Kaartik Soota

Immunomodulation for treatment of drug and device refractory gastroparesis.

Objective Patients with generalized autoimmune dysautonomia may also present with gastroparesis. Immune dysfunction in such patients can be evaluated using antibodies to glutamic acid decarboxylase (GAD) and full thickness biopsy of stomach. In this study, we utilize immunotherapy for treatment of drug and Gastric Electrical Stimulation (GES) resistant gastroparetic patients with evidence of neuroinflammation on full thickness gastric biopsy and had positive GAD65 autoantibodies. Material and methods We conducted a retrospective chart review of 11 female patients with drug and device resistant gastroparesis. Patients were treated for a total of 8–12 weeks with either intravenous immunoglobulin (IVIg), or combined mycophenolate mofetil (MM) and methylprednisolone, or only MM. Patients were excluded if they had previous side effects from steroid therapy, low scores on dual-energy X-ray absorptiometry (DEXA) scan results, immune-compromised conditions with infections like tuberculosis and zoster. Symptoms of nausea, vomiting, abdominal pain, early satiety/anorexia, bloating and total symptom score (TSS) as reported by the patients were recorded before and after the treatment at a follow up visit 2 to 16 weeks after initiation of therapy. Results Maximum symptom improvement was seen in patients treated with IVIg (67%). 6 patients (55%) had improvement in vomiting, whereas 5 patients (45%) had improvements in nausea, abdominal pain and bloating. Conclusions Immunomodulatory therapy shows positive outcomes in improving vomiting symptom in some gastroparetic patients who have coexisting positive autoimmune profiles. This preliminary data suggests the need for further investigations in immunotherapy targeted to patients with gastroparetic symptoms refractory to approved drug and device therapies.

Endoscopic Retrograde Cholangio-Pancreatography-Obtained Bile Culture Can Guide Antibiotic Therapy in Acute Cholangitis

Background: Only a small proportion of patients with biliary tree infection grow microorganisms in blood cultures. Antibiotics chosen or tailored based on organisms identified on blood cultures have a potential for under-treatment and unfavorable outcomes, including recurrent infection and early stent occlusion. In our current practice, we collect bile for culture if an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed in patients with suspected cholangitis. In this study, we compare the microbial yield of blood cultures and ERCP-obtained bile cultures in patients with ascending cholangitis. Methods: We reviewed medical records of all the patients treated for ascending cholangitis who had blood cultures and ERCP-obtained bile cultures at a tertiary care center between 2010 and 2016. Bile was collected for culture before injecting contrast, via a catheter after discarding the initial 3 mL. Results: Ninety-three patients were included with mean age of 71 (±15) years. Out of 93 patients, 11 (12%) had prior sphincterotomy, 29 (31%) had an indwelling biliary stent, and malignant obstruction was the most common etiology (34%). ERCP-obtained bile cultures were positive in 90 out of 93 (97%) patients with monomicrobial growth in 34 out of 93 (39%) patients. Mixed intestinal flora was noted in 3 patients. Blood cultures were positive in only 30 out of 93 patients (32%) and 24 out of 93 (26%) patients had monomicrobial growth. Totally 26 out of 30 patients (87%) grew the same organism as the bile culture, 3 grew an organism different from bile cultures, and one had no growth in the bile culture. On multivariable analysis, the presence of an indwelling biliary stent was the lone factor associated with polymicrobial growth, 83 vs. 52%, p = 0.007. Conclusion: ERCP-obtained bile cultures are a reliable and feasible mechanism to evaluate patients with suspected biliary tree infection. This technique has a significantly higher yield when compared to blood culture. Selection and tailoring of antibiotics based on bile culture in the management of ascending cholangitis are advised.