Laura Nieto

Beneficial Effect of Vegetable Protein Diet Supplemented With Psyllium Plantago in Patients With Hepatic Encephalopathy and Diabetes Mellitus

A controlled crossover study was performed in 8 diabetic patients with chronic portal-systemic encephalopathy. After a basal period the patients were treated during periods A and B. During period A, a meat protein diet (0.8 g/kg body wt, approximately 1800 kcal/day) was consumed and neomycin plus laxatives were given. During period B patients received vegetable protein (0.8 g/kg body wt, 1800 kcal/day). This diet was supplemented with psyllium fiber to reach 35 g of fiber per day. Four patients were randomly assigned to receive the treatments in the order A-B and the other 4 patients in the order B-A. At the end of the first experimental period, fasting glucose levels were 204 +/- 86 mg% in the meat protein diet group and 127 +/- 8 mg% in the vegetable protein diet group (p less than 0.014). The patients were receiving 2.5 +/- 0.2 g/day and 2.1 +/- 0.5 g/day of tolbutamide at the end of the meat protein diet and vegetable protein diet, respectively. In all cases, fasting glucose levels decreased at the end of the vegetable diet period regardless of the previous treatment. An improvement of greater than or equal to 25 mg% of fasting glucose levels was observed in 7 of the 8 patients after the vegetable protein diet and in no case after the meat protein diet (p less than 0.0078). The parameters of encephalopathy were comparable at the end of both the meat protein diet and the vegetable protein diet. A significant increase in the number of bowel movements was noticed after the vegetable diet plus fiber (p less than 0.01). We propose the use of vegetable diet plus fiber to facilitate the treatment of patients with both diabetes and hepatic encephalopathy.

Psychological impact of Crohn's disease on patients in remission: anxiety and depression risks

BACKGROUND the role of anxiety and depression in CD patients in remission has been poorly investigated. OBJECTIVE the aim of the study was to evaluate the frequency of anxiety and depression symptoms in CD patients in remission, and potential factors influencing the development of these symptoms. METHODS CD patients older than 18 years in remission for at least 6 months before study entry were included. CD remission was defined as a Crohn s Disease Activity Index (CDAI) < 150 points together with C-reactive protein < 5 mg/L. A demographic questionnaire was filled in, and all patients were clinically classified. The therapy maintaining remission was also recorded. A Hospital Anxiety and Depression scale (HAD) was administered to all patients. Results are shown as OR and 95% CI, and analyzed by logistic regression. RESULTS 92 consecutive patients were included (48 male, mean age 37 years, range from 18 to 71 years). One patient failed to correctly fill in the questionnaire. Anxiety and depression symptoms were present in 36 (39%) and 22 (24%) patients, respectively. Infliximab therapy was the only factor associated with anxiety (OR = 3.11; 95% CI: 1.03-9.43; p < 0.05). In contrast, the presence of depressive symptoms is less frequent in patients under infliximab therapy (OR = 0.16; 95% CI: 0.02-0.97; p < 0.05). CONCLUSIONS despite clinical remission, an important number of CD patients present with anxiety or depressive symptoms. Infliximab therapy in CD patients is associated to more anxiety but fewer depressive symptoms. CD patients in remission would probably benefit from psychological support.

Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study

OBJECTIVE Whether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms. DESIGN A prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI). RESULTS 213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39-6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97-21.85) were associated with the presence of changes of CP. CONCLUSION Morphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.

Mo1740 Prospective, Randomized Clinical Trial Comparing the Efficacy of Two Vaccines Against Hepatitis B Virus (HBV) in Inflammatory Bowel Disease (IBD) Patients

Introduction and aim: Indoleamine 2,3-dioxygenase (IDO) is expressed in innate immune cells and acts as the first rate-limiting step in the tryptophan (TRP) catabolism along the kynurenine pathway. Decreased serum TRP levels have been associated with active inflammation in Crohns disease (CD) due to induction of IDO (Gupta, Inflamm Bowel Dis 2012). We studied the effect of infliximab-induced downregulation of inflammation on serum levels of TRP and kynurenine, as well as mucosal IDO expression in patients with inflammatory bowel disease (IBD). Methods: Serum samples and endoscopically-derived ileal or colonic mucosal biopsies were obtained from controls and patients with active IBD, and this before and after their first treatment with infliximab. Short-term clinical response and mucosal healing were assessed by experienced clinicians at 4 or 10 weeks after a single infusion or induction schedule, respectively (Ferrante, Inflamm Bowel Dis 2007; Schnitzler, GUT 2009). Serum TRP and kynurenine were measured by high performance liquid chromatography, and IDO mucosal gene expression was measured by Affymetrix Human Genome U133 Plus 2.0 Arrays. Data were analyzed with SPSS software using non-parametric tests and p-values of 9-fold increased in active IBD patients before infliximab therapy vs. controls (pileum=0.001 and pcolon<0.001). Although the IDOmucosal expression levels significantly decreased after infliximab therapy in IBD responders when compared to their baseline samples (pshort-term response and pmucosal healing<0.001), the colonic expression still remained significantly higher than controls (pshort-term response<0.001 and pmucosal healing=0.002). Serum TRP levels were significantly decreased (p<0.001) and the kynurenine/ tryptophan (K/T) ratio was significantly increased (p=0.001) in active IBD patients when compared to controls. However, we found no significant effect of infliximab therapy on both the TRP levels and K/T ratio. Conclusion: This study demonstrates that mucosal IDO expression levels are increased and serum TRP levels decreased in IBD patients with active disease. Of note, after controlling the inflammation with infliximab therapy, both levels remained impaired in IBD responders showing a complete mucosal healing. This persistent upregulation of IDO in patients with complete colonic healing may explain why mucosal ulcers recur very early if patients do not receive maintenance therapy with infliximab.

Duplication of a 303 kb Locus Containing PRSS1 and PRSS2 is Associated With Hereditary Pancreatitis in a Spanish Kindred

Background:Etiologies of recurrent pancreatitis include anatomical anomalies, hereditary, metabolic and autoimmune disorders. A significant number of patients remain with a diagnosis of idiopathic pancreatitis. The advent of genetic analysis and electrophysiologic testing may further assist in the diagnostic process. Evidence has shown that specific genetic mutations in the cationic trypsinogen gene PRSS1 and the SPINK1 gene for pancreatic secretory trypsin inhibitor cause pancreatitis; furthermore cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations have been associated with pancreatitis. Aims :To present the work-up of patients with recurrent pancreatitis referred for genetic analysis and electrophysiological testing. Methods : Patients with recurrent, acute pancreatitis with no known etilology were referred to the Electrophysiology Laboratory, Division of Pediatric GI at Hadassah University Hospital for PRSS1 and SPINK1 gene mutations as well as evaluation of CFTR function by Nasal Potential Difference (NPD) testing. Results: A total of 42 patients with recurrent pancreatitis were evaluated; the mean age was 21 years ±14.9 years (range 2-54 yrs). A third (33%) of the patients was of Ashkenazi ancestry, 41% of mainly Sephardic ancestry, 24% of Arab ancestry and the remaining 2% of other ethnic background. There was a family history in 8 patients. The patients had a mean of 4 episodes (range 1-25). 6 (14%) patients showed PRSS1 genemutation (p.R112H and p.K23R) including 2 sets of siblings of Georgian Jewish ancestry with p.K23R. No SPINK1 mutation was found in the 26 patients submitted for testing. 3 patients out of 21 submitted for CFTR gene testing showed mutations (5T, F508del/p.L997F and D1152H/5T). 26 (61%) patients underwent sweat testing, with 13 patients with results >40 mmol/L. 35 (83%) patients had Nasal Potential Difference testing, 4 (11.5%) with abnormal results: 3 had sweat chloride>60mmol/L with no CFTR mutations found but one patient with D1152H/5T had a sweat test of 30 mmol/L. None of the 6 patients with PRSS1 gene mutation showed any concomitant CFTR dysfunction (by NPD or sweat testing) or gene mutation.Conclusion:This is the first study on recurrent pancreatitis in Israel examining both the presence of susceptibility gene mutations for pancreatitis and CFTR dysfunction. A prospective study with a larger number of patients may further clarify the impact of genetic mutations and CFTR dysfunction on the clinical presentation and outcome of recurrent pancreatitis.

S1361 Evaluation of the Bedside Index for Severity in Acute Pancreatitis (BISAP) in Assessing Mortality in Severe Acute Pancreatitis

Background: Early cholecystectomy is recommended by clinical practice guidelines for prevention of recurrence in mild gallstone-associated acute pancreatitis (GAP). Recent data indicates variation in adherence to these guidelines in the United States. Aims: To report 1) Trends in frequency of early cholecystectomy, 2) Impact of inpatient endoscopic sphincterotomy and 3) Predictors of early cholecystectomy in patients with mild GAP at an urban academic U.S. medical center. Methods: Patients with GAP were identified by imaging and liver function tests from a prospective cohort study of acute pancreatitis conducted at Brigham andWomens Hospital from June 2005 May 2009. Risk-adjustment was performed according to the Atlanta classification. Patients with severe acute pancreatitis were excluded. Early cholecystectomy was defined as surgery during the same admission or within 2 weeks of discharge. Annual trends in early cholecystectomy were evaluated. We performed a stratified analysis to evaluate the impact of inpatient endoscopic sphincterotomy on frequency of early cholecystectomy. We further evaluated the role of age, race, gender, insurance status and inpatient surgical consultation on likelihood of early cholecystectomy. Results: There were a total of 231 GAP cases during the study period. There were 33 (14.2%) severe cases that were excluded. Among the remaining 198 mild GAP cases, there was a significant trend to increased utilization of early cholecystectomy during the study period (Figure). Gender, race, and insurance status were not associated with likelihood of early cholecystectomy. Prior sphincterotomy did not impact the frequency of early cholecystectomy (χ2 p=0.09). The strongest factor associated with early cholecystectomy in mild GAP was an inpatient surgical consult (66% with surgical consult vs. 3.2% without, χ2 p<0.0001). Overall, 50% of mild GAP cases had a surgical consult during their hospitalization. Conclusions: Despite increased utilization of early cholecystectomy, overall adherence to guidelines was still low. Sphincterotomy did not impact likelihood of early cholecystectomy. Surgical consultation prior to discharge for mild GAP was associated with more timely cholecystectomy. Trends in Early Cholecystectomy for Mild GAP at a US Academic Medical Center, N=198

S1164 Is Maintenance Therapy with Biologics Associated to a Better Quality of Life (QOL) Compared to Conventional Drugs in Non-Active Crohn's Disease (CD) Patients?

G A A b st ra ct s age, 41 years) with pouchitis and in use of antibiotics. Ileal pouch endoscopy was performed, and tissue biopsy samples were collected for histopathological analysis. RESULTS: Colonic metaplasia was found in 15(36,6%) of 41 patients: 5(25%) of group 1, 8(57,1%) of group 2 and 2(28,6%) of group 3. However, no correlation was established between its presencewith pouchitis (p=0,17). No differences existed in mucosal atrophy, chronic or acute inflammation degree between the groups 1, 2 and 3 (p>0,45). No dysplasia or neoplastic changes were observed. Atrophy degree of ileal pouch mucosa correlated well with time of postoperative follow-up (p=0,05). CONCLUSIONS: Atrophic mucosal changes are more prominent in patients with longer time of postoperative follow-up. Therefore, not only fecal stasis and bacteria overgrowth are responsible for mucosal adaptations, and patients with longer followup are at higher risk of development of neoplastic changes. Pouchitis is not associated to colonic metaplasia.

M1147 Anxiety and Depression Symptoms in Crohn's Disease (CD) Patients in Remission

G A A b st ra ct s (1991-1995) as our true negative population (n=936,514).We linked to health administrative data and compared the accuracy of various algorithms of health services patterns to establish which best identified children with IBD. To validate accuracy for children <18y seen throughout Ontario, the charts of 593 patients with IBD (diagnosed 2001-2005) and 1241 patients without IBD were reviewed from 12 diverse practices throughout the province. RESULTS: A two-step algorithm based on whether patients underwent diagnostic colonoscopy was most accurate. Patients who underwent colonoscopy required 4 physician contacts or 2 hospitalizations (with ICD codes for IBD) within 3 years, while those without colonoscopy required 7 contacts or 3 hospitalizations within 3 years. For patients <12 years old, this algorithm achieved sensitivity 92.5% (95%CI 86.7-96.0%), specificity 100% (95%CI 100100%), PPV 74.7% (95%CI 67.6-80.8%), NPV 100% (95%CI 100-100%). For patients <15 years, sensitivity was 89.6% (95%CI 84.0-93.5%), specificity 100% (95%CI 100-100%), PPV 57.1% (95%CI 51.2-62.9%), NPV 100% (95%CI 100-100%). Chart validation resulted in sensitivity 91.1% (95%CI 88.4-93.2%), specificity 99.5% (95%CI 98.9-99.8%), LR+ 188, LR0.090. CONCLUSION: Health administrative data can accurately identify children with IBD. This algorithm will be used to develop the Ontario Crohns & Colitis Cohort (OCCC) in order to monitor incidence, outcomes and health services utilization of children with IBD in Ontario. Test characteristics for best two-step algorithm (scoped: 4 contacts or 2 hosp, not scoped: 7 contacts or 3 hosp) for different age groups applying cut-offs of various durations.