Anna Tavakkoli

Advantages of Azithromycin Over Erythromycin in Improving the Gastric Emptying Half-Time in Adult Patients With Gastroparesis

Background/Aims Current therapy for gastroparesis with prokinetic agents is limited by options and side effects. One macrolide, erythromycin (ERY), is associated with possible sudden cardiac death from QT prolongation due to P450 iso-enzyme inhibition. An alternative, azithromycin (AZI), lacks P450 inhibition. We compared the effect on gastric emptying half-times (t½) between AZI and ERY in patients diagnosed with gastroparesis by gastric emptying scintigraphy. Methods Patients stopped medications known to affect gastric emptying prior to the study, and then ingested 1 scrambled egg meal labeled with 18.5-37 MBq of technetium-99m sulfur colloid followed by continuous imaging for 120 minutes, at 1 minute per frame. A simple linear fit was applied to the rate of gastric emptying, and gastric emptying t½ was calculated (normal = 45-90 minutes). At 75-80 minutes, if the stomach had clearly not emptied, patients were given either ERY (n = 60) or AZI (n = 60) 250 mg IV and a new post-treatment gastric emptying t½ was calculated. Results Comparison of gastric emptying t½ showed a similar positive effect (mean gastric emptying t½ for AZI = 10.4 ± 7.2 minutes; mean gastric emptying t½ for ERY = 11.9 ± 8.4 minutes; p = 0.30). Conclusions AZI is equivalent to ERY in accelerating the gastric emptying of adult patients with gastroparesis. Given the longer duration of action, better side effect profile and lack of P450 interaction for AZI as compared with ERY, further research should evaluate the long term effectiveness and safety of AZI as a gastroparesis treatment.

Vitamin D Status and Concomitant Autoimmunity in Celiac Disease

Goals: To determine whether patients with celiac disease (CD) and low vitamin D levels also have a higher prevalence of other autoimmune diseases (AD) as compared with patients with normal vitamin D levels. Background: Patients with CD carry a higher risk of other autoimmune disorders. Because of its immunoregulatory properties, vitamin D deficiency has been proposed in the pathogenesis of a variety of AD. Whether low vitamin D levels in patients with CD can predict concomitant AD is unknown. Study: A retrospective cross-sectional study of 530 adult patients with CD and a 25-hydroxyvitamin D level on record at Columbia University Medical Center. Results: One hundred thirty-three patients (25%) had vitamin D deficiency. The prevalence of AD was similar among those with normal vitamin D levels (11%), insufficiency (9%), and deficiency (12%, P=0.66). On multivariate analysis, adjusting for age of CD diagnosis and sex, vitamin D deficiency was not associated with AD (odds ratio, 1.35; 95% confidence interval, 0.62-2.95). The risk of psoriasis was higher in patients with vitamin D deficiency (7% vs. 3%, P=0.04). Vitamin D deficiency was more common in those who presented with anemia (39%) than in those who did not (23% P=0.002). Conclusions: Vitamin D deficiency in CD is common but does not predict AD. The risk of psoriasis is increased in vitamin D-deficient CD patients. Assessment of vitamin D seems to be a high-yield practice, especially in those CD patients who present with anemia.

Use of combined methylene blue chromoendoscopy and intravenous secretin for endoscopic therapy in pancreas divisum

ecretin-enhanced MRCP (S-MRCP) demonstrating complete visum with a separate dorsal pancreatic duct (PD) headed minor papilla, and a short ventral PD merging with the comuct toward the major papilla. Reproduced with permission EL, Sherman S. Pancreas divisum: Clinical manifestations is. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. n July 1, 2018.) Copyright 2018 UpToDate, Inc. For more insit wwwuptodate.com.

Use of Appropriate Surveillance for Patients With Nondysplastic Barrett’s Esophagus

BACKGROUND & AIMS: Barrett’s esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Guidelines recommend that patients with nondysplastic BE (NDBE) undergo surveillance endoscopy every 3–5 years. We aimed to identify factors associated with surveillance endoscopy of patients with NDBE and identify trends in appropriate surveillance endoscopy of NDBE at a large tertiary care center. METHODS: We performed a retrospective analysis of data from a Barrett’s Esophagus Registry, identifying patients with NDBE who underwent endoscopy in 2002 or later. We identified patients with NDBE and collected data on length of BE segment, esophageal lesions, demographic features, medications, histology findings, comorbidities, development of EAC, and dates of follow‐up endoscopies. We defined appropriate surveillance as 3–5 years between 2nd and 3rd endoscopies, over‐utilizers as patients who had less than 3 years between their 2nd and 3rd endoscopies, under‐utilizers as patients who had more than 5 years between their 2nd and 3rd endoscopies; and never‐surveilled as patients who never received a 2nd endoscopy. The primary outcomes were effects of patient factors, year, and referring providers on appropriateness of surveillance intervals. RESULTS: We identified 477 patients with NDBE. Only 15.9% had appropriate surveillance; 37.9% were over‐utilizers 15.7% were under‐utilizers and 30.4% were never surveilled. Patients were less likely to be over‐surveilled if their primary care physician referred them for their 3rd endoscopy instead of a gastroenterologist (adjusted odds ratio, 0.51; 95% CI, 0.27–0.95). Male patients or those with an increased number of comorbidities were more likely to be under‐surveilled or never‐surveilled, whereas patients with long BE segment were more likely to be over‐surveilled. CONCLUSIONS: In a retrospective analysis of data from a registry of patients with BE, we found that less than 16% receive appropriate surveillance for NDBE. A primary care provider in the same health system as the endoscopy clinic reduced risk of over‐surveillance. This could reflect better coordination of care between specialists and primary care providers.

Predicting Lymph Node Metastases in Superficial Esophageal Adenocarcinoma

Philip S. Schoenfeld, Section Editor John Y. Kao, Section Editor 65 66 STAFF OF CONTRIBUTORS 67 68 69 70 71 72 73 74 75 Joseph Anderson, White River Junction, VT Johanna L. Chan, Houston, TX Matthew A. Ciorba, St. Louis, MO Massimo Colombo, Milan, Italy Gregory A. Cote, Charleston, SC Evan S. Dellon, Chapel Hill, NC Alex Ford, Leeds, United Kingdom Lauren B. Gerson, San Francisco, CA David S. Goldberg, Philadelphia, PA Samir Gupta, San Diego, CA

Su2084 Influence of Polymorphisms in the Cytokine Genes As Risk Factors for IBS and TMJD

Background: Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder with still unknown pathophysiology presumed to develop due to complex interactions between the sensitizing effects of inflammation, CNS dis-inhibition, gut immunity, psychosocial stressors and genetic influences. Prior studies have shown an increase of proinflammatory cytokines IL-6, IL-1β, and TNF-α from mononuclear cells within the cecum of subjects with IBS. IBS is also frequently associated with other chronic pain conditions such as temporomandibular disorders (TMD), which has an inflammatory influence and is found in 16% of patients with IBS. Objective: The aim of our study was to evaluate whether specific cytokine genes previously found to be associated with TMD are also associated with IBS. We hypothesized that if these two pain disorders share common pathophysiologic mechanisms, then they may show similar associations with polymorphisms in the proinflammatory cytokine genes. Methods: A total of 122 women were enrolled in this study (72 with IBS, 25 with TMD, and 25 controls). IBS subjects were diagnosed using Rome II criteria and those with TMD were evaluated using the research diagnosis criteria for TMD (RDC). Single nucleotide polymorphisms (SNPs) to be genotyped were selected based on results of prior identified risk loci for pain sensitivity in subjects with TMD analyzed by our group. Peripheral blood samples from all participants were analyzed using restriction fragment length polymorphisms of PCR chain products. A Chi-Square statistical analysis was used to compare allele frequencies across IBS, TMD and controls and haplotypes were constructed using EM algorithm and the association between haplotypes and test groups. Results: IL1 β, IL6 and TNFα SNPs were significantly associated with IBS compared to controls and TMD (p value ,.05). Two IL1 β SNPs (rs700518, rs 1143634), one TNF α SNP (rs1800629) and IL6 SNP were associated with IBS (p value , .05) versus controls. For IBS versus TMD, significant differences in allele frequencies emerged in the following SNPs, IL1 β (rs16944) and TNFα -(rs1800629 and rs1800683). The two-SNP haplotype of the TNF α gene was strongly associated with IBS compared with TMD and controls (p,0.0001). None of these polymorphisms were associated with TMD. Conclusion: Polymorphisms in specific cytokine genes may be a risk factor for IBS. The presence of the haplotype formed by SNPs rs1800629 and rs1800683 in the TNFα gene may increase the susceptibility to IBS in women. The lack of significance associations with TMD however may be due to our small sample size.

Sa1312 Vitamin D Status and Concomitant Autoimmunity in Celiac Disease

Results: One hundred thirty-three patients (25%) had vitamin D deficiency. The prevalence of AD was similar among those with normal vitamin D levels (11%), insufficiency (9%), and deficiency (12%, P=0.66). On multivariate analysis, adjusting for age of CD diagnosis and sex, vitamin D deficiency was not associated with AD (odds ratio, 1.35; 95% confidence interval, 0.62-2.95). The risk of psoriasis was higher in patients with vitamin D deficiency (7% vs. 3%, P=0.04). Vitamin D deficiency was more common in those who presented with anemia (39%) than in those who did not (23% P=0.002).