Repeat Esophagogastroduodenoscopy Research Articles

RATES OF REPEAT EGD IN NON-DIABETIC ADULTS WITH GLUCAGON-LIKE-PEPTIDE- 1 RECEPTOR AGONIST PRESCRIPTION: A RETROSPECTIVE MATCHED COHORT STUDY

Background and aimsData on endoscopic outcomes in adults without diabetes who are taking glucagon like peptide receptor agonist (GLP-1 RA) is limited so we aimed to compare repeat esophagogastroduodenoscopy (EGD) in this population to those without GLP-1 using retrospective matched case-control study. MethodsUsing TriNetX (Cambridge, MA), adults with BMI of ≥27 kg/m2 without diabetes who underwent diagnostic EGD were analyzed. Study group included individuals with ≥3 GLP-1 prescriptions and EGD ≥30 days after initial GLP-1 prescription. Control group was never prescribed GLP-1 RAs but had EGD after prescription of other weight loss medications. Outcomes were compared using risk-ratio in matched cohorts. ResultNo significant difference in repeat EGD (5.4% vs 4.2%, RR 1.28, 0.95–1.71) or new diagnosis of gastroparesis (1.1% vs 0.6%, RR 2.00, 0.94–4.27) was noted between the groups. ConclusionGLP-1 RAs may not substantially increase the risk of repeat endoscopy in individuals without diabetes.

768. ENDOSCOPIC MANAGEMENT OF COMPLEX THORACIC AORTA ANEURYSMAL SAC AND ENDOGRAFT INFECTION ASSOCIATED WITH AORTOESOPHAGEAL FISTULA

Abstract Background Aortoesophageal fistula (AEF) is a rare but life-threatening condition. Secondary AEF is a complex pathology occurring after thoracic aorta surgery with prosthetic graft, with an incidence of 1.6%. However, this is likely to rise with the increasing number of thoracic endovascular aortic repair (TEVAR) being performed. Management of secondary AEF is more challenging due to presence of adhesions in the pleural space, co-existing endograft infection and poor physiology of this group of patients. Definitive surgery carries high mortality rate and not all patients are suitable candidates. We review a case of secondary AEF with thoracic endograft infection managed non-operatively. Methods Our patient is a 70 years old man with a background of Stanford type A aortic dissection managed with ascending aorta and hemi-arch replacement with Dacron graft. Six years later, he had frozen elephant trunk reconstruction due to aneurysmal dilatation. Three months later, he underwent TEVAR for descending thoracic aorta aneurysm. Post-operation, he was diagnosed with Flavonifractor plautii bactaeremia secondary to infected aneurysmal sac and aortic stent graft and was initiated on antimicrobial therapy. During this time patient also developed recurrent episodes of haemoptysis. Bronchoscopy excluded an aortobronchial fistula and Oesophago-gastro-duodenoscopy (OGD) confirmed AEF at 25 cm from incisors. Results After discussion with a multidisciplinary team and patient, endoscopic management was chosen over surgery. Initial endoscopic closure of AEF with over-the-scope-clip appeared satisfactory but repeat OGD showed recurrence of new AEF which was partially closed with clips. Repeat imaging showed worsening mediastinal infection with larger gas-containing cavity. OGD was repeated with contrast demonstrating fistulous connection between the oesophagus and aneurysmal sac. A 7-French 4 cm double pigtail (DPT) stent was deployed into the sac under fluoroscopy to allow for trans-oesophageal drainage. Repeat imaging showed improvement in infection (Figure 1). Patient underwent endoscopic exchange of DPT stent 2 months after the initial insertion. Conclusion Definitive surgery for secondary AEF includes drainage of infection, explantation of infected endograft and aortic and oesophageal reconstruction. Oesophagectomy is preferred over primary repair of oesophageal defect. Not all patients will be suitable candidates for radical surgery and a non-operative approach may be required. Our patient likely has dense pleural and mediastinal adhesions from previous surgeries and thus, repeat surgery will be more challenging with increased risk of complications. However, if his mediastinal infection fails to resolve despite a period of DPT stent drainage, definitive surgery involving McKeown minimally invasive oesophagectomy with substernal gastric pull up would be required. Figure 1: Image A shows a large cavity with air and coalescent locules (arrow) prior to insertion of DPT stent. Image B shows a collapsed cavity (arrow) after DPT stent insertion.

The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study.

Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

Effects of glucagon-like peptide-1 receptor agonists on upper endoscopy in diabetic and nondiabetic patients

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) promote weight loss by suppressing appetite, enhancing satiety, regulating glucose metabolism, and delaying gastric motility. We sought to determine whether GLP-1 RA use could affect medical procedures such as EGD. We conducted a retrospective study of 35,183 patients who underwent EGD between 2019 and 2023, 922 of whom were using a GLP-1 RAs. Data were collected regarding demographics, diabetes status, retained gastric contents during EGD, incidence of aborted EGD, and necessity for repeat EGD. GLP-1 RA use was associated with a 4-fold increase in the retention of gastric contents (P< .0001), 4-fold higher rates of aborted EGD (P< .0001), and twice the likelihood of requiring repeat EGD (P= .0001), even after stratifying for the presence of diabetes. GLP-1 RA use can lead to delayed gastric emptying, affecting EGD adequacy regardless of the presence of diabetes, and may warrant dose adjustment to improve the safety and efficacy of these procedures.

A169 A RARE MANIFESTATION OF ENTERITIS DUE TO IMMUNE CHECKPOINT INHIBITOR: CASE REPORT OF PYLORIC STRICTURE

Abstract Background Immune checkpoint inhibitors (ICI) are immunomodulatory antibodies used to enhance the immune response against tumor cells that have revolutionized the treatment of various malignancies. ICIs pose a risk of immune-related adverse events in various organs including the gastrointestinal tract, with diarrhea and colitis being most common. ICIs can rarely cause involvement of the upper gastrointestinal tract, with case reports of gastritis, duodenitis, and esophagitis. There are very rare reports of strictures caused by ICIs, more frequently in the lower gastrointestinal tract, and only a few reports in the esophagus or duodenum. Aims We report a rare case of an upper gastrointestinal stricture due to ICI at the pylorus. Methods Case report. Results A 38-year-old woman with breast cancer on ICI pembrolizumab presented with several weeks of nausea and early satiety. She had started pembrolizumab 8 months prior, underwent neoadjuvant chemotherapy and mastectomy months ago, and completed radiation 6 weeks earlier. She also described nocturnal reflux and heartburn, but no vomiting, weight loss, or other gastrointestinal symptoms. Her examination was normal and recent bloodwork only showed a mild normocytic anemia. EGD (esophagogastroduodenoscopy) showed friable circumferential ulceration of the distal antrum with surrounding erythema and luminal narrowing from the pyloric channel to duodenum. 1-centimetre gastroscope was not passable but 4.9-millimetre pediatric gastroscope passed into the duodenum where there were no abnormalities past the duodenal bulb. Pathology showed granulation tissue, fibrinopurulent exudate, and antral mucosa with chronic active inflammation negative for Helicobacter pylori and malignancy. Oncology felt that radiation was too far from the pylorus to be responsible for the findings. High-dose proton pump inhibitor (PPI) and soft diet were recommended with minimal symptomatic improvement. 2 months later, she developed weight loss and repeat EGD showed minimal endoscopic improvement (Figure 1). ICI-related enteritis was suspected and she was started on prednisone 50 mg daily. Her appetite and nausea significantly improved. Steroid taper was planned for 8 weeks. At 3 months, symptoms recurred with prednisone taper. EGD showed only mild improvement of the duodenal stricture. Prednisone dose was increased. On repeat EGD at 7 months, the pylorus was patent with only granular inflammation predominantly in the apex of the duodenal bulb. She tolerated a slower prednisone taper thereafter. Conclusions ICI-related inflammation is common in the lower gastrointestinal tract and can less commonly affect the upper gastrointestinal tract. This is a rare report of upper gastrointestinal stricture and the first report known to us of pyloric stricture caused by ICI. Treatment may be challenging, but was achieved with PPI and high-dose steroids with slow taper. Funding Agencies None

Prevalence and Predictors of Barrett’s Esophagus After Negative Initial Endoscopy: Analysis From Two National Databases

Guidelines suggest a single screening esophagogastroduodenoscopy (EGD) in patients with multiple risk factors for Barrett's esophagus (BE). We aimed to determine BE prevalence and predictors on repeat EGD after a negative initial EGD, using 2 large national databases (GI Quality Improvement Consortium [GIQuIC] and TriNetX). Patients who underwent at least 2 EGDs were included and those with BE or esophageal adenocarcinoma detected at initial EGD were excluded. Patient demographics and prevalence of BE on repeat EGD were collected. Multivariate logistic regression was performed to assess for independent risk factors for BE detected on the repeat EGD. In 214,318 and 153,445 patients undergoing at least 2 EGDs over a median follow-up of 28-35 months, the prevalence of BE on repeat EGD was 1.7% in GIQuIC and 3.4% in TriNetX, respectively (26%-45% of baseline BE prevalence). Most (89%) patients had nondysplastic BE. The prevalence of BE remained stable over time (from 1 to >5 years from negative initial EGD) but increased with increasing number of risk factors. BE prevalence in a high-risk population (gastroesophageal reflux disease plus ≥1 risk factor for BE) was 3%-4%. In this study of >350,000 patients, rates of BE on repeat EGD ranged from 1.7%-3.4%, and were higher in those with multiple risk factors. Most were likely missed at initial evaluation, underscoring the importance of a high-quality initial endoscopic examination. Although routine repeat endoscopic BE screening after a negative initial examination is not recommended, repeat screening may be considered in carefully selected patients with gastroesophageal reflux disease and ≥2 risk factors for BE, potentially using nonendoscopic tools.

Gastric Intestinal Metaplasia in Children: Natural History and Clinicopathological Correlation.

Gastric intestinal metaplasia (GIM) is defined as the replacement of the normal gastric epithelium by intestinal-type epithelium. GIM is considered a preneoplastic lesion for gastric adenocarcinoma in adults and is found in 25% of Helicobacter pylori ( H pylori ) exposed adults. However, the significance of GIM in pediatric gastric biopsies is still unknown. We conducted a retrospective study of children with GIM on gastric biopsies at Boston Children's Hospital between January 2013 and July 2019. Demographic, clinical, endoscopic, and histologic data were collected and compared to age and sex-matched cohort without GIM. Gastric biopsies were reviewed by the study pathologist. GIM was classified as complete/incomplete based on Paneth cell presence or absence and limited/extensive based on its distribution in the antrum or both antrum and corpus. Of 38 patients with GIM, 18 were male (47%), mean age of detection was 12.5 ± 5.05 years (range, 1-18 years). The most common histologic was chronic gastritis (47%). Complete GIM was present in 50% (19/38) and limited GIM was present in 92% (22/24). H pylori was positive in 2 patients. Two patients had persistent GIM on repeat esophagogastroduodenoscopy (2/12). No dysplasia or carcinoma was identified. Proton-pump inhibitor use and chronic gastritis were more common in GIM patients compared to control ( P = 0.02). Most children with GIM had low-risk histologic subtype (complete/limited) for gastric cancer; GIM was rarely associated with H pylori gastritis in our cohort. Larger multicenter studies are needed to better understand outcomes and risk factors in children with GIM.

Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction.

Esophageal food impactions (EFI) often precede a diagnosis of eosinophilic esophagitis (EOE). Current guidelines suggest obtaining esophageal biopsies upon suspicion of EOE, treating with proton pump inhibitor (PPI), and repeating esophagogastroduodenoscopy (EGD). This study was conducted to determine provider practice patterns with these mentioned recommendations at the time of EFI. In this retrospective study, key outcomes were the proportion of patients who had EOE mucosal biopsies, EOE diagnosis, PPI initiation, and recommendations and completions of repeat EGD. Differences in outcomes among age, sex, race, off-hours time of procedure, and trainee involvement were examined. EOE diagnosis predictors were explored with logistic regression. Twenty-nine percent of the patients had esophageal biopsies taken at the time of index EGD (iEGD). Sixteen patients were diagnosed with EOE at the time of index EFI, while fourteen patients were diagnosed on subsequent EGDs. Among those diagnosed with EOE at iEGD, 94% were placed on PPI. Of patients with confirmed EOE on index biopsy, 63% of patients were recommended repeat EGD, of which 50% completed it within 90 days. Older age was protective of EOE diagnosis while no GERD history and endoscopist suspicion of EOE predicted diagnosis of EOE. Endoscopists uncommonly take biopsies at the time of EFI, which may delay diagnosis and treatment of EOE.

Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System

BackgroundGastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system.MethodsWe identified patients with biopsy-proven GIM between 2016–2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ2) tests were used to compare patients with and without multifocal GIM.ResultsThere were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2–3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients.ConclusionIn a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.

Yield of Repeat Endoscopy for Barrett's Esophagus After Normal Index Endoscopy.

Guidelines suggest 1-time screening with esophagogastroduodenoscopy (EGD) for Barrett's esophagus (BE) in individuals at an increased risk of esophageal adenocarcinoma (EAC). We aimed to estimate the yield of repeat EGD performed at prolonged intervals after a normal index EGD. We conducted a national retrospective analysis within the U S Veterans Health Administration, identifying patients with a normal index EGD between 2003 and 2009 who subsequently had a repeat EGD. We tabulated the proportion with a new diagnosis of BE, EAC, or esophagogastric junction adenocarcinoma (EGJAC) and conducted manual chart review of a sample. We fitted logistic regression models for the odds of a new diagnosis of BE/EAC/EGJAC. We identified 71,216 individuals who had a repeat EGD between 1 and 16 years after an index EGD without billing or cancer registry codes for BE/EAC/EGJAC. Of them, 4,088 had a new billing or cancer registry code for BE/EAC/EGJAC after the repeat EGD. On manual review of a stratified sample, most did not truly have new BE/EAC/EGJAC. A longer duration between EGD was associated with greater odds of a new diagnosis (adjusted odds ratio [aOR] for each 5 years 1.31; 95% confidence interval [CI] 1.19-1.44), particularly among those who were younger during the index EGD (ages 19-29 years: aOR 3.92; 95% CI 1.24-12.4; ages 60-69 years: aOR 1.19; 95% CI 1.01-1.40). The yield of repeat EGD for BE/EAC/EGJAC seems to increase with time after a normal index EGD, particularly for younger individuals. Prospective studies are warranted to confirm these findings.

The Approach to Performance of Quality Upper Endoscopy in Lynch Syndrome (QUELS)

Strong evidence demonstrates the protective benefit of frequent colonoscopy surveillance for colorectal cancer prevention in Lynch Syndrome (LS) and is endorsed by many guidelines. Until recently, the evidence supporting the utility of upper endoscopy [esophagogastroduodenoscopy (EGD)] for upper gastrointestinal (UGI) cancer surveillance was limited. Over the last 3 years, multiple studies have demonstrated that EGD surveillance in LS is associated with the detection of both precancerous lesions and early-stage UGI cancers. On the basis of the emerging favorable evidence derived from EGD surveillance programs, the 2022 National Comprehensive Cancer Network (NCCN) Guidelines for LS recommend UGI surveillance with EGD starting between age 30 and 40 years with repeat EGDs every 2 to 4 years, preferably in conjunction with colonoscopy, in all patients with a germline pathogenic variant (PV) in MLH1, MSH2, EPCAM, and MSH6 and, because of the lack of data, consideration in PMS2. Standardization of the approach to performing EGD surveillance in LS and reporting clinically actionable findings is requisite for both improving quality and understanding the cost efficiency and outcomes of patients undergoing EGD as a surveillance tool. Accordingly, the primary objective of this Quality of Upper Endoscopy in Lynch Syndrome (QUELS) statement is to articulate a framework for standardizing the approach to performing and reporting EGD findings in patients with LS by introducing emerging quality metrics. The recommendations presented herein were developed from available evidence and consensus-based expert opinion and provide a practical approach for clinicians applying EGD surveillance in accordance with the most recent and existing LS guidelines.

Congenital absence of splenic artery: a rare cause of upper gastrointestinal bleed

A 21-year-old woman presented as an emergency with upper abdominal discomfort and one episode of haematemesis. Physical examination, blood results and oesophagogastroduodenoscopy (OGD) were unremarkable. The patient collapsed following a large haematemesis 24 hours later and was intubated, ventilated and resuscitated. Repeat OGD demonstrated multiple areas of gastric angiodysplasia with active bleeding. Attempted haemostasis was unsuccessful. computed tomography angiography (CTA) demonstrated an absent splenic artery and multiple abnormal collaterals supplying the stomach, pancreas and spleen originating from a hypertrophied left gastric artery and gastro-epiploic arteries. Angiography demonstrated active bleeding from these abnormal collaterals, which were successfully embolised and haemostasis attained. On follow-up CTA, no evidence of further bleeding or infarction was noted. Congenital absence of the splenic artery is rare, with only four reported cases, and is an extremely rare cause of upper gastrointestinal bleeding.

Endoscopic Endolooping for giant Brunner’s gland adenoma

Brunner's gland adenoma (BGA) is a rare benign tumor of the duodenum, it is most found during routine esophagogastroduodenoscopy (EGD). a 52-year-old male patient presented with melena and severe anemia, EGD showed a large wide base polypoidal lesion arise from the anterior wall of duodenal bulb, biopsy taken by biopsy forceps, revealed BGA. After patient's consent, EGD and Endolooping done aiming for ischemia and autoamputation, 2 weeks later I repeat EGD with complete loss of duodenal lesion, we report this technique for the first time to treat large BGA.

PMON40 A Rare Etiology of Chronic Diarrhea: Zollinger-Ellison Syndrome

Abstract Introduction Zollinger-Ellison Syndrome (ZES) is a rare etiology of chronic diarrhea caused by a gastrin-secreting neuroendocrine tumor. Early suspicion can prevent multiple readmissions for recurrent diarrhea thus improving clinical outcomes through prompt diagnosis and treatment, as the following case highlights. Case presentation A 74-year-old African-American female with hypertension and chronic atrial fibrillation presented to the ED complaining of watery, non-bloody diarrhea for the past 3 weeks. She reports her symptoms worsened after completing a course of amoxicillin for pharyngitis one week prior. On further questioning, she reported intermittent diarrhea for over 20 years lasting approximately two days per episode. She denied recent travel, sick contacts, pet reptiles, and recent ingestion of undercooked meat. On arrival, she was afebrile and hemodynamically stable. She was admitted for an acute kidney injury with an elevated creatinine of 3.23 mg/dL (N: 0.6-1.1 mg/dL) due to dehydration. Her renal function improved with fluids, but she developed bloody diarrhea for which gastroenterology was consulted. Stool studies were negative for Shiga-toxin, C. difficile, lactoferrin, and parasites. Computed Tomography of the abdomen showed enteritis with fluid noted throughout the colon consistent with colitis. Unprepped colonoscopy revealed blood throughout the length of the colon, suggestive of an upper gastrointestinal bleed. Esophagogastroduodenoscopy (EGD) revealed multiple bleeding duodenal ulcers controlled with hemostasis. Her symptoms improved and she was discharged home on oral pantoprazole, and told to follow up outpatient. Two weeks later, she denied any new episodes of diarrhea, and a random serum gastrin level was elevated at 413 pg/mL (N: &amp;lt;180 pg/mL). Repeat gastrin level off pantoprazole for 7 days was also elevated at 678 pg/mL, and a serum Chromogranin A level was elevated at 629 pg/mL (N: &amp;lt;390 pg/mL). Repeat EGD found her Gastric pH to be 1 with multiple non-bleeding duodenal ulcers. Somatostatin receptor scintigraphy revealed a high intensity signal consistent with a duodenal gastrinoma causing ZES. She elected for surgical resection, and was discharged home on high dose pantoprazole. Three months later, she stated that her diarrhea had completely resolved. Conclusion This case confirms ZES as a rare cause of chronic diarrhea in the setting of multiple duodenal ulcers refractory to proton pump inhibitors. Diagnosis can be made with a fasting serum gastrin level &amp;gt;1000 pg/mL or &amp;gt;400 pg/mL with a gastric pH &amp;lt;1. A Secretin Stimulation Testing can also be used. Treatment starts with high dose proton pump inhibitors, octreotide for hormonal regulation, and surgical resection if necessary. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

S490 A Single Center Experience in the Management and Follow-Up of Patients With Esophagitis: A Retrospective Study

Introduction: Gastroesophageal reflux disease (GERD) is a chronic condition in which the reflux of gastric content into the esophagus results in symptoms and complications, such as erosive esophagitis, Barrett’s esophagus (BE), and esophageal adenocarcinoma. There are four grades of esophagitis increasing in severity from A to D. In patients with esophagitis on initial endoscopic evaluation, the current American College of Gastroenterology (ACG) guidelines recommend repeat esophagogastroduodenoscopy (EGD) after a minimum 8-week of proton pump inhibitor (PPI) therapy, to ensure healing of esophagitis and to determine the presence of BE. Our objectives were to characterize patients with esophagitis who presented to Saint Louis University Hospital (SLUH), understand practice patterns, and identify variables that predict disease progression and affect clinical outcomes. Methods: We identified 256 patients who presented to SLUH for EGD for any indication between 2012 and 2018 and were found to have endoscopic diagnosis of esophagitis. Laboratory and pathologic data were reviewed for initial and follow-up endoscopy. All categorical variables were analyzed by chi-square analysis. Analysis of variance (ANOVA) and t-tests were used for continuous data, and analysis was performed using SPSS version 27.0. Results: Out of the 256 patients who were diagnosed with esophagitis, 61 were classified as Grade A, 59 Grade B, 45 Grade C and 91 Grade D. The mean age was 59 ± 15 and the mean BMI was 27.3 ± 8. PPI prescription percentage, repeat EGD and outcomes are shown in Table. There was no statistically significant association between sex, ethnicity, smoking history, or alcohol use history and development of BE. Conclusion: Our study showed under-prescription of PPI in patients with esophagitis. Repeat EGD was only recommended for 28%, 32%, 49% and 57% of the patients with Grades A, B, C and D esophagitis, respectively. Stronger efforts should be taken to help adhere to the guidelines in prescribing acid-suppressive medications and recommending repeat EGD for patients with esophagitis. Development of esophageal cancer was the highest in those with Grade D esophagitis. Larger studies are needed to evaluate the risk of BE or dysplasia in patients with Grades A and B esophagitis and to provide additional data on rates of development of BE or esophageal cancer in the respective groups. Table 1. - Results of a single-center study on PPI prescription percentage, repeat EGD and outcomes in patients with endoscopic diagnosis of esophagitis Grade of esophagitis PPI treatment recommended Repeat EGD recommended Repeat EGD performed Barrett’s esophagus present on follow up Dysplasia present on follow up Esophageal cancer present on follow up A (N=61) 51 (84%) 17 (28%) 6 (35%) 2 (3.3%) 2 (3.3%) 1 (1.6%) B (N=59) 40 (68%) 19 (32%) 4 (21%) 3 (5.1%) 1 (1.7%) 1 (1.7%) C (N=45) 38 (84%) 22 (49%) 3 (14%) 1 (2.2%) 1 (2.2%) 1 (2.2%) D (N=91) 74 (81%) 52 (57%) 19 (37%) 8 (8.8%) 3 (3.3%) 5 (5.5%)

S3547 Cellulase With Prokinetics Is an Effective Dissolution Therapy for Gastric Phytobezoars

Introduction: Gastric phytobezoars are hard concretions of ingested vegetable/food matter in the stomach. They can significantly impair mucosal visualization during esophagogastroduodenoscopy (EGD). In the absence of outlet obstruction, dissolution therapy is recommended as a first step whilst evaluating for underlying causes. Different dissolution therapies for bezoar have been described. Cellulase, although first described in 1980’s has not been systematically examined and whether combined therapy with prokinetics is more effective is unknown. We describe two patients with large gastric phytobezoars found on EGD and successfully treated with cellulase plus adjuvant azithromycin for 5 days. Case Description/Methods: Case 1: A 37-year-old Caucasian woman with type 2 diabetes mellitus (DM), gastroparesis and obesity presented with a 2-year history of worsening GERD, dyspepsia, early satiety and Gastroparesis Cardinal Symptom Index (GCSI) of 24. EGD revealed a large phytobezoar, occupying 60% of stomach (Fig. 1a). She was treated with Cellulase 5 g dissolved in 200 ml of water, daily for 5 days on an empty stomach, and azithromycin 125 mg liquid bid for 3 weeks. She reported significant symptom improvement in 1 week. Repeat EGD after 2-3 weeks showed normal stomach with no bezoar (Fig. 1b), and GCSI improved to 18. Case 2: A 64-year-old Caucasian woman with Type 2 DM and gastroparesis presented with worsening nausea, vomiting, early satiety and GCSI of 22. Examination noted mild epigastric fullness with tenderness and succussion splash. EGD noted a large gastric bezoar occupying the 75% of stomach. She was treated with aforementioned regimen. EGD after 2 weeks was normal with no bezoar (Fig. 1c), and GCSI improved to 16 (Figure). Discussion: Gastric bezoars are rare with an estimated incidence of 0.3% on EGD. Risk factors include gastric dysmotility, gastric outlet obstruction, anticholinergic agents/opioids or psychiatric problems. They can be asymptomatic or cause abdominal pain, nausea, vomiting or early satiety. Agents used for chemical dissolution therapy (CDT) with varying results include cellulase, carbonated drinks, papain and acetylcysteine. Both of our patients had gastroparesis with poorly controlled DM and intolerance to metoclopramide. Possible risks of CDT include possible small bowel obstruction from partially dissolved bezoars. Combination therapy with Cellulase (5G), and Azithromycin (125 mg liquid bid, prokinetic) was safe and effective therapy for gastric phytobezoars without luminal obstruction.Figure 1.: 1. Endoscopic images (Patient 1) showing large phytobezoar (a) and repeat EGD in 2 weeks showing normal stomach after dissolution therapy (b). Normal EGD (patient 2) after dissolution therapy (c).

S2348 Novel Approach to Proximal Esophageal Stricture

Introduction: We present you a case of Stricture-induced severe dysphagia that was discovered to be caused by ulceration secondary to very proximal Zenker’s diverticulum (ZD). This case report also describes a novel approach to esophageal endoscopy through a retrograde approach. Case Description/Methods: Patient is an 80 y/o African American female with a past medical history of Gastroesophageal Reflux disease, Congestive Heart Failure, Chronic Kidney disease and Dementia who presented with Heart failure exacerbation. Patient reported weight loss and dysphagia to solid food and liquids for about 2 months. Patient then underwent a modified barium swallow study (MBSS), which showed concerns for esophageal stricture and evidence that the contrast material was not passing through the esophagus. Patient then underwent Esophagogastroduodenoscopy (EGD), which showed complete esophageal obstruction approximately 25 cm from the incisors and impacted food. The food was removed and a repeat EGD was done the next day showing a circumferential ulcer and no lumen could be identified. Biopsies were taken, which was negative for dysplasia or malignancy. After discussion with General Surgery, it was decided to proceed with Open Gastrostomy tube to allow enteral nutrition as well as access to dilate the esophagus in the retrograde fashion in the future. A repeat EGD after 4 weeks showed a healing ulcer and a blind pouch without an identifiable lumen. The ultrathin scope was advanced through the gastrostomy tract into the stomach and carefully advanced in a retrograde fashion through the lower esophageal sphincter throughout the esophagus. Narrowing was seen at the proximal end of the esophagus. The scope was advanced through this and with minimal resistance able to be advanced past the level of the stricture about 15 cm from the Incisors. Esophageal stent was deployed over the wire in an antegrade fashion with fluoroscopic guidance. This time, an area of concern was identified as a possible ZD proximal to the prior ulceration site which was later confirmed on an esophagram at the level of thoracic esophagus on the right side. Discussion: This case was challenging as the diagnosis of ZD was missed despite various testing. Patient had a long history of dysphagia and the impacted food led to ulceration and esophageal strictures. The diagnosis was established after a unique approach to the stricture. This case highlights that sometimes a careful examination is required as an approach to diagnosis of dysphagia in elderly.

S3576 Collagenous Gastritis: A Rare Cause of Anemia

Introduction: A relatively common cause of gastrointestinal symptoms including abdominal pain and diarrhea is microscopic colitis. Much less commonly seen is the related disorder collagenous gastritis, which relies on pathology and high clinical suspicion for diagnosis. We report on a case of a patient with this rare finding. Case Description/Methods: A 32-year-old male with a past medical history of achalasia status post myotomy presented with symptomatic normocytic anemia. His initial work up was significant for a hemoglobin of 5g/dL with reported use of non-steroidal anti-inflammatory drugs (NSAID). An esophagogastroduodenoscopy (EGD) showed atypical gastropathy with gross cobblestoning in the gastric body. Pathology showed chronic gastritis with focal gastric intestinal metaplasia, normal duodenal mucosal biopsies, and celiac disease serology was negative. Repeat EGD with gastric mapping demonstrated chronic gastritis, no intestinal metaplasia, negative H. pylori. Trichome stain highlighted increased subepithelial collagen layer which was confirmed by a gastrointestinal pathologist, consistent with collagenous gastritis. Colonoscopy was normal; colon biopsies were not taken as patient was asymptomatic. He was started on iron supplementation and remains well. (Figure) Discussion: Collagenous enteritides are a class of gastrointestinal disorders encompassing collagenous colitis, sprue, and gastritis. While collagenous colitis is relatively common, collagenous gastritis remains very rare. Typical symptoms include abdominal pain, nausea, diarrhea, and anemia. The most common endoscopic findings include gastric nodularity in the gastric body, erosions, and erythema. The diagnosis depends on pathologic findings of subepithelial infiltration with chronic inflammatory cells in the lamina propria, as well as deposition of collagen bands greater than 10 microns in thickness. The pathogenesis remains unclear, but medications like NSAIDs as well as smoking have been implicated. It is also associated with several autoimmune diseases including Sjogren’s and ulcerative colitis, causing postulation that there may be overexpression of HLA DR by epithelial cells and CD25 positive cells. There is currently no established therapy, and management is usually supportive care. Our case highlights the importance of a high level of suspicion for this rare disease, and pursuit of accurate diagnosis in the face of clinical perplexity. Likely etiology in our case appears to NSAIDs use which is known trigger for collagenous colitis.Figure 1.: Endoscopic view of the gastric body in collagenous gastritis.

S2358 Black Esophagus: A Case of Acute Esophageal Necrosis Secondary to Binge Drinking

Introduction: Acute esophageal necrosis (AEN) is a rare, potentially life threating and under-diagnosed syndrome that presents most commonly with upper GI bleeding, hematemesis, and abdominal pain. Here we present a case of an otherwise healthy, middle-aged man with coffee ground emesis who had classic findings of black, necrotic, ulcerative esophageal mucosa on esophagogastroduodenoscopy (EGD) after presenting in the setting of binge drinking. Case Description/Methods: A 47-year-old man with a history of alcohol use disorder presented to the hospital with multiple episodes of coffee ground emesis and epigastric pain. He recently restarted drinking alcohol. He denied any blood thinner use. He was hypertensive and tachycardic on arrival. His physical exam was overall non focal. His relevant lab work included a BUN 24, lactate of 8.3, lipase 11, Hgb 14.5 g/dL; AST, ALT, platelets, and INR were all normal. The patient was treated with IV fluids and started on a PPI drip. A CT scan of the abdomen/pelvis was performed and it was remarkable for nonspecific wall thickening of the thoracic esophagus. The GI service was consulted and an EGD was performed showing a 4 cm hiatal hernia and black mucosal necrosis in the mid and distal esophagus (Figure). The patient was made NPO, continued PPI therapy, and cardiothoracic surgery (CTS) was consulted. After gradual symptomatic improvement, he was discharged on lansoprazole, sucralfate, and morphine. He was maintained on a clear liquid diet until outpatient follow up with CTS, at which point his diet was gradually advanced without complications. Discussion: AEN is a rare condition with an incidence of 0.01-0.28% of patients undergoing EGD. The pathophysiology is usually multifactorial due to ischemic injury, gastric acid exposure and impaired mucosal repair mechanisms. Multiple medical comorbidities such as diabetes, hypotension, and alcohol abuse have been associated with an increased risk of developing AEN. In our case, binge drinking, and emesis likely contributed to AEN in an otherwise healthy patient. Management is largely supportive with hydration and acid suppression but can include surgery or balloon dilation if the course is complicated by perforation or stricture formation. Prompt performance of an EGD with timely referral to CTS is recommended for risk stratification and to guide follow up management. Repeat EGD is warranted after a month to document healing.Figure 1.: Esophagogastroduodenoscopy of the mid and distal esophagus.

S2257 Cirrhosis, Varices, and Barrett’s Esophagus: WATS3D-only Surveillance and Band Ligation in the Management of Nondysplastic Barrett’s Esophagus Progressing to High Grade Dysplasia With Underlying Esophageal Varices

Introduction: Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS3D) is an emerging technique used to collect esophageal samples via transepithelial brushing. WATS3D can be a safe and useful tool in Barrett’s esophagus (BE) management in patients with underlying small esophageal varices (EV) where traditional 4 quadrant cold forceps biopsies (CFB) would be contraindicated due to the risk of adverse events such as bleeding. We describe the utility of WATS3D-only surveillance combined with band ligation in the management and eradication of BE which progressed to high grade dysplasia (HGD) in a patient with underlying cirrhosis and EV. Case Description/Methods: We present a 66-year-old male with a history of nondysplastic (ND) BE (C0-M1), small Grade 1 EV and cirrhosis who presented for BE surveillance. Due to underlying EV and associated risk of bleeding, CFB was not performed and sampling with WATS3D-only was undertaken. WATS3D was first performed with surveillance esophagogastroduodenoscopy (EGD) in 2015 and demonstrated ND BE. On further EGD surveillance, BE histology remained ND until early 2021 where WATS3D revealed low grade dysplasia (LGD). Repeat EGD with WATS3D brushing was performed 4 months later, which demonstrated progression to HGD. Interval surveillance EGD with WATS3D brushing was, again, performed 4 months later and demonstrated LGD with rare foci of HGD. Of note, in both instances band ligation of the dysplastic segments was done. EGD with WATS3D 3 months later revealed endoscopic clearance of BE post-banding and pathology report revealed, ND, non-goblet cell metaplasia. The final interval surveillance EGD with WATS3D, 3 months later, showed complete eradication of BE with no evidence of intestinal metaplasia. Table 1 provides a thorough chronological description from first EGD to complete resolution of BE, 8 years later. Discussion: WATS3D has been increasingly shown to be an effective BE surveillance and screening tool. However, given the lack of data regarding appropriate surveillance windows for WATS3D-only BE surveillance, we performed sampling at shorter intervals than what would otherwise be recommended, to confirm the lack of dysplasia. This case presents a unique approach to WATS3D-only surveillance combined with band ligation therapy of dysplasia in the management of BE in a cirrhotic patient with underlying EV. Additionally, this case is unique in clearly documenting progression of a short segment of ND BE to HGD with WATS3D sampling alone. Table 1. - Summary of findings and intervention from first EGD to complete resolution of BE (8 year window) Date Variceal Grade Prague Score Number of BE Islands Sampling done by WATS3D Pathology Findings Banding therapy (# of bands) 04/09/14 2 C0-M1 3 No N/A 0 07/29/15 2 C0-M1 Scattered No N/A 0 12/2315 1 C0-M1 Scattered Yes No dysplasia 0 06/15/16 1 C0-M1 Scattered Yes No dysplasia 0 02/08/17 2 C0-M1 Scattered No N/A 4 01/22/18 1 C0-M1 1 No N/A 0 01/30/19 2 C0-M1 2 No N/A 0 01/29/20 1 C0-M1 2 No N/A 0 02/01/21 1 C0-M1 2 Yes Low-grade dysplasia 0 06/01/21 1 C0-M1 2 Yes High-grade dysplasia 3 10/25/21 1 C0-M1 2 Yes Low-grade with rare foci of high-grade dysplasia 2 01/25/22 1 N/A 3 Yes Non-goblet cell metaplasia, no dysplasia 0 04/25/22 1 N/A 0 Yes Squamocolumnar, no dysplasia or metaplasia 0