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530 Prevalence of Colorectal Neoplasia in Cirrhotic Patients Evaluated for Liver Transplantation in Comparison to a Healthy Screening Population
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abnormalities share a common pathophysiologic basis regardless of the designation. Contraction wave abnormalities are therefore clinically relevant and are associated with a heightened perceptive symptomatic state.
The Mechanics of Esophageal Bolus Transport Are Altered in Subjects Reporting Perception of Solid Bolus Hold up Taher Omari, Stamatiki Kritas, Jennifer C. Myers
AGA Abstracts
Introduction: The subjective perception of solid bolus hold up during swallowing is a common reason for referral for manometric investigation, yet standard measures of esophageal function relate poorly to patient perception and a large proportion of patients with dysphagia demonstrate no apparent abnormality on routine diagnostic testing for esophageal dysfunction. The utility of combined esophageal pressure-impedance recording has been recently enhanced by automated impedance manometry pressure-flow analysis (AIM analysis) and new metrics have been conceived that better describe the interactions between bolus transport and pressure generation. In this study we undertook to assess whether these new esophageal pressure-flow metrics were altered when subjects perceived solid bolus hold up. Methods: Esophageal high-resolution pressure-impedance recordings of 5ml/10ml liquid/viscous swallows and 2cm/4cm solid swallows from 20 control subjects (29-73 years) were analysed. Two solid state pressure(P)/impedance(Z) catheter configurations were used; 32 1cm P/16 2cm Z (Sandhill Scientific) and 36 1cm P/18 2cm Z (Given Imaging). Bolus flow resistance, the relationship between bolus compression and bolus flow timing, was assessed using the pressure flow index (PFI) (Myers et al Neurogastro. Mot. 2012; Nguyen et al Neurogastro. Mot. 2012). Heightened perception of bolus hold up was assessed on a swallow by swallow basis using a 6 point scale (1 = no perception, 2 = awareness of bolus transit, 3-6 = bolus hold up). Results: On a swallow by swallow analysis, heightened perception of solid boluses (swallows with scores 3+) was associated with a higher PFI (distal esophagus Odds Ratio for score 3+ 1.001 [1.000 1.002], p = 0.021). A significant correlation was observed between the maximum subject reported perception score and the average PFI for solids (distal esophagus Pearson's r = 0.690, p,0.001). Grouping of subjects in relation to bolus perception revealed that the PFI was elevated for solids and viscous boluses, but not liquids, in subjects reporting bolus hold up (Figure). Esophageal peak pressures and iso-contour defect size were not significantly related to bolus perception. Conclusion: We report novel findings in relation to mechanical factors during bolus transport that may enhance bolus perception. This study shows that heightened perception of a swallowed bolus relates to subtle differences in flow resistance, which suggests higher levels of muscle tension during the transition phase from a bolus-containing to a lumen-occluded esophageal segment.
Nutcracker esophagus: averaged contraction amplitudes ≥180 mmHg in the esophageal body; Broad waves:≥5.7 s; simultaneous contraction: contraction front velocity .6.8 cm/s; GSS: global symptom score, rated on a 10 cm visual analog scale; *p=0.02 compared to NE with Chicago Criteria being met 530 Prevalence of Colorectal Neoplasia in Cirrhotic Patients Evaluated for Liver Transplantation in Comparison to a Healthy Screening Population Philip Jeschek, Karoline G. Reinhart, Petra Salzl, Georg Heinze, Arnulf Ferlitsch, Michael H. Trauner, Monika Ferlitsch Background: Cirrhotic patients undergo colonoscopy as a part of evaluation for liver transplantation (LTX) in Austria, since there are considerations showing that progression to colorectal cancer may be affected by the following immunosuppressive therapy. Further, liver diseases like non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are associated with higher prevalence of adenomas. However, there is little data on the prevalence of colorectal adenomas in cirrhotic patients requiring LTX. Objectives: To evaluate liver cirrhosis as a risk factor for colorectal adenoma in liver transplant candidates. Methods: This retrospective cohort observational study compared screening colonoscopy outcomes from 570 cirrhotic patients who were listed for liver transplantation at Vienna General Hospital from 2000 to 2012 with age and sex matched controls (screening colonoscopies performed in healthy screening population subjects). The following variables were evaluated: gender, age, etiology and stage of cirrhosis, as well as body mass index. Primary outcome measures were polyp- (PDR), adenoma- (ADR) and advanced adenoma detection rate (AADR); secondary outcome measures were number, diameter and localization of the polyps detected in colonoscopy. Results: The median age was 54 years with 27.7% females and 72.3% males in both cohorts. Cirrhotic patients presented with a median Model for End-Stage Liver Disease score of 15.6. 10.74% were staged Child A, 38.03% Child B and 51.23% Child C. The leading etiology of cirrhosis was alcoholic liver disease, found in 48.6% of transplant candidates; hepatitis C in 31.23%, hepatitis B in 7.19% and biliary tract diseases in 7.72%. Other underlying etiologies were found in 11.4%. The comparative analysis revealed a significantly higher adenoma detection rate in cirrhotic patients compared to the screening cohort (29.11 vs. 22.54%; p=0.019). For advanced adenoma the difference was even higher (13.85% vs. 7.87%; p=0.0024). Therefore, relative risk was 1.29 (CI: 1.04-1.6) for adenoma and 1.76 (CI: 1.22-2.55) for advanced adenoma. As for multiple macroscopic lesions, more than four polyps were found in 7.54% of cirrhotic patients and in 1.40% of the screening cohort (p,0.0001). In cirrhotic women the ADR was almost twice as high as in healthy women (27.64% vs. 15.19%; p=0.0105) and the AADR was 11.38% versus 4.43% (p= 0.0279). In cirrhotic men the ADR was 29.61% (vs. 25.31%; p=0.2037) and there was a significantly higher AADR in cirrhotic men than in male screening subjects (14.80% vs. 9.18%, p=0.0208). Conclusions: Compared to healthy screening subjects, cirrhotic patients, and especially cirrhotic women are at higher risk of developing colorectal neoplasia. Therefore, an earlier referral for colonoscopy should be considered in these patients.
529 Esophageal Contraction Wave Abnormalities on High Resolution Manometry (HRM) Not Meeting Chicago Classification Criteria: Are They Clinically Relevant? Faiz Mirza, Nitin Sainani, Satish Munigala, C. Prakash Gyawali The Chicago Classification for esophageal motor disorders uses two metrics, distal contractile integral (DCI) and distal latency (DL) to address vigor and timing of esophageal body contraction. However, contraction wave abnormalities with low contraction vigor and normal DL may not make Chicago Classification criteria for a motor diagnosis. We evaluated Chicago Classification criteria in a cohort of patients with contraction wave abnormalities, and compared symptom scores between cohorts with and without a Chicago Classification diagnosis to assess the clinical relevance of esophageal body contraction wave abnormalities. METHODS: All patients undergoing esophageal HRM (Given Imaging, Los Angeles, CA) with contraction wave abnormalities over a 6 year period (2006-2011) were eligible for inclusion. Contraction wave abnormalities included mean averaged amplitudes ≥180 mmHg (nutcracker esophagus, NE), multiple peaked waves with or without broad contraction wave .5.7 s (MPW/BW), and .20% simultaneous contraction (SC) with contraction front velocity .6.8 cm/s. All patients completed a symptom questionnaire designating dominant symptom, symptom index (product of symptom severity and frequency measured on 5 point Likert scales, 0-4) and a global symptom score (GSS) on a 10 cm visual analog scale. All HRM studies were re-evaluated using Manoview ESO 3.0, and Chicago Classification diagnosis recorded. Recorded parameters were compared between cohorts with and without a Chicago Classification motor disorder. RESULTS: Over the study period, 281 patients (age 57±0.9, 58% F) with contraction wave abnormalities on HRM completed symptom questionnaires and were eligible for this study. Of these 87 (31.0%) had NE, 99 (35.2%) had MPW, and 92 (32.7%) had SC. Chicago criteria was not met in 74 (26.3%). Concordance with Chicago criteria was higher for NE (92.0%) and SC (78.3%), and least for MPW/BW (52.5%). GSS was similar within MPW/BW and SC cohorts, regardless of whether Chicago criteria were met (p.0.05 for each comparison, Table), and higher for NE when Chicago criteria were not met (p=0.02). Similarly, symptom indices for dominant symptoms were similar or higher in patients not meeting Chicago criteria (p .0.05 for each comparison, Table). Age and gender distribution, and dominant symptoms were similar regardless of Chicago criteria being met. CONCLUSIONS: A significant proportion of esophageal body contraction wave abnormalities do not meet the thresholds for a Chicago Classification diagnosis, but are as symptomatic as those meeting these thresholds. We speculate that contraction wave
531 Systematic Endoscopic Surveillance in a High-Risk Cohort Is Feasible for the Detection of Early Gastric Neoplasia Lee Guan Lim, Zhu Feng, Khek-Yu Ho, Chia Chung-King, Christopher J. Khor, ChoonJin Ooi, Kwong Ming Fock, Jimmy B. So, Wee Chian Lim, Khoon-Lin Ling, Tiing Leong Ang, Andrew S. Wong, Andrea Rajnakova, Ming Teh, Supriya Srivastava, Khay Guan Yeoh Background: Gastric cancer is a curable disease if detected early. Endoscopy surveillance is the only way to detect gastric cancer in the early stages. More targeted screening and surveillance is required in countries with intermediate incidence rate of gastric cancer. The Gastric Cancer Epidemiology and Molecular Genetics Program (GCEP), initialized in 2004, is a prospective multicentre study with the ultimate goal of developing an optimal approach and cost-effective algorithm for targeted screening for gastric cancer in the Singapore Chinese population. Objective: To determine whether systematic prospective endoscopic surveillance is feasible for the detection of early gastric cancer in Singapore Chinese cohort. Method: Chinese subjects aged 50 years and above were recruited from gastroenterology clinics of four major public hospitals in Singapore from 2004-2010. Endoscopy surveillance was offered for a minimum of 5 years. Informed consent was obtained from all subjects and the study was approved by the institutional review boards. The main outcome measurement is the number of subjects who develop high grade dysplasia or gastric adenocarcinoma. Results: 3033 subjects with mean age 59±7 years were recruited. 51% were male, 16% had family history of gastric cancer and 30% had Helicobacter pylori infection history based on their medical records. The prevalence of chronic gastritis, current H.pylori infection, atrophic gastritis and intestinal metaplasia at baseline were 81%, 20%, 19% and 44% respectively. The study is in progress, 1300 subjects have completed 5 years of surveillance and the rest will complete by 2015. 18 high grade dysplasia or early gastric cancers were detected so
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AGA Abstracts
abnormalities share a common pathophysiologic basis regardless of the designation. Contraction wave abnormalities are therefore clinically relevant and are associated with a heightened perceptive symptomatic state.
The Mechanics of Esophageal Bolus Transport Are Altered in Subjects Reporting Perception of Solid Bolus Hold up Taher Omari, Stamatiki Kritas, Jennifer C. Myers
AGA Abstracts
Introduction: The subjective perception of solid bolus hold up during swallowing is a common reason for referral for manometric investigation, yet standard measures of esophageal function relate poorly to patient perception and a large proportion of patients with dysphagia demonstrate no apparent abnormality on routine diagnostic testing for esophageal dysfunction. The utility of combined esophageal pressure-impedance recording has been recently enhanced by automated impedance manometry pressure-flow analysis (AIM analysis) and new metrics have been conceived that better describe the interactions between bolus transport and pressure generation. In this study we undertook to assess whether these new esophageal pressure-flow metrics were altered when subjects perceived solid bolus hold up. Methods: Esophageal high-resolution pressure-impedance recordings of 5ml/10ml liquid/viscous swallows and 2cm/4cm solid swallows from 20 control subjects (29-73 years) were analysed. Two solid state pressure(P)/impedance(Z) catheter configurations were used; 32 1cm P/16 2cm Z (Sandhill Scientific) and 36 1cm P/18 2cm Z (Given Imaging). Bolus flow resistance, the relationship between bolus compression and bolus flow timing, was assessed using the pressure flow index (PFI) (Myers et al Neurogastro. Mot. 2012; Nguyen et al Neurogastro. Mot. 2012). Heightened perception of bolus hold up was assessed on a swallow by swallow basis using a 6 point scale (1 = no perception, 2 = awareness of bolus transit, 3-6 = bolus hold up). Results: On a swallow by swallow analysis, heightened perception of solid boluses (swallows with scores 3+) was associated with a higher PFI (distal esophagus Odds Ratio for score 3+ 1.001 [1.000 1.002], p = 0.021). A significant correlation was observed between the maximum subject reported perception score and the average PFI for solids (distal esophagus Pearson's r = 0.690, p,0.001). Grouping of subjects in relation to bolus perception revealed that the PFI was elevated for solids and viscous boluses, but not liquids, in subjects reporting bolus hold up (Figure). Esophageal peak pressures and iso-contour defect size were not significantly related to bolus perception. Conclusion: We report novel findings in relation to mechanical factors during bolus transport that may enhance bolus perception. This study shows that heightened perception of a swallowed bolus relates to subtle differences in flow resistance, which suggests higher levels of muscle tension during the transition phase from a bolus-containing to a lumen-occluded esophageal segment.
Nutcracker esophagus: averaged contraction amplitudes ≥180 mmHg in the esophageal body; Broad waves:≥5.7 s; simultaneous contraction: contraction front velocity .6.8 cm/s; GSS: global symptom score, rated on a 10 cm visual analog scale; *p=0.02 compared to NE with Chicago Criteria being met 530 Prevalence of Colorectal Neoplasia in Cirrhotic Patients Evaluated for Liver Transplantation in Comparison to a Healthy Screening Population Philip Jeschek, Karoline G. Reinhart, Petra Salzl, Georg Heinze, Arnulf Ferlitsch, Michael H. Trauner, Monika Ferlitsch Background: Cirrhotic patients undergo colonoscopy as a part of evaluation for liver transplantation (LTX) in Austria, since there are considerations showing that progression to colorectal cancer may be affected by the following immunosuppressive therapy. Further, liver diseases like non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are associated with higher prevalence of adenomas. However, there is little data on the prevalence of colorectal adenomas in cirrhotic patients requiring LTX. Objectives: To evaluate liver cirrhosis as a risk factor for colorectal adenoma in liver transplant candidates. Methods: This retrospective cohort observational study compared screening colonoscopy outcomes from 570 cirrhotic patients who were listed for liver transplantation at Vienna General Hospital from 2000 to 2012 with age and sex matched controls (screening colonoscopies performed in healthy screening population subjects). The following variables were evaluated: gender, age, etiology and stage of cirrhosis, as well as body mass index. Primary outcome measures were polyp- (PDR), adenoma- (ADR) and advanced adenoma detection rate (AADR); secondary outcome measures were number, diameter and localization of the polyps detected in colonoscopy. Results: The median age was 54 years with 27.7% females and 72.3% males in both cohorts. Cirrhotic patients presented with a median Model for End-Stage Liver Disease score of 15.6. 10.74% were staged Child A, 38.03% Child B and 51.23% Child C. The leading etiology of cirrhosis was alcoholic liver disease, found in 48.6% of transplant candidates; hepatitis C in 31.23%, hepatitis B in 7.19% and biliary tract diseases in 7.72%. Other underlying etiologies were found in 11.4%. The comparative analysis revealed a significantly higher adenoma detection rate in cirrhotic patients compared to the screening cohort (29.11 vs. 22.54%; p=0.019). For advanced adenoma the difference was even higher (13.85% vs. 7.87%; p=0.0024). Therefore, relative risk was 1.29 (CI: 1.04-1.6) for adenoma and 1.76 (CI: 1.22-2.55) for advanced adenoma. As for multiple macroscopic lesions, more than four polyps were found in 7.54% of cirrhotic patients and in 1.40% of the screening cohort (p,0.0001). In cirrhotic women the ADR was almost twice as high as in healthy women (27.64% vs. 15.19%; p=0.0105) and the AADR was 11.38% versus 4.43% (p= 0.0279). In cirrhotic men the ADR was 29.61% (vs. 25.31%; p=0.2037) and there was a significantly higher AADR in cirrhotic men than in male screening subjects (14.80% vs. 9.18%, p=0.0208). Conclusions: Compared to healthy screening subjects, cirrhotic patients, and especially cirrhotic women are at higher risk of developing colorectal neoplasia. Therefore, an earlier referral for colonoscopy should be considered in these patients.
529 Esophageal Contraction Wave Abnormalities on High Resolution Manometry (HRM) Not Meeting Chicago Classification Criteria: Are They Clinically Relevant? Faiz Mirza, Nitin Sainani, Satish Munigala, C. Prakash Gyawali The Chicago Classification for esophageal motor disorders uses two metrics, distal contractile integral (DCI) and distal latency (DL) to address vigor and timing of esophageal body contraction. However, contraction wave abnormalities with low contraction vigor and normal DL may not make Chicago Classification criteria for a motor diagnosis. We evaluated Chicago Classification criteria in a cohort of patients with contraction wave abnormalities, and compared symptom scores between cohorts with and without a Chicago Classification diagnosis to assess the clinical relevance of esophageal body contraction wave abnormalities. METHODS: All patients undergoing esophageal HRM (Given Imaging, Los Angeles, CA) with contraction wave abnormalities over a 6 year period (2006-2011) were eligible for inclusion. Contraction wave abnormalities included mean averaged amplitudes ≥180 mmHg (nutcracker esophagus, NE), multiple peaked waves with or without broad contraction wave .5.7 s (MPW/BW), and .20% simultaneous contraction (SC) with contraction front velocity .6.8 cm/s. All patients completed a symptom questionnaire designating dominant symptom, symptom index (product of symptom severity and frequency measured on 5 point Likert scales, 0-4) and a global symptom score (GSS) on a 10 cm visual analog scale. All HRM studies were re-evaluated using Manoview ESO 3.0, and Chicago Classification diagnosis recorded. Recorded parameters were compared between cohorts with and without a Chicago Classification motor disorder. RESULTS: Over the study period, 281 patients (age 57±0.9, 58% F) with contraction wave abnormalities on HRM completed symptom questionnaires and were eligible for this study. Of these 87 (31.0%) had NE, 99 (35.2%) had MPW, and 92 (32.7%) had SC. Chicago criteria was not met in 74 (26.3%). Concordance with Chicago criteria was higher for NE (92.0%) and SC (78.3%), and least for MPW/BW (52.5%). GSS was similar within MPW/BW and SC cohorts, regardless of whether Chicago criteria were met (p.0.05 for each comparison, Table), and higher for NE when Chicago criteria were not met (p=0.02). Similarly, symptom indices for dominant symptoms were similar or higher in patients not meeting Chicago criteria (p .0.05 for each comparison, Table). Age and gender distribution, and dominant symptoms were similar regardless of Chicago criteria being met. CONCLUSIONS: A significant proportion of esophageal body contraction wave abnormalities do not meet the thresholds for a Chicago Classification diagnosis, but are as symptomatic as those meeting these thresholds. We speculate that contraction wave
531 Systematic Endoscopic Surveillance in a High-Risk Cohort Is Feasible for the Detection of Early Gastric Neoplasia Lee Guan Lim, Zhu Feng, Khek-Yu Ho, Chia Chung-King, Christopher J. Khor, ChoonJin Ooi, Kwong Ming Fock, Jimmy B. So, Wee Chian Lim, Khoon-Lin Ling, Tiing Leong Ang, Andrew S. Wong, Andrea Rajnakova, Ming Teh, Supriya Srivastava, Khay Guan Yeoh Background: Gastric cancer is a curable disease if detected early. Endoscopy surveillance is the only way to detect gastric cancer in the early stages. More targeted screening and surveillance is required in countries with intermediate incidence rate of gastric cancer. The Gastric Cancer Epidemiology and Molecular Genetics Program (GCEP), initialized in 2004, is a prospective multicentre study with the ultimate goal of developing an optimal approach and cost-effective algorithm for targeted screening for gastric cancer in the Singapore Chinese population. Objective: To determine whether systematic prospective endoscopic surveillance is feasible for the detection of early gastric cancer in Singapore Chinese cohort. Method: Chinese subjects aged 50 years and above were recruited from gastroenterology clinics of four major public hospitals in Singapore from 2004-2010. Endoscopy surveillance was offered for a minimum of 5 years. Informed consent was obtained from all subjects and the study was approved by the institutional review boards. The main outcome measurement is the number of subjects who develop high grade dysplasia or gastric adenocarcinoma. Results: 3033 subjects with mean age 59±7 years were recruited. 51% were male, 16% had family history of gastric cancer and 30% had Helicobacter pylori infection history based on their medical records. The prevalence of chronic gastritis, current H.pylori infection, atrophic gastritis and intestinal metaplasia at baseline were 81%, 20%, 19% and 44% respectively. The study is in progress, 1300 subjects have completed 5 years of surveillance and the rest will complete by 2015. 18 high grade dysplasia or early gastric cancers were detected so
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AGA Abstracts