Linda A. Lee

Accuracy and reliability of the endoscopic classification of portal hypertensive gastropathy

BACKGROUNDnThere is no consensus regarding the endoscopic classification of the severity of portal hypertensive gastropathy. This study compared the accuracy and reproducibility of the 2-category classification system (2-CCS) with the 3-category classification system (3-CCS).nnnMETHODSnNinety-eight endoscopic pictures of portal hypertensive gastropathy and 22 of nonspecific gastritis were selected. Eight duplicate sets were generated, each in a different random order. These were shown to 6 experienced endoscopists during 2 sessions 1 week apart with 4 slide sets at each session. Each picture was scored by using either the 2-CCS or 3-CCS. Kappa statistics and percent agreement were used to estimate the reproducibility and agreement.nnnRESULTSnThe mean percentage agreement among the 4 separate readings for each observer was significantly lower for the 3-CCS compared with the 2-CCS (mean [standard deviation] = 33.5% [8.9%] vs. 64.9% [9.1%]; p = 0.0001). The mean (SD) interobserver kappa values were 0.44 (0.03) for the 3-CCS and 0.52 (0.04) for the 2-CCS (p = 0.02), and the respective intraobserver kappa values were 0.43 (0.1) and 0.63 (0.06) (p = 0.002).nnnCONCLUSIONSnEven though both the 2-CCS and 3-CCS have substantial limitations with regard to specificity and reliability, there were better agreement and reproducibility with the simpler classification system for portal hypertensive gastropathy.

Control of alkaline reflux esophagitis after total gastrectomy by a percutaneous jejunostomy tube.

Postoperative alkaline reflux esophagitis is a potentially devastating complication after total gastrectomy. The advent of the Roux-en-Y reconstruction has significantly decreased the incidence of this complication. However, when reflux esophagitis occurs, it is often refractory to medical treatment. Even though surgical revision of the Roux-en-Y anastomosis is the management option of choice, affected patients (especially those with advanced metastatic cancers) are often poor surgical candidates. We describe a novel treatment of refractory alkaline reflux esophagitis in a patient after radical total gastrectomy with Roux-en-Y reconstruction for advanced gastric carcinoma. Radiologic placement of a percutaneous jejunostomy tube into the proximal jejunal limb resulted in significant symptomatic relief by external diversion of the pancreaticobiliary drainage, and the procedure was associated with minimal discomfort. Nonsurgical pancreaticobiliary diversion should be considered in those patients with refractory alkaline reflux esophagitis that occurs after total gastrectomy.

Su1449 Incidence and Clinical Significance of Delayed Gastric Emptying for Liquids in Gastroparesis and Chronic Unexplained Nausea and Vomiting (CUNV)

Introduction. Diabetic gastroparesis is defined as delayed gastric emptying not caused by obstruction or structural abnormality. Normal function of the gastric and intestinal mechanical activity is mediated by slow wave electrical activity in the stomach and small bowel. Previous studies using both electrogastrogram and magnetogastrogram have shown gastric slowwave dysrhythmias associated with gastroparesis, but no study has yet examined possible effects of gastroparesis on the intestinal slow wave. Methods. We recorded intestinal slow waves in diabetic patients with gastroparesis (N=7) and healthy controls (N=7) using the magnetoenterogram (MENG), which uses a Superconducting QUantum Interference Device (SQUID) to convert magnetic fields associated with intestinal slow waves into voltage signals. Second Order Blind Identification (SOBI) was used to reduce noise and isolate the intestinal slow wave signal from confounding magnetic artifact, and we computed the power spectrum of the intestinal slow wave using a Fast Fourier Transform technique. We analyzed dominant frequency, amplitude and percentage of power distributed (PPD) in brady, normo and tachyarrhythmic frequency ranges. Results. In gastroparesis patients, we found a significant decrease in postprandial dominant intestinal slow wave frequency from 10.2 ± 0.4 cpm to 8.8 ± 0.5 cpm (p<0.05) whereas the dominant frequency for control subjects increased from 9.9 ± 0.5 cpm to 10.8 ± 0.4 cpm (p<0.05). We did not observe significant differences in preand postprandial PPDs computed from controls or patients. Conclusions. Diabetic gastroparesis is associated with bradyarrhythmia, but not uncoupling, of the intestinal slow wave. Biomagnetic measurements of the MENG can assess intestinal slow wave activity in healthy and diseased tissue noninvasively.

296 Effectiveness of Gastric Electrical Stimulation in Gastroparesis: Results From a Large Prospectively Collected Database of a National Gastroparesis Registry

Effectiveness of Gastric Electrical Stimulation in Gastroparesis: Results From a Large Prospectively Collected Database of a National Gastroparesis Registry Thomas L. Abell, Richard W. McCallum, Kevin P. May, Laura Wilson, Henry P. Parkman, William L. Hasler, Kenneth L. Koch, William J. Snape, John O. Clarke, Linda Anh B. Nguyen, Irene Sarosiek, Gianrico Farrugia, Jorge Calles-Escandon, James Tonascia, Linda A. Lee, Frank A. Hamilton, Pankaj J. Pasricha

299 Diabetic and Idiopathic Gastroparesis Is Associated With Loss of Antral Interstitial Cells of Cajal and CD206 Positive Macrophages

Effectiveness of Gastric Electrical Stimulation in Gastroparesis: Results From a Large Prospectively Collected Database of a National Gastroparesis Registry Thomas L. Abell, Richard W. McCallum, Kevin P. May, Laura Wilson, Henry P. Parkman, William L. Hasler, Kenneth L. Koch, William J. Snape, John O. Clarke, Linda Anh B. Nguyen, Irene Sarosiek, Gianrico Farrugia, Jorge Calles-Escandon, James Tonascia, Linda A. Lee, Frank A. Hamilton, Pankaj J. Pasricha

Su1431 Abdominal Pain in Gastroparesis: A Common Symptom Associated With Gender, Anxiety and Other Gastroparesis Symptoms

Abdominal pain is seen in many patients with gastroparesis, but is not well characterized or recognized as a symptom of gastroparesis. Aims: 1) Describe characteristics of abdominal pain in gastroparesis; and 2) Determine differences in abdominal pain between diabetic (DG) and idiopathic gastroparesis (IG). Methods: Gastroparetic patients were enrolled at 8 centers into the NIH Gastroparesis Registry from September 2012 to October 2014. Patients had symptoms of gastroparesis for >12 weeks, delayed gastric emptying, negative endoscopy. History and physical examinations, questionnaires assessing symptoms (PAGI-SYM), quality of life (PAGI-QOL, SF-36), psychologic state (Beck Depression Inventory, State Trait Anxiety Index, PHQ-15), and a questionnaire characterizing abdominal pain were obtained. Results: 117 gastroparesis patients were enrolled: 74 IG, 40 DG, and 3 Post-Nissen. Overall, 92% of patients were experiencing abdominal pain. Abdominal pain was described as discomforting (38%) or distressing (27%), occurring every day in 52%, and most often localized in the upper middle portion of the abdomen (35% of patients) or middle central portion (19%). Abdominal pain worsened with eating in 52%, occurred at night (46%), and interfered with sleep (29%). Severity of upper abdominal pain, assessed by PAGI-SYM, was severe or very severe in 35% of patients, was more severe in females (p=0.001), and associated with decreased quality of life by PAGI-QOL (p=0.03) and SF-36 physical (p=0.11) and mental (p=0.10) components. Abdominal pain severity was associated with other symptoms of gastroparesis: nausea/vomiting subscale (p=0.03), early satiety/postprandial fullness subscale (p<0.001), and bloating subscale (p=0.002); but not gastric emptying. Abdominal pain severity was associated with other pain-related conditions, IBS (p=0.02) and migraine headaches (p=0.03), but not fibromyalgia. Upper abdominal pain was associated with increased PHQ-15 somatic symptom score (p=0.007), state anxiety (p=0.04), but not trait anxiety (p= 0.25) or depression (p=0.22). Upper abdominal pain severity was not significantly different between IG and DG (2.9±1.7 vs 2.5±1.7; p=0.30). Abdominal pain occurred with eating more often in IG (63 vs 35%; p<0.01) and was shorter duration in IG: less than one hour in 55% of IG vs 9% of DG; p=0.003. Upper abdominal pain severity was independently associated with female gender (OR 18.9; p=0.01), other gastroparesis symptoms (OR 2.8; p<0.001), and state anxiety score (OR=1.03; p=0.04). Conclusions: Abdominal pain is common in patients with gastroparesis, both idiopathic and diabetic. Upper abdominal pain severity is associated with decreased quality of life, female gender, anxiety and other gastroparesis symptoms. Thus, abdominal pain in gastroparesis patients needs understanding and treatment to reduce morbidity from this important symptom.