Abstracts respectively. Of those individuals with HIDA scans ordered, only 18.5% were deemed appropriate (20.0% for bile leak, 12.7% for acute cholecystitis, and 22.0% for biliary colic). When scans were ordered inappropriately, subsequent management changes occurred in only 8.15% of these patients. Conclusion: The vast majority of inpatient HIDA scans are inappropriately ordered, adding to cost of care while adding no clinical benefit. In patients with biliary tract signs and symptoms, following consensus guidelines can help the clinician decide on the most appropriate imaging work-up and avoid unnecessary testing.
334 Pancreatic Adenocarcinoma: Have Current Diagnostic Techniques and Treatments Improved Outcomes? Rohit Chappidi, MD, Stephen Sontag, MD. Hines Veterans Affairs Hospital, Maywood, IL. Introduction: Pancreatic cancer (PC), the fourth most common cause of cancer-related deaths in the United States has an estimated 1-year and 5-year survival rate of 25% and 5%, respectively. Adenocarcinoma (AdCa) subtype accounts for 95% of PC and is the most aggressive form of this malignancy. Treatments are either curative (Whipple surgery or pancreatectomy) or palliative (gastric or biliary bypass surgeries, chemotherapy, radiation or chemoradiation). The purpose of this study was to examine the outcome of every patient with pancreatic AdCa at our institution who was diagnosed, staged, and treated according to the National Comprehensive Cancer Network (NCCN) guidelines. Methods: All veterans from 2000 to 2014 who were diagnosed with pancreatic AdCa at the Hines VA Hospital were included in this study. Patients were staged and classified into 3 groups according to treatment goals: (1) surgical cure, (2) surgical palliation (debulking gastric or biliary bypass surgeries), and (3) non-surgical palliation. Results: Of the 58 patients diagnosed with pancreatic AdCa, 91% initially presented with a diagnosis of stage 2, stage 3, or stage 4. Median survival based on stage and treatment goals are shown in Table 1 (p=0.005) and Table 2. All patients diagnosed with stage 0-1 are currently living. In AdCa stages 2, 3, and 4, there was no statistically significant improvement in mortality independent of the treatment goal. All stage 4 patients were deceased within 10 months of diagnosis and had the worst prognosis. Conclusion: Current modalities and treatments are not helping improve outcomes in patients diagnosed with pancreatic AdCa. Unless patients are diagnosed at early stages (0-1), prognosis is poor. Independent of staging, only patients undergoing surgical cure have a chance of survival 5 years after diagnosis. Despite advances in imaging, interventional procedures, and surgical therapies, these dismal outcomes are statistically similar to historical figures.
[334]
Table 1. % Diagnosed at Initial Presentation
Stage
Median Survival (months)
0-1
9%
—
2
22%
17.8
3
50%
17
4
19%
4.2
[334]
Table 2. % of patients
Median Survival (months)
Surgical Cure
Treatment Goal
38%
21.6
Surgical Palliation
24%
8.5
Non-Surgical Palliation
38%
5.7
ics to increase the confidence level of diagnosing serous, mucinous, and IPMN lesions. In addition, we evaluated the change in management and impact on surveillance intervals. We retrospectively reviewed data on 16 patients who underwent EUS-guided endomicroscopy over 1 year. Before the beginning of the procedure, the olivette device is attached to the proximal end of a 19G standard puncture needle, once the stylet has been removed from the needle. The nCLE probe is then correctly positioned inside the needle, the white luer is tightened in order to be locked onto the miniprobe. The miniprobe can now remain inside the needle for insertion into the endoscope and puncturing. However, it must be retracted from 2 cm inside the needle, to protect it during the puncture; 2.5 mL of 10% fluorescein are injected intravenously in order to allow fluorescent imaging. Microscopic real-time sequences are recorded during 5-10 minutes inside the lesion. For cystic tumors, the sequences will be acquired preferably against the cyst wall, to image cellular structures. The cyst fluid is then aspirated, as per standard of care in an EUS-FNA procedure, and analyzed for chemistry, cytology, and/or tumor markers. The images were reviewed by 2 independent experienced physicians. Results: See Table 1. Conclusion: The addition of nCLE improved confidence in diagnosis of nature of cystic lesion in 80% of the retrospective cohort. nCLE impacted management by stopping surveillance in 60% of our cases. Adding nCLE may enhance detection of IPMN with 80% specificity, leading to closer follow-up and stop surveillance in benign serous cystadenomas. Addition of in vivo microscopy to current algorithm of cyst evaluation may potentially improve morbidity related to cyst surgeries.
336 Pancreaticopleural Fistula in a Patient With Pancreatic Pseudocysts Treated With Endoscopic Cystogastrostomy Saurav Luthra, MD, Vasvi Singh, MD, Raheel Khalid, MD, Deerajnath Lingutla, MD. Internal Medicine, Unity Health System, Rochester, NY. Introduction: Pleural effusion in a patient with pancreatic pseudocyst is a rare but serious complication that forms due to a direct connection between the pseudocyst and the pleural cavity by pancreaticopleural fistula. It may be the primary presentation in some patients having the pseudocyst and can lead to diagnostic and management difficulties. We are presenting here a case of massive pleural effusion from a pancreaticopleural fistula treated with endoscopic ultrasound (EUS)-guided cystogastrostomy. Case Report: A 23-year-old male with history of alcohol-related acute pancreatitis 1 year ago and another episode of pancreatitis with infected pseudocysts 2 months ago, presented with left-sided pleuritic chest pain, radiating to back, mild cough, clear sputum, and shortness of breath for 2 days. He denied any abdominal pain, nausea, vomiting, fever, or chills. Lab work revealed lipase 190 u/L and amylase 390 u/L. CT scan chest showed large left-sided pleural effusion, and the pseudocysts around the pancreas, as compared to the last CT scan, had decreased in size. We did thoracentesis draining 1000 cc of brownish-red exudative fluid having amylase level of 18,425 u/L, which revealed the diagnosis. A MRCP was also performed that reported collapsed pancreatic duct with no necrotizing pancreatitis, smaller pseudocysts with a larger collection remaining in the left anterior abdomen and normal biliary structures. He got a second thoracentesis 2 days later and amylase level was 27,380 u/L this time. Given his ongoing symptoms and recurrent pleural effusions he was transferred to a pancreaticobiliary center where he got pancreatic stent placement, PEG tube insertion for bowel rest, pleural catheter placement for continued drainage, and EUS-guided cystogastrostomy double stents placement. Follow-up CT scan of abdomen showed near resolution of the fluid collection in the lesser sac and interval decrease in collection in the left upper quadrant. Conclusion: Pancreaticopleural fistula can be rare complication of pseudocysts, which can be very challenging to manage. Use of amylase level in pleural fluid analysis is helpful in diagnosis. Treatment may be conservative but in some cases drainage of the pseudocysts may be required by surgical versus endoscopic measures. We have documented here a case of pancreaticopleural fistula managed by endoscopic cystogastrostomy which is associated with less morbidity as compared to the surgical options.
Am J Gastroenterol 2014; 109:S101–S123; doi:10.1038/ajg.2014.276
SMALL INTESTINE/UNCLASSIFIED 335 nCLE (Needle-Based Confocal Laser Endomicroscopy) in Evaluation of Indeterminate Pancreatic Cystic Lesions: A Single-Center Experience
337
Virendra Joshi, MD, FACG. Ochsner Clinic, New Orleans, LA. Introduction: Pancreatic cysts are a group of lesions with heterogeneous malignant potential. Currently, there are no consistently reliable biomarkers or imaging modalities to aid in cyst diagnosis, classification, and to predict biologic behavior. Confocal laser endomicroscopy is a novel tool to assess pancreatic cystic lesions, which are indeterminate on clinical radiologic imaging, EUS, and biomarker analysis. Methods: We evaluated endoscopic ultrasound (EUS)-guided in vivo endomicroscopic characteristics of pancreatic cyst wall and correlated with cystic fluid chemistry and EUS imaging, along with demograph-
[335]
Partial Balloon Deflation for Controlled Withdrawal of Single Balloon Enteroscopy Abiodun Laoye, MD,1 Steven Gorcey, MD2. 1. Internal Medicine, Jersey Shore University Medical Center, Neptune, NJ; 2. Monmouth Medical Center, Long Branch, NJ. Introduction: An 80-year-old female with chronic paroxysmal atrial flutter on aspirin presented for iron deficiency anemia evaluation. The hemoglobin and hematocrit were 11.5 and 34.9. Endoscopy was negative; video capsule revealed a suspicious area oozing fresh blood. Visualization and localization were
Table 1. Results Age (mean)
Sex M/F
Imaging CT
Symptoms/Incidental
Cyst Fluid Clear/Viscous
Serous
75
0/10
100% indeterminate
80% asymptomatic
clear
200
Mucinous
50
2/2
100% indeterminate
50% asymptomatic
bloody
3000
IPMN
70
2/0
100% indeterminate
50 % asymptomatic
bloody
500
© 2014 by the American College of Gastroenterology
CEA Mean
The American Journal of GASTROENTEROLOGY
S101
S102
Abstracts
poor, and neoplasm could not be ruled out. A single balloon enteroscopy was performed. We were able to advance the scope to the ileum confirmed by biopsy. After tattooing the most distal point, withdrawal began. Using the pause button on the Olympus inflator device, partial balloon deflation was achieved. The proper amount of deflation was determined by trial and error. After 2 seconds of deflation, we pressed the pause button and checked the resistance to withdrawal. Adequate deflation was considered at the point where withdrawal was controlled without resistance. We were able to prevent rapid unplaiting of the small bowel off the over tube and flatten the folds for better visualization. Glucagon was also utilized to reduce motility. The area in question was located, biopsied, and tattooed. Pathology revealed chronic inflammation with a hyperplastic component. NSAID enteropathy secondary to the aspirin was the most likely diagnosis. Discussion: The small bowel had long been a black box for endoscopists due to its long length and multiple complex loops, making it impossible to evaluate with conventional endoscopy. Although the wireless video capsule allows for the visualization of the small bowel, its major drawbacks are the inability to accurately localize and biopsy lesions, as well as a high negative predictive value. In 2007, single-balloon enteroscopy was introduced, allowing endoscopists to intubate deep into the small bowel by plaiting it onto the scope and over tube. The single-balloon system consists of an Olympus 200-cm enteroscope, a disposable silicone splinting tube with an inflatable balloon, and an inflation control unit. After deep intubation of the small bowel, the conventional technique for withdrawal is to deflate the over tube balloon and retract both the scope and over tube together. The drawback of this technique is rapid unplaiting of the small bowel off the over tube, often resulting in incomplete visualization. Using our technique of partial balloon deflation described above, we were able to achieve controlled withdrawal with great visualization. In addition, the balloon allows for traction of bowel folds similar to that obtained in capassisted endoscopy. As studies with colonoscopy have shown, controlled withdrawal increases lesion detection. With partial balloon deflation in single-balloon enteroscopy, one can achieve a similar degree of controlled withdrawal to that of colonoscopy.
Results: Seventy-nine subjects were enrolled. The most common investigator assessed drug-related AEs were headache, UTI, and GI symptoms, generally similar in frequency across treatment groups. There were no study withdrawals due to AEs, nor any drug-related serious AEs. Gut contractility parameters poorly correlated with symptom severity for the treatment cohort (n=51; r0.12). Symptom improvement was observed at the 2 lower doses (10 and 50 mg) of C. Further analysis was conducted with these treatment groups (n=10). Small bowel CT correlated moderately with GCSI total score (r= -0.76; p=0.01), bloating (r= -0.72; p=0.02), and postprandial fullness (r= -0.84; p90% and K >0.80). The main analyses were based on data from 677 NFCA and 82 TJUH respondents with self-reported CD. Respondents were predominantly female (NFCA: 91%, TJUH: 74%, p< 0.001) and were aged 18 to 86 (mean = 45). Compared to NFCA respondents, TJUH respondents were more likely to report a diagnosis of CD by a GI physician (78% vs. 59%, p = 0.001) and through a small bowel biopsy (82% vs. 68%, p = 0.011). The proportion reporting receiving a physician recommendation for relative screening was substantially higher for TJUH than for NFCA (78% vs. 44%, p 0.05). Conclusion: Our study demonstrates that there are deficiencies in the basic understanding of issues surrounding intestinal disease. These findings could be used as a quality measure for a planned implementation of an educational program regarding intestinal disease and transplantation principles.
[343]
Table 1. Comparison Between Incomplete and Complete Retrograde Enteroscopies
Total procedure time
55.6 min (SD 5.5)*
Time to reach cecum
3 min (3–6)*
53.5 min (SD 18.2)* 5 min (3–17)*
Time to intubate ileum
20 min (15–44)^
10 min (2–33)^
Depth of ileum intubation
60 cm (45–65)#
125 cm (50–235)#
[341] Table 1. Correct Responses for Evaluation of Medical Knowledge of Intestinal Disease *P > 0.05; ^P=0.03; #P=0.04. Category (N)
PI
MI
TI
TC (69)
15.86%
35.51%
20.29%
NTC (139)
32.32%
41.55%
21.94%
PGY1-3 (170)
27.39%
40.44%
22.06%
344
PGY4-7 (38)
24.47%
35.53%
18.42%
A Comparison of the Epidemiology and Natural History of Chronic Stenosing Enteritis and Crohn’s Disease Veronica Baptista, MD, Neil Marya, MD, Benjamin Hyatt, MD, David Cave, MD, PhD, FACG. Dept of Medicine, Div of Gastroenterology, University of Massachusetts Medical Center, University Campus, Worcester, MA.
342 Surprisingly High Incidence of Mental Health DIsorders in the Celiac Database Abraham Yacoub, MD, Andrew Hammoud, MD, Leslie Bank, MD, FACG. United Health Services Wilson Memorial Hospital, Johnson City, NY. Introduction: Celiac disease is an autoimmune disease that damages the lining of the duodenum. The damage is due to a reaction to gliadin (gluten protein), which is mainly found in wheat. Surprisingly, celiac disease may present with a variety of psychiatric comorbidities. Our study focused on the high incidence of mental health disorders in the celiac database. Methods: A retrospective chart review of 261 patients with celiac disease at Binghamton Gastroenterology Associates in Binghamton, New York, between 6/1/2009 to 11/25/2013. Results: Two hundred sixty-one patients were included in our study. All the patients were diagnosed with celiac disease. The ages of patients ranged from pediatric to geriatric. Forty patients (15.3%) had depression, 2 patients (0.7%) had anxiety, 1 patient (0.3%) had schizophrenia, 1 patient (0.3%) had multiple personality disorder, 41 patients (15.7%) had arthritis, 39 patients (14%) had thyroid disease, 22 patients (8%) had diabetes, 5 patients (1.9%) had dermatitis herpetiformis,1 patient (0.3%) had Sjögren’s syndrome, 1 patient (0.3%) had autoimmune hepatitis, 1 patient (0.3%) had ulcerative colitis, 1 patient (0.3%) had Reynaud’s syndrome, and 1 (0.3%) patient had sarcoidosis. Conclusion: A high incidence of mental health disorders was observed in our celiac database. Studies have shown a strong association between celiac disease and mental health disorders; however, the mechanism is poorly understood. Therefore, more research is needed to further understand the mechanism. Clinicians who encounter patients with mental health disorders should keep celiac disease in their differential diagnosis
Introduction: We have previously described chronic stenosing enteritis (CSE), a disorder notable for large indolent superficial ulcers and stenoses in the mid small intestine resulting in iron deficiency anemia. The goal of this study is to investigate the natural history and epidemiology of CSE as compared with Crohn’s disease (CD). Methods: Between 2007 and 2013, our group identified and surveyed 14 patients with CSE based on the predominant signs and symptoms of iron deficiency anemia, obscure GI bleeding, abdominal pain, and lack of diarrhea. Nine patients with concurrently diagnosed small bowel CD were surveyed as controls. Patients were questioned regarding symptom severity, treatments and outcome, employment, and travel history. This study was approved by the Institutional Review Board at UMass Medical Center. Statistical analysis utilized 2-sample t-tests to determine significance. Results: Data demonstrated a significantly different mean age of symptom onset for CSE and CD (49.4 vs. 28.0 years old; p=0.01). Symptoms most commonly reported in CSE were abdominal pain and blood in stool; CD patients reported more diarrhea and abdominal pain. Symptoms were reported to be significantly more severe by CD patients than for CSE patients (9.3 vs. 7.3 on a 1-10 scale; p=0.03), and were also more frequent in CD compared to CSE (120 vs. 20 times per month; p=0.05). Most CD patients were treated with anti-TNF agents, whereas CSE patients were treated with intravenous or oral iron supplements. In the CD cohort, 44% of patients were placed on anti-TNF agents before surgery; 22% had a small bowel resection (SBR); 0% had recurrence following SBR. In the CSE cohort, 28% of patients were placed on anti-TNF agents after SBR; 50% had SBR, 57% of those patients had recurrence. In regards to employment, 29% CSE patients were engineers compared with 0% CD patients. Of the CD patients, 0% described their highest level of occupation as “managerial” or “executive,” compared with 42% of CSE patients. Travel history was also more extensive for CSE patients with an average of 36.2 trips abroad their lifetime compared with 0.89 trips for CD patients. Conclusion: CSE is a rare and separate entity from CD. Our study demonstrates several characteristics that differ between these 2 conditions, including symptom type, frequency, severity, age distribution, social status, and travel history. The differences and social status and the travel histories noted suggest different environmental factors may play a role in their etiology and/or pathogenesis.
343 Colon and Ileum Intubation Times Are a Significant Component of the Time it Takes to Perform Retrograde Overtube-Assisted Enteroscopy and May Affect Procedure Efficiency Luis Lara, MD, Andrew Ukleja, MD, Ferenando Castro, MD, FACG, Nicole Palekar, MD, Tolga Erim, DO, Alison Schneider, MD, Ronnie Pimentel, MD, FACG, Brenda Jimenez, MD, Roger Charles, MD, FACG. Cleveland Clinic Florida, Weston, FL. Introduction: Retrograde double balloon overtube-assisted enteroscopy (rDBE) is used to investigate distal small bowel pathology. These are time-intense procedures, and most centers allocate 90-min blocks for them. The database was reviewed to determine rDBE total procedure time, the fraction of time it took to reach the cecum and intubate the ileum, and potential factors for incomplete rDBE. Methods: All rDBE are performed using a Fujinon EN-450T5 enteroscope and TS-13140 balloon overtube (Fujinon, Inc, Saitama, Japan) with propofol sedation. Data were captured from August 2012 to November 2013. Patients with unaltered intestinal anatomy and recorded total procedure time, time to cecum, time to ileum intubation, and estimated depth of insertion (in cm) were included. Means and medians were compared and p
334 Pancreatic Adenocarcinoma: Have Current Diagnostic Techniques and Treatments Improved Outcomes? Rohit Chappidi, MD, Stephen Sontag, MD. Hines Veterans Affairs Hospital, Maywood, IL. Introduction: Pancreatic cancer (PC), the fourth most common cause of cancer-related deaths in the United States has an estimated 1-year and 5-year survival rate of 25% and 5%, respectively. Adenocarcinoma (AdCa) subtype accounts for 95% of PC and is the most aggressive form of this malignancy. Treatments are either curative (Whipple surgery or pancreatectomy) or palliative (gastric or biliary bypass surgeries, chemotherapy, radiation or chemoradiation). The purpose of this study was to examine the outcome of every patient with pancreatic AdCa at our institution who was diagnosed, staged, and treated according to the National Comprehensive Cancer Network (NCCN) guidelines. Methods: All veterans from 2000 to 2014 who were diagnosed with pancreatic AdCa at the Hines VA Hospital were included in this study. Patients were staged and classified into 3 groups according to treatment goals: (1) surgical cure, (2) surgical palliation (debulking gastric or biliary bypass surgeries), and (3) non-surgical palliation. Results: Of the 58 patients diagnosed with pancreatic AdCa, 91% initially presented with a diagnosis of stage 2, stage 3, or stage 4. Median survival based on stage and treatment goals are shown in Table 1 (p=0.005) and Table 2. All patients diagnosed with stage 0-1 are currently living. In AdCa stages 2, 3, and 4, there was no statistically significant improvement in mortality independent of the treatment goal. All stage 4 patients were deceased within 10 months of diagnosis and had the worst prognosis. Conclusion: Current modalities and treatments are not helping improve outcomes in patients diagnosed with pancreatic AdCa. Unless patients are diagnosed at early stages (0-1), prognosis is poor. Independent of staging, only patients undergoing surgical cure have a chance of survival 5 years after diagnosis. Despite advances in imaging, interventional procedures, and surgical therapies, these dismal outcomes are statistically similar to historical figures.
[334]
Table 1. % Diagnosed at Initial Presentation
Stage
Median Survival (months)
0-1
9%
—
2
22%
17.8
3
50%
17
4
19%
4.2
[334]
Table 2. % of patients
Median Survival (months)
Surgical Cure
Treatment Goal
38%
21.6
Surgical Palliation
24%
8.5
Non-Surgical Palliation
38%
5.7
ics to increase the confidence level of diagnosing serous, mucinous, and IPMN lesions. In addition, we evaluated the change in management and impact on surveillance intervals. We retrospectively reviewed data on 16 patients who underwent EUS-guided endomicroscopy over 1 year. Before the beginning of the procedure, the olivette device is attached to the proximal end of a 19G standard puncture needle, once the stylet has been removed from the needle. The nCLE probe is then correctly positioned inside the needle, the white luer is tightened in order to be locked onto the miniprobe. The miniprobe can now remain inside the needle for insertion into the endoscope and puncturing. However, it must be retracted from 2 cm inside the needle, to protect it during the puncture; 2.5 mL of 10% fluorescein are injected intravenously in order to allow fluorescent imaging. Microscopic real-time sequences are recorded during 5-10 minutes inside the lesion. For cystic tumors, the sequences will be acquired preferably against the cyst wall, to image cellular structures. The cyst fluid is then aspirated, as per standard of care in an EUS-FNA procedure, and analyzed for chemistry, cytology, and/or tumor markers. The images were reviewed by 2 independent experienced physicians. Results: See Table 1. Conclusion: The addition of nCLE improved confidence in diagnosis of nature of cystic lesion in 80% of the retrospective cohort. nCLE impacted management by stopping surveillance in 60% of our cases. Adding nCLE may enhance detection of IPMN with 80% specificity, leading to closer follow-up and stop surveillance in benign serous cystadenomas. Addition of in vivo microscopy to current algorithm of cyst evaluation may potentially improve morbidity related to cyst surgeries.
336 Pancreaticopleural Fistula in a Patient With Pancreatic Pseudocysts Treated With Endoscopic Cystogastrostomy Saurav Luthra, MD, Vasvi Singh, MD, Raheel Khalid, MD, Deerajnath Lingutla, MD. Internal Medicine, Unity Health System, Rochester, NY. Introduction: Pleural effusion in a patient with pancreatic pseudocyst is a rare but serious complication that forms due to a direct connection between the pseudocyst and the pleural cavity by pancreaticopleural fistula. It may be the primary presentation in some patients having the pseudocyst and can lead to diagnostic and management difficulties. We are presenting here a case of massive pleural effusion from a pancreaticopleural fistula treated with endoscopic ultrasound (EUS)-guided cystogastrostomy. Case Report: A 23-year-old male with history of alcohol-related acute pancreatitis 1 year ago and another episode of pancreatitis with infected pseudocysts 2 months ago, presented with left-sided pleuritic chest pain, radiating to back, mild cough, clear sputum, and shortness of breath for 2 days. He denied any abdominal pain, nausea, vomiting, fever, or chills. Lab work revealed lipase 190 u/L and amylase 390 u/L. CT scan chest showed large left-sided pleural effusion, and the pseudocysts around the pancreas, as compared to the last CT scan, had decreased in size. We did thoracentesis draining 1000 cc of brownish-red exudative fluid having amylase level of 18,425 u/L, which revealed the diagnosis. A MRCP was also performed that reported collapsed pancreatic duct with no necrotizing pancreatitis, smaller pseudocysts with a larger collection remaining in the left anterior abdomen and normal biliary structures. He got a second thoracentesis 2 days later and amylase level was 27,380 u/L this time. Given his ongoing symptoms and recurrent pleural effusions he was transferred to a pancreaticobiliary center where he got pancreatic stent placement, PEG tube insertion for bowel rest, pleural catheter placement for continued drainage, and EUS-guided cystogastrostomy double stents placement. Follow-up CT scan of abdomen showed near resolution of the fluid collection in the lesser sac and interval decrease in collection in the left upper quadrant. Conclusion: Pancreaticopleural fistula can be rare complication of pseudocysts, which can be very challenging to manage. Use of amylase level in pleural fluid analysis is helpful in diagnosis. Treatment may be conservative but in some cases drainage of the pseudocysts may be required by surgical versus endoscopic measures. We have documented here a case of pancreaticopleural fistula managed by endoscopic cystogastrostomy which is associated with less morbidity as compared to the surgical options.
Am J Gastroenterol 2014; 109:S101–S123; doi:10.1038/ajg.2014.276
SMALL INTESTINE/UNCLASSIFIED 335 nCLE (Needle-Based Confocal Laser Endomicroscopy) in Evaluation of Indeterminate Pancreatic Cystic Lesions: A Single-Center Experience
337
Virendra Joshi, MD, FACG. Ochsner Clinic, New Orleans, LA. Introduction: Pancreatic cysts are a group of lesions with heterogeneous malignant potential. Currently, there are no consistently reliable biomarkers or imaging modalities to aid in cyst diagnosis, classification, and to predict biologic behavior. Confocal laser endomicroscopy is a novel tool to assess pancreatic cystic lesions, which are indeterminate on clinical radiologic imaging, EUS, and biomarker analysis. Methods: We evaluated endoscopic ultrasound (EUS)-guided in vivo endomicroscopic characteristics of pancreatic cyst wall and correlated with cystic fluid chemistry and EUS imaging, along with demograph-
[335]
Partial Balloon Deflation for Controlled Withdrawal of Single Balloon Enteroscopy Abiodun Laoye, MD,1 Steven Gorcey, MD2. 1. Internal Medicine, Jersey Shore University Medical Center, Neptune, NJ; 2. Monmouth Medical Center, Long Branch, NJ. Introduction: An 80-year-old female with chronic paroxysmal atrial flutter on aspirin presented for iron deficiency anemia evaluation. The hemoglobin and hematocrit were 11.5 and 34.9. Endoscopy was negative; video capsule revealed a suspicious area oozing fresh blood. Visualization and localization were
Table 1. Results Age (mean)
Sex M/F
Imaging CT
Symptoms/Incidental
Cyst Fluid Clear/Viscous
Serous
75
0/10
100% indeterminate
80% asymptomatic
clear
200
Mucinous
50
2/2
100% indeterminate
50% asymptomatic
bloody
3000
IPMN
70
2/0
100% indeterminate
50 % asymptomatic
bloody
500
© 2014 by the American College of Gastroenterology
CEA Mean
The American Journal of GASTROENTEROLOGY
S101
S102
Abstracts
poor, and neoplasm could not be ruled out. A single balloon enteroscopy was performed. We were able to advance the scope to the ileum confirmed by biopsy. After tattooing the most distal point, withdrawal began. Using the pause button on the Olympus inflator device, partial balloon deflation was achieved. The proper amount of deflation was determined by trial and error. After 2 seconds of deflation, we pressed the pause button and checked the resistance to withdrawal. Adequate deflation was considered at the point where withdrawal was controlled without resistance. We were able to prevent rapid unplaiting of the small bowel off the over tube and flatten the folds for better visualization. Glucagon was also utilized to reduce motility. The area in question was located, biopsied, and tattooed. Pathology revealed chronic inflammation with a hyperplastic component. NSAID enteropathy secondary to the aspirin was the most likely diagnosis. Discussion: The small bowel had long been a black box for endoscopists due to its long length and multiple complex loops, making it impossible to evaluate with conventional endoscopy. Although the wireless video capsule allows for the visualization of the small bowel, its major drawbacks are the inability to accurately localize and biopsy lesions, as well as a high negative predictive value. In 2007, single-balloon enteroscopy was introduced, allowing endoscopists to intubate deep into the small bowel by plaiting it onto the scope and over tube. The single-balloon system consists of an Olympus 200-cm enteroscope, a disposable silicone splinting tube with an inflatable balloon, and an inflation control unit. After deep intubation of the small bowel, the conventional technique for withdrawal is to deflate the over tube balloon and retract both the scope and over tube together. The drawback of this technique is rapid unplaiting of the small bowel off the over tube, often resulting in incomplete visualization. Using our technique of partial balloon deflation described above, we were able to achieve controlled withdrawal with great visualization. In addition, the balloon allows for traction of bowel folds similar to that obtained in capassisted endoscopy. As studies with colonoscopy have shown, controlled withdrawal increases lesion detection. With partial balloon deflation in single-balloon enteroscopy, one can achieve a similar degree of controlled withdrawal to that of colonoscopy.
Results: Seventy-nine subjects were enrolled. The most common investigator assessed drug-related AEs were headache, UTI, and GI symptoms, generally similar in frequency across treatment groups. There were no study withdrawals due to AEs, nor any drug-related serious AEs. Gut contractility parameters poorly correlated with symptom severity for the treatment cohort (n=51; r0.12). Symptom improvement was observed at the 2 lower doses (10 and 50 mg) of C. Further analysis was conducted with these treatment groups (n=10). Small bowel CT correlated moderately with GCSI total score (r= -0.76; p=0.01), bloating (r= -0.72; p=0.02), and postprandial fullness (r= -0.84; p90% and K >0.80). The main analyses were based on data from 677 NFCA and 82 TJUH respondents with self-reported CD. Respondents were predominantly female (NFCA: 91%, TJUH: 74%, p< 0.001) and were aged 18 to 86 (mean = 45). Compared to NFCA respondents, TJUH respondents were more likely to report a diagnosis of CD by a GI physician (78% vs. 59%, p = 0.001) and through a small bowel biopsy (82% vs. 68%, p = 0.011). The proportion reporting receiving a physician recommendation for relative screening was substantially higher for TJUH than for NFCA (78% vs. 44%, p 0.05). Conclusion: Our study demonstrates that there are deficiencies in the basic understanding of issues surrounding intestinal disease. These findings could be used as a quality measure for a planned implementation of an educational program regarding intestinal disease and transplantation principles.
[343]
Table 1. Comparison Between Incomplete and Complete Retrograde Enteroscopies
Total procedure time
55.6 min (SD 5.5)*
Time to reach cecum
3 min (3–6)*
53.5 min (SD 18.2)* 5 min (3–17)*
Time to intubate ileum
20 min (15–44)^
10 min (2–33)^
Depth of ileum intubation
60 cm (45–65)#
125 cm (50–235)#
[341] Table 1. Correct Responses for Evaluation of Medical Knowledge of Intestinal Disease *P > 0.05; ^P=0.03; #P=0.04. Category (N)
PI
MI
TI
TC (69)
15.86%
35.51%
20.29%
NTC (139)
32.32%
41.55%
21.94%
PGY1-3 (170)
27.39%
40.44%
22.06%
344
PGY4-7 (38)
24.47%
35.53%
18.42%
A Comparison of the Epidemiology and Natural History of Chronic Stenosing Enteritis and Crohn’s Disease Veronica Baptista, MD, Neil Marya, MD, Benjamin Hyatt, MD, David Cave, MD, PhD, FACG. Dept of Medicine, Div of Gastroenterology, University of Massachusetts Medical Center, University Campus, Worcester, MA.
342 Surprisingly High Incidence of Mental Health DIsorders in the Celiac Database Abraham Yacoub, MD, Andrew Hammoud, MD, Leslie Bank, MD, FACG. United Health Services Wilson Memorial Hospital, Johnson City, NY. Introduction: Celiac disease is an autoimmune disease that damages the lining of the duodenum. The damage is due to a reaction to gliadin (gluten protein), which is mainly found in wheat. Surprisingly, celiac disease may present with a variety of psychiatric comorbidities. Our study focused on the high incidence of mental health disorders in the celiac database. Methods: A retrospective chart review of 261 patients with celiac disease at Binghamton Gastroenterology Associates in Binghamton, New York, between 6/1/2009 to 11/25/2013. Results: Two hundred sixty-one patients were included in our study. All the patients were diagnosed with celiac disease. The ages of patients ranged from pediatric to geriatric. Forty patients (15.3%) had depression, 2 patients (0.7%) had anxiety, 1 patient (0.3%) had schizophrenia, 1 patient (0.3%) had multiple personality disorder, 41 patients (15.7%) had arthritis, 39 patients (14%) had thyroid disease, 22 patients (8%) had diabetes, 5 patients (1.9%) had dermatitis herpetiformis,1 patient (0.3%) had Sjögren’s syndrome, 1 patient (0.3%) had autoimmune hepatitis, 1 patient (0.3%) had ulcerative colitis, 1 patient (0.3%) had Reynaud’s syndrome, and 1 (0.3%) patient had sarcoidosis. Conclusion: A high incidence of mental health disorders was observed in our celiac database. Studies have shown a strong association between celiac disease and mental health disorders; however, the mechanism is poorly understood. Therefore, more research is needed to further understand the mechanism. Clinicians who encounter patients with mental health disorders should keep celiac disease in their differential diagnosis
Introduction: We have previously described chronic stenosing enteritis (CSE), a disorder notable for large indolent superficial ulcers and stenoses in the mid small intestine resulting in iron deficiency anemia. The goal of this study is to investigate the natural history and epidemiology of CSE as compared with Crohn’s disease (CD). Methods: Between 2007 and 2013, our group identified and surveyed 14 patients with CSE based on the predominant signs and symptoms of iron deficiency anemia, obscure GI bleeding, abdominal pain, and lack of diarrhea. Nine patients with concurrently diagnosed small bowel CD were surveyed as controls. Patients were questioned regarding symptom severity, treatments and outcome, employment, and travel history. This study was approved by the Institutional Review Board at UMass Medical Center. Statistical analysis utilized 2-sample t-tests to determine significance. Results: Data demonstrated a significantly different mean age of symptom onset for CSE and CD (49.4 vs. 28.0 years old; p=0.01). Symptoms most commonly reported in CSE were abdominal pain and blood in stool; CD patients reported more diarrhea and abdominal pain. Symptoms were reported to be significantly more severe by CD patients than for CSE patients (9.3 vs. 7.3 on a 1-10 scale; p=0.03), and were also more frequent in CD compared to CSE (120 vs. 20 times per month; p=0.05). Most CD patients were treated with anti-TNF agents, whereas CSE patients were treated with intravenous or oral iron supplements. In the CD cohort, 44% of patients were placed on anti-TNF agents before surgery; 22% had a small bowel resection (SBR); 0% had recurrence following SBR. In the CSE cohort, 28% of patients were placed on anti-TNF agents after SBR; 50% had SBR, 57% of those patients had recurrence. In regards to employment, 29% CSE patients were engineers compared with 0% CD patients. Of the CD patients, 0% described their highest level of occupation as “managerial” or “executive,” compared with 42% of CSE patients. Travel history was also more extensive for CSE patients with an average of 36.2 trips abroad their lifetime compared with 0.89 trips for CD patients. Conclusion: CSE is a rare and separate entity from CD. Our study demonstrates several characteristics that differ between these 2 conditions, including symptom type, frequency, severity, age distribution, social status, and travel history. The differences and social status and the travel histories noted suggest different environmental factors may play a role in their etiology and/or pathogenesis.
343 Colon and Ileum Intubation Times Are a Significant Component of the Time it Takes to Perform Retrograde Overtube-Assisted Enteroscopy and May Affect Procedure Efficiency Luis Lara, MD, Andrew Ukleja, MD, Ferenando Castro, MD, FACG, Nicole Palekar, MD, Tolga Erim, DO, Alison Schneider, MD, Ronnie Pimentel, MD, FACG, Brenda Jimenez, MD, Roger Charles, MD, FACG. Cleveland Clinic Florida, Weston, FL. Introduction: Retrograde double balloon overtube-assisted enteroscopy (rDBE) is used to investigate distal small bowel pathology. These are time-intense procedures, and most centers allocate 90-min blocks for them. The database was reviewed to determine rDBE total procedure time, the fraction of time it took to reach the cecum and intubate the ileum, and potential factors for incomplete rDBE. Methods: All rDBE are performed using a Fujinon EN-450T5 enteroscope and TS-13140 balloon overtube (Fujinon, Inc, Saitama, Japan) with propofol sedation. Data were captured from August 2012 to November 2013. Patients with unaltered intestinal anatomy and recorded total procedure time, time to cecum, time to ileum intubation, and estimated depth of insertion (in cm) were included. Means and medians were compared and p
