Repeat Gastroscopy After Initial Diagnosis of Benign Gastric Ulcer Has a Low Yield of Detecting Cancer

Abstracts

disease in juvenile patients. The aim of this study is to evaluate both characteristics of small bowel disease and usefulness of CE and DBE in juveniles. Methods: From August 2003 through June 2007, CE (PillCamTMSB, Given Imaging Ltd. Israel) and/ or DBE (EN-450P5, EN-450T5, Fujinon Co., Saitama, Japan) was performed in 16 juvenile patients suspicious of small bowel disease (7 male, 9 female; mean age 19.3 years, range 11-22 years). Twelve of 16 patients underwent CE whereas 9 patients did DBE, that is, 5 patients had both exam. Results: The reasons for the study were gastrointestinal bleeding (n Z 7), multiple colon polyps(n Z 4), unexplained abdominal pain (n Z 3), and chronic diarrhea(n Z 2). Small bowel abnormalities were detected using CE in 7 (58%) of the 12 patients and in 7 (78%) of the 9 patients using DBE.(Table). Among the 5 patients performed with both examination, 2 patients had small bowel ulcers and 1 patient showed no abnormality with both examination. One patient had small bowel erosion detected only in CE finding and another patient had vascular malformation was seen only in DBE. The final diagnosis of 16 patients were made as small bowel erosion or ulcers (n Z 4), Peutz-Jegher syndrome (n Z 2), Crohn’s disease (n Z 2), hyperplastic polyposis (n Z 2), vascular malformation(n Z 2) and peri-appendiceal abscess (n Z 1). Other three patients did not have any abnormalities in both exams. There were no any serious complications including bleeding, retention or perforation. Conclusion: Similar to pattern in adults, Our study showed various small bowel disease in juvenile patients suggesting CE and DBE as useful and well-tolerated method with a high diagnostic yield for the management of suspected small bowel disease in juveniles. Endoscopic findings

CE (N Z 12) DBE (N Z 9)

Erosion or ulcer

Polyp Lymphoid hyperplasia

Angiodysplasia

Ileal edema & extrinsic compression

Nonspecific finding

4

1

1

1

0

5

4

1

0

1

1

2

T1670 Trends in Epidemiology and Therapy of Upper Gastrointestinal Hemorrhage from Gastroduodenal Ulcer Disease - The UT Southwestern GI Bleed Team Experience Luis F. Lara, Jayaprakash Sreenarasimhaiah, Shou Jiang Tang, Samir Gupta, Prabhakar P. Swaroop, William C. Santangelo, William M. Lee, Don C. Rockey Introduction: The incidence of gastric ulcer is increasing, while duodenal ulcer is becoming less frequent. Large studies report primary hemostasis rates of 80-90% in patients with gastroduodenal ulcer disease. We hypothesized that implementation of an organized team approach would improve primary hemostasis rates, and now report this experience. Methods: The UTSW GI Bleed Team was initiated 1/06 in an effort to improve patient care, and to study GI bleeding (GIB). Patients with any form of GI bleeding resulting in endoscopy are prospectively registered in a database. Patients with duodenal ulcer (DU) and gastric ulcer (GU) were identified. A retrospective cohort of patients was also identified by searching ICD-9 codes for gastroduodenal ulcer from 9/03 through 12/05 and hemostasis rates were compared among the two study periods. Results: In the prospective analysis, 522 patients were evaluated. 109 (21%) were diagnosed with PUD, 40 (8%) with DU and 69 (13%) with GU. Characteristics (age, sex, ASA/NSAID use, hemoglobin, blood transfusions, INR, and Rockall score) were similar between DU and GU. 15/40 (38%) DU and 28/69 (41%) GU underwent endoscopic therapy. The different types of therapy used are shown in the table. Primary hemostasis was achieved in 13/15 (87%) DU and 23/28 (82%) GU (p O 0.5). For DU, primary hemostasis was lowest for BiCap/epinephrine (epi) (75%) and epi alone (80%), and for GU it was lowest for heater probe (HP) alone or with epi (0%), and BiCap/epi (78%). Primary hemoclip (HC) therapy was successful in 100% patients. Of the two DU failures, one had successful rescue hemoclip (HC) therapy, the other failed arterial embolization and had surgery. Of the five GU failures, four had successful HC rescue therapy and one successful embolization. 69 patients with PUD were retrospectively identified from 9/03 through 12/05. Primary hemostasis was successful in 91% of patients, lowest for BiCap/epi (67%). Of the six failures, five had successful rescue therapy with HC. Conclusion: GU was the most common cause of ulcer related upper GIB in the prospective cohort. The rate of successful hemostasis was similar in the two periods, but HC was used more frequently in the more recent era. Primary hemostasis rates were best when hemoclips were used, and HC’s were the preferred therapy for failures. The implication that primary hemostasis rates may be better with HC needs to be weighed against cost and other factors. Endoscopic Therapy Prospective Retrospective

HC

HC/epi

Epi

HP

HP/epi

BiCap

BiCap/epi

PH

RH

7 2

8 4

9 12

2 1

3 36

1 3

13 11

84% 91%

71% 83%

PH: primary hemostasis; RH: rescue hemostasis

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T1671 Repeat Gastroscopy After Initial Diagnosis of Benign Gastric Ulcer Has a Low Yield of Detecting Cancer Sam Al-Sohaily, Vid P. Suttor, Robert G. Batey, Rupert W. Leong Introduction and Aims: A repeat gastroscopy to ensure ulcer healing and to exclude malignancy is the standard of care after treating patients with gastric ulcers (GU). The quality of modern gastroscopy has improved significantly, allowing superior assessment of GU and exclusion of gastric cancer on initial endoscopy. This study questions the need of a repeat endoscopy following the initial diagnosis of a benign GU. Methods: A 12 month retrospective review of consecutive patients diagnosed with GU on gastroscopy was conducted. Predictors of malignant GU were evaluated. Results: From Jan 2006 to Jan 2007, 130 patients with GU were included (54% males, mean age 64 years, main indication was GI bleeding). On initial endoscopy, the appearance was suspicious of malignancy in 10 patients (7.6%). 7 were confirmed to be adenocarcinoma on biopsy. The other 3 were benign on extensive biopsies on multiple occasions. EUS and/or confocal endomicroscopy were used on some of the suspicious looking ulcers to further assess their nature. The statistically significant predictors of malignant GU were ulcer location and ulcer size. Malignant GU was located in the body in 70% (P Z 0.002). The mean size of malignant GU was 3.4 cm and for benign GU it was 0.9 cm (P !0.0001). Only 14% of benign GU were larger than 1 cm, while malignant GU were larger than 1 cm in 71% (P Z 0.0001). The commonest site for benign ulcer was the antrum and prepylorus (75%). Patient presentation, age, and gender were not statistically different between benign and malignant GU. Fifty seven patients had repeat gastroscopy with a mean interval of 3 months (range 1 week - 6 months). On repeat gastroscopy, only 6 patients had residual GU R0.5 cm or new findings, while 52 patients (92%) had near or complete healing with or without residual scarring. No patients had gastric cancer on repeat gastroscopy. Conclusions: Repeat endoscopy for documentation of GU healing in the absence of suspicious features has a low yield of diagnosing cancer. The main predictors of malignant GU are site and size of the ulcer. The absence of malignant features on endoscopy and biopsy is reassuring. In our series, all benign GU on initial gastroscopy remained benign on repeat endoscopy. The cost effectiveness of the current approach of repeat endoscopy is questionable.

T1672 Helicobacter Pylori Diversity in Gastric Cancer and GERD Among Singapore Chinese Population Kwong Ming Fock, Dhamodaran Subbiah, Eng Kiong Teo, Tiing Leong Ang Introduction: H.pylori (Hp) infection leads to divergent clinical outcomes like PUD, chronic gastritis, gastric cancers (GC) and GERD. Bacterial factors, host factors, combination of both and environmental factors play major role in establishing the disease. We hypothesize that diverse genetic factors cause GC and GERD in our population. Aim: To determine various genotypes associated with GC and GERD among Singaporean Chinese population. Materials & Methods: H.pylori was cultured from 182 Chinese patients (52GC, 70 gastritis & 60 GERD) were analyzed in this prospective, on-going study. DNA was extracted, sequence analysis and genotyping was performed using specific gene primers of various virulence factors such as cagPAI, vacAs1, s2, m1, m2, cagE, babA2, sabA and oipA. Results: Univariate and multivariate analysis revealed that cagPAI, cagE, babA2, sabA and oipA were significant among GC when compared with gastritis (p ! 0.001). oipA ‘‘on’’ status was significantly associated with expression of cagPAI and suppression of sabA (p ! 0.01). Sequence analysis of representative Hp strains indicated that cagPAI, cagE, babA2, sabA and oipA oipA exhibited O92% identity to previously published data. Univariate analysis of GERD revealed that cagE, babA2 and oipA were significant (P ! 0.01), whereas, multivariate analysis revealed that none of the genotypes were significant. Conclusion: Our ongoing, prospective study indicates that Hp genetic diversity is related to clinical presentation. Virulence factors associated with GC were: CagPAI, CagE and outer membrane proteins (SabA, OipA, babA2). Host factors may have a moderating role in the clinical manifestation of Hp infection. Majority of oipA genotype is detected at functional status. The ‘‘on’’ status was significantly related to gastric cancer. This could probably be associated with enhanced interleukin-8 secretion and inflammation, important at initial stages of disease process. Further studies will be focused on measurement of levels of interleukin, OipA proteins or anti-OipA antibody in patients’ sera, pathological assessment & oipA functional status and disease presentation. Hp strains from GERD patients did not significantly express any of the genotypes when compared to NUD patients. Our study suggests these genotypes may protect against the development of GERD in our population. References: (1) Yamaoka Y, Kwon DH and Graham DY (2002). A Mr 34,000 proinflammatory outer membrane protein (oipA) of Hp. PNAS 20:7533-7538. (2) Yamaoka Y, Kikuchi S, El-Zimaity H. M, et al (2002). Importance of Hp oipA in clinical presentation, gastric inflammation, and mucosal interleukin-8 production. Gastroenterol 123:414-424.

T1673 Validation in the Usual Practice of a Simultaneous Urea Breath Test During the Urgent Gastroscopy in the Peptic Bleeding Benito Velayos, Luis Fernandez, Ana Almaraz, Rocı´O Aller, Lourdes Olmo, Fernando Calle, Teresa Arranz, Jose Manuel Gonzalez Background: The diagnosis of the Helicobacter pylori (HP) infection in the upper gastrointestinal bleeding is cost-effectiveness. Nevertheless, the blood located in the stomach reduces the accuracy of the direct methods. Moreover, the early use

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