Sa2038 Characterization of Dysphagia Predominant Eosinophilic Esophagitis (EoE-D), With and Without Food Impaction: 101 Adolescents

AGA Abstracts

Figure 1. En face OCT images and OCT angiography (OCTA) from a patient with diffusetype GAVE before radiofrequency ablation (RFA) (A, B) and immediately after RFA (C, D). (A) En face OCT image over the GAVE region at a depth of 260 µm where distorted surface mucosal pattern was present (arrows). (B) En face OCTA at 260 µm depth showed ectatic vessels (red arrows), which are associated with erythematous spots as shown in the endoscopy image (inlet, A). (C) En face OCT image over the GAVE region immediately after RFA at a depth of 260 µm where tissue surface was obscured by coagulum, as shown in the corresponding endoscopy image (inlet, C). (D) OCTA at the same depth as (C) showed no microvasculature in regions of coagulum due to signal attenuation. Scale bars: 1mm.

receive PN (n=7) was 11.7± 2.2 at Time-1 vs. 15.9± 2.4 at Time-2 (P=0.07). CONCLUSION: This pilot analysis concludes that an interval of 3.6 weeks between 2 measurements can detect significant changes in weight, %BF and %FFM by ADP and anthropometric measures. There was no correlation between ADP and anthropometric measurements. Further studies are needed to determine if PN has an influence on body composition parameters. Table 1. Maturational effect on body composition parameters and anthropometric measure

Figure 2. En face OCT images and OCT angiography (OCTA) from a patient with diffusetype GAVE before radiofrequency ablation (RFA) application (A, B) and over the treated region in the follow-up visit (C, D). (A) En face OCT image over the GAVE region at a depth of 250 µm where distorted surface mucosal pattern was identified (arrows). (B) OCTA at 250 µm depth showed ectatic vessels (red arrows). (C) En face OCT image at 220 µm depth over previously RFA-treated region where distorted surface mucosal pattern was observed in smaller area (red arrows). (D) OCTA at the same depth as (C) showed a regular vascular pattern in most of regions where some ectatic vessels can still be observed (arrows). Endoscopy image also showed severity of the GAVE region was improved but not resolved completely on follow-up endoscopy (inlet C) compared to that in previous EGD visit before RFA application (inlet, A). Scale bars: 1mm.

Sa2037 Analysis of Acute Pancreatitis Management in Children Monica Shukla-Udawatta, Ronald L. Thomas, Mohammad El-Baba BACKGROUND: Etiology, manifestations and course of acute pancreatitis is often different in pediatrics than adults. There is limited data on management and outcomes of pancreatitis in children and often has been reflective of adult guidelines. This single center retrospective investigation of management of acute pancreatitis assesses whether certain management has more favorable outcomes than others. METHODS: The study is a retrospective analysis of 134 patients between 0-18 years of age who presented to Children's Hospital of Michigan with a confirmed diagnosis of acute pancreatitis between January 2010 and December 2015. Patients with recurrent/ chronic pancreatitis were excluded. Data was analyzed using frequencies, Mann Whitney U tests, Spearman's Rank correlation, and linear regression. RESULTS: Of the 134 patients, 70 females and 64 males; mean age 12.7±4.0 years. Etiologies were idiopathic 41 (31%), metabolic 24 (18%), infectious 26 (19%), biliary tract diseases 21 (16%), drug-induced 17 (13%) and others 5 (4%). Initial manifestations included abdominal pain 87 (65%), emesis 24 (18%), and several symptoms related to underlying disease 23 (17%). Initial diagnostic imaging study was ultrasound (US) in 123 (92%). Computed tomography was only performed in 4 (3%). US findings were: normal 88 (66%), Gallbladder disease 19 (14%), pancreatic edema and/or peripancreatic fluid 16 (11%). Mean length of hospital stay (LOS) was 7.4±9.6 days. Twenty two patients required care in Pediatric Intensive Care Unit: 6 had diabetic ketoacidosis, 10 had severe and/or necrotizing pancreatitis with complications and 6 had sepsis. Thirteen patients had complications: 3 pseudocysts, 2 necrotizing pancreatitis, 6 sepsis, 1 peritonitis, and 1 pleural effusion. Eight patients underwent ERCP and nine patients required cholecystectomy. Intravenous fluid (IVF) was administered at maintenance rate in 69 patients and at 1.5 maintenance rate in 56; 9 did not receive IVF. Seventeen patients required parenteral nutrition. Patients who received IVF at a higher rate in comparison to the maintenance rate remained NPO for less time (mean=1.75±1.4 days vs 2.14±2.9 days; respectively). Mean LOS of patients on higher fluid rate compared to maintenance rate were 7.03±8.8 days vs 8.0±10.5, respectively (p<0.001). On linear regression, each additional day that patients remained NPO, LOS increased by 2 days (p <0.001). CONCLUSION: Due to lack of pediatric guidelines for acute pancreatitis, specific evidence based management is not routinely followed and thus outcomes remain variable. Our study shows that there is a positive correlation between LOS and delay of onset of enteral feeds. Our data supports that early enteral nutrition and aggressive fluid hydration can improve outcomes by decreasing LOS, improve quality of life, and reduce costs.

Sa2035 Fiber-Optic Raman Spectroscopy for Label-Free In Vivo Molecular Diagnostics of Gastrointestinal Neoplasia at Endoscopy Wei Zheng, Kan Lin, J Wang, KY Ho, M Teh, KG Yeoh, Jimmy B. So, A Shabbir, Zhiwei Huang Raman spectroscopy has emerged as a promising clinical modality to improve early cancer detection in gastrointestinal (GI) tracts. Here we present in vivo demonstration of a novel 785 nm excitation multiplexed fiber-optic Raman endoscopy technique that can simultaneously measure fingerprint (FP) (800 - 1800 cm-1) and high-wavenumber (HW) (2800 - 3600 cm1 ) Raman spectra in real-time from gastrointestinal epithelia for early GI cancer detection and diagnosis. We construct a complete in vivo Raman spectral library of preneoplastic and neoplastic conditions in esophagus, gastroesophageal junction, stomach and colorectum ( n= 362 patients). The multiplexed FP/HW Raman endoscope device uncovers unprecedented new molecular-level insights into the diversity of gastrointestinal neoplasms. Epithelial neoplasms can ubiquitously be differentiated on the basis of changes in proteins, lipids, deoxyribonucleic acids, and water composition and structure. Synergizing the complimentary FP and HW Raman modalities proved diagnostic advantageous over either FP or HW Raman technique for significantly improving label-free in vivo molecular diagnostics of early cancer in GI tracts during clinical endoscopic examinations.

Sa2036 Patterns of Change in Body Composition and Anthropometric Parameters in NICU Infants Anushree Algotar, Kim Siler-Wurst, Swetha Sitaram, Ala Shaikhkhalil, Ish Gulati, Sudarshan Jadcherla

Sa2038 Characterization of Dysphagia Predominant Eosinophilic Esophagitis (EoE-D), With and Without Food Impaction: 101 Adolescents Vijayalakshmi Kory, Mohamad Hatahet, Vaishali Bothra, Alan Schwartz, James Berman, Kiranmai Gorla, Thirumazhisai S. Gunasekaran

BACKGROUND: Average weight gain in the hospitalized neonate varies from 10-20 g/kg/ day. However, the composition of this weight may not be ideal in comparison to reference values or healthy neonates. Optimal fat and lean body mass are important factors predicting long-term outcomes across the lifespan. Enteral and parenteral nutritional manipulations and metabolic factors may alter body composition thus, influencing prognosis. Body composition can be estimated by traditional methods of skinfold thickness measurement or by innovative methods such as Air Displacement Plethysmography (ADP). Measuring body composition indices can provide further guidance to individualize nutritional therapy. AIMS: 1) To investigate the patterns of body composition change in non-syndromic, non-surgical, clinically stable neonates in the Neonatal Intensive Care Unit born ‡ 32 weeks gestation across maturation. 2) To examine whether change in proportion of body fat (%BF) correlates with change in anthropometric measurements. 3) To examine the effect of parenteral nutrition (PN) on %BF. METHODS: Hospitalized neonatal ICU neonates underwent body composition measurements (%BF, %FFM) by air displacement plethysmography (ADP) via PEAPOD© at 37.5±0.7 weeks (Time-1) and 41.0±0.7 weeks (Time-2) corrected gestational age. Concurrent anthropometric measurements (skinfold thickness, abdominal girth, mid-arm circumference, cm) were obtained. Nutritional data (PN frequency) was recorded from chart review. Data was analyzed using paired-t tests and linear regression models, presented as mean ± SEM, median (IQR), or %. RESULTS: Twenty-two neonates (54% males, 32.2 ± 0.9 weeks gestation) were evaluated with median interval of 3.6(2.9-4.0) weeks between studies. Maturational effect on body composition parameters and anthropometric measures are shown (Table 1). For every 1 week increase in age, abdominal girth increased significantly by 0.8±0.4 cm (P = 0.03). No relationships between change in %BF and change in anthropometric measures were observed (P > 0.05). % BF of neonates who received PN (n=11) was 10.6 ± 1.9 at increase at Time-1 vs. 11.9± 1.5 at Time-2 (P=0.4). %BF of neonates who did not

AGA Abstracts

EoE in children is associated with many symptoms, Consensus-2011 statement classifies patients into four groups based on predominant symptom; EoE- D, abdominal pain (AP), GERD and failure to thrive. Previously, we showed the features and outcome of EoE-D with and without food impaction (FI) in a small group of 36 patients.1 Now we compare a larger group with a longer term follow up. Aim: Compare clinical features, endoscopy+ biopsy, and outcomes of 101 EoE - D patients presenting with and without FI. Methods: In this retrospective study, patients with EoE-D seen between 9/2005 and 8/2015 were stratified into; Group I, with FI and Group II, without FI. Physical findings, CBC, esophagram, EGD+ biopsies of the duodenum, antrum, distal and mid esophagus were captured. Diagnosis of EoE was made as per the consensus guidelines. Treatments included topical or oral steroids, dietary modification, +/-PPIs, as per our EoE Clinic protocol. Severity of nausea, vomiting, regurgitation, early satiety and heartburn were scored as: absent -0, mild -1, and severe-2 except dysphagia had a score up to 3 with FI. Results: Patients; Gr I- 40, Gr II- 61, mean age 11.4 and 10.3 yrs(p=.25). Clinical features, X-ray, EGD + biopsy findings are given in Tables 1,2. All patients with FI required endoscopic removal, and strictures, if present, were dilated later. There were no perforations. Follow up: Gr I; mean 1.5 yrs (range 1/12-8 yrs) and in Gr II 1.1 yrs (1/12- 7yrs). Symptom improvement; Gr I, Gr II, mean dysphagia score improved from 3 to 1.21 and 1.08 to 0.65 (p<.001 for main effects of group and time and interaction between group and time) and mean composite score from 3.4 to 1.49 and 2.49 to 1.48 (p<.001 for main effects, p=.02 for interaction). Gr I, 21/40(52.5%) and Gr II 39/

S-436

an esophageal stricture after previous surgery. Most children presenting with food bolus impaction therefore had underlying esophageal pathology. Conclusions: Food bolus impaction in children is nearly always a consequence of underlying esophageal disorder, of which EoE is the most common. We recommend that all children presenting with food bolus impaction have esophageal biopsies for EoE.

Sa2040 Food Impaction in Pediatric Patients With Eosinophilic Esophagitis Anne C. Mudde, Nicole Heinz, Madeleine Stout, Kitzia Colliard, Rina Wu, Edda Fiebiger, Samuel Nurko Introduction Eosinophilic esophagitis (EoE) is a chronic, inflammatory esophageal disease, characterized by eosinophilic inflammation and esophageal dysfunction. Upper gastrointestinal (GI) symptoms in EoE are age-dependent. Adults and adolescents typically experience dysphagia and food impaction, while the occurrence of food impaction in younger children is less common and poorly investigated. There is limited information regarding the natural history of food impaction in adolescents. Objective The aim of this research is to characterize a cohort of pediatric EoE patients who experienced food impaction, and describe their management of food impaction. Methods Retrospective cohort study of pediatric EoE patients who experienced food impaction. EoE patients aged 18 years or under, were included when their medical record described at least one incidence of true esophageal food impaction. Patients with EoE that also had a diagnosis of achalasia, esophageal atresia, or tracheoesophageal fistula were excluded. Results 32 children with EoE that experienced food impaction were identified . 91% were male. Average age at diagnosis of EoE was 13.9 +/- 3.0 years (age range 6.7-17.8 years). Average BMI at diagnosis of EoE was 21.4 (+/- 4.2) km/ m2. In all children food impaction was the initial presenting symptom. In 81% the impacted food was meat. Onset of upper GI symptoms was reported in 17 patients and varied between 0 months and 5 ½ years previous to the occurrence of food impaction. 28 children underwent allergy testing, 23 of which tested positive for food and/or environmental allergens. In 7 patients the impaction resolved before presenting to the ER. Figure 1 gives an overview of the medical treatment provided in the ER to 25 patients that presented with food impaction. No patient had esophageal strictures. Conclusions Food impaction resolved spontaneously in 40% of the children visiting the ER. This finding might have implications for the clinical management of food impaction in an emergency setting.

*Gr I Abnormal : 3 stricture, 1 small caliber esophagus, 1 spasm, 1 esophageal reflux. Gr II Abnormal: 1 stricture, 1 spasm, 2 esophageal reflux, 2 abnormal swallowing, 3 mucosal irregularity, 1 esophageal tear. Table 2:EGD and Esophageal biopsy findings at Diagnosis

Sa2039 Food Bolus Impaction in Children Is Nearly Always From Eosinophilic Esophagitis Thomas C. Bradley, Geoffrey D. Withers, Looi C. Ee Introduction: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Incidence and prevalence of this condition is increasing. The presentation of EoE varies with age but dysphagia is common in adults and older children. We hypothesize that most children requiring endoscopic management of food bolus impaction will have EoE. Methods: Retrospective review of all patients presenting or referred with food bolus impaction to a tertiary paediatric hospital between 1st Nov 2011 and 31st Dec 2014 inclusive. ICD-10 codes for endoscopy and removal of foreign body (30478-00, 30478-10) were used to identify patients who required endoscopy. All patients with esophageal foreign bodies were reviewed but only those with food in the esophagus were included in the study. EoE was defined as the presence of ‡15 eosinophils/ high power field on biopsy in either proximal and/or distal esophagus. Results: 138 endoscopies were performed in 133 children. Esophageal foreign bodies were noted in 78 procedures of which 76 were performed emergently. Procedures were mainly performed by gastroenterologists (n=50) and otolaryngologists (n=23). Common foreign bodies include coins (n=33), food (n=22), button battery (n=3), dental wire (n=3), and toys (n=3). 22 endoscopies were performed in 19 patients for food bolus impaction, and histology available in 14/19 (74%) patients. 79% (15/19) of these patients were male and median age at presentation was 12.08 (range 0.85-15.05) years. 79% (11/14) of those biopsied fulfilled histologic criteria for EoE. Interestingly the remaining 3 patients who had biopsies all demonstrated esophageal eosinophilia although their count (range 3-13eos/hpf) was insufficient to be diagnostic of EoE. 2/5 patients who did not have biopsies were known to have

Sa2041 Transpyloric Feeding in Gastroesophageal Reflux Associated Apnea of Preterm Neonates: Interim Results From a Single Center, Single Arm Trial Tamoghna Biswas, Somosri Ray, Tapas K. Sabui, Rakesh Mondal, Jiban Krishna De, Sudipta Misra Background: Retrospective studies have suggested a causal relationship between apnea and gastroesophageal reflux, though it remains controversial as both are common in premature neonates. We prospectively evaluated the efficacy and safety of transpyloric continuous feeding in preterm neonates with apnea suspected to be due to reflux; as such feeding reduces gastroesophageal reflux. . Methods: A single center, single arm, open label prospective interventional study was conducted in a tertiary care hospital of Eastern India. The study was approved by the Institutional Ethics committee of the Medical College Kolkata. Intramural preterm neonates with at least one episode of apnea without any comorbidities known to cause apnea and clinical features of gastroesophageal reflux, such as, regurgitation, backarching, choking, coughing, unexplained crying and irritability, post-prandial vomiting, etc. ; were included in the study. Non weighed feeding tube was placed transpyloriclly as described elsewhere. Continuous naso-duodenal tube feeding was administered for 72 hours. Exclusion criteria were, neonates not on enteral feeding, those on invasive mechanical ventilation, those with major congenital abnormalities, and those with conditions like sepsis, neurodeficits, hypoglycaemia etc. that can cause apnea. Primary outcome measure was the

S-437

AGA Abstracts

AGA Abstracts

61(64%) had a follow up EGD, at 8-12 weeks and peak eos. count was 33.9 (SD35.5) and 30.5 (SD 27.5) and mean was 25.8 and 21.6 respectively (p=0.59). Patients with strictures (4); it stayed open after dilation while the small caliber esophagus was recalcitrant. 5/40 (12.5%) patients in Gr I had recurrence of FI and none in Gr II developed FI. Conclusion: There were no significant differences in the clinical features and endoscopic findings and outcome of dysphagia of the two groups. The peak eosinophil count was higher in the FI group, at presentation and follow up, suggesting more inflammation in this group. 12.5% of FI group patients had recurrence of FI. Strictures opened up and remained open, while small caliber esophagus was recalcitrant. The EoE-D, food impaction group, with its increased inflammation and recurrence risk may require more aggressive therapy. Less inflammation (Gr II) reduces risk of FI. More prospective studies with long term follow up are needed to validate this data. 1Gunasekaran T, Characterization of Dysphagia Associated EoE in Children with and without FI. DDW May 2015 Table 1:Presenting Symptoms and Esophagram