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Can computers improve the accuracy of ultrasonographic gastric emptying assessment?
GASTROENTEROLOGY Vol. 114, No. 4
A720 AGA ABSTRACTS G2977 CAN COMPUTERS IMPROVE THE ACCURACY OF ULTRASONOGRAPHIC GASTRIC EMPTYING ASSESSMENT? M.Bellini, F. Costa, P, Alduini, A. Tomar, *F. Flandoli, M. Rucco, A. Ricchiuti, P. Ciccorossi, M. Spataro, G. Maltinti, S. Marchi. Gastroenterology Unit, *Department of applied mathematics; University of Pisa. Ultrasound can be used to obtain a reliable determination of gastric emptying by measuring the antral sectional area which increases after a meal and then decreases progressively in a linear manner. This technique is non-invasive, inexpensive and safe. Some parameters, such as final emptying time are relatively easy to achieve even when performing evaluations every 30' (solidliquid meals). On the contrary, carrying out the procedure at these intervals, it can be difficult to achieve precise results for maximum antral distension (MAD) which is also very important because of its possible correlation with dyspeptic problems. An accurate evaluation of this parameter at shorter intervals would be very time-consuming. The aim of the study was to verify whether 30' interval determinations were sufficient to provide an accurate assessment of the MAD time, when a computer analysis, with suitable software, was performed. Twenty healthy volunteers (9f, 1 Ira; mean age ± SD: 31.4 ± 4.12) were enrolled. Ultrasonographic evaluation of the antral area was performed by measuring the longitudinal and the anteroposterior diameters corresponding to the sagittal plane passing through the superior mesenteric vein and using the formula r~AB/4, in fasting state, at the end of a standardized solid-liquid meal (900 Kcal) (To) and at 5' intervals for 90'. Statistical analysis was performed using t test. The values obtained in fasting state, at T 0, at 30', 60', 90' were analyzed by a software program (Maple V 2.0) using cubic-spline interpolation of the data of each patient; the curve was made by pieces of polynomials of degree 3 on each time step and was the smoothest in a natural geometric sense (1). Performing evaluations every 5' MAD was 20', whereas if determinations were only carried out at 30' intervals MAD would be reached at 30' (p<0.0001). The interpolation analysis, carried out by Maple V 2.0 program on these last data, showed that MAD was reached at 19.72'. Maple V 2.0 analysis performed over results obtained at 30'-intervals and the evaluations carried out every 5' provided the same results. Using a suitable software program achieves an accurate evaluation of MAD avoiding too frequent determinations of the antral area which are highly time-consuming for the operator; it provides more accurate information from the ultrasonographic gastric emptying assessment without further loss of time. [1] J. Stoer and R. Bulirsch: Introduction to numerical analysis. SpringerVerlag; New York, 1983 • G2978 INTER-RELATIONSHIPS AMONG FUNCrIONAL GASTROINTESTINAL DISORDERS. EJ Bennett, C-A Badcnck, CC Tennant and JE Kellow. Depts. of Gastroenterology, Biostatistics and Psychological Medicine, Royal North Shore Hospital, University of Sydney, NSW, Australia Distinct symptom-based subgroups of functional gastrointestinal disorder (FGID) can be recognised. The relationships between and within these disorders, however, remain unclear; if significant inter-relationships exist, these may facilitate investigation of possible common patbogenetic factors in the FGID subgroups. Methods: We therefore studied 188 unselected outpatients fulfilling the criteria for one or more functional gastroduodenal or functional bowel disorder (Drossman et al). FGID classification was determined using the Bowel Disease Questionnaire (BDQ); RL dyspepsia was included because these latter symptoms frequently overlap with FD and with IBS. Independence among subgroups was assumed ~ priori. Primary relationships between FGID subgroups were determined using logistic regression analyses which simultaneously adjusted for age, gender and the presence of other syndromes. Subgroups assessed included (1) those within functional dyspepsia (FD), namely ulcer-like (UL) dyspepsia, dysmotility-like (DL) dyspepsia, and reflux-like (RL) dyspepsia; and (2) those within the functional bowel disorders (FBD), namely irritable bowel syndrome (IBS), functional constipation (FC), and unspecified functional bowel disorder (UFBD). Low prevalence precluded functional diarrhea and functional abdominal pain syndrome from analysis. Results- Based on conditional probabilities, the only significant relationship between a FBD and a FD syndrome was the association of IBS with DL dyspepsia (OR = 2.5, 95% CI=1.3,5; p=0.005). Among the FD, RL was significantly predicted by both UL dyspepsia (OR=3.6, 95% CI=1.7,7.9; p=0.002) and DL dyspepsia (OR=2.6, 95% CI=1.3,4.5; p=0.003) whereas UL and DL dyspepsia were statistically independent of each other. No association was found between RL or UL dyspepsia and IBS, or between FD subgroups and FC or UFBD. Gender differences were specific to DL (female) and UL dyspepsia (male) alone. Con.clusion: The strong association between IBS and DL dyspepsia suggests a common pathogenetic basis for these two disorders. Specific patterns of interrelationships, independence, and gender-relatedness among FD subgroups support the symptom-based classification of the FGID.
G2979 THE ECONOMIC BURDEN OF IRRITABLE B O W E L SYNDROME IN CANADA. JD. Bentkover, C. Field, EM. Greene, V. Plourde, JP. Casciano, KPMG Peat Marwick LLP, Boston, MA, Ctre Hospitalier de l'Universit6 de Montrtal, Montrtal, QU., Canada. INTRODUCTION: Irritable Bowel Syndrome (IBS) represents a significant economic and social burden to Canada: approximately 15.3% (3.3 million) of the 21.95 million Canadians over 20 years of age suffer from IBS, 40% (1.3 million) actively seek care for their symptoms while the remaining 60% (2 million) have symptoms compatible with IBS but manage the disease without any formal clinical consultation. Individuals with IBS are subject to a diverse set of symptoms which are chronic and episodic in nature. Thus, the treatment of IBS varies depending on a patient's symptoms, the consulting physician, and the province in which the patient is being treated. Due to the chronic nature of the disease and variety of treatments for this syndrome, IBS contributes significantly to the total health care expenditures in Canada. AIMS: To estimate the economic burden associated with IBS in Canada per annum. METHODS: KPMG Peat Marwick LLP conducted a cost-of-illness study estimate the total annual economic burden of Irritable Bowel Syndrome (IBS) to the provincial health plans of Ontario, Quebec, and Canada overall. Our analysis included a multicenter retrospective chart review, comprehensive literature evaluation, and interviews with expert clinicians (Delphi and clinical advisory panels). These various research methodologies were combined to accurately capture 1BS medical resource utilization by accounting for the clinical treatment variation associated with IBS. KPMG further employed a multi-state Markov model to quantify the costs of the full course of clinical management associated with IBS patients. RESULTS: Our results indicate that IBS is a cosily disease to Canada and its provinces. From a societal perspective (including all direct and indirect costs), we estimate the total annual cost of IBS to Canada is Can$1,370,773,705 for the population over the age of 20. Of that Can$352,315,260 is direct cost and Can$1,018,458,445 is indirect cost. The direct medical costs for IBS are .47% of Canada' 1996 national health expenditures (Can$75.2 billion). From the perspective of the provincial health plans (excluding dug costs for those under 65 and indirect costs), it is estimated that the total cost of IBS is Can$321,069,320 to all the provincial health plans in Canada combined, Can$75,098,336 to the province of Quebec, and Can$126,865,700 to the province of Ontario. The provincial health plans' direct medical costs for IBS are .61% of Canada's public health expenditures for 1996 (Can$52.6 billion). A sensitivity analysis conducted by varying key parameters in the model confirmed the robustness of these results. CONCLUSIONS: IBS represents a tremendously important economic burden in Canada over a one year period of time. As a consequence, specific strategies should be undertaken to educate physicians and control this expenditure. G2980
EMERGENT
DECOMPRESSION DURING LACTULOSE-ASSOCIATED COLONIC DISTENTION. M Bernstein. T Howard, J Lowell, S Shenoy, C Caldwell. Hepatology Section and Department of Surgery, Washington University School of Medicine, St. Louis, MO Hospitalized encephalopathic patients awaiting liver transplantation (OLT) are often on appropriate doses of lactulose. These OLT patients are prone to colonic hypomotility and distention, which may be exaccerbated by lactulose. Colonic dilatation can rarely prohibit adequate visualization intraoperatively. We describe our experience with 4 patients on lactulose for encephalopathy who underwent emergent colonic decompression during OLT between 11/95 and 5/97. RESULTS: Four inpatients underwent OLT with the diagnoses of HCV, PBC, giant cell hepatitis, and cryptogenic cirrhosis. All four were treated with lactulose 30cc 2-6 hours for at least 72 hours prior to OLT. None of the patients had evidence of colonic obstruction nor a history Of Ogilvie's syndrome or ileus. The colonic distention was prohibitive to adequate visualization of the surgical field. Three patients required intraoperative decompressive colonoscopies. One underwent emergent needle decompression of the cecum. Decompression facilitated adequate visualization and successful surgery in all cases. The patient requiring needledecompression experienced a temporary colocutaneous fistula, while those needing colonoscopic decompression experienced uneventful post operative courses. The incidence of colonic distention during the time period of November 95 to May 97, was 4.2% (4/94). CONCLUSIONS: Colonic dilatation can rarely increase surgical difficulty during OLT. At our institution, colonoscopic decompression intraoperatively was the preferred approach to this rare occurrence. To avoid colonic distention in our hospitalized encephalopathic patients, we now use lactulose sparingly in the mangement of patients for whom OLT is imminent. LIVER
INTRAOPERATIVE
TRANSPLANTATION
FOR
G2981 TIlE SUPERIOR LAXATIVE EFFECTS OF PSYLLIUM OVER CALCIUM POLYCARBOPItlL IN A DOG MODEL: IMPLICATIONS FOR HUMAN LAXATIVE USERS WITH HIGH GASTRIC pH. K. J. Best, B. P. Daggy, R. M. Schewe, 0. R. Carryl, D. A. Berry. The Procter and Gamble Co., Mason, OH Some laxative users take antacids, H 2 antagonists, or proton pump inhibitors, which give them a higher gastric pH than normal laxative users. The eldedy
A720 AGA ABSTRACTS G2977 CAN COMPUTERS IMPROVE THE ACCURACY OF ULTRASONOGRAPHIC GASTRIC EMPTYING ASSESSMENT? M.Bellini, F. Costa, P, Alduini, A. Tomar, *F. Flandoli, M. Rucco, A. Ricchiuti, P. Ciccorossi, M. Spataro, G. Maltinti, S. Marchi. Gastroenterology Unit, *Department of applied mathematics; University of Pisa. Ultrasound can be used to obtain a reliable determination of gastric emptying by measuring the antral sectional area which increases after a meal and then decreases progressively in a linear manner. This technique is non-invasive, inexpensive and safe. Some parameters, such as final emptying time are relatively easy to achieve even when performing evaluations every 30' (solidliquid meals). On the contrary, carrying out the procedure at these intervals, it can be difficult to achieve precise results for maximum antral distension (MAD) which is also very important because of its possible correlation with dyspeptic problems. An accurate evaluation of this parameter at shorter intervals would be very time-consuming. The aim of the study was to verify whether 30' interval determinations were sufficient to provide an accurate assessment of the MAD time, when a computer analysis, with suitable software, was performed. Twenty healthy volunteers (9f, 1 Ira; mean age ± SD: 31.4 ± 4.12) were enrolled. Ultrasonographic evaluation of the antral area was performed by measuring the longitudinal and the anteroposterior diameters corresponding to the sagittal plane passing through the superior mesenteric vein and using the formula r~AB/4, in fasting state, at the end of a standardized solid-liquid meal (900 Kcal) (To) and at 5' intervals for 90'. Statistical analysis was performed using t test. The values obtained in fasting state, at T 0, at 30', 60', 90' were analyzed by a software program (Maple V 2.0) using cubic-spline interpolation of the data of each patient; the curve was made by pieces of polynomials of degree 3 on each time step and was the smoothest in a natural geometric sense (1). Performing evaluations every 5' MAD was 20', whereas if determinations were only carried out at 30' intervals MAD would be reached at 30' (p<0.0001). The interpolation analysis, carried out by Maple V 2.0 program on these last data, showed that MAD was reached at 19.72'. Maple V 2.0 analysis performed over results obtained at 30'-intervals and the evaluations carried out every 5' provided the same results. Using a suitable software program achieves an accurate evaluation of MAD avoiding too frequent determinations of the antral area which are highly time-consuming for the operator; it provides more accurate information from the ultrasonographic gastric emptying assessment without further loss of time. [1] J. Stoer and R. Bulirsch: Introduction to numerical analysis. SpringerVerlag; New York, 1983 • G2978 INTER-RELATIONSHIPS AMONG FUNCrIONAL GASTROINTESTINAL DISORDERS. EJ Bennett, C-A Badcnck, CC Tennant and JE Kellow. Depts. of Gastroenterology, Biostatistics and Psychological Medicine, Royal North Shore Hospital, University of Sydney, NSW, Australia Distinct symptom-based subgroups of functional gastrointestinal disorder (FGID) can be recognised. The relationships between and within these disorders, however, remain unclear; if significant inter-relationships exist, these may facilitate investigation of possible common patbogenetic factors in the FGID subgroups. Methods: We therefore studied 188 unselected outpatients fulfilling the criteria for one or more functional gastroduodenal or functional bowel disorder (Drossman et al). FGID classification was determined using the Bowel Disease Questionnaire (BDQ); RL dyspepsia was included because these latter symptoms frequently overlap with FD and with IBS. Independence among subgroups was assumed ~ priori. Primary relationships between FGID subgroups were determined using logistic regression analyses which simultaneously adjusted for age, gender and the presence of other syndromes. Subgroups assessed included (1) those within functional dyspepsia (FD), namely ulcer-like (UL) dyspepsia, dysmotility-like (DL) dyspepsia, and reflux-like (RL) dyspepsia; and (2) those within the functional bowel disorders (FBD), namely irritable bowel syndrome (IBS), functional constipation (FC), and unspecified functional bowel disorder (UFBD). Low prevalence precluded functional diarrhea and functional abdominal pain syndrome from analysis. Results- Based on conditional probabilities, the only significant relationship between a FBD and a FD syndrome was the association of IBS with DL dyspepsia (OR = 2.5, 95% CI=1.3,5; p=0.005). Among the FD, RL was significantly predicted by both UL dyspepsia (OR=3.6, 95% CI=1.7,7.9; p=0.002) and DL dyspepsia (OR=2.6, 95% CI=1.3,4.5; p=0.003) whereas UL and DL dyspepsia were statistically independent of each other. No association was found between RL or UL dyspepsia and IBS, or between FD subgroups and FC or UFBD. Gender differences were specific to DL (female) and UL dyspepsia (male) alone. Con.clusion: The strong association between IBS and DL dyspepsia suggests a common pathogenetic basis for these two disorders. Specific patterns of interrelationships, independence, and gender-relatedness among FD subgroups support the symptom-based classification of the FGID.
G2979 THE ECONOMIC BURDEN OF IRRITABLE B O W E L SYNDROME IN CANADA. JD. Bentkover, C. Field, EM. Greene, V. Plourde, JP. Casciano, KPMG Peat Marwick LLP, Boston, MA, Ctre Hospitalier de l'Universit6 de Montrtal, Montrtal, QU., Canada. INTRODUCTION: Irritable Bowel Syndrome (IBS) represents a significant economic and social burden to Canada: approximately 15.3% (3.3 million) of the 21.95 million Canadians over 20 years of age suffer from IBS, 40% (1.3 million) actively seek care for their symptoms while the remaining 60% (2 million) have symptoms compatible with IBS but manage the disease without any formal clinical consultation. Individuals with IBS are subject to a diverse set of symptoms which are chronic and episodic in nature. Thus, the treatment of IBS varies depending on a patient's symptoms, the consulting physician, and the province in which the patient is being treated. Due to the chronic nature of the disease and variety of treatments for this syndrome, IBS contributes significantly to the total health care expenditures in Canada. AIMS: To estimate the economic burden associated with IBS in Canada per annum. METHODS: KPMG Peat Marwick LLP conducted a cost-of-illness study estimate the total annual economic burden of Irritable Bowel Syndrome (IBS) to the provincial health plans of Ontario, Quebec, and Canada overall. Our analysis included a multicenter retrospective chart review, comprehensive literature evaluation, and interviews with expert clinicians (Delphi and clinical advisory panels). These various research methodologies were combined to accurately capture 1BS medical resource utilization by accounting for the clinical treatment variation associated with IBS. KPMG further employed a multi-state Markov model to quantify the costs of the full course of clinical management associated with IBS patients. RESULTS: Our results indicate that IBS is a cosily disease to Canada and its provinces. From a societal perspective (including all direct and indirect costs), we estimate the total annual cost of IBS to Canada is Can$1,370,773,705 for the population over the age of 20. Of that Can$352,315,260 is direct cost and Can$1,018,458,445 is indirect cost. The direct medical costs for IBS are .47% of Canada' 1996 national health expenditures (Can$75.2 billion). From the perspective of the provincial health plans (excluding dug costs for those under 65 and indirect costs), it is estimated that the total cost of IBS is Can$321,069,320 to all the provincial health plans in Canada combined, Can$75,098,336 to the province of Quebec, and Can$126,865,700 to the province of Ontario. The provincial health plans' direct medical costs for IBS are .61% of Canada's public health expenditures for 1996 (Can$52.6 billion). A sensitivity analysis conducted by varying key parameters in the model confirmed the robustness of these results. CONCLUSIONS: IBS represents a tremendously important economic burden in Canada over a one year period of time. As a consequence, specific strategies should be undertaken to educate physicians and control this expenditure. G2980
EMERGENT
DECOMPRESSION DURING LACTULOSE-ASSOCIATED COLONIC DISTENTION. M Bernstein. T Howard, J Lowell, S Shenoy, C Caldwell. Hepatology Section and Department of Surgery, Washington University School of Medicine, St. Louis, MO Hospitalized encephalopathic patients awaiting liver transplantation (OLT) are often on appropriate doses of lactulose. These OLT patients are prone to colonic hypomotility and distention, which may be exaccerbated by lactulose. Colonic dilatation can rarely prohibit adequate visualization intraoperatively. We describe our experience with 4 patients on lactulose for encephalopathy who underwent emergent colonic decompression during OLT between 11/95 and 5/97. RESULTS: Four inpatients underwent OLT with the diagnoses of HCV, PBC, giant cell hepatitis, and cryptogenic cirrhosis. All four were treated with lactulose 30cc 2-6 hours for at least 72 hours prior to OLT. None of the patients had evidence of colonic obstruction nor a history Of Ogilvie's syndrome or ileus. The colonic distention was prohibitive to adequate visualization of the surgical field. Three patients required intraoperative decompressive colonoscopies. One underwent emergent needle decompression of the cecum. Decompression facilitated adequate visualization and successful surgery in all cases. The patient requiring needledecompression experienced a temporary colocutaneous fistula, while those needing colonoscopic decompression experienced uneventful post operative courses. The incidence of colonic distention during the time period of November 95 to May 97, was 4.2% (4/94). CONCLUSIONS: Colonic dilatation can rarely increase surgical difficulty during OLT. At our institution, colonoscopic decompression intraoperatively was the preferred approach to this rare occurrence. To avoid colonic distention in our hospitalized encephalopathic patients, we now use lactulose sparingly in the mangement of patients for whom OLT is imminent. LIVER
INTRAOPERATIVE
TRANSPLANTATION
FOR
G2981 TIlE SUPERIOR LAXATIVE EFFECTS OF PSYLLIUM OVER CALCIUM POLYCARBOPItlL IN A DOG MODEL: IMPLICATIONS FOR HUMAN LAXATIVE USERS WITH HIGH GASTRIC pH. K. J. Best, B. P. Daggy, R. M. Schewe, 0. R. Carryl, D. A. Berry. The Procter and Gamble Co., Mason, OH Some laxative users take antacids, H 2 antagonists, or proton pump inhibitors, which give them a higher gastric pH than normal laxative users. The eldedy