to presentation was reportedly negative. The remainder of his laboratory testing, including troponin, cardiac enzymes, and HIV status was negative. A chest x-ray showed left hilar prominence. High-resolution computerized tomography (CT) imaging of the chest showed subcarinal and left hilar lymphadenopathy and a soft-tissue density measuring 3 cm x 2 cm in the subcarinal region, inseparable from the right lateral wall of the mid-esophagus (Figure 1). Upper endoscopy showed an esophageal opening at 30 cm from the incisors (Figure 2). Bronchoscopy showed an opening into the left main bronchus with no airway stenosis. Contrast injection under fluoroscopic guidance confirmed a bronchoesophageal fistula (BEF) (Figure 3). A fully covered self-expanding metal stent was placed to aid in closure (Figure 4). A bronchoalveolar lavage and a Quantiferon test both confirmed active tuberculosis. The patient commenced anti-tuberculosis medications and required repeat endoscopy and replacement of the stent after 8 weeks. A repeat CT chest with oral contrast after 16 weeks showed resolution of the BEF which was confirmed after subsequent stent removal. Discussion: A BEF is uncommon, and not initially considered in patients presenting with dysphagia. In retrospect, our patient reported coughing while drinking, raising suspicions for a BEF. A tuberculous BEF is rare but becomes a distinct possibility in the setting of immunosuppression. Clinicians should remain vigilant for atypical infections in immunosuppressed patients presenting with dysphagia.Figure 1.: CT/ fluoroscopy and endoscopic imaging demonstrating bronchoesophageal fistula.

S2418 Crohn’s Colitis Mimicking Ischemic Colitis: A Case Report

Introduction: Crohn’s disease (CD) can mimic ischemic colitis (IC) in the elderly. Here we present an elderly male diagnosed with CD when IC was initially suspected, and further evaluation revealed that CD was the primary diagnosis. Case description/methods: A 69-year-old male with a history of coronary artery disease with recent percutaneous coronary angioplasty & stent placement on aspirin and clopidogrel presented with hematochezia. He had an acute onset of a large amount of rectal bleeding and denied any other symptoms or having prior hematochezia or chronic diarrhea. Exam noted for hemodynamic stability with no tenderness to palpation of abdomen. Hemoglobin was 10.3 from 17 (Normal [N]: 13.5-17.5 gm/dl). Clinically suspected to have IC. Esophagogastroduodenoscopy (EGD) showed a small superficial non-bleeding gastric ulcer, gastritis, and duodenitis, and no stigmata of recent bleeding. Colonoscopy revealed three large deep ulcers in the proximal descending colon, splenic flexure, and distal transverse colon, with the largest ulcer measuring 50 mm. These ulcers were characterized by heaped up margins with some reactive granulation tissue, suggestive of chronicity. Biopsies showed focal acute cryptitis and diffuse lymphoplasmacytic inflammation in lamina propria without architectural distortion. CT angiography abdomen and pelvis showed widely patent arterial vasculature. Clopidogrel was held for 2 weeks to check healing of ulceration. Repeat colonoscopy showed similar findings, without improvement of ulcerations. Repeat colonic biopsies showed chronic moderately active colitis with ulceration, cytomegalovirus staining was negative. Fecal calprotectin was >3000 [N: < 49 ug/g]. C-reactive protein was 63 [N: < 9 mg/L]. MR Enterography with no small bowel disease but noted hyperenhancement and thickening in the ascending and transverse colon. The initial findings, work up and lack of resolution, was most consistent with CD. Discussion: It is critical to distinguish IC from CD for appropriate management of patients. Differentiating between IC and CD can be challenging in the elderly. Endoscopy and histologic evaluation can aid correct diagnosis. Repeat endoscopy to assess progression or resolution is of utmost importance in differentiating CD from IC, but data is limited on appropriate timing. Lack of follow up endoscopy will most likely lead to misdiagnosis and incorrect management of the underlying pathology. Thus, a high index of suspicion must be maintained when discerning CD from IC.Figure 1.: A: Initial colonoscopy showing heaping upped margins of the splenic flexure ulcerations. B: Repeat colonoscopy showing deep colonic ulceration with heaped up margins at the area of splenic flexure without any resolution.

S2322 Tighten Your Pantalones for This Pantaloon Bleed

Introduction: Diverticula can develop anywhere along the small bowel, most commonly in the duodenum. While most patients with duodenal diverticula are asymptomatic, some develop complications such as obstruction, diverticulitis, obstructive jaundice, and bleeding. Here, we present a unique manifestation of bleeding within a periampullary diverticulum. Case Description/Methods: A 66-year-old male with a history of hypertension, diabetes mellitus, end-stage renal disease, atrial fibrillation, and recent four-vessel coronary artery bypass grafting (CABG) presented with unstable angina and fatigue. Following his CABG 2 months ago, he was placed on warfarin and aspirin. His exam revealed hypotension, conjunctival pallor, active bowel sounds, and melena. His hemoglobin (Hb) was 5 g/dL compared to a baseline of 9.2 g/dL two months prior. Blood urea nitrogen was 154 mg/dL and creatinine was 3.47 mg/dL, elevated from his baseline. INR was 6.9 and troponin-I was 66.9 ng/mL. An electrocardiogram did not show ST-segment elevation. After medical management of his myocardial infarction, an upper endoscopy was only remarkable for a large periampullary diverticulum (PAD) containing a clot. Over the next 3 days, his Hb continued to downtrend despite transfusion. A repeat endoscopy showed blood in the gastric body and antrum, blood clots in the duodenal bulb, and oozing blood from the diverticulum. At this time, a side-viewing scope was utilized for better visualization and showed a large pantaloon diverticulum straddling a ridge overlying the common bile duct (CBD) with an ulcer and visible vessel (Figure 1). Hemostatic clip placement led to the cessation of the bleed. (Figure 2). His hemodynamics stabilized and he was maintained on twice-daily pantoprazole. There was a transient rise in his AST and ALT, which resolved spontaneously. The patient did not re-bleed. Discussion: Our patient had an ulcer within a pantaloon PAD that was only appreciated with a side-viewing duodenoscope. Thus, if there is any suspicion of blood within a large duodenal diverticulum such as a clot, the use of a side-viewing scope is warranted. Furthermore, treatment of this lesion was challenging as the ridge overlayed the CBD, raising concern for injuring the CBD or causing obstruction through endoclips or cautery, so the former was employed taking care not to grasp excess tissue other than the visible vessel. While the transient rise in the transaminases suggested a CBD obstruction, this was short-lived and no clinical sequelae ensued.

Rates and predictors of repeat preoperative endoscopy for elective colorectal resections: how can we avoid repeated procedures?

Despite limited endoscopy resources, repeat endoscopy prior to surgery is commonly practised. Our aim was to determine repeat preoperative endoscopy rates and factors influencing this practice at a high-volume Canadian tertiary centre. A retrospective cohort study was conducted on all patients undergoing elective colorectal resections for benign and malignant neoplasms at a tertiary centre in Winnipeg, Canada between 2007 and 2017. Multivariable logistic regression analysis was used to identify predictors of repeat preoperative endoscopy. Of 1062 patients identified, mean age was 68years and 56% were male. Rate of repeat preoperative endoscopy was 29%. On multivariable analysis, male sex (OR 1.68, CI 1.19-2.34, p = 0.003) and lesions located in the left colon (OR 2.73, CI 1.79-4.14, p < 0.001), rectosigmoid (OR 9.11, CI 2.14-38.8, p = 0.003), and rectum (OR 4.06, CI 2.58-6.38, p < 0.001) were at increased odds of undergoing repeat preoperative endoscopy. Patients with a tattoo placed at index endoscopy were at markedly lower odds of undergoing repeat preoperative endoscopy (OR 0.48, CI 0.34-0.68, p < 0.001). Index endoscopist specialty was not a significant predictor of repeat endoscopy (OR 0.76, CI 0.54-1.06, p = 0.09). Repeat preoperative lower endoscopy is commonly practised and may be unnecessary if appropriate identification and documentation of lesions has been achieved. Tattooing of suspicious lesions is a key modifiable factor associated with reduced likelihood of repeat preoperative endoscopy. This study highlights the need for standardized guidelines and endoscopy reporting practices given the delays and costs associated with repeat preoperative endoscopy.

Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study

ObjectiveWhile it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess...

Treatment of Gastric Antral Vascular Ectasia With Radiofrequency Ablation Does Not Improve Patient Outcomes

Gastric antral vascular ectasia (GAVE) affects between 4% and 30% of patients with cirrhosis and leads to high healthcare utilization.1,2 Some patients experience gastrointestinal bleeding, which is typically treated with argon plasma coagulation (APC).3-6 Radiofrequency ablation (RFA) is a promising intervention for GAVE which recurs despite APC treatment.6 We hypothesized that primary treatment with RFA would reduce hospital admissions, frequency of transfusions and time to repeat endoscopy when compared to APC treatment.

Efficient treatment of esophageal nutrition bezoars: dissolution outmatches removal\u2014the Zurich approach

Enteral feed bezoars are difficult to treat and can lead to serious adverse events. There is no standardized treatment approach and various strategies have been suggested. We herein describe three cases of successful dissolutions of feed bezoars consisting of Promote® Fibre Plus with sodium bicarbonate 8.4% in critically ill patients. To provide the rationale for this approach, the effect of sodium bicarbonate 8.4% on enteral feed concretions was studied in vitro. First, Promote® Fibres Plus was incubated with hydrochloric acid with gradually decreasing pH values to establish a pH at which the solution solidifies. The resulting enteral feed concretion was exposed to sodium bicarbonate 8.4% and Coca Cola®. All patients were successfully treated with sodium bicarbonate 8.4% without the need of lengthy or repeat endoscopies. In vitro, Promote® Fibres Plus solidifies when acidified below a pH of 4.6. The resulting enteral feed concretions dissolved when exposed to sodium bicarbonate 8.4%. Incubation with Coca Cola® had no effect. We provide evidence that enteral feed bezoars consisting of Promote® Fibres Plus can be efficiently and safely treated with sodium bicarbonate 8.4% offering a new approach for daily patient care.

Real world management of esophageal ulcers: analysis of their presentation, etiology, and outcomes.

Esophageal ulcers are a rare cause of upper gastrointestinal morbidity and may be due to different etiologies. We sought to systematically evaluate patients with esophageal ulcers and describe their presentations, endoscopic findings, etiologies, treatments, and outcomes. Patients diagnosed with esophageal ulcers over an 11-year period were retrospectively identified from our institution's electronic medical records. We identified 100 patients with esophageal ulcers (0.49% of patients undergoing upper endoscopy). Half of them presented due to gastrointestinal bleeding and three-quarters were admitted to the hospital. The majority were in the lower esophagus. Twenty-two unique etiologies, including multiple iatrogenic causes, were diagnosed in 91 of the cases. The most common etiology was gastroesophageal reflux disease (57%), followed by non-steroidal anti-inflammatory drug use (7%), malignancies (3%), vomiting (3%), caustic ingestion (2%), pill esophagitis (2%) and radiation (2%). Many etiologies showed a predilection for specific segments of the esophagus. Nine ulcers required endoscopic intervention and all were treated successfully. Repeat endoscopies were performed 5 times for diagnostic or "second look" reasons, none of which changed the patients' diagnosis or treatment. No patients required surgery or stricture dilation. One patient's ulcer was complicated by perforation and he subsequently died. Four other patients died from non-ulcer related causes. While the majority of ulcers were due to gastroesophageal reflux disease, 22 different etiologies were identified. Many were due to medication or iatrogenic causes. Repeat endoscopy did not appear to be helpful. While the incidence was low, they were frequently associated with significant morbidity.

Endoscopic Evaluation for Stricture Formation Post Button Battery Ingestion

Every year, there are over 3300 ingestions of button batteries, mostly by young children. Initial presentation of button battery ingestion may be nonspecific, with a delay in diagnosis and removal resulting in increased risk of complications. We present the case of a five-year-old female who presented with vomiting following unwitnessed button battery ingestion. The battery was impacted in the middle esophagus for at least six hours. Endoscopy was performed for immediate removal and showed a Grade 2B erosion, warranting nasogastric tube placement. The patient remained asymptomatic following discharge and had a barium swallow that was read as normal. However, a repeat endoscopy one month later visualized stricture formation at the previous battery injury site. This case highlights the importance of both clinician and parent awareness of button battery ingestion and demonstrates that endoscopy provides the most accurate assessment of esophageal injury and complication development, even in asymptomatic patients.

Long term outcomes of sporadic large fundic gland polyps: a single-center experience

Background and study aims Sporadic fundic gland polyps (FGP) are the most common type of gastric polyp, reported in 0.8%–1.9% of patients undergoing Esophagogastroduodenoscopy (EGD). Data on long-term outcomes of large FGP is limited. We aim to study the natural history of sporadic large (≥ 10 mm) FGPs. Patients and methods All adults who underwent EGD for any indication from April 2014 to December 2019 at a tertiary care center were retrospectively assessed, and patients with FGP (≥10mm) were identified. Data on baseline characteristics and long-term outcomes were recorded. Follow-up data were recorded for patients who underwent repeat endoscopy to evaluate for rates of dysplasia and cancer. Results A total of 4,000 patients with a diagnosis of FGP were screened and 132 large, biopsy-proven FGPs were included in the final analysis. The most common indication for EGD was gastroesophageal reflux disease (61%). During a follow-up period of 3.2 years, the rate of dysplasia, was 4.0%. Subgroup analysis based on size (10–19 mm and ≥ 20 mm) showed no significant difference in overall outcomes. Conclusion Repeat EGDs for surveillance should not be routinely performed since large (≥10 mm) sporadic FGPs are mostly benign without significant malignant potential.

Gastric amyloidosis presenting as acute upper gastrointestinal bleeding: a case report

BackgroundAmyloidosis is characterized by extracellular tissue deposition of fibrils, composed of insoluble low-molecular-weight protein subunits. The type, location, and extent of fibril deposition generates variable clinical manifestations. Gastrointestinal (GI) bleeding due to amyloid deposition is infrequent. Previous literature describes upper GI bleeding (UGIB) in patients with known amyloid disease. Here, we describe a case of recurrent UGIB that ultimately led to a diagnosis of GI amyloidosis and multiple myeloma in a patient with no history of either.Case presentationA 76-year-old male presented to the emergency department with frank hematemesis, melena, and a decreased level of consciousness. Management required intensive care unit (ICU) admission with transfusion, intubation, and hemodynamic support. Upper endoscopy revealed gastritis with erosions and nodularity in the gastric cardia and antrum. Hemostasis of a suspected bleeding fundic varix could not be achieved. Subsequently, the patient underwent computerized tomography (CT) angiography and an interventional radiologist completed embolization of the left gastric artery to address potentially life-threatening bleeding. Complications included development of bilateral pleural effusions and subsegmental pulmonary emboli. Pleural fluid was negative for malignancy. He was transferred to a peripheral hospital for continued care and rehabilitation. Unfortunately, he began re-bleeding and was transferred back to our tertiary center, requiring re-admission to the ICU and repeat endoscopy. Repeat biopsy of the gastric cardial nodularity was reported as active chronic gastritis and ulceration. However, based on the unusual endoscopic appearance, clinical suspicion for malignancy remained high. He exhibited symptoms of congestive heart failure following standard resuscitation. Transthoracic echocardiogram (TTE) demonstrated a reduced ejection fraction of 35–40% and a strain pattern with apical sparing. Following discussions between the treating gastroenterologist, consulting cardiologist, and pathologist, Congo Red staining was performed, revealing submucosal amyloid deposits. Hematology was consulted and investigations led to diagnosis of multiple myeloma (MM) and immunoglobulin light-chain (AL) amyloidosis. The patient was treated for MM for four months prior to cessation of therapy due to functional and cognitive decline.ConclusionsGI amyloidosis can present with various non-specific clinical symptoms and endoscopic findings, rendering diagnosis a challenge. This case illustrates GI amyloidosis as a potential—albeit rare—etiology of UGIB.

Eosinophil-Derived Neurotoxin Predicts Response to Proton-Pump Inhibitor Treatment in Pediatric Eosinophilic Esophagitis.

There are no tests or patient factors to help predict the best treatment approach for a patient with eosinophilic esophagitis (EoE). The prevalence of proton-pump inhibitor (PPI) responsive EoE in children ranges from 30% to 71% with multiple studies showing similar characteristics in responders and nonresponders. Eosinophil-derived neurotoxin (EDN), an eosinophilic granule protein, measured in esophageal brushing has been shown to be a viable measure of disease activity in EoE. Our aim is to determine if EDN can help predict response to PPI in pediatric patients with EoE. We conducted a prospective cross-sectional study to compare EDN between PPI-responsive and PPI-nonresponsive EoE subjects from 2018 through 2020. Enrolled patients with active EoE were treated with high-dose PPI and underwent repeat endoscopy to determine PPI-responsiveness. EDN was measured at baseline endoscopy, before any treatment, and at follow up endoscopy, after PPI therapy. Subjects were divided into PPI-responsive and nonresponsive groups. EDN, endoscopic reference score (EREFS), and peak eosinophilic count (PEC) were compared. Fifteen out of the 36 enrolled subjects with EoE (age range 2-18 years, 73.3% male) were PPI-responsive and 21 (age range 2-19 years, 95.2% male) were PPI-nonresponsive. EDN concentration was significantly higher in the PPI-nonresponsive group than in the PPI-responsive group (219.1 ± 229 mcg/mL vs 75.7 ± 60 mcg/mL, respectively, P = 0.036). There was no difference between the two groups in EREFS (P = 0.55) or PEC (P = 0.15). EDN measured in esophageal epithelial samples obtained by brushing during endoscopy may predict PPI-responsiveness in children and young adults with EoE.

Acute gastrointestinal bleeding: proposed study outcomes for new randomised controlled trials.

Acute gastrointestinal bleeding (GIB) remains a common cause of hospitalisation. However, interpretation and comparisons of published studies in GIB have been hampered by disparate study methodology. To make recommendations about outcome measures to be used in future randomised controlled trials (RCTs) of patients with acute bleeding from any GI source (nonvariceal UGI, variceal, small bowel, or colon) and suggest new RCTs in acute GIB for future peer-reviewed funding. As part of a National Institutes of Health conference entitled "Hemostatic Outcomes in Clinical Trials", a group of GIB experts performed targeted critical reviews of available evidence with the goal of proposing a bleeding outcome that could potentially be applied to different disciplines. In addition, the panel sought to develop a clinically meaningful primary endpoint specifically for acute GIB, potentially allowing a more contemporary regrouping of clinically relevant outcomes. The primary endpoint proposed was a composite outcome of further bleeding within 30days after randomisation leading to red blood cell transfusion, urgent intervention (repeat endoscopy; interventional radiology or surgery), or death. Secondary outcomes may include the individual components of the primary outcome, length of hospitalisation, serious adverse events, and health care resource utilisation. The proposed endpoint may help move the GIB field forward by focusing on the most clinically relevant outcomes for patients with acute GIB of all types and informing study design and importance of sample size determination for future RCTs in GIB.

Systematic review with meta-analysis: neoplasia detection rate and post-endoscopy Barrett's neoplasia in Barrett's oesophagus.

Neoplasia detection rate, the proportion of Barrett's oesophagus patients with high-grade dysplasia or oesophageal adenocarcinoma detected at index surveillance endoscopy has been proposed as a quality metric. However, the correlation between neoplasia detection rate and a clinically relevant outcome like post-endoscopy Barrett's neoplasia remains unknown. Post-endoscopy Barrett's neoplasia refers to the rate of high-grade dysplasia or oesophageal adenocarcinoma on repeat endoscopy within one year of an index screening examination revealing non-dysplastic Barrett's oesophagus or low-grade dysplasia. To assess correlation between neoplasia detection rate and post-endoscopy Barrett's neoplasia. We performed a systematic search of multiple databases from date of inception to June 2021 to identify cohort studies reporting both neoplasia detection rate and post-endoscopy Barrett's neoplasia. Data from each study were pooled using a random effects model, and their correlation assessed using meta-regression. Heterogeneity was assessed and a priori planned subgroup analyses were conducted. Ten studies with 27894 patients with Barrett's oesophagus were included. The pooled neoplasia detection rate and post-endoscopy Barrett's neoplasia were 5.0% (95% CI: 3.4%-7.1%, I2 =97%) and 19.6% (95% CI: 10.1%-34.7%, I2 =96%), respectively. Meta-regression revealed a statistically significant inverse relationship between the two variables (coefficient -3.50, 95% CI: -4.63 to -2.37, P<0.01). With every 1% increase of neoplasia detection rate, post-endoscopy Barrett's neoplasia decreased by 3.50%. Heterogeneity was high despite adjusting for study quality and performing several subgroup analyses. We observed a statistically significant inverse correlation between neoplasia detection rate and post-endoscopy Barrett's neoplasia. Additional studies are needed to further validate this correlation.

The Utility of Repeated Endoscopy in Patients with Gastrointestinal Graft-Versus-Host Disease: Single Center Retrospective Analysis

BackgroundGraft versus host disease (GVHD) of the gut is associated with significant morbidity and mortality risk after allogeneic hematopoietic cell transplant (allo-HCT). Endoscopy and biopsies of the gut mucosa is recommended to confirm the clinical findings of gut GVHD and to rule out infectious etiologies. There is paucity of data to guide when to repeat endoscopy after inconclusive findings of first endoscopy or after failure of first line treatment with steroids. We aimed to study if repeat biopsy is helpful in these patients for treatment decisions.MethodsIn this study, we retrospectively reviewed medical records of all patients who underwent endoscopies twice for clinical suspicion of GI GVHD after undergoing allo-HCT between 2012 to 2016 at University of Iowa. Demographic, disease, allo-HCT characteristics as well as endoscopic and histological findings during first and second endoscopies were extracted from medical records. We sought to identify if any findings on second endoscopy led to changes in the clinical management of these patients. Additionally, we documented if repeat endoscopy led to any complications.ResultsOf the 318 patients (pts) reviewed, 24 pts underwent endoscopy twice after allotransplant for clinical suspicion of GVHD. Median age (range) was 55 (18-72) years and 13 pts were male. The most common diagnosis was myelodysplastic syndrome (n=10), followed by acute myelogenous leukemia (n=7), acute lymphoblastic leukemia (n=4), Non-Hodgkin lymphoma (n=2) and Chronic myelogenous leukemia (n=1). HLA matched unrelated donor (n=13) was the most common type of transplant followed by HLA matched related donor (n=5), HLA mismatched -unrelated donor (n=5) and one was cord blood transplant. The most common GVHD prophylaxis used was Tacrolimus + methotrexate (n=17), followed by Tacrolimus + Mycophenolate Mofetil (n=7). At the time of first endoscopy 6 pts had only a colonoscopy, 4 pts had sigmoidoscopy, 2 had only upper endoscopy and 12 pts had both upper and lower endoscopy. At first endoscopy 20 pts (80%) showed abnormal findings that included 16 pts with GVHD alone, 1 pt with GVHD and CMV, and 3 pts with GVHD and infectious colitis. The remaining 4 pts had normal endoscopic findings on first endoscopy (2 underwent sigmoidoscopies, 1 colonoscopy, and 1 upper and lower endoscopy). On repeat colonoscopy in these 4 pts with normal first investigation, (3 underwent upper and lower endoscopies and one upper endoscopy on repeat procedure) 3 pts were found to have GVHD and 1 pt had EBV-PTLD. Among the 20 pts who had histological evidence of GVHD on initial endoscopy, 6 pts exhibited improvement in histological findings leading to de-escalation of therapy, 8 pts showed worsening histological findings of GVHD and 2 showed presence of CMV resulting in significant change in management (escalation of therapy), 2 pts had no histological changes. One pt who had initial histological findings of GVHD and CMV displayed significant improvement leading to de-escalation of therapy. Three pts with GVHD along with infectious colitis on biopsy subsequently showed improvement on repeat biopsy leading to de-escalation of therapy. Overall, no complications of repeating the procedures were noted. The endoscopic and histological findings of the first and second endoscopies are shown in Table 1.ConclusionThis study supports the utility of repeat endoscopy in persistently symptomatic patients when there is no improvement with initial treatment based on the results of the first endoscopy. Additionally, repeat endoscopy can guide both escalation and de-escalation of therapy in this patient population without any significant complications or side effects. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Gastric Hyperplastic Polyps Can Shrink After Discontinuation of Proton Pump Inhibitors: A Case Series Compared With Continuation of Proton Pump Inhibitors.

This study investigated whether gastric hyperplastic polyps (GHPs) shrink after discontinuation of proton pump inhibitor (PPI) alone. Long-term use of PPIs has been reported to increase the incidence of GHPs, which sometimes bleed and cause anemia. We experienced a patient whose recurrent hemorrhagic GHPs associated with long-term use of PPIs had disappeared after discontinuation of PPIs. This study was conducted retrospectively at Kyoto University Hospital. Patients with histologically confirmed GHPs who had been taking PPIs for >6 months and who had undergone a repeat endoscopy within 2 years were included. Polyp shrinkage was defined as the disappearance of polyps or a reduction of >50% in the long diameter of the largest polyp. Six patients who discontinued PPIs were compared with 17 patients who continued PPIs. Polyp shrinkage was significantly more frequent in the PPI-discontinuation group (5/6, 83%) than in the PPI continuation group (0/17, 0%) (P<0.001). In 2 patients in the PPI-discontinuation group, the polyps completely disappeared finally. These findings suggest that discontinuation of PPIs can shrink GHPs in patients using PPIs.

OP01 Comparison of fecal transplantation, fecal transplantation with the novel UC diet or the UC diet alone for Refractory Mild to Moderate Active Ulcerative Colitis: The CRAFT UC randomized controlled trial

Abstract Background We evaluated if integration of novel diets for donors and patients in addition to fecal transplantation (FT) could increase FT remission in refractory ulcerative colitis (UC) or have an independent effect on remission. We developed a novel diet specifically designed for the dysbiosis of UC and to decrease factors that impair goblet cells or mucous production. Methods This was a blinded randomized controlled pilot trial in adults with UC, defined by a simple clinical colitis activity index (SCCAI) of ≥5 and &amp;lt; 11 and endoscopic Mayo score 2–3, refractory to medication. Group 1 received free diet and standard FT by colonoscopy on day 1and rectal enemas from a single donor on days 2 and 14 without dietary conditioning of the donor. Group 2: FT as above but with dietary pre-conditioning of the donor for 14 days and a diet (UC Diet- UCD) for the patients after FT. Group 3 received the UC Diet alone without FT. Patients underwent a repeat endoscopy at week 8. The primary endpoint was clinical steroid free remission, defined as SCCAI &amp;lt;3, at week 8. Results Fifty-one of the 96 planned patients were enrolled. The mean age was 40.4 ±12.5 years, 28/51(54.9%) had failed a biologic, 15/40 (29.4%) were on steroids at enrolment. Remission week 8 in Group 1 was 2/17(11.8%), Group 2 was 4/19 (21.1%), and 6/15 (40%) Group 3 (NS). Endoscopic remission was present in Group 1: 2/17(12%), Group 2: 3/19(16%) and 4/15 (27%) Group 3. Mucosal healing (Mayo 0) was achieved only in Group 3 (3/15, 20%) vs. 0/36 patients receiving FT (P=0.022). Exacerbation of disease occurred in 3/17 (17.6%) Group1, 4/19 (21.1%) Group 2, and 1/15 (6.7%) Group 3 (NS). The study was stopped for futility by a safety monitoring board. Conclusion Fecal transplantation was not effective in this UC cohort. A UC Diet alone appeared to achieve higher clinical remission (40%) and mucosal healing than single donor FT with or without diet in mild to moderate UC failing medical therapy. This diet should be investigated further in a RCT specifically designed for the UCD. This study was supported by an ECCO Pioneer grant

Nonselective Beta-Blockers in Compensated Cirrhosis: Preventing Variceal Hemorrhage or Preventing Decompensation?

Nonselective Beta-Blockers in Compensated Cirrhosis: Preventing Variceal Hemorrhage or Preventing Decompensation?

Use of Lumen-Apposing Metal Stents for Inflammatory Bowel Disease-Related Strictures at a Pediatric Center: A Case Series

Use of Lumen-Apposing Metal Stents for Inflammatory Bowel Disease-Related Strictures at a Pediatric Center: A Case Series

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.