Jessica Davis

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

Metastatic Pancreatic Adenocarcinoma During Pregnancy

We present a rare case of metastatic pancreatic adenocarcinoma diagnosed antepartum. A high index of suspicion must be maintained to diagnose pancreatic cancer during pregnancy. We recommend a thorough history and physical and aggressive pursuit of sensitive imaging in patients with persistent symptoms. If pancreatic adenocarcinoma is diagnosed, a multidisciplinary approach that focuses on patient goals should be undertaken. The effect of pregnancy on tumor growth rates is unknown.

Gastroenterologists inconsistently advise against tobacco use in inflammatory bowel disease patients

REFERENCES 1. Friedman S, Cheifetz AS, Farraye FA, et al. Factors that affect adherence to surveillance colonoscopy in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19:534–539. 2. Subramanian S, Klosterman M, Amonkar MM, et al. Adherence with colorectal cancer screening guidelines: a review. Prev Med. 2004;38:536–550. 3. Bernstein CN, Blanchard JF, Kliewer E, et al. Cancer risk in patients with inflammatory bowel disease. Cancer. 2001;91:854–862. 4. Vienne A, Simon T, Cosnes J, et al. Low prevalence of colonoscopic surveillance of inflammatory bowel disease patients with longstanding extensive colitis: a clinical practice survey nested in the CESAME cohort. Aliment Pharmacol Ther. 2011;23:188–195.

Severe human monocytic ehrlichiosis presenting with altered mental status and seizures

A previously healthy 66-year-old woman living in the Mid-Atlantic USA presented to the hospital with lethargy, ataxia and slurred speech. 2 weeks prior she had removed a tick from her right groin. She reported malaise, fevers, diarrhoea, cough and a rash. Physical examination revealed a maculopapular rash on her chest, and lung auscultation revealed bi-basilar rales. Laboratory tests were remarkable for hyponatraemia, leucopenia and thrombocytopenia. Chest X-ray demonstrated bilateral pleural effusions with pulmonary oedema. She was treated with ceftriaxone and azithromycin for possible community-acquired pneumonia but declining mental status necessitated intensive care unit transfer. Vancomycin and doxycycline were added. Her course was complicated by seizures requiring antiepileptic therapy. Peripheral blood smear demonstrated morulae in monocytes. Serum Ehrlichia chaffeensis DNA was positive confirming the diagnosis of human monocytic ehrlichiosis. She recovered without residual neurological deficits after 10 days of doxycycline therapy.

Sa1035 A High Stakes Learning Environment: Fellow-Performed Colonoscopies Are Associated With Lower ADRs

and presentation skills. Seventy-five percent of these fellows subsequently taught gastrointestinal pathophysiology. The majority of fellows organized teaching sessions locally, regionally and nationally in their current positions. One third perceived that the fellowship helped their academic promotions. On the basis of these data, we recommend that an optional, unfunded Gastrointestinal Pathophysiology Teaching Fellowship be incorporated into GI Fellowship Programs as a means of increasing academic teaching and leadership skill sets in interested fellows.

Su1101 Investigating the Smoking Gun: Should Tobacco Use Be Incorporated Into Colorectal Screening Guidelines?

Background: Inadequate bowel preparation before colonoscopy is common, resulting in clinical and economic harms. The US Multi-Society Taskforce advocates use of both written and oral instructions for patients before colonoscopy. However, little is known about the most effective method of patient education. This systematic review aims to assess the effectiveness of patient-oriented educational interventions in improving the quality of bowel preparation. Methods: Studies were identified from MEDLINE, EMBASE, Cochrane, CINAHL, and Web of Science. Two investigators evaluated each abstract for the following inclusion criteria: evaluation of a patient-oriented educational intervention, prospective design, and measurement of bowel preparation quality with a validated scale. Included studies underwent duplicate data extraction by 2 investigators using a standardized approach. Extracted data included the method of intervention, timing of intervention, staffing of intervention, purgative used, bowel preparation scale used, and bowel preparation quality. Methodological quality of studies was assessed using amodified Downs and Black instrument. Due to significant heterogeneity in assessment of outcomes, meta-analysis was not performed. Results: 1080 unique published studies were identified, and 7 of these studies met inclusion criteria. Five studies were randomized controlled trials, and 2 were quasi-experimental. The number of patients analyzed ranged from 99 to 969. 3 studies were performed in the US, 2 in Taiwan, 1 in China, and 1 in Korea. 3 interventions used paper-based tools (1 cartoon, 2 illustrated brochures), 2 interventions used videos, 1 intervention used face-to-face education, and 1 used telephone calls. In 6 of the 7 studies, the educational intervention was effective in improving bowel preparation quality, with an absolute increase in bowel preparation adequacy ranging from 2% to 32%. No study accounted for all significant confounders of bowel preparation quality (i.e. constipation, diabetes, opiates, socioeconomic status, literacy rate, age, gender, BMI). Validity scores ranged from 12-23, with a median value of 18, indicating fair methodological quality. Conclusions: Patient-oriented educational interventions significantly improve bowel preparation quality, but existing studies are of variable quality and may have limited generalizability. Gastroenterologists should work internally and with referring practices to ensure that patients receive evidence-based preparation education. Future studies should focus on comparative effectiveness and cost-effectiveness of educational interventions

Clinical Practice Patterns Suggest Female Patients Prefer Female Endoscopists

We read with great interest the recent review by Chacko et al. [1], ‘‘Colorectal Cancer Screening and Prevention in Women,’’ that describes the pathophysiologic gender differences in the behavior of colorectal cancer. The authors discussed the methods and performance of colorectal cancer screening among female patients. They note that given these gender differences, a ‘‘one size fits all’’ approach to colorectal cancer screening will likely evolve into a more personalized rubric that accounts for the biologic and epidemiologic differences they characterize. As noted in the review, several survey-based studies [2, 3] have shown that female patients have a preference for female endoscopists. Interestingly, however, at least one small study has shown that explicitly accommodating this preference did not increase compliance with colorectal cancer screening [4]. Given the evidence that women may prefer a gender-concordant endoscopist, we sought to evaluate whether female gastroenterologists in an academic setting were more likely to provide colonoscopies for female patients than male providers. We examined medical records for all colonoscopies performed at an urban university in a 12-month period. A total of 3189 colonoscopy records were reviewed. There were 1807 female patients and 1382 male patients. Of the eight endoscopists, three were women and five were men. 68.8 % of the procedures performed by female endoscopists were on female patients versus 51.4 % of the procedures performed by male endoscopists (p\ 0.0001). The mean female/male patient ratio was 2.52 for female providers and 1.05 for male providers (p = 0.0241). In patients C60 years of age, the female/male ratio was 2.30 for female providers and 1.10 for male providers (p = 0.0352). In patients \60 years old, the female/male ratio was 3.11 for female providers and 1.05 for male providers (p = 0.1249). Both Caucasian and AfricanAmerican women preferred female endoscopists. Female providers had a mean ratio of 1.63 females/males in Caucasian patients, while males had 0.63 (p = 0.0016). Among African-American patients, female providers had a 2.98 female/male ratio, while male providers had a 1.41 female/male ratio (p = 0.0493). There were not enough Hispanic patients to include analysis by gender. Our study shows that, in practice, female gastroenterologists are significantly more likely to provide colonoscopies for female patients than male providers. This finding persisted in older patients and among different races in subgroup analysis. Our findings support prior survey-based evidence that female patients prefer a gender-concordant endoscopist [2, 3] and suggest that, based on clinical practice patterns, there may be an additional group of female patients with an unstated preference for female providers that is not captured by survey-based study. Provider background and institutional factors may play a role as well. In our study, our patients were seen at an academic center in an urban setting. & Marie L. Borum mborum@mfa.gwu.edu

P-105 Gastroenterologist Laboratory Testing in Patients with Inflammatory Bowel Disease Does Not Increase Linearly by Decade

BACKGROUND: Laboratory testing is important in the overall management of chronic diseases. Aging can result in increased utilization of laboratory services. Individuals with inflammatory bowel disease (IBD) frequently require laboratory tests because they can serve as objective measurements of disease activity. There is limited data which has evaluated the use of laboratory testing in the different age ranges of adult patients with inflammatory bowel disease. This study correlated decade of age with the frequency of gastroenterologist-ordered laboratory testing in individuals with IBD. METHODS: A retrospective medical record review of inflammatory bowel disease patients at a university medical center during an 18 month period was performed using a multispecialty electronic health record. There were no exclusion factors. Patient age, gender, disease type, and laboratory testing performed by the gastroenterologist were obtained. A database, maintaining patient confidentiality, was created. Assessment of the frequency of laboratory tests were performed at the following age decades: <20, 20–29, 30–39, 40–49, 50–59, 60–69, and 70+ years. Statistical analysis was performed using ANOVA and T-testing, with statistical significance set at P < 0.05. The study was approved by the university institutional review board. RESULTS: Medical record of 316 IBD patients were reviewed. There were 189 women and 127 men, with a mean age of 41.8 years. One hundred seventy-one patients had Crohn’s disease, 143 with Ulcerative Colitis, and 2 with indeterminate colitis. A mean of 5.8 outpatient laboratory encounters occurred in patients <20, 6.8 in patients 20–29, 10.2 in patients 30–39, 11.1 in patients 40–49, 6.8 in patients 50–59, 7.0 in age 60–69 and 6.0 in patients age 70 or order during the study period (P = 0.034). Both young and geriatric patients received less laboratory studies on average when compared to patients age 30–50. This finding was pronounced in women: a mean of 9 outpatient laboratory occurred in women <20, 7.2 in women 20–29, 10.8 in women 30–39, 14.5 in women age 40–49, 6.9 age 50–59, 8.2 in women 60–69, and 5.1 in women 70 or older (P = 0.014). In men, however, differences in mean labs per decade did not reach statistical significance (P = 0.772). Women overall received an average of 9.3 tests during the study period while men received 7.2 (P = 0.044). CONCLUSIONS: Few studies have analyzed utilization of laboratory tests in inflammatory bowel disease at different age ranges. This study revealed that laboratory testing does not increase linearly with advancing decades of age. The number of gastroenterologist-ordered laboratory tests for inflammatory bowel disease peaked at age 30–50 years. The reason for this pattern is uncertain, but may represent new diagnoses or increased exacerbations. As this effect was statistically significant in women, this raises the question about the potential for gender-specific concerns. Less frequent laboratory testing in older patients may reflect gastroenterologist’ desire not to duplicate existing laboratory studies performed by other specialty providers. While inflammatory bowel disease is a chronic illness that warrants close monitoring, there is no evidence that laboratory expenditures by gastroenterologists linearly increase with advancing age. Further examination of physician laboratory testing patterns in inflammatory bowel disease is warranted.

P-055 Evaluating Whether Platelet Counts Are a Low Cost Alternative to ESR and CRP in the Evaluation of IBD Patients

BACKGROUND: Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly checked in IBD patients who present with symptoms of active disease. These markers have been shown to correlate with disease activity. Inflammatory markers can be costly and are affected by other factors including age, anemia, temperature and time to processing. Thrombocytosis has also been shown to positively correlate with disease activity. In an effort to reduce the financial burden associated with the delivery of healthcare, we evaluated whether measuring thrombocytes is an effective alternative to monitoring inflammatory markers in IBD patients with active disease. METHODS: Medical records of 321 patients with ulcerative colitis (UC) and Crohn’s disease at an urban academic inflammatory bowel disease center during an eighteen-month period were evaluated. All encounter-types in which either platelets, ESR, or CRP were available within one week of the visit were examined. Patient age, disease type, symptom activity, ESR and CRP were obtained. A database was created using Microsoft Excel. Statistical analysis was performed using Fisher’s Exact test with significant set at P <0.05. The study was approved by the institutional review board. RESULTS: In 165 encounters of patients with symptoms of active disease, platelets were obtained in 144 encounters, ESR in 57 encounters and CRP in 59 encounters. In 343 encounters of patients without symptoms consistent with active disease, platelets were obtained in 299 encounters, ESR in 79 encounters and CRP in 78 encounters. Thrombocytosis (P = 0.0047), elevated ESR (P = 0.0051) and elevated CRP (P = 0.0039) were all found to be significantly associated with active disease symptoms. In 52 encounters with symptomatic patients, ESR and platelet counts were obtained concurrently. Among encounters associated with elevated ESR, 36% had thrombocytosis while 64% had normal platelet counts. There was no significant difference in these groups (P = 0.12). In 50 encounters with symptomatic patients, CRP and platelet counts were obtained concurrently. Thirty-one percent of encounters associated with elevated CRP values had thrombocytosis, while 69% had normal platelets. There was no significant difference in these groups (P = 0.32). CONCLUSIONS: With the rising cost of healthcare and initiatives such as the Affordable Health Care Act, there is increasing pressure to deliver quality, cost-effective care to patients. Thus, it is important that testing not only enhance the quality of medical care, but be financially appropriate. Similar to previous reports, thrombocytosis, elevated ESR, and elevated CRP were all significantly associated with symptoms of active disease in IBD patients. In this study, thrombocytosis did not significantly correlate with elevated inflammatory markers. While not statistically significant, the inflammatory markers were more commonly elevated in symptomatic patients compared to the presence of thrombocytosis. These outcomes may be due to the low total number of patient encounters in which both tests were obtained. Despite additional costs, judicious use of ESR and CRP is appropriate in the evaluation of patients whose symptoms are suggestive of active disease. Further studies are needed to examine the cost-effectiveness of these tests.