Kadirawel Iswara

Early Intensive Resuscitation of Patients With Upper Gastrointestinal Bleeding Decreases Mortality

OBJECTIVE:Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study.METHODS:A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention.RESULTS:Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21–94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p = 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p = 0.04).CONCLUSION:Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.

472 Decreased Mortality in Acute Pancreatitis Related to Early Aggressive Hydration

Background: Gastroparesis is a well recognized complication of diabetes and can contribute to poor glycemic control. Diabetic gastroparesis is associated with loss of interstitial cells of Cajal. We have previously studied gastroparesis by serially measuring gastric emptying in diabetic NOD mice and demonstrated that delayed gastric emptying is associated with loss of up-regulation of heme oxygenase-1 (HO1), an increase in oxidative stress and loss of Kit. Induction of HO1 reversed delayed gastric emptying, lowered markers of oxidative stress and restored Kit expression. HO1 catalyzes the breakdown of heme into iron, biliverdin and carbon monoxide (CO). The metabolite of HO1 that restores normal gastric function is not known. Aims: Determine whether inhalation of CO can reduce oxidative stress, increase Kit expression and reverse delayed gastric emptying in diabetic NODmice.Methods: Gastric emptying of solids was measured using a [13C]octanoic acid based breath test. Mice were considered diabetic when blood glucose levels were >250 mg/dL. Mice that developed delayed gastric emptying (T1/2 >118min) received either CO by inhalation (250 ppm for 6 hours daily) or not. Serum malondialdehyde was measured as a marker of oxidative stress. Kit and HO1 expression levels were determined in immunoblots of protein extracted from the external muscle layers of the body and antrum of the stomach. Statistical analyses were done using paired t test and Mann Whitney rank-sum test for non parametric data. Results: 8 NOD mice with delayed gastric emptying were studied (mean T1/2±SEM: 160±10 min, normal 67-118 min). CO treatment reversed the gastric emptying delay in all 4 mice within 2 weeks of treatment (mean T1/2±SEM: 81±5 min, n=4), whereas gastric emptying remained delayed in all the control animals (mean T1/2±SEM: 181±8 min, n = 4). In CO treated mice, malondialdehyde levels were reduced from 394±21 nmol/ml to 41±14 nmol/ml, mean±SEM, n = 3, p 0.05, Mann Whitney). Conclusions: CO decreased oxidative stress and increased Kit expression and reversed diabetic gastroparesis in NODmice without an increase in HO1 expression. These data suggest that the production of CO by HO1 is a major contributor to the protective effect of HO1 on diabetic gastroparesis in mice. Supported by NIH DK68055 and DK57061.

333 The Effect of Obesity on Bowel Preparation for Colonoscopy: Results From a Large Prospective Study at an Urban Health Care Center

Background/Purpose: Childhood obesity is a growing epidemic in the United States. However, healthcare providers, including medical students and residents, do not feel prepared to diagnose obesity, perform counseling, or treat obesity and its complications. The purpose of this study is to design a web-based module to adequately deliver educational content pertinent to medical students on the topic of pediatric obesity. The effectiveness of the module was evaluated in terms of content mastery and overall satisfaction using a pre-test, post-test, and post-test survey. We hypothesize that there will be a significant increase in knowledge on key content areas related to the topic of pediatric obesity after viewing the web-based module. Methods: An IRB approved, prospective study of 217 third year U.S. medical students was performed. Students were given a pre-test followed by educational content delivered in the form of a web-based module, then a post-test. Test questions centered on areas of the assessment, evaluation, counseling, treatment, and complications of pediatric obesity. Participants served as their own controls to compare pretest and posttest scores. Overall satisfaction with both the content and method of delivery of the web-based module was assessed using a post-test survey. Results: Completing the web-based module resulted in improved scores when comparing post-test to pre-test scores. Average scores increased from 77.4% correct on the pre-test to 93.6% on the post-test, an overall 16.2% increase in content mastery (95% CI 13.9-18.5, p<0.00001). In addition, students were overall highly satisfied with both the content and delivery method of the module as reported on the post-test satisfaction survey. Conclusions: The web-based method of instruction shows potential for increasing knowledge in the important areas of assessment, counseling, consequences, and treatment plans surrounding the topic of pediatric obesity. Students reported overall satisfaction with this web-basedmethod of instruction. In an era of increasing demands on student time, this web-based module served the purpose of delivering education with objective documentation of improved student knowledge. We plan to expose other health-care learners to the pediatric obesity module.

M1016 Potential Savings for Federal Funding of a Colorectal Cancer Screening Program in Uninsured Patients: A Cost-Effectiveness Analysis

Introduction: The comparability of cost-effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data on tests, populations, and designs are combined. Furthermore cost-effectiveness studies frequently suffer from unrealistic assumptions, e.g. concerning differences in screening participation and adherence to follow-up. Based on empirical data from a representative randomised controlled screening trial with FOBT in the Netherlands (Van Rossum, et al. Gastroenterology 2008), we aimed to compare cost-effectiveness of one round of immunochemical faecal-occult-blood-test (OC-Sensor®, I-FOBT) screening, with one round of guaiac based faecal-occult-blood-test (HemoccultII®, G-FOBT) screening and no screening. Methods: We designed a Markov model of the cost-effectiveness of CRC screening with FOBT and no screening in asymptomatic average risk individuals between 50 and 75 years. From a third-party payer perspective we analysed data with first and second order Monte Carlo simulation over 10 years of one year cycles. Empirical data were completed with cancer registry and literature data. Costs were presented in Euros using a discount rate of 4%. Effects were measured as life years gained using a discount rate of 1.5%. Results: I-FOBT resulted in more life years gained and costs saved (i.e. I-FOBT dominated) compared to G-FOBT and no screening. A hypothetical person invited for colorectal cancer screening with I-FOBT would on average save 0.003 life-years and €5 compared to G-FOBT and compared to no screening 0.006 life-years and €45. Ten years after a single round I-FOBT screening, in the Dutch population aged 50-75 years (n= 4,460,265), 25,200 life-years and €220 million would have been saved compared to no screening. I-FOBT remained the dominant screening strategy in sensitivity analyses when varying colorectal cancer incidence and major cost drivers. Conclusions: CRC screening with I-FOBT dominated G-FOBT and no screening. Accounting for uncertainty surrounding important parameters did not alter this conclusion. Table. Cost-effectiveness according to intention-to-screen analysis of one round immunochemical FOBT screening compared to one round guaiac FOBT screening or no screening

Colonic ulceration leading to massive lower gastrointestinal bleeding in a patient with Wegener’s granulomatosis: a rare presentation

Wegeners Granulomatosis is a rare disease characterized by a triad of necrotizing granulomas of the upper respiratory and lower respiratory tract and glomerulonephritis. The pathology is defined by the triad of small vessel vasculitis, granulomatous inflammation and necrosis. Associated symptoms can be scleritis, arthritis, purpura and neuropathy. We present a patient with Wegeners granulomatosis who presented with massive lower gastrointestinal bleeding secondary to colonic ulceration. A 35 year-old woman with a 10 year history of Wegeners Granulomatosis presented with hemoptysis and shortness of breath for one month. There were also complaints of nausea and vomiting for one day and painful oral ulcerations for three days. Past medical history also included asthma and anemia. On admission, physical exam was significant for ulcerative lesions on the tongue, buccal mucosa and midline lips. Lungs had bilateral ronchi in upper lung fields. Abdominal exam was normal and stool giuiac was negative. Laboratory analysis was significant for leukocytes 15,200, hematocrit 24.4. Treatment with intravenous steroids and cyclophosphamide was begun. On the seventh day of admission, the patient began to have massive lower gastrointestinal bleeding, passing blood and clots from the rectum. Upper endoscopy revealed only gastritis. Colonoscopy was performed which revealed fresh blood and clots. There were multiple 1–2 cm ulcerations in the cecum and ascending colon. Hemostasis was achieved with heater probe and injection of epinephrine. This case represents the first report of colonic ulceration from Wegeners granulomatosis leading to massive lower gastrointestinal bleeding. An ischemic process complicating the typical vasculitis seen in Wegeners disease is suspected as causing the colonic ulcers. Despite standard medical treatment of Wegeners granulomatosis, the colonic ulcers do not appear to respond. Endoscopic therapy is required and appears effective.

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases morbidity and mortality

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases morbidity and mortality