Neel K. Mann

Video capsule endoscopy impacts decision making in pediatric IBD: a single tertiary care center experience.

Background: Little is known about the impact of video capsule endoscopy (VCE) on decision making in pediatric patients with IBD. Moreover, few studies have reported on the outcomes of treatment changes made based on VCE findings. Our aim was to identify the added value of VCE in pediatric patients in a tertiary IBD center with established or suspected IBD, by assessing changes in treatments and outcomes before and after VCE. Methods: A retrospective chart review was performed in children with established (n = 66) or suspected (n = 17) IBD who underwent VCE. Diagnostic classifications, treatments, and clinical outcomes before and 1 year after VCE were compared. Results: Primary indications for VCE included patients treated for Crohns disease (CD) with poor growth or active symptoms (60%), patients with ulcerative colitis/IBD-unclassified (19%), and suspected IBD (20%). Abnormal VCE was seen in 86% of patients with CD, of whom 75% underwent treatment escalation. One year after VCE, patients with CD improved in growth (mean z-scores at baseline and 12 months, −0.5 and 0.2, respectively; P < 0.0001), mean body mass index (18.3 and 19.8, respectively; P = 0.004), mean erythrocyte sedimentation rate (25 versus 16, respectively; P = 0.012), and median Harvey–Bradshaw Index (2 and 0, respectively; P = 0.003). VCE revealed more extensive disease than concurrent imaging modalities in 43% of the patients with CD. VCE “ruled out” IBD in 94% who had suspected IBD, whereas 50% with presumed ulcerative colitis/IBD-unclassified had a diagnosis changed to CD. Conclusions: VCE provides additional clinical information that impacted management of pediatric patients with IBD in a tertiary IBD center and was associated with improved outcomes.

Is a repeat double balloon endoscopy in the same direction useful in patients with recurrent obscure gastrointestinal bleeding

Goals: To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB). Background: OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE. Study: We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed. Results: Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P<0.001). Three patients underwent the third DBE. Angiodysplasias were detected in 2 patients (66.7%). Conclusions: Repeat DBE in the same direction may detect bleeding sources in 53% of recurrent OGIB patients. The probability of bleeding source detection in repeat DBE is higher in patients with a prior positive DBE.

Sa1237 Long-Term Evaluation of Preoperative Wireless Capsule Endoscopy As a Predictor of Outcome After Ileal Pouch-Anal Anastomosis

Background: Mucosal healing (MH) in inflammatory bowel disease has been associated with improved clinical outcomes, including clinical remission, fewer hospitalizations, and fewer surgeries. However, varying results have been reported, as partial mucosal healing has often appeared to have similar clinical benefits to complete MH, and outcomes have been reported at widely varying times of follow-up. We aimed to obtain more accurate estimates of the benefits of partial and complete mucosal healing through meta-regression. Materials and Methods: A PubMed and EMBASE search on terms associated with inflammatory bowel disease, pharmacologic interventions, and mucosal healing/endoscopic assessment was conducted, and 1572 potential papers identified. Screening for relevance by title and abstract identified 157 papers for full-text review, of which 19 met criteria for data extraction. These papers were reviewed and data abstracted by 2 reviewers (AR and TL). Sample-size-weighted meta-regressions using mucosal healing, time from intervention to endoscopy, and time of follow-up as predictors of clinical remission (CR), hospitalization, and surgeries were performed. Results: Using multivariate weighted meta-regression, we found partial or complete MH was a strong predictor of good clinical outcomes. For clinical remission, data from 12 manuscripts on 1256 subjects was analyzed, and complete MH and shorter duration of follow-up were significant predictors of sustained CR (both p<0.01). However, any healing (partial or complete MH) was a slightly better (NS) predictor than complete MH. The adjusted R2 for the adjCR model was 0.74, but only 0.34 for the hospitalization model and 0.36 for the surgery model. For hospitalizations, 7 studies of 451 subjects were able to be analyzed. Similar trends were seen with, any healing weakly associated with fewer hospitalizations and longer time of follow-up weakly associated with more hospitalizations. For surgeries, 19 studies of 2188 subjects were analyzed. Mucosal healing was associated with fewer surgeries, and longer follow-up with more surgeries (both p<0.01). Conclusions: Mucosal healing is a strong predictor of long-term clinical remission and fewer surgeries, and is weakly associated with fewer hospitalizations. Achieving partial MH was not significantly less beneficial for clinical remission or surgery, though this study may have been underpowered to find this difference. The predictive benefits of mucosal healing degraded with longer time of follow-up.

Metastatic Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) of Unknown Primary: A Diagnostic Strategy for Localizing the Primary Lesion

Background: Localization of primary GEP-NETs is a diagnostic challenge of paramount importance, as resection of the primary lesion may increase treatment efficacy and improve prognosis. Aims: To evaluate the diagnostic value of capsule endoscopy (CE), double balloon enteroscopy (DBE), endoscopic ultrasound (EUS), octreotide scan (OS) and PET-CT for localizing primary GEP-NETs. Methods: Retrospective evaluation of patients with metastatic GEP-NETs and an unknown primary per CT or MRI. These patients had at least one of the 5 diagnostic modalities for localization. Tissue diagnosis was used to confirm the primary lesion. Results: 39 patients with biopsy-proven metastatic GEP-NET were referred to our center for a diagnostic evaluation between July 2002 and September 2010. The mean age was 58, 56% female. We ultimately identified the primary in 30 patients (77%) with various combinations of CE, DBE and EUS. CE was positive in 11/22 patients (50%), 8 of whom were confirmed. DBE was positive in 17/27 procedures (63%) and performed in a total of 22 patients. EUS, usually done after a negative intestinal search, was positive in 11/27 (65%). Octreotide scans were positive in 12/23 patients (52%) with 9 confirmations. 7 patients underwent all 3 endoscopic procedures; 6/7 patients (84%) had the primary localized. Overall, the sensitivities of CE, DBE and EUS were 60% 73% and 77%, respectively (see table). OS, typically considered the gold standard, had a sensitivity of only 59%. PET-CT scans were done on 4 patients and all were negative. Conclusions: CE, DBE, and EUS are highly effective in identifying the primary lesion for patients with metastatic GEP-NETs of unknown primary, especially when all three modalities are utilized. OS is imprecise in localizing lesions and may be less sensitive than any of the 3 endoscopic procedures. The value of PET-CT in the search for the primary lesion remains to be determined. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of Each Procedure for Detection of Primary Lesions

M1246 Diaphragm Strictures (DS): Location, Number and Dose-Relation to NSAID Exposure as Evaluated by Double Balloon Enteroscopy (DBE)

evaluation of IDA. Methods: Adults presenting for outpatient EGD and colonoscopy were prospectively enrolled. Sera were obtained for determination of iron status, serum transferrin receptor(sTfR), ESR, and CRP. Subjects with IDA were compared to a control group without anemia. Quantification of stool blood was performed. Extensive data including socioeconomic factors and clinical features were collected. Serum for hepcidin was collected fasting, at the same time of day; measurements were performed by a combination of cation exchange chromatography and time-of-flight mass spectrometry. Results: 46 subjects were enrolled. Age, gender, BMI, race, and ethnicity were all similar (p = NS). The subjects were stratified into those who had ongoing blood loss to account for IDA, and those who did not. In only 1 control subject was hepcidin undetectable. In 5 subjects with IDA, hepcidin levels were elevated. None of these 5 subjects had a history of menorrhagia, or evidence of blood loss from the GIT. Mean ESR and CRP were not significantly different, however sTfR was found to be increased in the group with IDA when compared to the control group (p <0.05). Conclusion: In this cohort of subjects with IDA, sTfR was significantly higher than in the controls, consistent with the diagnosis of IDA. However, contrary to prior assertions, hepcidin levels are not always undetectable in adults with IDA. In these patients, who do not have “anemia of chronic disease,” and do not have ongoing blood loss, hepcidin levels may be a reflection of the etiology of, rather than a response to, IDA. Support: This study was supported by NIH Grant UL1RR024982.