- Email: [email protected]
W1191 Increased Diagnostic Yield of Small Bowel Tumors With PillCam: the Role of Capsule Endoscopy in Diagnosis and Treatment of Gastrointestinal Stromal Tumours (GIST). Italian Single-Centre Experience
AGA Abstracts
with a microcontroller, decoded the load-modulated sensor signals in the carrier. The microcontroller processed received data, and recorded the time and corresponding modulated frequencies into a text file in a secured digital (SD) memory card. The text file was imported into a spreadsheet for graphic display by computer. The portable module used a rechargeable 1800mAh flat lithium battery. Sampling rates were programmable in the microcontroller. Functions such as alerts, memory erase, read/busy indication, sensor position detection and battery indicator were included. Detection of reflux episodes, measurement distances, signal integrity, repeatability, stability, motion artifacts, implant-reader misalignment and power consumption have been characterized. Results: Two modulated frequency bands transduce sensor signals to the reader (10-15kHz for impedance variations and 25-30kHz for pH variations). The frequency modulations have linear relationships with the impedance/pH values. The working distance between the batteryless implant and the reader is set at 6 cm. In motion artifact tests, the coverage area was 2.5cmx2.5cm about the center of the reader, yielding repeatable results for each reflux episode. With a fixed location for the implant, the reader can move around 1cm in all 3-D directions, or rotate/tilt up to 52 degrees in two axes (as may occur with body motions) without affecting signal integrity. In a 96-hour experiment, the measured data from randomized reflux episodes were stable with the discharging battery voltage, time and various motion parameters randomly applied to the test setup. With a 1-Hz sampling rate, the module battery life outlasted the 96-hour experiment. Conclusion: We have developed an implantable, wireless pH/impedance monitoring system, consisting of a batteryless dual-sensor implant and a portable reader, for detecting acidic and nonacidic reflux episodes. The system is now ready for testing in clinical situations.
Conclusion Patency capsules have previously been shown to be useful in identifying small bowel strictures. However, failure of capsule passage can also be due to delayed GI transit or structural defects such as diverticulae. Risk factors for delayed transit include hypothyroidism, Type II diabetes mellitus and constipating drugs. These factors need to be considered when requesting this test. References: 1. 1. Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults Gut 2008;57:125-136. W1189 Influence of Simeticone and Metoclopramide Administration for Capsule Endoscopy Preparation Josep Maria Dedeu Cusco, Ines Ana Ibañez, Xavier Bessa, Cristina Alvarez, Luis Barranco, Agustin Seoane, Carmen Alonso, Jordi Muñoz Galitó, Lucía Marquez, Alex Cañas, Montserrat Andreu, Felipe Bory, Begona Gonzalez Suarez Presence of intraluminal bubbles and impossibility to visualize entire small bowel are limitations in capsule endoscopy. It has been described that procinetic and/or antiflatulent drugs administration, would help to obtain better results. Objectives: 1. To analyze the effect of metoclopramide administration on gastric and intestinal transits time. 2. To evaluate the quality of images after simeticone ingestion. Patients and methods: We included 142 patients from March 2007 until January 2008. Patients were randomized, prospectively in 4 groups for the administration of metoclopramide (10 mg), simeticone (80 mg) or both previously to capsule ingestion: Group I (control, 38 patients), Group II (metoclopramide and simeticone, 35 patients), Group III (metoclopramide, 37 patients) and Group IV (simeticone, 32 patients). Presence of intestinal gas was classified in 4 grades (0-3), according to a scale recently described. We analyzed separately proximal and distal small bowel segments. Results: 142 patients (71 men and 71 women, Mean age: 56.7 +/- 19.2 years). Gastric transit time was 40.8 +/- 53.7 minutes in control group vs 22.5 +/-20.3 minutes in patients taking metoclopramide (p=0.08). There were no significant differences in intestinal transit time. In proximal small bowel 97.2% of patients in group II had none or minima bubbles compared to 57.9% of patients in control group. Distally, 42.1% of patients in control group had a lot of gas avoiding to visualize mucous compared to 2.9 % of patients in group II (p= 0.002). No side effects were observed. Conclusions: Our results suggest that simeticone and procinetic drugs ingestion before capsule endoscopy reduced bubbles in the intestinal lumen and improved the visualization of the small bowel.
W1187 Use of PillCam ESO in Determining the Prevalence of Esophageal Disease in Patients Presenting to the Emergency Department With Chest Pain and Without Acute Coronary Syndrome Anupam Singh, Calvin Lee, Dmitry Finkelberg, Anne Foley, Gregory Volturo, Joel Gore, Patricia Hibberd, David R. Cave Background and Aim: Chest pain accounts for more than 6 million Emergency Department (ED) visits per year in the USA. Of these approximately 25% have an acute coronary syndrome (ACS). In the remainder, 20 to 60% have esophageal mucosal disease by conventional endoscopy. Those with esophageal disease often receive no diagnosis and no medical management. We conducted a pilot study to evaluate the use of PillCam ESO testing to determine the prevalence of esophageal disease in patients with non cardiac chest pain (NCCP) presenting to the ED. Methods: We screened 68 patients (30-85yrs) who presented to the ED with chest pain, after they had ruled out for an ACS,using a TIMI score of 2 or less, and for other life threatening causes of chest pain,using an accepted standard chest pain diagnostic protocol. Other exclusions including dysphagia, abdominal pain, a history of inflammatory bowel disease, implantable cardiac devices and pregnancy. Eligible subjects were invited to participate and after informed consent was obtained, a simplified ingestion protocol (SIP) for esophageal capsule endoscopy was performed. The video images were reviewed by an experienced reader. Results: Of the 68 patients screened, 26 patients were enrolled (14 males,12 females) with mean age of 46yrs (32-63yrs). Mean esophageal transit time for the capsule was 2mins 25 secs (2 secs to 12mins 44 secs).Esophageal mucosal abnormalities were detected in 11 patients (44%). Erosive esophagitis (LA Grade A-C) was found in 10 patients (40%) and mucosal change consistent with Barrett's esophagus was found in 1 patient (4 %).‘Felinization' of the esophagus was found in 7 patients (28%), 2 with esophagitis and 5 without. Additional findings included retained gastric contents despite prolonged fasting of more than 17 hrs in 1 patient. The duodenum was visualized in 10 patients, 5 of whom had duodenitis. Prolonged esophageal transit of >12 mins and > 8 mins in 2 patients respectively suggested dysmotility. The procedure was well tolerated. There were 2 technical failures. There were no capsule related complications. Anti secretory therapy and anti reflux measures were instituted for patients with esophagitis. Conclusions: The ESO capsule endoscopy is a simple, non invasive, well tolerated procedure with a high yield for detection of esophagitis and other conditions in patients with NCCP presenting to the ED. Early diagnosis of esophageal mucosal disease in this setting, and the ability to direct treatment may lead to better patient management and reduce the need for further testing. The significance of ‘felinization' in this setting remains to be determined.
W1190 Clinical Experience With the Patency Capsule: A Single Center Retrospective Review Benjamin J. Hyatt, Dmitry Finkelberg, Elena Tsai, David R. Cave BACKGROUND: Capsule endoscopy (CE) is a useful diagnostic tool for visual inspection of the small intestine. Although relatively uncommon, one of the major complications of CE is long-term capsule retention at stenoses which may require surgery or endoscopic removal. The patency capsule (PC) (Agile Capsule, Given Imaging), a radio-opaque dissolvable tablet, can be used prior to CE in patients at high-risk for stricture to evaluate for potential capsule retention. OBJECTIVE: To assess the utility of PC for predicting capsule retention in high-risk individuals. METHODS: This study is a retrospective review of all cases of PC performed at a single tertiary care medical center over a two-year period. To verify presence or absence of PC, the study authors reviewed all plain abdominal films. Our standard protocol for the PC requires ingestion of the capsule and a plain abdominal film at 30 hours after ingestion. These films are then reported by a radiologist. RESULTS: During the study period, a total of 54 PC's were performed. A positive study (PC seen on abdominal x-ray) was noted in 26 patients (48%). Of these 26, the PC was located in the small bowel in 19 cases (73%), colon in 5 cases (19%), and stomach in 2 cases (8%). In the group of 54 patients, a total of 29 CE's were performed. CE was performed in 2 patients with Crohn's disease who had positive PC studies showing possible location of PC in the ileocecal region. CE was pursued in these cases based on clinical judgment that the location of PC was either in the cecum, or in an area that CE could be retrieved by endoscopy if retained. The CE was transiently retained in both patients. Two CE's (7% of 29 CE's performed) were transiently retained in patients who had a negative PC study. Two patients (4% of 54 PC performed) who were initially given a “negative” PC study result were found to have a retained PC on retrospective review. Both subsequently underwent CE, and the CE was retained in both patients. DISCUSSION: PC is a useful means of identifying cases in which CE is likely to be retained. However, in some patients CE's are retained despite negative PC study. PC's can occasionally be present on x-ray but may be overlooked potentially leading to CE retention. Education of radiologists should be considered regarding the difference in appearance between the PC and CE.
W1188 Failure of Patency Capsules- A District General Hospital Experience in the UK Punyanganie S. de Silva, Lynette Baldwin, Yin M. Miao Introduction & Aims Patency capsules can be used prior to video capsule endoscopy (VCE) to exclude stricturing lesions that may impede capsule advancement. Current BSG guidelines[1] recommend usage in those patients with abdominal pain or obstructive type symptoms. Failure of the patency capsule to pass within 36 hours may suggest obstructive pathology. Its use therefore reduces the need for pre-capsule fluoroscopic imaging. We report our experience over a two year period and highlight other aetiological factors that may delay the passage of the patency capsule. Methodology A retrospective study assessing VCEs undertaken at a UK district general hospital over two years (2007-2009). Most patients had Given patency capsules prior to the actual study. Those that did not were the ones that had had a recent barium follow-through (BaFT). Where patency capsule had been used and passage failed, a barium follow through or CT imaging was undertaken. Thyroid function tests, Hb1AC levels, concurrent disease and current medication were recorded. Results During the 2 year period 73/110 (66.4%) patients had a patency capsule prior to VCE. 7/ 73 patencies failed (9.6%). All were female patients. Median age was 71 years (range 4085 years). The indication for the VCE was recurrent iron deficiency anaemia with normal preceding gastroscopy and colonoscopy. There were no complaints of pre-VCE abdominal pain and inflammatory markers were normal. On further radiological imaging, 1/7 (14%) had a previously undiagnosed small bowel stricture on barium follow through. 3/7 (43%) had small bowel or colonic micro-diverticulae. Slow transit was documented in 2/7 of the BaFTs (29 %). 1/7 (14%) had a normal BaFT. Six out of these seven (86%) failed capsules had poorly controlled Type II diabetes mellitus (43%), hypothyroidism with raised TSH levels (29%), or were taking constipating agents (14%) such as codeine and amitriptyline.
AGA Abstracts
W1191 Increased Diagnostic Yield of Small Bowel Tumors With PillCam: the Role of Capsule Endoscopy in Diagnosis and Treatment of Gastrointestinal Stromal Tumours (GIST). Italian Single-Centre Experience Maria Elena Riccioni, Riccardo Urgesi, Cristiano Spada, Rossella Cianci, Guido Costamagna Background: Gastrointestinal Stromal Tumors (GIST) are the most common mesenchymal tumours of the stomach and small intestine. In the past, tumor diagnosis was often delayed after the first bleeding episode because of the inaccessibility of the small bowel. Study: To report on the prevalence of small bowel GIST in a population that underwent capsule endoscopy (CE). A retrospective analysis of the charts of 500 patients who underwent CE from 2001 and 2007 for different indications was performed. Setting: the major indications for CE were obscure-occult or obscure-overt bleeding. We included 289 patients with obscure-occult or obscure-overt bleeding and 211 with other indications. The outcome was assessed by reviewal of the charts and telephone contact with patients. The Fisher's exact
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W1194 Impact of an Extensive Thiopurine Methyltransferase (TPMT) Genotyping in Inflammatory Bowel Disease Patients Who Experienced Myelosuppression During Antipurine Therapy Olivier Dewit, Tom G. Moreels, Filip J. Baert, Harald Peeters, Reenaers Catherine, Martine De Vos, Philippe P. Van Hootegem, Vinciane Muls, Gigi Veereman, Fazia Mana, Joannes Holvoet, Serge Naegels, Yves Horsmans, Jean-Luc Gala Background & Aims: Azathioprine (AZA) is an immunosuppresive drug that is widely used in IBD. Among its side effects, myelosuppression (MS) is of major concern. Patients with TPMT deficiency have a high risk of MS when exposed to standard dose of AZA. In a previous study *, only 27 % of Crohn's Disease Caucasian patients with MS had a mutant allele of the TPMT gene associated with enzyme deficiency. Since this study, a number of new TPMT mutations have been described and our aim was to investigate their clinical relevance. Secondary aim was to evaluate, in TPMT deficient and normal pts, the delay, the severity, the complications, the hospitalization and outcome of MS. Methods: Inclusion criteria were leukopenia (white blood cell count < 3000/mm3), and /or thrombocytopenia (platelets < 100000/mm3) while taking AZA therapy. Patients (n=61, CD: 48, UC:13) were included from 11 Belgian centers. The median treatment dose was 2 mg/kg (0.7-2.5). Data were collected about the onset of treatment, the onset of MS, concomitant medications at that time, complications and hospitalization. For each patient, 30 milliliters venous blood was drawn at distance of MS event, in EDTA-treated tubes and sent to a central laboratory for full TPMT cDNA sequence analysis (exon 4 to 10), specifically designed to avoid the co-amplification of the TPMT pseudo-gene. Results: forty-six out of 61 were homozygous for the wild-type TPMT genotype (High methylator, HM), 11/61 were heterozygous for at least 1 non functional mutation (intermediate methylator, IM) and 4 were homozygous for non functional mutation (low methylator, LM). In the spectrum of 22 known TPMT mutations, only TPMT 2*, 3B* and 3C* mutated alleles were identified. According to the expected methylator status, median delay between AZA initiation and MS was 2 months (5 weeks-5 months) in the LM pts, 2,75 months (4 weeks-6 years) in IM pts ; and 6 months (11 days7 years) in HM. Occurrence of infections was the most frequent complication and was found in TPMT deficient pts 6/15 (40%) as well as normal TPMT pts 15/46 (33 %). No death was reported. Hospitalization was necessary in 7/15 pts (47 %) with deficient TPMT genotype and in 12/46 (26 %) of the patients with normal TPMT genotype. The median duration of hospitalization was 15 days (range 2-42) and similar in both groups. Conclusions: In this series of Caucasian IBD patient, only 1/4 (25 %) of MS during AZA was associated with TPMT deficient genotype. However, a shorter median time to MS onset and a proportionally higher rate of hospitalization was recorded in TPMT deficient pts. * Colombel et al, Gastroenterology 2000; 118:1025-1030.
W1192 Evaluation of Quick View of Rapid® 5 Access for Examination of Video Capsule Endoscopies Akiko Shiotani, Ryuji Nishi, Keisuke Honda, Makiko Kawakami, Hiroshi Imamura, Hiroshi Matsumoto, Ken-ichi Tarumi, Tomoari Kamada, Jiro Hata, Ken Haruma Background: Reading recorded images of video capsule endoscopy (VCE) takes on average 40-60 min. Since it is very time-consuming, one possible cost-effective strategy could be the use of expert endoscopic assistant and available software to select images. The availability of Quick View of RAPID® reader, which is software to assist the reader, is not applicable for clinical use because of the low sensitivity for detection of lesions and clinical usefulness of any software has not been proved. Aim: To evaluate clinical utility of RAPID® 5 Access in VCE examinations and find the optimum setting mode for reading to increase of diagnosis yield in shorten reading time. Methods: Two well-trained doctors and one expert nurse read the previous recorded images in 10 volunteers with known mucosal injury induced by low dose aspirin and in 10 obscure GI bleeding (OGIB) patients known to have a variety of lesions. We compared the detection rate of the lesions using quick view between RAPID® Reader ver. 4.1 and RAPID® 5 Access. We also compared the detection rate of the lesions and reading time among 3 setting modes of RAPID® 5 Access (A, single auto mode view speed 12; B quad view manual speed 35; C, single manual quick view speed 6). Results: The sensitivities of denuded redness (74% vs. 55.6%), erosion (74% vs.59.2%), large erosion (96% vs. 96%), and ulcer (100% vs. 50%) in the comparison of the rate of detection of the images in aspirin study by RAPID® 5 Access were significantly higher than those by RAPID® Reader. Quick view of RAPID® 5 Access detected all main lesions in OGIB patients, while RAPID® Reader missed 7 lesions (ie, 3 ulcer lesions, 3 elevated lesions and 1 malignant lesion). Comparison among the 3 modes of RAPID® 5 Access showed that the mode with single manual quick view and speed 6 was superior in both detection rate and reading time compared to the other modes. Conclusions: The Quick View of RAPID® 5 Access may improve diagnostic yield reducing reading time.
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Safety of Thiopurines in a Population-Based Cohort of Inflammatory Bowel Disease Laurent Peyrin Biroulet, Edward V. Loftus, William S. Harmsen, Alan R. Zinsmeister, William J. Sandborn
Safety of Thiopurine Therapy in Inflammatory Bowel Disease (IBD): LongTerm Follow-up Study of 3,900 Patients Maria Chaparro, Ingrid Ordas, Eduardo Cabre, Valle Garcia, Guillermo Bastida, Mireia Penalva, Fernando Gomollon, Esther Garcia-Planella, Olga Merino, Ana Gutiérrez, Maria Esteve, Montserrat Andreu, M. García-Sepulcre, Joaquín Hinojosa, Isabel Vera, Fernando Muñoz, Juan L. Mendoza, Jose Luis Cabriada, Miguel A. Montoro, Manuel Barreiro, Gloria Ceña, Cristina Saro, Xavier Aldeguer Mante, Jesus Barrio, Javier P. Gisbert
Background and Aims: Few data on the safety profile of thiopurines in a population-based cohort of inflammatory bowel disease (IBD) exist. Methods: Using the resources of the Rochester Epidemiology Project, we identified all patients (pts) who had received azathioprine (AZA) or 6-mercaptopurine (6MP) among incident cases of IBD from Olmsted County, Minnesota, diagnosed between 1970 and 2004 and followed through 2005. All clinical and biological data were reviewed. Results were expressed as number of adverse events (AEs) per 100 pt-years of exposure to thiopurines. Results: A total of 165 (108 Crohn's disease, 57 ulcerative colitis, UC) pts out of 688 with IBD (310 Crohn's disease, 378 UC) were treated with AZA and/or 6MP. Median duration of thiopurine use was 10.9 months (range, 2 days-11.1 years) in UC and 3.0 years (1 day-12.0 years) in Crohn's disease. Forty UC pts (70%) experienced a total of 109 AEs. AEs judged as probably related to thiopurine treatment (n=59) included liver toxicity (abnormal liver tests or liver injury) not leading to therapeutic intervention (n=22), leukopenia without infection but leading to therapeutic intervention (n= 13), digestive symptoms (n=8), leukopenia without infection and not leading to therapeutic intervention (n=3), flu-like symptoms (n=3), arthralgia (n=2), neutropenia without leukopenia (n=2), one pancreatitis, one B-cell non-Hodgkin lymphoma, and others (n=4). The incidence of AEs was 800 per 100 pt-years of thiopurine exposure (+/-1560) in UC. Ninetyfour Crohn's disease pts (87%) experienced a total of 318 AEs. AEs judged as probably related to thiopurine treatment (n=155) included liver toxicity not leading to therapeutic intervention (n=74), digestive symptoms (n=19), leukopenia without infection leading or not to therapeutic intervention (n=18 and 19, respectively), liver toxicity leading to therapeutic intervention (n=6), infection without leukopenia (n=4), neutropenia without leukopenia (n= 3), flu-like symptoms (n=3), cutaneous lesions (n=3), and others (=6). The incidence of AEs was 840 (+/-3710) per 100 pt-years of exposure to thiopurines in Crohn's diseases. The AEs occurred independently of thiopurine dosage in both Crohn's disease and UC. When examining the first course of thiopurine in each pt, 55 IBD pts (33%) discontinued due to an AE. Conclusion: In this population-based cohort, the incidence of AEs per 100 pt-years of exposure to thiopurines ranged from 800 to 840 in IBD. Stopping drug due to AEs was frequent. Leukopenias and abnormal liver tests occurred frequently during the course of IBD, underscoring the need to closely monitor patients on thiopurines. Only one lymphoma was observed.
Background:Azathioprine (AZA) and mercaptopurine (MP) have shown to be effective in inducing and maintaining remission in IBD patients.The occurrence of adverse events (AE) is a major drawback in the use of AZA/MP. Aims:To evaluate the cumulative incidence, incidence rates, distribution and chronology of AE in patients on thiopurine treatment.To identify predictive factors associated with the development of thiopurine-induced AE. Methods:Retrospective review of medical records of IBD patients on thiopurine therapy from a National Spanish database (ENEIDA). Long-term incidence of AE was estimated using the Kaplan-Meier analysis.Cox-regression analysis was performed to identify potential predictive factors of AE. Results:3,900 patients (mean age 40 years, 59%male, 30%ulcerative colitis, 70% Crohn's disease (CD)) were included. 95% were on azathioprine and 5% on mercaptopurine. The median follow-up with thiopurines was 44 months (range 0-420). AE occurred a median of 1 month after starting treatment. The cumulative incidence of AE was 26%, with an annual risk of 7% per patient-year of treatment. 51% of AE causing discontinuation of treatment occurred in the first month of treatment, 76% after 6 months and 80% after 12 months. Most frequent AE were nauseas(8%), hepatotoxicity(4%), myelotoxicity(4%) and pancreatitis(4%). Three patients had lymphoma. Female gender (OR=1.4;95%CI=1.1-1.8) and CD(OR=2.5; 2-3) increased the risk of having nauseas. The risk of hepatotoxicity was lower in females (OR=0.6; 0.4-0.9) and higher in CD (OR=3.3, 2.5-4.5). The risk of myelotoxicity was significantly higher in patients treated with MP (OR=5; 2.5-11) and in females (OR=3.6; 2-6). The risk of pancreatitis was higher in CD (OR=2.5; 2-3.4). Overall, 17% of patients discontinued the treatment with thiopurines due to AE. 37% of these patients started thiopurines again, and 40% of them had AE again (4% with the same drug, and 36% after switching to the other thiopurine). Conclusions: 1.As many as 1/4 patients on thiopurine therapy had AE during follow-up. 2.A high proportion of patients(17%) had to discontinue the treatment with thiopurines due to AE. 3.More than half of patients that re-started thiopurine treatment after its discontinuation due to AE tolerated it. 4.Several predictor factors for some AE have been identified.
W1196 One Hour Infliximab Infusion in Infammatory Bowel Disease is Save and Well Tolerated Thomas W. Lee, Sandra L. Beard, Richard N. Fedorak Background: Infliximab (IFX), administered by intravenous infusion, is a chimeric monoclonal antibody to tumour necrosis factor alpha with proven efficacy in inducing and maintaining remission of inflammatory Bowel Disease (IBD). A protocol used in the initial
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AGA Abstracts
AGA Abstracts
test and Student's “t” test was used to statistically analyse the results. Results: 20 patients (4.0%) were diagnosed with small bowel tumors by CE; 9 were GIST (45.0%). It was observed that traditional endoscopic and radiological methods failed to diagnose GIST in all these cases. CE was false negative in only one case in which the diagnosis of GIST was made by angiography. All CE positive patients and the patient diagnosed by angiography underwent surgical treatment with normalization of the haemoglobin values at follow-up. Limitations: the small number of cases. Conclusions: CE diagnosed GIST in 9/10 patients establishing it as an effective and sensitivity diagnostic modality in comparison to traditional radiology and confirming an important role for CE in the algorithm for the diagnostic workup in suspected small bowel tumors.
with a microcontroller, decoded the load-modulated sensor signals in the carrier. The microcontroller processed received data, and recorded the time and corresponding modulated frequencies into a text file in a secured digital (SD) memory card. The text file was imported into a spreadsheet for graphic display by computer. The portable module used a rechargeable 1800mAh flat lithium battery. Sampling rates were programmable in the microcontroller. Functions such as alerts, memory erase, read/busy indication, sensor position detection and battery indicator were included. Detection of reflux episodes, measurement distances, signal integrity, repeatability, stability, motion artifacts, implant-reader misalignment and power consumption have been characterized. Results: Two modulated frequency bands transduce sensor signals to the reader (10-15kHz for impedance variations and 25-30kHz for pH variations). The frequency modulations have linear relationships with the impedance/pH values. The working distance between the batteryless implant and the reader is set at 6 cm. In motion artifact tests, the coverage area was 2.5cmx2.5cm about the center of the reader, yielding repeatable results for each reflux episode. With a fixed location for the implant, the reader can move around 1cm in all 3-D directions, or rotate/tilt up to 52 degrees in two axes (as may occur with body motions) without affecting signal integrity. In a 96-hour experiment, the measured data from randomized reflux episodes were stable with the discharging battery voltage, time and various motion parameters randomly applied to the test setup. With a 1-Hz sampling rate, the module battery life outlasted the 96-hour experiment. Conclusion: We have developed an implantable, wireless pH/impedance monitoring system, consisting of a batteryless dual-sensor implant and a portable reader, for detecting acidic and nonacidic reflux episodes. The system is now ready for testing in clinical situations.
Conclusion Patency capsules have previously been shown to be useful in identifying small bowel strictures. However, failure of capsule passage can also be due to delayed GI transit or structural defects such as diverticulae. Risk factors for delayed transit include hypothyroidism, Type II diabetes mellitus and constipating drugs. These factors need to be considered when requesting this test. References: 1. 1. Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults Gut 2008;57:125-136. W1189 Influence of Simeticone and Metoclopramide Administration for Capsule Endoscopy Preparation Josep Maria Dedeu Cusco, Ines Ana Ibañez, Xavier Bessa, Cristina Alvarez, Luis Barranco, Agustin Seoane, Carmen Alonso, Jordi Muñoz Galitó, Lucía Marquez, Alex Cañas, Montserrat Andreu, Felipe Bory, Begona Gonzalez Suarez Presence of intraluminal bubbles and impossibility to visualize entire small bowel are limitations in capsule endoscopy. It has been described that procinetic and/or antiflatulent drugs administration, would help to obtain better results. Objectives: 1. To analyze the effect of metoclopramide administration on gastric and intestinal transits time. 2. To evaluate the quality of images after simeticone ingestion. Patients and methods: We included 142 patients from March 2007 until January 2008. Patients were randomized, prospectively in 4 groups for the administration of metoclopramide (10 mg), simeticone (80 mg) or both previously to capsule ingestion: Group I (control, 38 patients), Group II (metoclopramide and simeticone, 35 patients), Group III (metoclopramide, 37 patients) and Group IV (simeticone, 32 patients). Presence of intestinal gas was classified in 4 grades (0-3), according to a scale recently described. We analyzed separately proximal and distal small bowel segments. Results: 142 patients (71 men and 71 women, Mean age: 56.7 +/- 19.2 years). Gastric transit time was 40.8 +/- 53.7 minutes in control group vs 22.5 +/-20.3 minutes in patients taking metoclopramide (p=0.08). There were no significant differences in intestinal transit time. In proximal small bowel 97.2% of patients in group II had none or minima bubbles compared to 57.9% of patients in control group. Distally, 42.1% of patients in control group had a lot of gas avoiding to visualize mucous compared to 2.9 % of patients in group II (p= 0.002). No side effects were observed. Conclusions: Our results suggest that simeticone and procinetic drugs ingestion before capsule endoscopy reduced bubbles in the intestinal lumen and improved the visualization of the small bowel.
W1187 Use of PillCam ESO in Determining the Prevalence of Esophageal Disease in Patients Presenting to the Emergency Department With Chest Pain and Without Acute Coronary Syndrome Anupam Singh, Calvin Lee, Dmitry Finkelberg, Anne Foley, Gregory Volturo, Joel Gore, Patricia Hibberd, David R. Cave Background and Aim: Chest pain accounts for more than 6 million Emergency Department (ED) visits per year in the USA. Of these approximately 25% have an acute coronary syndrome (ACS). In the remainder, 20 to 60% have esophageal mucosal disease by conventional endoscopy. Those with esophageal disease often receive no diagnosis and no medical management. We conducted a pilot study to evaluate the use of PillCam ESO testing to determine the prevalence of esophageal disease in patients with non cardiac chest pain (NCCP) presenting to the ED. Methods: We screened 68 patients (30-85yrs) who presented to the ED with chest pain, after they had ruled out for an ACS,using a TIMI score of 2 or less, and for other life threatening causes of chest pain,using an accepted standard chest pain diagnostic protocol. Other exclusions including dysphagia, abdominal pain, a history of inflammatory bowel disease, implantable cardiac devices and pregnancy. Eligible subjects were invited to participate and after informed consent was obtained, a simplified ingestion protocol (SIP) for esophageal capsule endoscopy was performed. The video images were reviewed by an experienced reader. Results: Of the 68 patients screened, 26 patients were enrolled (14 males,12 females) with mean age of 46yrs (32-63yrs). Mean esophageal transit time for the capsule was 2mins 25 secs (2 secs to 12mins 44 secs).Esophageal mucosal abnormalities were detected in 11 patients (44%). Erosive esophagitis (LA Grade A-C) was found in 10 patients (40%) and mucosal change consistent with Barrett's esophagus was found in 1 patient (4 %).‘Felinization' of the esophagus was found in 7 patients (28%), 2 with esophagitis and 5 without. Additional findings included retained gastric contents despite prolonged fasting of more than 17 hrs in 1 patient. The duodenum was visualized in 10 patients, 5 of whom had duodenitis. Prolonged esophageal transit of >12 mins and > 8 mins in 2 patients respectively suggested dysmotility. The procedure was well tolerated. There were 2 technical failures. There were no capsule related complications. Anti secretory therapy and anti reflux measures were instituted for patients with esophagitis. Conclusions: The ESO capsule endoscopy is a simple, non invasive, well tolerated procedure with a high yield for detection of esophagitis and other conditions in patients with NCCP presenting to the ED. Early diagnosis of esophageal mucosal disease in this setting, and the ability to direct treatment may lead to better patient management and reduce the need for further testing. The significance of ‘felinization' in this setting remains to be determined.
W1190 Clinical Experience With the Patency Capsule: A Single Center Retrospective Review Benjamin J. Hyatt, Dmitry Finkelberg, Elena Tsai, David R. Cave BACKGROUND: Capsule endoscopy (CE) is a useful diagnostic tool for visual inspection of the small intestine. Although relatively uncommon, one of the major complications of CE is long-term capsule retention at stenoses which may require surgery or endoscopic removal. The patency capsule (PC) (Agile Capsule, Given Imaging), a radio-opaque dissolvable tablet, can be used prior to CE in patients at high-risk for stricture to evaluate for potential capsule retention. OBJECTIVE: To assess the utility of PC for predicting capsule retention in high-risk individuals. METHODS: This study is a retrospective review of all cases of PC performed at a single tertiary care medical center over a two-year period. To verify presence or absence of PC, the study authors reviewed all plain abdominal films. Our standard protocol for the PC requires ingestion of the capsule and a plain abdominal film at 30 hours after ingestion. These films are then reported by a radiologist. RESULTS: During the study period, a total of 54 PC's were performed. A positive study (PC seen on abdominal x-ray) was noted in 26 patients (48%). Of these 26, the PC was located in the small bowel in 19 cases (73%), colon in 5 cases (19%), and stomach in 2 cases (8%). In the group of 54 patients, a total of 29 CE's were performed. CE was performed in 2 patients with Crohn's disease who had positive PC studies showing possible location of PC in the ileocecal region. CE was pursued in these cases based on clinical judgment that the location of PC was either in the cecum, or in an area that CE could be retrieved by endoscopy if retained. The CE was transiently retained in both patients. Two CE's (7% of 29 CE's performed) were transiently retained in patients who had a negative PC study. Two patients (4% of 54 PC performed) who were initially given a “negative” PC study result were found to have a retained PC on retrospective review. Both subsequently underwent CE, and the CE was retained in both patients. DISCUSSION: PC is a useful means of identifying cases in which CE is likely to be retained. However, in some patients CE's are retained despite negative PC study. PC's can occasionally be present on x-ray but may be overlooked potentially leading to CE retention. Education of radiologists should be considered regarding the difference in appearance between the PC and CE.
W1188 Failure of Patency Capsules- A District General Hospital Experience in the UK Punyanganie S. de Silva, Lynette Baldwin, Yin M. Miao Introduction & Aims Patency capsules can be used prior to video capsule endoscopy (VCE) to exclude stricturing lesions that may impede capsule advancement. Current BSG guidelines[1] recommend usage in those patients with abdominal pain or obstructive type symptoms. Failure of the patency capsule to pass within 36 hours may suggest obstructive pathology. Its use therefore reduces the need for pre-capsule fluoroscopic imaging. We report our experience over a two year period and highlight other aetiological factors that may delay the passage of the patency capsule. Methodology A retrospective study assessing VCEs undertaken at a UK district general hospital over two years (2007-2009). Most patients had Given patency capsules prior to the actual study. Those that did not were the ones that had had a recent barium follow-through (BaFT). Where patency capsule had been used and passage failed, a barium follow through or CT imaging was undertaken. Thyroid function tests, Hb1AC levels, concurrent disease and current medication were recorded. Results During the 2 year period 73/110 (66.4%) patients had a patency capsule prior to VCE. 7/ 73 patencies failed (9.6%). All were female patients. Median age was 71 years (range 4085 years). The indication for the VCE was recurrent iron deficiency anaemia with normal preceding gastroscopy and colonoscopy. There were no complaints of pre-VCE abdominal pain and inflammatory markers were normal. On further radiological imaging, 1/7 (14%) had a previously undiagnosed small bowel stricture on barium follow through. 3/7 (43%) had small bowel or colonic micro-diverticulae. Slow transit was documented in 2/7 of the BaFTs (29 %). 1/7 (14%) had a normal BaFT. Six out of these seven (86%) failed capsules had poorly controlled Type II diabetes mellitus (43%), hypothyroidism with raised TSH levels (29%), or were taking constipating agents (14%) such as codeine and amitriptyline.
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W1191 Increased Diagnostic Yield of Small Bowel Tumors With PillCam: the Role of Capsule Endoscopy in Diagnosis and Treatment of Gastrointestinal Stromal Tumours (GIST). Italian Single-Centre Experience Maria Elena Riccioni, Riccardo Urgesi, Cristiano Spada, Rossella Cianci, Guido Costamagna Background: Gastrointestinal Stromal Tumors (GIST) are the most common mesenchymal tumours of the stomach and small intestine. In the past, tumor diagnosis was often delayed after the first bleeding episode because of the inaccessibility of the small bowel. Study: To report on the prevalence of small bowel GIST in a population that underwent capsule endoscopy (CE). A retrospective analysis of the charts of 500 patients who underwent CE from 2001 and 2007 for different indications was performed. Setting: the major indications for CE were obscure-occult or obscure-overt bleeding. We included 289 patients with obscure-occult or obscure-overt bleeding and 211 with other indications. The outcome was assessed by reviewal of the charts and telephone contact with patients. The Fisher's exact
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W1194 Impact of an Extensive Thiopurine Methyltransferase (TPMT) Genotyping in Inflammatory Bowel Disease Patients Who Experienced Myelosuppression During Antipurine Therapy Olivier Dewit, Tom G. Moreels, Filip J. Baert, Harald Peeters, Reenaers Catherine, Martine De Vos, Philippe P. Van Hootegem, Vinciane Muls, Gigi Veereman, Fazia Mana, Joannes Holvoet, Serge Naegels, Yves Horsmans, Jean-Luc Gala Background & Aims: Azathioprine (AZA) is an immunosuppresive drug that is widely used in IBD. Among its side effects, myelosuppression (MS) is of major concern. Patients with TPMT deficiency have a high risk of MS when exposed to standard dose of AZA. In a previous study *, only 27 % of Crohn's Disease Caucasian patients with MS had a mutant allele of the TPMT gene associated with enzyme deficiency. Since this study, a number of new TPMT mutations have been described and our aim was to investigate their clinical relevance. Secondary aim was to evaluate, in TPMT deficient and normal pts, the delay, the severity, the complications, the hospitalization and outcome of MS. Methods: Inclusion criteria were leukopenia (white blood cell count < 3000/mm3), and /or thrombocytopenia (platelets < 100000/mm3) while taking AZA therapy. Patients (n=61, CD: 48, UC:13) were included from 11 Belgian centers. The median treatment dose was 2 mg/kg (0.7-2.5). Data were collected about the onset of treatment, the onset of MS, concomitant medications at that time, complications and hospitalization. For each patient, 30 milliliters venous blood was drawn at distance of MS event, in EDTA-treated tubes and sent to a central laboratory for full TPMT cDNA sequence analysis (exon 4 to 10), specifically designed to avoid the co-amplification of the TPMT pseudo-gene. Results: forty-six out of 61 were homozygous for the wild-type TPMT genotype (High methylator, HM), 11/61 were heterozygous for at least 1 non functional mutation (intermediate methylator, IM) and 4 were homozygous for non functional mutation (low methylator, LM). In the spectrum of 22 known TPMT mutations, only TPMT 2*, 3B* and 3C* mutated alleles were identified. According to the expected methylator status, median delay between AZA initiation and MS was 2 months (5 weeks-5 months) in the LM pts, 2,75 months (4 weeks-6 years) in IM pts ; and 6 months (11 days7 years) in HM. Occurrence of infections was the most frequent complication and was found in TPMT deficient pts 6/15 (40%) as well as normal TPMT pts 15/46 (33 %). No death was reported. Hospitalization was necessary in 7/15 pts (47 %) with deficient TPMT genotype and in 12/46 (26 %) of the patients with normal TPMT genotype. The median duration of hospitalization was 15 days (range 2-42) and similar in both groups. Conclusions: In this series of Caucasian IBD patient, only 1/4 (25 %) of MS during AZA was associated with TPMT deficient genotype. However, a shorter median time to MS onset and a proportionally higher rate of hospitalization was recorded in TPMT deficient pts. * Colombel et al, Gastroenterology 2000; 118:1025-1030.
W1192 Evaluation of Quick View of Rapid® 5 Access for Examination of Video Capsule Endoscopies Akiko Shiotani, Ryuji Nishi, Keisuke Honda, Makiko Kawakami, Hiroshi Imamura, Hiroshi Matsumoto, Ken-ichi Tarumi, Tomoari Kamada, Jiro Hata, Ken Haruma Background: Reading recorded images of video capsule endoscopy (VCE) takes on average 40-60 min. Since it is very time-consuming, one possible cost-effective strategy could be the use of expert endoscopic assistant and available software to select images. The availability of Quick View of RAPID® reader, which is software to assist the reader, is not applicable for clinical use because of the low sensitivity for detection of lesions and clinical usefulness of any software has not been proved. Aim: To evaluate clinical utility of RAPID® 5 Access in VCE examinations and find the optimum setting mode for reading to increase of diagnosis yield in shorten reading time. Methods: Two well-trained doctors and one expert nurse read the previous recorded images in 10 volunteers with known mucosal injury induced by low dose aspirin and in 10 obscure GI bleeding (OGIB) patients known to have a variety of lesions. We compared the detection rate of the lesions using quick view between RAPID® Reader ver. 4.1 and RAPID® 5 Access. We also compared the detection rate of the lesions and reading time among 3 setting modes of RAPID® 5 Access (A, single auto mode view speed 12; B quad view manual speed 35; C, single manual quick view speed 6). Results: The sensitivities of denuded redness (74% vs. 55.6%), erosion (74% vs.59.2%), large erosion (96% vs. 96%), and ulcer (100% vs. 50%) in the comparison of the rate of detection of the images in aspirin study by RAPID® 5 Access were significantly higher than those by RAPID® Reader. Quick view of RAPID® 5 Access detected all main lesions in OGIB patients, while RAPID® Reader missed 7 lesions (ie, 3 ulcer lesions, 3 elevated lesions and 1 malignant lesion). Comparison among the 3 modes of RAPID® 5 Access showed that the mode with single manual quick view and speed 6 was superior in both detection rate and reading time compared to the other modes. Conclusions: The Quick View of RAPID® 5 Access may improve diagnostic yield reducing reading time.
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Safety of Thiopurines in a Population-Based Cohort of Inflammatory Bowel Disease Laurent Peyrin Biroulet, Edward V. Loftus, William S. Harmsen, Alan R. Zinsmeister, William J. Sandborn
Safety of Thiopurine Therapy in Inflammatory Bowel Disease (IBD): LongTerm Follow-up Study of 3,900 Patients Maria Chaparro, Ingrid Ordas, Eduardo Cabre, Valle Garcia, Guillermo Bastida, Mireia Penalva, Fernando Gomollon, Esther Garcia-Planella, Olga Merino, Ana Gutiérrez, Maria Esteve, Montserrat Andreu, M. García-Sepulcre, Joaquín Hinojosa, Isabel Vera, Fernando Muñoz, Juan L. Mendoza, Jose Luis Cabriada, Miguel A. Montoro, Manuel Barreiro, Gloria Ceña, Cristina Saro, Xavier Aldeguer Mante, Jesus Barrio, Javier P. Gisbert
Background and Aims: Few data on the safety profile of thiopurines in a population-based cohort of inflammatory bowel disease (IBD) exist. Methods: Using the resources of the Rochester Epidemiology Project, we identified all patients (pts) who had received azathioprine (AZA) or 6-mercaptopurine (6MP) among incident cases of IBD from Olmsted County, Minnesota, diagnosed between 1970 and 2004 and followed through 2005. All clinical and biological data were reviewed. Results were expressed as number of adverse events (AEs) per 100 pt-years of exposure to thiopurines. Results: A total of 165 (108 Crohn's disease, 57 ulcerative colitis, UC) pts out of 688 with IBD (310 Crohn's disease, 378 UC) were treated with AZA and/or 6MP. Median duration of thiopurine use was 10.9 months (range, 2 days-11.1 years) in UC and 3.0 years (1 day-12.0 years) in Crohn's disease. Forty UC pts (70%) experienced a total of 109 AEs. AEs judged as probably related to thiopurine treatment (n=59) included liver toxicity (abnormal liver tests or liver injury) not leading to therapeutic intervention (n=22), leukopenia without infection but leading to therapeutic intervention (n= 13), digestive symptoms (n=8), leukopenia without infection and not leading to therapeutic intervention (n=3), flu-like symptoms (n=3), arthralgia (n=2), neutropenia without leukopenia (n=2), one pancreatitis, one B-cell non-Hodgkin lymphoma, and others (n=4). The incidence of AEs was 800 per 100 pt-years of thiopurine exposure (+/-1560) in UC. Ninetyfour Crohn's disease pts (87%) experienced a total of 318 AEs. AEs judged as probably related to thiopurine treatment (n=155) included liver toxicity not leading to therapeutic intervention (n=74), digestive symptoms (n=19), leukopenia without infection leading or not to therapeutic intervention (n=18 and 19, respectively), liver toxicity leading to therapeutic intervention (n=6), infection without leukopenia (n=4), neutropenia without leukopenia (n= 3), flu-like symptoms (n=3), cutaneous lesions (n=3), and others (=6). The incidence of AEs was 840 (+/-3710) per 100 pt-years of exposure to thiopurines in Crohn's diseases. The AEs occurred independently of thiopurine dosage in both Crohn's disease and UC. When examining the first course of thiopurine in each pt, 55 IBD pts (33%) discontinued due to an AE. Conclusion: In this population-based cohort, the incidence of AEs per 100 pt-years of exposure to thiopurines ranged from 800 to 840 in IBD. Stopping drug due to AEs was frequent. Leukopenias and abnormal liver tests occurred frequently during the course of IBD, underscoring the need to closely monitor patients on thiopurines. Only one lymphoma was observed.
Background:Azathioprine (AZA) and mercaptopurine (MP) have shown to be effective in inducing and maintaining remission in IBD patients.The occurrence of adverse events (AE) is a major drawback in the use of AZA/MP. Aims:To evaluate the cumulative incidence, incidence rates, distribution and chronology of AE in patients on thiopurine treatment.To identify predictive factors associated with the development of thiopurine-induced AE. Methods:Retrospective review of medical records of IBD patients on thiopurine therapy from a National Spanish database (ENEIDA). Long-term incidence of AE was estimated using the Kaplan-Meier analysis.Cox-regression analysis was performed to identify potential predictive factors of AE. Results:3,900 patients (mean age 40 years, 59%male, 30%ulcerative colitis, 70% Crohn's disease (CD)) were included. 95% were on azathioprine and 5% on mercaptopurine. The median follow-up with thiopurines was 44 months (range 0-420). AE occurred a median of 1 month after starting treatment. The cumulative incidence of AE was 26%, with an annual risk of 7% per patient-year of treatment. 51% of AE causing discontinuation of treatment occurred in the first month of treatment, 76% after 6 months and 80% after 12 months. Most frequent AE were nauseas(8%), hepatotoxicity(4%), myelotoxicity(4%) and pancreatitis(4%). Three patients had lymphoma. Female gender (OR=1.4;95%CI=1.1-1.8) and CD(OR=2.5; 2-3) increased the risk of having nauseas. The risk of hepatotoxicity was lower in females (OR=0.6; 0.4-0.9) and higher in CD (OR=3.3, 2.5-4.5). The risk of myelotoxicity was significantly higher in patients treated with MP (OR=5; 2.5-11) and in females (OR=3.6; 2-6). The risk of pancreatitis was higher in CD (OR=2.5; 2-3.4). Overall, 17% of patients discontinued the treatment with thiopurines due to AE. 37% of these patients started thiopurines again, and 40% of them had AE again (4% with the same drug, and 36% after switching to the other thiopurine). Conclusions: 1.As many as 1/4 patients on thiopurine therapy had AE during follow-up. 2.A high proportion of patients(17%) had to discontinue the treatment with thiopurines due to AE. 3.More than half of patients that re-started thiopurine treatment after its discontinuation due to AE tolerated it. 4.Several predictor factors for some AE have been identified.
W1196 One Hour Infliximab Infusion in Infammatory Bowel Disease is Save and Well Tolerated Thomas W. Lee, Sandra L. Beard, Richard N. Fedorak Background: Infliximab (IFX), administered by intravenous infusion, is a chimeric monoclonal antibody to tumour necrosis factor alpha with proven efficacy in inducing and maintaining remission of inflammatory Bowel Disease (IBD). A protocol used in the initial
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test and Student's “t” test was used to statistically analyse the results. Results: 20 patients (4.0%) were diagnosed with small bowel tumors by CE; 9 were GIST (45.0%). It was observed that traditional endoscopic and radiological methods failed to diagnose GIST in all these cases. CE was false negative in only one case in which the diagnosis of GIST was made by angiography. All CE positive patients and the patient diagnosed by angiography underwent surgical treatment with normalization of the haemoglobin values at follow-up. Limitations: the small number of cases. Conclusions: CE diagnosed GIST in 9/10 patients establishing it as an effective and sensitivity diagnostic modality in comparison to traditional radiology and confirming an important role for CE in the algorithm for the diagnostic workup in suspected small bowel tumors.