Anju Malieckal

Carcinoid Tumors of the Gastrointestinal Tract

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

Review of efficacy and safety of laxatives use in geriatrics

AIM To study the efficacy and safety of pharmacological treatment of constipation in geriatrics. METHODS PubMed, MEDLINE, google scholar, and Ovid were searched to identify human studies performed on the use of laxatives in elderly with constipation, which were conducted between January 1990 and January 2013 using the specified keywords. Controlled studies that enrolled geriatric patients with a diagnosis of constipation and addressed the efficacy and/or the safety of pharmacological treatments were included. Studies were excluded from this review if they were non-controlled trials, case series, or case reports. RESULTS Out of twenty three studies we initially retrieved in our search, only nine studies met the eligibility criteria of being controlled trials within geriatrics. The laxatives examined in the nine studies were senna, lactulose, sorbital, polyethylene glycol (PEG), lubiprostone, linaclotide, and prucalopride. In those studies, senna combinations had a higher efficacy than sorbitol or lactulose as well as, a very good adverse effect profile. PEG was also shown to be safe and effective in geriatric population. Furthermore, it has been shown that PEG is as safe in geriatrics as in general population. New agents like lubiprostone and prucalopride show promising results but the data about these agents in geriatrics are still limited which warrants further investigation. CONCLUSION Senna combinations and PEG appear to have a more favorable profile over the other traditionally used laxatives in elderly patients with constipation.

Endoscopic and imaging appearance after injection of an ano-rectal bulking agent.

The use of hyaluronic acid and dextranomer (Solesta, Salix) injection in the anal canal is an emerging modality in the treatment of fecal incontinence. However, little is known regarding the endoscopic and radiological appearance following injection of this ano-rectal bulking agent. We report computed tomography and endoscopic findings after hyaluronic acid/dextranomer injection in the ano-rectal area.

Mo1078 Management of Chronic Constipation by Gastroenterologists

Background: Constipation is a common symptom, encountered by primary care physicians (PCPs) and gastroenterologists (GIs). We recently examined the management of chronic constipation by PCPs, and found that only a minority of PCPs use established criteria for diagnosis. PCPs were found to rarely use published imagery to improve accuracy of patient reported stool form. It also gave an insight into the preferred 1st-line laxatives used by PCPs. This follow up study focused on GIs to understand their approach to management of chronic constipation and to compare it with PCPs. Methods: 129 PCPs had participated in the earlier survey. In this study 27 GIs from 3 large urban teaching community hospitals in NYC were surveyed. Both surveys (PCP & GI) were multiple-choice questionnaires that addressed similar issues about prevalence and diagnosis of constipation. However, additional questions focused on management were included for specialists. Responses between groups were compared. Results: Prevalence differed between groups. The majority of GIs reported a prevalence of 15-20% while the majority of PCPs reported 20-25%. Reported usage of Rome classification criteria for GIs vs PCPs was 63% vs 29% respectively. Bristol images for stool consistency were not widely used in either group (38% of GIs and 13% of PCPs). 54% of patients encountered by GIs report using OTC laxatives. Whereas ,20% of patients reported using OTC laxatives to 73% of PCPs. 37% of GIs initiated further work up for constipation in patients who failed a trial of laxatives. Only 11% of PCPs referred their patients to GIs if patients did not respond to initial laxative use. The preferred 1st-line choice of laxatives for GIs was Polyethylene Glycol whereas for PCPs it was Bisacodyl. 69% of GIs and 70% of PCPs recommend colonoscopy only if the patient presents with alarm symptoms in conjunction with constipation. Most of the PCPs (75%) and GIs (74%) were aware of Melanosis Coli and counseled their patients regarding the stimulant laxative induced side effect. Most GIs modified their prep for colonoscopy in patients with chronic constipation. The most common modification was a 2 day liquid diet before Polyethylene Glycol. 80% of PCPs were satisfied with the assistance they received from their GI counterparts in the management of constipation. 30% of GIs routinely coordinate care with PCPs to optimize therapy. Conclusion: This study highlighted differences between PCPs and GIs in diagnosis and treatment of chronic constipation. In comparison to GIs only a minority of PCPs use established criteria to diagnose constipation. Managing patients with chronic conditions like constipation requires reassurance and well coordinated care by all members of their medical team. This survey should initiate the process for further improving care and coordination in the management of chronic constipation.

S1226 Does Therapy for Clostridium difficile Positive Without Localizing Features in an ICU Have an Impact on Patient Outcomes

Background: Intravenous immunoglobulin (IVIG) has been used for many years as an adjunct to treat severe and recurrent Clostridium difficile infection. The concentration of serum antibodies to toxins A and B have been shown to correlate with an asymptomatic carrier state in patients with C. difficile colonization. Furthermore, the lack of development of an effective humoral response to C. difficile toxins may result in increased risk of development of recurrent infection. Objective: Studies of IVIG treatment for C. difficile infection have been inconclusive. We therefore sought to examine whether the effectiveness of IVIG therapy could be altered by variability in anti-toxin antibody content in commercial preparations of IVIG. Methods: Antibodies against C. difficile toxins A and B were measured by ELISA in eight commercially-available immunoglobulin preparations. These preparations represent those that are commonly available for IVIG therapy and included two products that have high titers of antibodies against cytomegalovirus (CMV) and respiratory syncytial virus (RSV). Results: Different preparations of IVIG demonstrated approximately a fourfold variability in antibody content against toxin A and toxin B. Preparations that are formulated to contain high-titers of antibodies against CMV and RSV did not contain higher titers of antibody against C. difficle toxins over standard IVIG preparations. Conclusions: Currently-utilized preparations of immunoglobulin, used as IVIG in the treatment of C. difficile colitis show substantial variability in their anti-C. difficile toxin A and B titers. The ability of these preparations to neutralize toxin effect may be affected by anti-toxin titers and this variability may contribute to variations in the published literature with regard to efficacy of IVIG in severe and recurrent C. difficile colitis.