Abhinav Sankineni

Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis

Pyloric dysfunction has been associated with gastroparesis, particularly diabetic gastroparesis. Endoscopic functional luminal imaging probe (EndoFLIP) uses 16 sensors inside a balloon that is inflated inside a sphincter to assess physiologic characteristics. The aim of this study was to measure the pressure, diameter, cross‐sectional area (CSA), and distensibility of the pylorus using EndoFLIP in patients with gastroparesis. In addition, the relationship between pyloric pathophysiology with gastroparesis etiology, symptoms, and gastric emptying was assessed.

Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding

Hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater) is a rare, potentially life-threatening and obscure cause of upper gastrointestinal bleeding. It is caused by rupture of the psuedoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic psuedocyst in the context of pancreatitis or pancreatic tumors. It can pose a significant diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy. A 61-year-old female with HIV and alcoholism presented with 3 weeks of intermittent abdominal pain and melena. Examination revealed hypotension with pallor and mild epigastric tenderness. She was found to have severe anemia and a high serum lipase. It was decided to perform a contrast-enhanced computed tomography (CT) scan that demonstrated a hemorrhagic pancreatic pseudocyst with possible active bleeding into the cyst. An emergent angiogram showed a large pseudoaneurysm of the pancreaticoduodenal artery that was successfully embolized. Subsequent endoscopy showed blood near ampulla of Vater confirming the diagnosis of hemosuccus pancreaticus. Thus the bleeding pseudocyst was communicating with pancreatic duct. The patient had no further episodes of gastrointestinal bleeding. Hemosuccus pancreaticus should be considered in patients with intermittent crescendo-decrescendo abdominal pain, gastrointestinal bleeding and a high serum lipase. Contrast-enhanced CT scan can be an excellent initial diagnostic modality and can lead to prompt angiography for embolization of the bleeding pseudoaneurysm and can eliminate the need for surgery.

Diabetes mellitus is an independent risk for gastroesophageal reflux disease among urban African Americans

An association between gastroesophageal reflux disease (GERD) and diabetes mellitus (DM) has been reported. Studies have not been population-based and have failed to include a representative sample of African American subjects. The aim of the study was to determine if DM is independently associated with GERD among urban African Americans. Single-center, population-based survey utilizing a complex, stratified sampling design. To obtain a simple random sample of the entire African American community, targeted survey zones and hand-delivered invitations were identified. Participating subjects had to be self-described African American, age ≥18. Surveys were completed at a computer terminal assisted by a research coordinator. Four hundred nineteen subjects (weighted sample size of 21 264 [20 888-23 930]). GERD prevalence was 23.7% (95% confidence interval [CI] 23.2-23.9). GERD prevalence was 41.5 % in those with DM versus 20.6 % for those without (P < 0.001). Those with GERD had DM longer but had lower glycohemoglobin levels. The prevalence of ≥2 DM comorbidities was higher in those with GERD (odds ratio [OR] = 2.06; 95% CI 1.71-2.48). In the final model, age >40, DM, increasing body mass index, harmful drinking, and increasing smoking dependence were independently associated with GERD. For DM, there was significant effect modification by gender. In males, the risk was (OR = 4.63; 95% CI 3.96-5.40), while in females, the risk was markedly attenuated (OR = 1.79; 95% CI 1.61-2.00). Among urban African Americans, there is an independent association between DM and GERD that appears to be stronger in men. More information is needed to understand this association.

Bolus retention in hiatal hernia identified by high-resolution esophageal manometry with impedance

Esophageal acid retention in a hiatal hernia (HH) may play a role in gastro‐esophageal reflux. The aims of this study were to determine the prevalence of bolus retention (BR) in HH and to compare pressure profiles in patients with HH with BR in the hernia to those with bolus clearance (BC) through the hernia using high‐resolution esophageal manometry with impedance (HREMI).

Slow esophageal propagation velocity: association with dysphagia for solids

Background  Spastic disorders of the esophagus, associated with rapid esophageal propagation velocity, are classically associated with dysphagia and/or chest pain. The aim of this study was to characterize patients with slow esophageal propagation velocity (SPV) on high‐resolution esophageal manometry (HRM).

Mo1355 Factors Affecting Cholecystectomy in Acute Gallstone Pancreatitis in a Nationwide Inpatient Sample

Background: Age Adjusted Charlson Comorbidity Index (AACCI) has been studied in the past to predict morbidity and mortality in various clinical conditions. At the same time there has been various markers and scores developed to predict morbidity and mortality in acute pancreatitis. Most of the tools used in acute pancreatitis, were unable to reach adequate sensitivity and specificity. However AACCI was never studied in the setting of acute pancreatitis. We hypothesized that AACCI which reflects the influence of burden of comorbid conditions, may predict outcomes in acute pancreatitis. We studied correlation between AACCI and length of hospital stay in individuals admitted with acute pancreatitis.Methods: We conducted retrospective observational study between January 1, 2009 and June 30, 2011 including all individuals admitted to our institutionwith acute pancreatitis.We collected demographic, laboratory, and radiological data. We used Length of Stay (LOS) as a measure of inpatient morbidity and extracted LOS days from medical records. We calculated AACCI based on comorbid conditions noted in electronic medical records. We divided study population into 3 groups based on AACCI score, Group A (scores 0 to 2), Group B (scores 3 to 5) and Group C (score 6 and above). We analyzed data using standard statistical methods and JMP11 software. Results: There were 209 individuals who met the inclusion criteria as per current definition of acute pancreatitis. Men and women were represented equally. There were 51% Hispanics and 49% non-Hispanics of which 80% were African Americans. There were no significant differences in LOS between women and men (10.25 vs. 10.42 days, p 0.91), between Hispanics and non-Hispanics (9.23 vs. 10.82, p 0.28). Also we did not notice any difference in length of stay based on etiology of acute pancreatitis. However we found significant increase in length of stay parallel to increase in AACCI (Table 1). (Group A 8.31, Group B 11.09 and Group C 15.44 days, p 0.002) Conclusion: Increase in Age Adjusted Charlson Comorbidity Index predicted prolonged Length of Stay, in patients hospitalized with acute pancreatitis. Our study is unique in studying relation between AACCI and LOS in acute pancreatitis especially in minority populations. Further studies are needed to relate AACCI with various local and systemic complications in acute pancreatitis, which may give single tool to predict outcomes without elaborative laboratory or radiological work up. Table 1

969 Bolus Retention in Hiatal Hernias Identified by High-Resolution Esophageal Manometry With Impedance: Pathophysiological and Clinical Significance

Background & Aims: Given the previous evidence for involvement of Prostaglandin E2 (PGE2) and the EP1 receptor in processing of esophageal sensation, the present study investigated the effect of diclofenac sodium, a nonsteroidal anti-inflammatory drug, on esophageal sensation induced by distal acid infusion in healthy volunteers. Methods: Twelve healthy male subjects were enrolled in a randomized, placebo-controlled crossover study. After oral administration of either diclofenac or placebo, acid (hydrochloric acid, 0.15 mol/ L) was perfused into the lower esophagus for 30 minutes. Diclofenac (37.5 mg) was given twice at 6 hours and 2 hours before acid perfusion. Heartburn symptoms were evaluated using a validated categorical rating scale with a higher values corresponding to increasing intensity. The acid perfusion sensitivity score (APSS) was assessed. Before and after acid perfusion, endoscopic biopsies were taken from the distal esophagus. PGE2 concentration (pg/mg protein) in the biopsy samples was measured using ELISA. Results: Except in 1 subject, eleven subjects (age range 26-41, mean 32.9 years) completed this study. The APSS was significantly lower in the diclofenac group compared to the placebo group (diclofenac group vs placebo group: 79.1 ± 14.9 vs 137.1 ± 20.4, P , 0.01). The time to first sensation (min) was significantly longer after diclofenac treatment (diclofenac group vs placebo group: 13.7 ± 2.3 vs 5.6 ± 1.5, P , 0.01). PGE2 levels after acid perfusion in the esophageal biopsy samples were significantly higher in the placebo group (before acid vs after acid: 7.7 ± 1.2 vs 23.3 ± 5.2, P , 0.05), but not in the diclofenac group (before acid vs after acid: 6.4 ± 1.1 vs 11.4 ± 3.5, P . 0.05). Furthermore, there was a clear correlation between the APSS and the elevated levels of PGE2 in the esophagus (r = 0.53, P , 0.05). Conclusions & Inferences: This study demonstrated that diclofenac may attenuate acid-induced esophageal sensation by inhibition of PGE2 overproduction in the human esophagus. PGE2 in the esophagus may play a significant role in the esophageal symptom generation, and may be a new therapeutic target for controlling symptoms such as heartburn.

1087 Gastric Interstitial Cells of Cajal Quantification on Full Thickness Gastric Biopsy Provides Prognostic Information for Treatment Responses to Gastric Electric Stimulation

and SMW total scores remained when analysis was limited to normal or delayed gastric emptying (p<0.05, p<0.05). Only 13% (3/24) needed tube feeds and 13% (3/24) parenteral nutrition after GES. School absences decreased from 57% to 31% of school days. Overall, 65% (13/20) reported their health was much improved after GES versus 15% (3/20) the same or worse. The majority (15/20) were satisfied with GES. Three were not satisfied due to lack of improvement, one developed back pain and another was later diagnosed with an eating disorder. Five reported complications. Four had discomfort or tenderness at the implantation site and another had a dead battery. Conclusions: In the largest series to date of pediatric patients who have undergone GES for GP and/or FD, we have found significant and sustained improvement not only in upper GI symptoms but also in quality of life and perception of global health. Patients were less dependent on tube feeding or parenteral nutrition and had fewer school absences. The majority is satisfied with the decision to place GES. Future studies are needed to assess for possible placebo effect and to evaluate predictors of outcome and long-term prognosis.

Tu1483 Symptoms of Small Intestinal Bacterial Overgrowth in Patients With Gastroparesis

Background: Delayed gastric emptying is commonly seen in small intestinal bacterial overgrowth (SIBO), and is often proposed as a major risk factor for this condition. The 14C DXylose breath test (XBT) has been used to diagnose SIBO and based on our data has demonstrated excellent reliability as a diagnostic measure (King & Toskes Gastro 1986). Delayed gastric emptying affects the delivery of nutrients to the small intestine and therefore could impact the results of XBT. Objectives: We aim to evaluate (1) whether delayed gastric emptying affects the pattern of D-Xylose BT results, and (2) whether delayed gastric emptying increases the risk of SIBO. Methods: A retrospective chart review was conducted on 846 patients with XBT between 2005 and 2009, male: female 168:678 (ratio 1:4), median age 57 years (age range 20-88). All of the patients were referred by GI clinics for various GI symptoms to rule out SIBO. The XBT was obtained by measuring 14C at baseline, 30, 60 and 180 minutes as per our protocol. Positive XBT was defined as an increased value of 14C at any one or more time points. A delayed gastric emptying by gastric emptying scintigraphy (GES) was defined by T1/2 greater than 90 minutes after ingestion of a standard 254 calorie meal based on 2 hour continuous scanning. Results: Of 846 patients with XBT, 498 patients tested positive for SIBO. Of these patients positive for SIBO, 229 had GES completed and 41% (94/229) were found to have delayed gastric emptying. Of 348 patients with a negative XBT, 167 had GES with 45% (75/167) having delayed gastric emptying. The risk of delayed gastric emptying was similar in both XBT positive and the negative group, with a likelihood ratio of 0.7, p>0.2. Of 229 patients with a positive XBT, the proportion of patients with a positive D-Xylose BT at 30 and 60 minutes were similar in both the normal and abnormal GES groups. However, a significantly increased number of patients with delayed gastric emptying had a positive XBT at 180 minutes (72.7% vs 54.4%, likelihood ratio = 6, p<0.02). Conclusion: Delayed gastric emptying significantly delays XBT positivity to 180 minutes. Prolonged duration of XBT up to the 180-minute period would increase the sensitivity of the breath test in patients with underlying motility disorders such as gastroparesis or even small bowel dysmotility. Surprisingly, based on our retrospective analysis, delayed gastric emptying was not found to be an independent risk factor of SIBO. A well-designed prospective study in the future with standard GES would be indicated to assess the association of SIBO and gastroparesis. (Acknowledgment: This study was funded by University of Florida CTSI NIH Grant UL1RR029890, and UF KL2RR029888 Award to Baha Moshiree MD, MS)