- Email: [email protected]
Comparison of polyethylene glycol-electrolyte lavage (PEG-EL) preparation versus standard preparation on small bowel mucosal visualization for wireless capsule endoscopy (WCE)
S74
Abstracts
214 PHYSICIAN AWARENESS OF CELIAC DISEASE Mary Farid, D.O., Bhairavi Patel, M.D., Devika Patel, Robert D. Zipser, M.D., FACG*. San Dimas, CA. Purpose: Celiac disease is a common disorder (up to 0.7%), but still infrequently diagnosed. In our recent survey of over 1000 patients with celiac disease only 6% were diagnosed by their primary care physicians. We sought to determine physician awareness of celiac disease presentations, symptoms, associated disorders and diagnostic tests. Methods: Surveys with multiple-choice questions were mailed to all family physicians (FPs) (n⫽140) and gastroenterologists (GIs) (n⫽31) listed in telephone books and on-line yellow pages in San Bernardino County, California. This county includes a medical school, large rural areas and populous metropolitan suburbs. Results: Over 50% of FPs and GIs responded to the survey. Almost all physicians were aware that celiac disease involved sensitivity to wheat products, but only 33% of FPs and 35% of GIs knew that onset of symptoms was much more common in adulthood than in childhood. Celiac disease is common in patients with type 1 diabetes (2%-6% prevalence), but only 13% of FPs and 47% of GIs were aware of the association. There was more awareness of the associations with thyroid disease (23% FPs, 53% GIs) and IgA deficiency (34% FPs, 59% GIs). When questioned on symptoms of celiac disease, almost all FPs knew that diarrhea was frequent, but symptoms resembling irritable bowel syndrome (68%), psychological disorders (43%) and fibromyalgia-like illnesses (39%) were less well appreciated. All GIs but less than one-half of FPs were aware that irondeficiency anemia and osteoporosis were mainfestations of celiac disease, and few knew that untreated celiac disease may cause infertility (7% of FPs, 47% of GIs). In response to questions on diagnostic techniques, all GIs and most FPs were aware of the use of small bowel biopsy; however, only 43% of FPs were aware of blood tests to screen for celiac disease. Despite an average of over 19 years in practice, less than one-third (28%) of family physicians had ever diagnosed a patient with celiac disease. All GIs had diagnosed multiple patients with celiac disease. Conclusions: These data are consistent with surveys of patients reporting that their primary care physicians infrequently made the diagnosis of celiac disease. The survey results from this county suggest a need to increase awareness of celiac disease, particularly among primary care physicians, and particularly the recognition of adult presentations, the associated disorders, and the use of serologic screening tests.
215 THE ROLE OF DIARRHEAGENIC ESCHERICHIA COLI IN ACUTE DIARRHEA OF CHILDREN IN KARAJ, IRAN Mohammad-Reza Zali, M.D., Koorosh MoezArdalan, M.D.*, Siavosh Salmanzadeh-Ahrabi, Ph.D., Effat Habibi, M.Sc., Fereshteh Jaafari, B.S., Haleh Edalatkhah, B.S., Sanaz MoezArdalan, B.S., Koorosh Zolfagharian, B.S., Mohsen Rezaei Hemami, M.D. RCGLD, Tehran, Islamic Republic of Iran. Purpose: The role of diarrheagenic E. coli strains in acute diarrhea of children is controversial and there are a lot of conflicting results on this subject from different countries. In the present case-control study the role of 4 important categories of E. coli strains was investigated among children for the first time in Iran. Methods: From May to July of 2002, 102 acute diarrhea patients, under 5 years of age, from medical centers in Karaj and 104 matched controls without diarrhea were included in the study. PCR of mixed culture, which has been evaluated as a highly sensitive method, was used for detection of diarrhoeagenic E. coli strains in fecal samples. DNA was extracted from the primary mixed culture of fecal samples and was subjected to 6 different PCR reactions targeting STEC (stx1 and stx2 genes), ETEC (LT and ST toxin producing genes), EPEC (eae gene), and EAEC (pCVD432 plasmid)
AJG – Vol. 98, No. 9, Suppl., 2003
respectively. As many colonies as required, were assayed to find the isolate carrying the target sequences. Results: The most frequent pathogroup was EAEC (37.3%). EAEC, STEC (stx1 and stx2), and ETEC (LT) were found in a significantly higher number of cases compared with controls. No significant difference was observed for EPEC and ETEC (ST) between the two groups (Table 1). Comparing the isolation rate between cases and controls in two age groups of less than 1 and 1–5 years of age. Only, EAEC was more frequently isolated among both patients less than 1 year (OR: 4.8, CI: 1.6 –14.2) and 1–5 years (OR: 3.3, CI: 1.3– 8.2), compared with controls. Isolation rate of STEC (stx1) (OR: 4.1; CI: 1.1–15.9), STEC (stx2) (OR: 2.2, CI: 1.8 –2.7), and ETEC (LT) (OR: 5.7, CI: 1.5–21.5) were higher only in patients younger than 1 year of age compared with matched controls. Table 1. Diarrheagenic E. coli in children with acute diarrhea and controls Pathogen
Case
Control
OR*
CI (95%)†
EAEC ETEC (LT) STEC (stx1) STEC (stx2) EPEC ETEC (ST)
38 (37.3%) 18 (17.6%) 17 (16.7%) 13 (12.7%) 10 (9.8%) 9 (8.8%)
14 (13.5%) 8 (7.7%) 5 (4.8%) 2 (1.9%) 10 (9.6%) 10 (9.6%)
3.8 2.6 4.0 7.4 1.0 0.9
2.0–7.6 1.0–6.2 1.4–11.2 1.6–34.0 0.4–2.6 1.6–34.0
*Odd’s ratio; † 95% confidence interval
Conclusions: Among diarrheagenic E. coli strains, EAEC, STEC (stx1 and stx2), and ETEC (LT) can be considered as significant diarrheal pathogens among children in this region.
216 COMPARISON OF POLYETHYLENE GLYCOL-ELECTROLYTE LAVAGE (PEG-EL) PREPARATION VERSUS STANDARD PREPARATION ON SMALL BOWEL MUCOSAL VISUALIZATION FOR WIRELESS CAPSULE ENDOSCOPY (WCE) Colm J. O’Loughlin, M.B., Andrew I. Sable, M.D., Waleed Alazmi, M.D., Jamie S. Barkin, M.D., M.A.C.G.*. University of Miami, Mount Sinai Medical Center, Miami, FL. Purpose: WCE is an exciting new technology allowing evaluation of the small intestinal mucosa. Unfortunately, similar to standard endoscopy, WCE studies may be limited by endoluminal debris. The purpose of this prospective, blinded study was to compare standard preparation consisting of a clear liquid diet and an overnight fast followed by simethicone just prior to capsule ingestion to standard preparation plus PEG-EL for effect on intestinal visualization by WCE. Methods: Forty-six WCE recordings from patients undergoing capsule endoscopy to evaluate obscure gastrointestinal bleeding (OGIB) were reviewed by three gastroenterologists, blinded as to whether the patients had received PEG-EL or not prior to the procedure. Each study was scored individually and ranked as follows; good/excellent: clean small bowel/ minimal liquid or bubbles present/unlikely that mucosal lesions were missed; fair/inadequate: mucosal areas obscured by small bowel contents and/or debris resulting in possible missed areas/repeat exam required. The small intestinal emptying time (SIET) for each study was recorded by the primary investigator. All patients underwent standard preparation consisting of an overnight fast, preceeded by clear liquid diet, and simethicone elixir ⬍30 minutes prior to capsule ingestion. The PEG-EL group received, in addition to standard preparation, 2 liters of PEG-EL consumed between 16:00 hours and 18:00 hours the day prior to WCE. Results: Of the 46 patient recordings viewed (age range 26 – 84 yrs, 53% male) 25 received preparation with PEG-EL in addition to standard preparation and 21 received standard preparation alone. All 25 patients completed the PEG-EL preparation without difficulty. There were no significant side-effects reported. There was excellent agreement on small intestinal visualization among the endoscopists (⫽0.8). The examination was considered to be adequate, with no limitations in 22/25 patients who received
AJG – September, Suppl., 2003
PEG-EL and in 13/21 who underwent standard preparation only (P⬍0.05). The mean SIET in the PEG-EL group and in the standard preparation group was 4hrs 13mins amd 4hrs 9mins respectively (NS). Conclusions: Preparation with PEG-EL prior to WCE significantly improves small bowel visualization and should be utilized in all patients. 217 LYMPHOCYTIC DUODENITIS: A POSSIBLE PREDICTOR OF RESPONSE TO GLUTEN WITHDRAWAL IN PATIENTS WITH FUNCTIONAL GI DISEASE Sanjay K. Reddy, M.D., Thomas Park, M.D., Emeka C. Eze, M.D., Shriram Jakate, M.D., Satyajit Deshmukh, M.D., Susan L. Mikolaitis, R.D., Mark T. DeMeo, M.D., Ali Keshavarzian, M.D.*. Rush University, Chicago, IL. Purpose: There is an increasing awareness of the prevalence of Celiac Disease in populations beyond traditional at-risk groups. Increased intraepithelial lymphocytes (IEL’s) and increased lamina propria cellularity (lymphocytic duodenitis (LD)) may represent early gluten-mediated damage. We assessed the role of gluten withdrawal in patients with various GI symptoms found to have LD. Methods: 93 patients with LD diagnosed during evaluation of functional GI complaints were given a standard survey by phone including Rome 2, quality of life (QoL) SF12, and response to gluten free diet (GFD). LD was defined as greater than 40 –100 IEL’s per high power field, in the absence of villous atrophy, by our dedicated GI pathologist who was blinded to subsequent therapy. GI symptoms were classified by Rome 2 into ‘IBS’ and ‘minor’ (remaining) functional categories. Results: 87 of 93 (94%) of patients fulfilled Rome 2 criteria for functional bowel disease (48% IBS/45% ‘minor’ disorders). 63 of 93 (67%) were started on GFD. 42 of 63 (66%) responded to therapy with GFD. The group who responded to therapy had significant improvement in QoL score, and rated the diet manageable. The diagnosis of IBS and ‘minor’ disorders were unchanged in the diet-unresponsive group; in contrast, none of the subjects responding to GFD had IBS after therapy (and only 18 of 42 (42%) had ‘minor’ diagnosis post-GFD). The post-treatment presence of functional GI disorders in the group not receiving GFD decreased only 16%. Age, gender, presenting Rome 2 classification, and length of GFD failed to predict response. Conclusions: GFD in this group of patients with LD leads to decreased functional symptoms and an improvement in QoL scores. Biopsy for diagnosis of LD may lead to changes in therapy for functional bowel patients. Although no clinical features seem to predict response to gluten withdrawal, a trial of GFD would seem reasonable in this population. A placebo-controlled, randomized trial is needed to define the efficacy of gluten withdrawal therapy in functional patients with histology consistent with lymphocytic duodenitis. 218 A TALE OF TWO CITIES: TYPICAL CELIAC SPRUE PRESENTING SYMPTOMS ARE SIGNFICANTLY MORE COMMON IN TURKISH THAN IN U.S. PATIENTS Murat Palabiyikoglu, M.D., V.A. Botoman, M.D.*, Sahin Coban, M.D., Gregory F. Bonner, M.D., Sherry Woodhouse, M.D. Cleveland Clinic Florida, Weston, FL and University of Ankara, Ankara, Turkey. Aim: Recent studies suggest an increasing prevalence of atypical initial presenting symptoms of celiac disease in Western countries. We aimed to compare the presenting symptoms of celiac disease at two comparable referral institutions: one in South Florida (SFL) and one in Ankara, Turkey (ANK). Materials and Methods: We retrospectively reviewed the records from 1991-2001 at Cleveland Clinic Florida and University of Ankara for patients with an initial diagnosis of celiac disease by small bowel biopsy. We tabulated patient demographics, typical (chronic diarrhea, weight loss, steatorrhea) and atypical symptoms and findings (anemia, fatigue, osteopenia, abdominal pain, short stature, infertility) in both groups. A numerical
Abstracts
S75
score 1 was assigned to symptom/signs in each typical (0 –3) and atypical (0 – 6) symptom group. The presentations and findings between the Turkish and American patients at diagnosis were compared using: two-tailed t-test and Fisher’s exact test—(InStat v.3.0). Results: There were 28 pts in the SFL group(51% men) and 40 pts in the ANK(35% men)-p⫽NS. The Turkish pts were significantly younger at diagnosis-⌾36⫾ 2yrs vs. US pts- ⌾66⫾3yrs p⬍0.0001. Typical symptoms scores were similar- ANK ⌾1.1⫾0.2 vs SFL ⌾1.3⫾0.3 patients p⫽NS. Atypical symptom scores were significantly higher the US pts: ANK ⌾1.2⫾0.1 vs SFL ⌾1.9⫾0.2—p⬍0.01. Significant differences (p⬍0.01) in the incidence of symptoms/signs were seen for: chronic diarrhea (ANK 95% vs. SFL 50%), Albumin ⬍3.5g (ANK 30% vs. SFL 4%), and mean red blood cell MCV (ANK MCV ⌾77⫾2.2 vs. SFL MCV ⌾86⫾1.8). Conclusions: Although retrospective, this study points to striking differences in the clinical presentation of celiac disease in pts in South Florida and Ankara Turkey. South Florida patients were significantly older at diagnosis, and more likely to present with atypical symptoms. Turkish patients were much younger, and more likely to present with chronic diarrhea, hypoalbuminemia, and microcytosis—as was more commonly seen in the US in the 1960’s and 70’s. These findings raise the question of an interplay of demographics with diet and genetics in the presenting symptoms celiac disease in these two distant geographic areas.(all data mean ⌾⫾SEM). 219 PREVALENCE OF NON-HELICOBACTER PYLORI DUODENAL ULCER IN KARACHI, PAKISTAN Wasim Jafri, F.R.C.P., FACG*, Javed Yakoob, Ph.D., Nadim Jafri, F.C.P.S., Shahab Abid, F.C.P.S., Saeed Hamid, F.R.C.P., FACG, Hasnain Alishah, F.R.C.P., FACG. Aga Khan University Hospital, Karachi, Sindh, Pakistan. Purpose: To determine the prevalence of non-Helicobacter pylori (H. pylori) non-NSAID related duodenal ulcers in patients with acid-peptic disease. Methods: Medical records of patients who attended gastroenterology department at Aga Khan University hospital from 1999 –2001 and had endoscopic diagnosis of duodenal ulcers were reviewed. Duodenal ulcer associated with Helicobacter pylori (H. pylori) infection were diagnosed on the basis of EGD, rapid urease test and histopathology where as history of NSAIDs use defined NSAIDs-related duodenal ulcer. Non- H. pylori nonNSAID duodenal ulcers were those without H. pylori infection and history of NSAIDs intake. Co-morbid conditions noted in these cases included hypertension, ischemic heart disease, diabetes mellitus, dyslipidemia, prosthetic heart valves, depression, arthritis and tuberculosis. Results: Acid-peptic disease was diagnosed in 2260 patients and 9.6% (217/2260) had duodenal ulcer. H. pylori infection related duodenal ulcer were 61.3% (133/217), non-H. pylori non-NSAID 28.5% (62/217) and NSAID- related 18% (39/217). Past history of peptic ulcer disease was present in 15.2 % (33/217) cases with H. pylori infection 66.6% (22/33) and 18% (6/33) in non-H. pylori non-NSAIDs ulcer. Co-morbid conditions in H. pylori infection were 54% (26/48) and 31.2% (15/48) in non-H. pylori non-NSAID ulcer. Conclusions: Duodenal ulcers are common in association with H. pylori infection. In the presence of co-morbid conditions non- H. pylori nonNSAID duodenal ulcer is not a more likely possibility in our patients.
220 CAPSULE ENDOSCOPY [CE] IN THE DETECTION AND MANAGEMENT OF NSAID INDUCED INJURY OF THE SMALL INTESTINE Faisal M. Bhinder, M.D., David R. Cave, M.D.*, Douglas Schneider, M.D., Roger Mitty, M.D., Renee Wolff, M.D., Kent Ferris, M.D. St. Elizabeth’s Medical Center, Boston, MA and GI Assoc., Knoxville, TN.
Abstracts
214 PHYSICIAN AWARENESS OF CELIAC DISEASE Mary Farid, D.O., Bhairavi Patel, M.D., Devika Patel, Robert D. Zipser, M.D., FACG*. San Dimas, CA. Purpose: Celiac disease is a common disorder (up to 0.7%), but still infrequently diagnosed. In our recent survey of over 1000 patients with celiac disease only 6% were diagnosed by their primary care physicians. We sought to determine physician awareness of celiac disease presentations, symptoms, associated disorders and diagnostic tests. Methods: Surveys with multiple-choice questions were mailed to all family physicians (FPs) (n⫽140) and gastroenterologists (GIs) (n⫽31) listed in telephone books and on-line yellow pages in San Bernardino County, California. This county includes a medical school, large rural areas and populous metropolitan suburbs. Results: Over 50% of FPs and GIs responded to the survey. Almost all physicians were aware that celiac disease involved sensitivity to wheat products, but only 33% of FPs and 35% of GIs knew that onset of symptoms was much more common in adulthood than in childhood. Celiac disease is common in patients with type 1 diabetes (2%-6% prevalence), but only 13% of FPs and 47% of GIs were aware of the association. There was more awareness of the associations with thyroid disease (23% FPs, 53% GIs) and IgA deficiency (34% FPs, 59% GIs). When questioned on symptoms of celiac disease, almost all FPs knew that diarrhea was frequent, but symptoms resembling irritable bowel syndrome (68%), psychological disorders (43%) and fibromyalgia-like illnesses (39%) were less well appreciated. All GIs but less than one-half of FPs were aware that irondeficiency anemia and osteoporosis were mainfestations of celiac disease, and few knew that untreated celiac disease may cause infertility (7% of FPs, 47% of GIs). In response to questions on diagnostic techniques, all GIs and most FPs were aware of the use of small bowel biopsy; however, only 43% of FPs were aware of blood tests to screen for celiac disease. Despite an average of over 19 years in practice, less than one-third (28%) of family physicians had ever diagnosed a patient with celiac disease. All GIs had diagnosed multiple patients with celiac disease. Conclusions: These data are consistent with surveys of patients reporting that their primary care physicians infrequently made the diagnosis of celiac disease. The survey results from this county suggest a need to increase awareness of celiac disease, particularly among primary care physicians, and particularly the recognition of adult presentations, the associated disorders, and the use of serologic screening tests.
215 THE ROLE OF DIARRHEAGENIC ESCHERICHIA COLI IN ACUTE DIARRHEA OF CHILDREN IN KARAJ, IRAN Mohammad-Reza Zali, M.D., Koorosh MoezArdalan, M.D.*, Siavosh Salmanzadeh-Ahrabi, Ph.D., Effat Habibi, M.Sc., Fereshteh Jaafari, B.S., Haleh Edalatkhah, B.S., Sanaz MoezArdalan, B.S., Koorosh Zolfagharian, B.S., Mohsen Rezaei Hemami, M.D. RCGLD, Tehran, Islamic Republic of Iran. Purpose: The role of diarrheagenic E. coli strains in acute diarrhea of children is controversial and there are a lot of conflicting results on this subject from different countries. In the present case-control study the role of 4 important categories of E. coli strains was investigated among children for the first time in Iran. Methods: From May to July of 2002, 102 acute diarrhea patients, under 5 years of age, from medical centers in Karaj and 104 matched controls without diarrhea were included in the study. PCR of mixed culture, which has been evaluated as a highly sensitive method, was used for detection of diarrhoeagenic E. coli strains in fecal samples. DNA was extracted from the primary mixed culture of fecal samples and was subjected to 6 different PCR reactions targeting STEC (stx1 and stx2 genes), ETEC (LT and ST toxin producing genes), EPEC (eae gene), and EAEC (pCVD432 plasmid)
AJG – Vol. 98, No. 9, Suppl., 2003
respectively. As many colonies as required, were assayed to find the isolate carrying the target sequences. Results: The most frequent pathogroup was EAEC (37.3%). EAEC, STEC (stx1 and stx2), and ETEC (LT) were found in a significantly higher number of cases compared with controls. No significant difference was observed for EPEC and ETEC (ST) between the two groups (Table 1). Comparing the isolation rate between cases and controls in two age groups of less than 1 and 1–5 years of age. Only, EAEC was more frequently isolated among both patients less than 1 year (OR: 4.8, CI: 1.6 –14.2) and 1–5 years (OR: 3.3, CI: 1.3– 8.2), compared with controls. Isolation rate of STEC (stx1) (OR: 4.1; CI: 1.1–15.9), STEC (stx2) (OR: 2.2, CI: 1.8 –2.7), and ETEC (LT) (OR: 5.7, CI: 1.5–21.5) were higher only in patients younger than 1 year of age compared with matched controls. Table 1. Diarrheagenic E. coli in children with acute diarrhea and controls Pathogen
Case
Control
OR*
CI (95%)†
EAEC ETEC (LT) STEC (stx1) STEC (stx2) EPEC ETEC (ST)
38 (37.3%) 18 (17.6%) 17 (16.7%) 13 (12.7%) 10 (9.8%) 9 (8.8%)
14 (13.5%) 8 (7.7%) 5 (4.8%) 2 (1.9%) 10 (9.6%) 10 (9.6%)
3.8 2.6 4.0 7.4 1.0 0.9
2.0–7.6 1.0–6.2 1.4–11.2 1.6–34.0 0.4–2.6 1.6–34.0
*Odd’s ratio; † 95% confidence interval
Conclusions: Among diarrheagenic E. coli strains, EAEC, STEC (stx1 and stx2), and ETEC (LT) can be considered as significant diarrheal pathogens among children in this region.
216 COMPARISON OF POLYETHYLENE GLYCOL-ELECTROLYTE LAVAGE (PEG-EL) PREPARATION VERSUS STANDARD PREPARATION ON SMALL BOWEL MUCOSAL VISUALIZATION FOR WIRELESS CAPSULE ENDOSCOPY (WCE) Colm J. O’Loughlin, M.B., Andrew I. Sable, M.D., Waleed Alazmi, M.D., Jamie S. Barkin, M.D., M.A.C.G.*. University of Miami, Mount Sinai Medical Center, Miami, FL. Purpose: WCE is an exciting new technology allowing evaluation of the small intestinal mucosa. Unfortunately, similar to standard endoscopy, WCE studies may be limited by endoluminal debris. The purpose of this prospective, blinded study was to compare standard preparation consisting of a clear liquid diet and an overnight fast followed by simethicone just prior to capsule ingestion to standard preparation plus PEG-EL for effect on intestinal visualization by WCE. Methods: Forty-six WCE recordings from patients undergoing capsule endoscopy to evaluate obscure gastrointestinal bleeding (OGIB) were reviewed by three gastroenterologists, blinded as to whether the patients had received PEG-EL or not prior to the procedure. Each study was scored individually and ranked as follows; good/excellent: clean small bowel/ minimal liquid or bubbles present/unlikely that mucosal lesions were missed; fair/inadequate: mucosal areas obscured by small bowel contents and/or debris resulting in possible missed areas/repeat exam required. The small intestinal emptying time (SIET) for each study was recorded by the primary investigator. All patients underwent standard preparation consisting of an overnight fast, preceeded by clear liquid diet, and simethicone elixir ⬍30 minutes prior to capsule ingestion. The PEG-EL group received, in addition to standard preparation, 2 liters of PEG-EL consumed between 16:00 hours and 18:00 hours the day prior to WCE. Results: Of the 46 patient recordings viewed (age range 26 – 84 yrs, 53% male) 25 received preparation with PEG-EL in addition to standard preparation and 21 received standard preparation alone. All 25 patients completed the PEG-EL preparation without difficulty. There were no significant side-effects reported. There was excellent agreement on small intestinal visualization among the endoscopists (⫽0.8). The examination was considered to be adequate, with no limitations in 22/25 patients who received
AJG – September, Suppl., 2003
PEG-EL and in 13/21 who underwent standard preparation only (P⬍0.05). The mean SIET in the PEG-EL group and in the standard preparation group was 4hrs 13mins amd 4hrs 9mins respectively (NS). Conclusions: Preparation with PEG-EL prior to WCE significantly improves small bowel visualization and should be utilized in all patients. 217 LYMPHOCYTIC DUODENITIS: A POSSIBLE PREDICTOR OF RESPONSE TO GLUTEN WITHDRAWAL IN PATIENTS WITH FUNCTIONAL GI DISEASE Sanjay K. Reddy, M.D., Thomas Park, M.D., Emeka C. Eze, M.D., Shriram Jakate, M.D., Satyajit Deshmukh, M.D., Susan L. Mikolaitis, R.D., Mark T. DeMeo, M.D., Ali Keshavarzian, M.D.*. Rush University, Chicago, IL. Purpose: There is an increasing awareness of the prevalence of Celiac Disease in populations beyond traditional at-risk groups. Increased intraepithelial lymphocytes (IEL’s) and increased lamina propria cellularity (lymphocytic duodenitis (LD)) may represent early gluten-mediated damage. We assessed the role of gluten withdrawal in patients with various GI symptoms found to have LD. Methods: 93 patients with LD diagnosed during evaluation of functional GI complaints were given a standard survey by phone including Rome 2, quality of life (QoL) SF12, and response to gluten free diet (GFD). LD was defined as greater than 40 –100 IEL’s per high power field, in the absence of villous atrophy, by our dedicated GI pathologist who was blinded to subsequent therapy. GI symptoms were classified by Rome 2 into ‘IBS’ and ‘minor’ (remaining) functional categories. Results: 87 of 93 (94%) of patients fulfilled Rome 2 criteria for functional bowel disease (48% IBS/45% ‘minor’ disorders). 63 of 93 (67%) were started on GFD. 42 of 63 (66%) responded to therapy with GFD. The group who responded to therapy had significant improvement in QoL score, and rated the diet manageable. The diagnosis of IBS and ‘minor’ disorders were unchanged in the diet-unresponsive group; in contrast, none of the subjects responding to GFD had IBS after therapy (and only 18 of 42 (42%) had ‘minor’ diagnosis post-GFD). The post-treatment presence of functional GI disorders in the group not receiving GFD decreased only 16%. Age, gender, presenting Rome 2 classification, and length of GFD failed to predict response. Conclusions: GFD in this group of patients with LD leads to decreased functional symptoms and an improvement in QoL scores. Biopsy for diagnosis of LD may lead to changes in therapy for functional bowel patients. Although no clinical features seem to predict response to gluten withdrawal, a trial of GFD would seem reasonable in this population. A placebo-controlled, randomized trial is needed to define the efficacy of gluten withdrawal therapy in functional patients with histology consistent with lymphocytic duodenitis. 218 A TALE OF TWO CITIES: TYPICAL CELIAC SPRUE PRESENTING SYMPTOMS ARE SIGNFICANTLY MORE COMMON IN TURKISH THAN IN U.S. PATIENTS Murat Palabiyikoglu, M.D., V.A. Botoman, M.D.*, Sahin Coban, M.D., Gregory F. Bonner, M.D., Sherry Woodhouse, M.D. Cleveland Clinic Florida, Weston, FL and University of Ankara, Ankara, Turkey. Aim: Recent studies suggest an increasing prevalence of atypical initial presenting symptoms of celiac disease in Western countries. We aimed to compare the presenting symptoms of celiac disease at two comparable referral institutions: one in South Florida (SFL) and one in Ankara, Turkey (ANK). Materials and Methods: We retrospectively reviewed the records from 1991-2001 at Cleveland Clinic Florida and University of Ankara for patients with an initial diagnosis of celiac disease by small bowel biopsy. We tabulated patient demographics, typical (chronic diarrhea, weight loss, steatorrhea) and atypical symptoms and findings (anemia, fatigue, osteopenia, abdominal pain, short stature, infertility) in both groups. A numerical
Abstracts
S75
score 1 was assigned to symptom/signs in each typical (0 –3) and atypical (0 – 6) symptom group. The presentations and findings between the Turkish and American patients at diagnosis were compared using: two-tailed t-test and Fisher’s exact test—(InStat v.3.0). Results: There were 28 pts in the SFL group(51% men) and 40 pts in the ANK(35% men)-p⫽NS. The Turkish pts were significantly younger at diagnosis-⌾36⫾ 2yrs vs. US pts- ⌾66⫾3yrs p⬍0.0001. Typical symptoms scores were similar- ANK ⌾1.1⫾0.2 vs SFL ⌾1.3⫾0.3 patients p⫽NS. Atypical symptom scores were significantly higher the US pts: ANK ⌾1.2⫾0.1 vs SFL ⌾1.9⫾0.2—p⬍0.01. Significant differences (p⬍0.01) in the incidence of symptoms/signs were seen for: chronic diarrhea (ANK 95% vs. SFL 50%), Albumin ⬍3.5g (ANK 30% vs. SFL 4%), and mean red blood cell MCV (ANK MCV ⌾77⫾2.2 vs. SFL MCV ⌾86⫾1.8). Conclusions: Although retrospective, this study points to striking differences in the clinical presentation of celiac disease in pts in South Florida and Ankara Turkey. South Florida patients were significantly older at diagnosis, and more likely to present with atypical symptoms. Turkish patients were much younger, and more likely to present with chronic diarrhea, hypoalbuminemia, and microcytosis—as was more commonly seen in the US in the 1960’s and 70’s. These findings raise the question of an interplay of demographics with diet and genetics in the presenting symptoms celiac disease in these two distant geographic areas.(all data mean ⌾⫾SEM). 219 PREVALENCE OF NON-HELICOBACTER PYLORI DUODENAL ULCER IN KARACHI, PAKISTAN Wasim Jafri, F.R.C.P., FACG*, Javed Yakoob, Ph.D., Nadim Jafri, F.C.P.S., Shahab Abid, F.C.P.S., Saeed Hamid, F.R.C.P., FACG, Hasnain Alishah, F.R.C.P., FACG. Aga Khan University Hospital, Karachi, Sindh, Pakistan. Purpose: To determine the prevalence of non-Helicobacter pylori (H. pylori) non-NSAID related duodenal ulcers in patients with acid-peptic disease. Methods: Medical records of patients who attended gastroenterology department at Aga Khan University hospital from 1999 –2001 and had endoscopic diagnosis of duodenal ulcers were reviewed. Duodenal ulcer associated with Helicobacter pylori (H. pylori) infection were diagnosed on the basis of EGD, rapid urease test and histopathology where as history of NSAIDs use defined NSAIDs-related duodenal ulcer. Non- H. pylori nonNSAID duodenal ulcers were those without H. pylori infection and history of NSAIDs intake. Co-morbid conditions noted in these cases included hypertension, ischemic heart disease, diabetes mellitus, dyslipidemia, prosthetic heart valves, depression, arthritis and tuberculosis. Results: Acid-peptic disease was diagnosed in 2260 patients and 9.6% (217/2260) had duodenal ulcer. H. pylori infection related duodenal ulcer were 61.3% (133/217), non-H. pylori non-NSAID 28.5% (62/217) and NSAID- related 18% (39/217). Past history of peptic ulcer disease was present in 15.2 % (33/217) cases with H. pylori infection 66.6% (22/33) and 18% (6/33) in non-H. pylori non-NSAIDs ulcer. Co-morbid conditions in H. pylori infection were 54% (26/48) and 31.2% (15/48) in non-H. pylori non-NSAID ulcer. Conclusions: Duodenal ulcers are common in association with H. pylori infection. In the presence of co-morbid conditions non- H. pylori nonNSAID duodenal ulcer is not a more likely possibility in our patients.
220 CAPSULE ENDOSCOPY [CE] IN THE DETECTION AND MANAGEMENT OF NSAID INDUCED INJURY OF THE SMALL INTESTINE Faisal M. Bhinder, M.D., David R. Cave, M.D.*, Douglas Schneider, M.D., Roger Mitty, M.D., Renee Wolff, M.D., Kent Ferris, M.D. St. Elizabeth’s Medical Center, Boston, MA and GI Assoc., Knoxville, TN.