Alicia Alvarez

Endoscopic botox injections in therapy of refractory gastroparesis

Gastroparesis (GP) is a common disease seen in gastroenterology practice particularly in western countries, and it may be underdiagnosed. The available drug therapies for this condition are quite disappointing. Botulinum toxin type A (BT) has been found to be effective therapy in various spastic disorders of smooth muscle of gastrointestinal tract. However, the benefits of BT injections in GP have been unclear. Several retrospective and open label studies have shown clinical advantages of intrapyloric Botulinum toxin type A injections, while two small randomized trials did not show positive results. Therefore, the available published studies yielded conflicting results leading to fading out of botox therapy for GP. We recognize possible clinical benefit of BT injections without any disadvantages of this treatment. We are calling for revisiting the endoscopy guided botox therapy in refractory GP. In this review we discuss important features of these studies pointing out differences in results among them. Differences in patient selection, doses and method of administration of botox toxin in the prior studies may be the cause of conflicting results. The mechanism of action, indications, efficacy and side-effects of BT are reviewed. Finally, we recognize limited evidence to recommend BT in GP and calling attention for future research in this field since no advances in drug management had been made in the last two decades.

Long-Term Therapy With Teduglutide in Parenteral Support-Dependent Patients With Short Bowel Syndrome: A Case Series

OBJECTIVE To review all cases of parenteral support (PS)-dependent patients with short bowel syndrome (SBS) treated with teduglutide (Gattex, Shire) and to evaluate its efficacy and adverse effects. METHODS This is a retrospective descriptive cohort of SBS patients treated with teduglutide. Demographics, bowel length, primary diagnosis, PS volume/duration, teduglutide dose, and side effects were collected prospectively. RESULTS Six SBS patients (4 females, 2 males) received teduglutide. Mean age was 46.3 years (range 26-71). SBS etiology was vascular (n = 3), multiple resections (n = 2), and strangulation (n = 1). Length of residual small bowel was between 30-120 cm. The bowel anatomy was colon present (n = 3) and stoma n = 3 (ileostomy, 2; colostomy, 1). PS duration was 1.5-14 years. Weekly PS volume was mean 7.7 liters/week (1-14). Number of PS days per week ranged 1-7 days. Mean duration of teduglutide therapy was 31 months (24-36). All patients achieved ≥20% reduction in PS weekly volume within 6 months. PS was weaned in all patients. Adverse effects included abdominal bloat/discomfort (n = 3), stoma enlargement (n = 3), bowel obstruction (n = 1), and congestive heart failure (n = 1). CONCLUSIONS All PS-dependent SBS patients treated with teduglutide were weaned off PS. Patients with colon in continuity and lower PS weekly volume requirements were weaned off PS sooner than those with end-stomas and higher PS volume requirements. Teduglutide was well tolerated. Additional clinical studies of teduglutide in SBS patients with marginal PS requirements are needed.

Comparison of Adenoma Detection Rates in Afro-Caribbeans and Non-Hispanic Whites Undergoing First Screening Colonoscopy.

Objectives The African American population has a higher prevalence of advanced colon adenomas when compared with non-Hispanic whites and Hispanics, but the risk in other black populations has not been evaluated. Although the Afro-Caribbean population is a significant demographic segment in some regions of the United States, the data are limited on the prevalence of colon adenomas in this group and there is no comparison with a non-Hispanic white population. The objective of our study was to compare the prevalence of adenomas in Afro-Caribbean versus non-Hispanic white populations. Methods A total of 880 Afro-Caribbean patients and 1828 non-Hispanic white patients undergoing their first screening colonoscopy between January 2008 and August 2014 was included in the study. Results A total of 2708 patients met entry criteria for the study. The adenoma detection rate among Afro-Caribbeans was 29% and 31% among non-Hispanic whites. There was no statistically significant difference in the prevalence of adenomas in the two groups (P = 0.28), and the rate of advanced adenomas also was similar in both groups (8.6% in Afro-Caribbeans, 9.2% in non-Hispanic whites; P = 0.60). A multivariate analysis also found no difference in the occurrence of adenomas (P = 0.60) or advanced adenomas (P = 0.99) between Afro-Caribbeans and non-Hispanic whites. Conclusions We found a similar adenoma detection rate and advanced adenoma prevalence among Afro-Caribbeans and non-Hispanic whites undergoing their first screening colonoscopy. As such, the Afro-Caribbean population may not have the same risk of colorectal neoplasia as what has been described for African Americans. Based on these results, it is appropriate to initiate colorectal cancer screening for Afro-Caribbeans at age 50 as recommended for non-Hispanic whites.

Mucinous Appendiceal Adenocarcinoma Presenting as Sister Mary Joseph Nodule: Case Report and Brief Review of Literature

Sister Mary Joseph nodule is a rare form of umbilical metastasis. Often, this is the only initial presenting sign for an underlying internal malignancy and is usually associated with poor prognosis. Although the gastrointestinal tract is the most common primary site, the majority of these metastases are from gastric and colorectal sites. We report a case of Sister Mary Joseph nodule in a patient with no GI complaints. Further evaluation led to the diagnosis of primary mucinous adenocarcinoma of the appendix. Primary mucinous adenocarcinoma of the appendix is a very rare tumor type that can give rise to umbilical metastases. To the best of our knowledge, only 3 cases of adenocarcinoma of the appendix metastasizing to the umbilicus have been reported in the medical literature.

Su1890 Local and Systemic Complications of Acute Pancreatitis According to the Revised Atlanta Classification: A Nation-Wide Multicenter Prospective Study

Local and Systemic Complications of Acute Pancreatitis According to the Revised Atlanta Classification: A Nation-Wide Multicenter Prospective Study Enrique de-Madaria, Jose Pamies-Guilabert, Guillermo Garcia, Jose L. de Benito, Jennifer Hinojosa-Guadix, Fatima Fernandez Gutierrez del Alamo, Pilar Marques-Garcia, Isabel Iranzo Gonzalez-Cruz, Monica E. Perez Munante, Lluis Oms, Maria D. Esteba, Ana Pardillos-Tome, Eduardo Bajador, Oswaldo Moreno, Juan I. Cervera Miguel, David Martinez-Ares, Maria P. Bondelle-Bello, Federico Arguelles-Arias, Ana M. Arguelles-Arias, Patricia Latorre Ano, Gregorio Martin Benitez, Carla Tafur Sanchez, Maria Antonia Udaondo Cascante, Maria J. Soria de la Cruz, Jesus Leal Tellez, Daniel De la Iglesia Garcia, Roberto Garcia Figueiras, Cristina Gil Garcia-Ollauri, Ricardo Ituarte Uriarte, Carmen L. Rosales, Jordi Soriano, Maria Rodriguez Pelaez, Alicia Mesa Alvarez, Elida E. Oblitas Susanibar, Maria M. Menso

Food Impaction Due to Nutcracker Esophagus

Nutcracker esophagus is an esophageal motility disorder characterized by the presence of hypertensive contraction waves. These waves can have very high amplitudes, but they maintain a peristaltic pattern and therefore, bolus passage is minimally affected. Esophageal food impactions are rare in nutcracker esophagus. Our patient was a previously asymptomatic man who presented with an esophageal meat impaction due to nutcracker esophagus in which high-resolution manometry played a key role in the diagnosis. Although a rare etiology, nutcracker esophagus can result in esophageal food impaction. High-resolution manometry plays a critical role in the diagnosis of specific motility disorders, even in the setting of minimal symptoms.

Su2067 Results of Gastric Emptying Tested With Wireless Motility Capsule in Chronic Constipation Patients Before and After Lubiprostone

Introduction: The study is the first one in Asia comparing a PEG 4000 to another osmotic laxative (lactulose) in children with chronic constipation. Patients and Methods: This randomized, double-blind, lactulose controlled study was conducted in 2 parallel groups in 2 centers in 88 children in Thailand. Male or female (outpatient) children aged between 12 to 36 months were included if they had a chronic constipation (defined as ≥ 3 months of ≤ 2 bowel movements (BMs) per week and/or one of the following symptoms: pebblelike, hard stool, painful defecation, encopresis). Constipation should have been treated by dietary advice for at least two weeks without improvement. Qualified subjects were randomly assigned to receive either PEG 4000 or lactulose, over a 4 weeks treatment period. The dosing were the approved dose in this class of age, i.e. PEG 4000 = 2 sachets of 4g (1 in the morning, 1 in the evening), lactulose = 1 sachet of 3.3g (in the morning) and 1 sachet of lactulose placebo (in the evening).The primary criterion was the number of Bowel Movement (BM) during the 4th week. Results: Both treatment groups in ITT population (43 in PEG 4000, 44 in lactulose) were similar in their demographic characteristics: mean (SD) age: 1.99 (± 0.50) year; constipation duration: mean (SD) 43.80 (± 25.42) weeks. Results of the number of BM/week (Mean ± SD) were respectively in PEG 4000 and lactulose: at baseline 0.5±0.5 and 0.7±0.5, at Week 4: 1.1±0.5 and 0.8±0.4. Adjusting for the BM at baseline, there was a significant difference (p=0.0005) in the number of BM during the 4th week between treatment groups in favour of the PEG 4000 group. The adjusted mean change from baseline in BM of PEG 4000 treatment (0.5117) is significantly higher than that of the lactulose treatment group (0.1479). The corresponding treatment effect estimate (0.3637, 95% CI: [0.1642, 0.5633]) is statistically significant (p= 0.0005). The number of TEAEs considered possibly or probably related to the study drug is comparable in both treatment groups. All of the SAEs recorded were considered not related to the study drugs. Conclusion: PEG 4000 has a better efficacy than lactulose for the treatment of chronic constipation in Asiatic children.

Tu2078 The Effect of Lubiprostone on Regional Alimentary Tract Transit Times Measured by Wireless Motility Capsule in Patients With Chronic Constipation

Introduction: Lubiprostone, a selective type 2 chloride channel (ClC-2) activator, induces a chloride-rich intestinal fluid secretion which diminishes viscoelasticity of luminal contents and increases lubrication. These effects have led to increased stool frequency and relief of symptoms in patients with chronic constipation (CC). While radionuclide studies have indicated acceleration in colon transit, the impact of lubiprostone on transit times in specific regions of the gut has not been clarified. These measurements can now be achieved by the novel wireless motility capsule (WMC) technology in patients with CC. Our aim was to investigate the effects of lubiprostone on gastric emptying (GET), small bowel (SBTT), colon (CTT) and small/large bowel (SLBTT) transit times assessed by WMC in CC (Rome III) patients. Methods: Twenty nine female patients with CC, mean age 38 (19-64) mean weight 167 lbs (111-305) were tested with WMC before treatment and on day number 8 after receiving 24 mcg BID of lubiprostone. GET was calculated from the time WMC was ingested until the point at which there was an abrupt and sustained increase in pH of more than 2 units from the gastric pH to an absolute pH of .6.0. SBTT was defined as the elapsed time from capsule leaving the stomach until capsule arrived at the cecum. This was determined by a sudden drop of pH.1 unit, for longer than 1 h, which was preceded by a gradual, sustained rise in pH as the capsule passes through the distal small bowel. CTT was defined as the time interval between the point of entry into the cecum and the exit of WMC from the body. SLBTT includes SBTT and CTT. Statistical analysis, using Mann-Whitney Rank Sum Test was performed using Sigma-Stat software. Results are presented as Median with 25-75 percentiles range. Results: After administration of lubiprostone gastric emptying was slowed by 14.5% to 4.02h (2.27-8.82) versus 3.51h (2.38-12.83) at baseline (P=0.913); SBTT was significantly accelerated by 12.2% to 4.03h (3.13-4.49) when compared with 4.59 h (4.00-6.32) at baseline (P=0.010) and CTT was accelerated by 10.1% to 35.1h (22.66-47.99) vs 39.05h (22.61-63.39) before treatment ( P=0.328). The comparison of SLBTT before and after therapy with lubiprostone showed 18.9% reduction of this regional transit time with median being 46.24h (30.97-80.47) at baseline and 37.55h (24.49-54.21) while on medication (P=0.128). Conclusions: 1) During treatment with lubiprostone the acceleration of SBTT is more pronounced that colon transit in CC patients. 2) This implies that type 2 chloride channel activation within the small bowel does affect small intestine motility patterns in patients with chronic constipation. 3) The very modest delay in gastric emptying was not accompanied by clinically relevant nausea and is unlikely to explain the nausea side effect profile of lubiprostone.