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Tu2054 Shunt Surgery for Extra Hepatic Portal Venous Obstruction: Keeping It Simple
AGA Abstracts
bleeds in two patients were found. Univariate analysis identified seven factors which influenced post treatment bleeding: male (p=0.042), emergency case (p ,0.001), EVL (p=0.001), the presence of Red Color Sign (p=0.009), Child Pugh grade B or C (p ,0.001), the presence of hepatocellular carcinoma (HCC) (p=0.005), and younger age (p=0.003). There was no significant difference between patients with and without hemophilia (p=0.197). On multivariate analysis, emergency case (p=0.01), the presence of HCC (p ,0.01), and younger age (p=0.01) were significantly associated with early bleeding. Conclusion: Under appropriate clotting factor replacement therapy, hemophiliac patients can be received endoscopic variceal treatment. Tu2054 BM=bowel movement Table 2. Summary of Intervention Trials
Shunt Surgery for Extra Hepatic Portal Venous Obstruction: Keeping It Simple Virandera P. Bhalla, Jagdish C. Vij, Ravindra Vats, Deep Goel Aim To present a simple cost effective and innovative approach for surgical shunting to lower portal pressures and compare the same with the more complex REX shunt. Background Beginning with the Eck fistula, surgical shunts for lowering portal pressures have always been an interesting proposition. During the 80's and 90's many centres had impressive series of portosystemic shunts. About this time endoscopic management strategies developed rapidly and proved invaluable in management of bleeding varices associated with portal hypertension (PHT) and interest in surgical shunting waned. Introduction of the REX shunt for bypassing an extrahepatic portal block by performing a mesenterico left portal shunt has again brought surgery for patients with extrahepatic portal obstruction with good liver function back into reckoning. The REX shunt was initially described for paediatric patients with extrahepatic obstruction. While it is a good shunt to lower portal pressure even while it maintains hepatofugal blood flow it is challenging to plan and technically demanding to learn and perform. Indian experience suggests that the proximal leinorenal shunt is a simpler shunt which is relatively easy to learn and do. There is no need for elaborate imaging studies to plan the shunt and often a simple abdominal ultrasonography has been used for planning surgery. Also pressure monitoring including wedge hepatic venous pressure gradient is possibly not essential in making management decisions for diagnosed PHT with good liver function. Compared to this the Rex shunt needs elaborate angiography and involves operating in the region of the porta hepatis often in the presence of collaterals. The left portal branch may also be involved by the extending main portal vein thrombus and there is a need for an interposition autologous or synthetic graft. Patients and methods The comparison with the REX shunt is based on a twenty year experience from 1993-2012 of 92 patients who underwent surgical shunting for portal hypertension with good liver function. The commonest causes of PHT were portal vein thrombosis and non cirrhotic portal fibrosis in 72/ 92 cases. GI bleeding in 66/92 patients was the commonest indication for shunting. Diagnosis of PHT in a patient with a GI bleed was based on the presence of splenomegaly on clinical examination and demonstrated esophageal varices on endoscopy. The abdominal ultrasound provided adequate information to plan surgery. The procedure performed was splenectomy with a Proximal Leino Renal shunt. No routine post shunt anticoagulation was used. No post shunt hepatic encephalopathy was encountered in this group. Shunt patency rate was 86% at one year follow up. Conclusion The simple management plan suggested may well be a better treatment option than the REX shunt.
BM = bowel movement Tu2056 Antibodies to Cytolethal Distending Toxin B and Auto-Antibodies to Human Vinculin Are Elevated in IBS Subjects Walter Morales, Emily Marsh, Zachary Marsh, Stacy Weitsman, Gene Kim, Christopher Chang, Mark Pimentel
Tu2055 Effect of Opioids on the Gastrointestinal Tract: A Systematic Review David Lin, Christopher Stave, Lauren B. Gerson
Recent data support that irritable bowel syndrome (IBS) can develop after gastroenteritis. In an animal model of post-infectious IBS, cytolethal distending toxin B (CdtB) appears to be important in the development of IBS and small intestinal bacterial overgrowth (SIBO). In this animal model, antibodies to CdtB bind neurological elements in the gut wall including interstitial cells of Cajal (ICC) and ganglia through a process of molecular mimicry/ autoimmunity. The protein on these nerves to which this mimicry occurs was found to be vinculin, and antibodies to vinculin predict SIBO in rats. In this study, we translate these antibody tests to humans to determine the titers of anti-CdtB and anti-vinculin antibodies in the serum of subjects with IBS and inflammatory bowel disease (IBD). Methods: Consecutive IBS subjects meeting Rome III criteria were recruited from a GI Motility clinic (n=45). In addition, 30 subjects with IBD were recruited from a tertiary care IBD clinic. Finally, 20 healthy controls were identified based on a negative symptom questionnaire. All subjects were consented and serum samples were obtained. An enzyme-linked immunosorbent assay (ELISA) was created by coating 96 well plates with either 0.4μg of recombinant vinculin or 0.4μg/mL of purified CdtB per well. Serum from each subject was added to the wells and incubated for 90 minutes. The wells were washed and then secondary antibodies were added to each well. The optical density (OD) measures were determined using a plate reader. Results: In plates coated with CdtB, the mean OD for IBS serum was 1.89±0.12. This was significantly greater than for subjects with IBD (1.35±0.22) (P ,0.05) or healthy controls (1.46±0.20) (P,0.05). In plates coated with vinculin, the mean OD for IBS serum was 0.53±0.07. This was significantly greater than for subjects with IBD (0.21±0.09) (P ,0.05). There was a trend for a difference from healthy controls (0.31±0.10) (P=0.11). There was no difference between IBS-C or IBS-D for either antibody. Conclusions: Both anti-CdtB and autoimmune anti-vinculin antibodies are detectable in IBS subjects and are seen to be elevated in IBS compared to controls and IBD. The detection of anti-CdtB and anti-vinculin suggest new clues to the diagnosis and pathophysiology of IBS. This is the first study to link acute gastroenteritis to an autoimmune process in IBS.
Background: The usage of opioids has been gradually increasing in the US, and narcotics are frequently prescribed for relief of chronic abdominal pain (Dorn, CGH 2012). Administration of opioids has been associated with narcotic-induced gastroparesis, small and large bowel dysfunction, and hyperalgesia syndrome. We performed a systemic review to determine the prevalence of these conditions and the effectiveness of available medical therapies. Methods: We performed a literature search using Pubmed (1950-present), SCOPUS (1823present), and the following search terms: "analgesics", "opioid/adverse effects", "nausea and /or vomiting", "hyperalgesia", "gastroparesis", "constipation", "bowel", "gastrointestinal disease" and "therapy." We used an evidence based approach to the literature using a standard grading system (Guyatt, BMJ 2008) where Evidence Level A was data from randomized controlled trials, and Level B from case-controlled studies. Results: Of the initial 600 publications, 416 remained after exclusion of duplications. The number of articles were excluded for the following reasons: Reviews and editorials (214), case reports/series (31), basic science or animal studies (64), or topic of post-operative ileus (11). Of the remaining publications, those pertaining to prevalence of opioid-induced bowel dysfunction and/or therapeutics targeting opioid-induced bowel dysfunction resulted in 26 articles. One article was excluded since it only listed prevalence of combined nausea and vomiting. Four case-control studies including 2592 opioid users described prevalence of gastrointestinal symptoms as shown in Table 1. Constipation was reported in approximately 49% of patients, abdominal pain in 45%, straining in 44% and bloating in 30%. No studies described prevalence of narcoticinduced gastroparesis, measured by gastric scintigraphy, however nausea was reported by a mean of 21% and vomiting in 9% of the cohort. Table 2 contains a summary of the intervention trials for narcotic-induced bowel dysfunction. Limited randomized controlled (RCT) data demonstrated efficacy for ondansetron and droperidol in the reduction of nausea and emesis. For constipation, the usage of alvimopan in 4 RCTs demonstrated efficacy compared to placebo for the percentage of patients reporting more than 3 BM/week (64±8% versus 43±11%, p=0.02). Subcutaneous methylnaltrexone in 6 clinical trials demonstrated efficacy compared to placebo regarding time to first bowel movement (mean 65%±30% versus 11%±20% for placebo, p=0.01). Conclusions: Significant gastrointestinal symptoms are reported in approximately 50% of subjects using opioids. The usage of opioid receptor antagonists have been shown to be beneficial for relief of narcotic-induced constipation. Therapies for upper gastrointestinal tract symptoms and narcotic-induced bowel dysfunction remain limited. Table 1. Prevalence of Gastrointestinal Symptoms in Opioid Users
AGA Abstracts
S-914
bleeds in two patients were found. Univariate analysis identified seven factors which influenced post treatment bleeding: male (p=0.042), emergency case (p ,0.001), EVL (p=0.001), the presence of Red Color Sign (p=0.009), Child Pugh grade B or C (p ,0.001), the presence of hepatocellular carcinoma (HCC) (p=0.005), and younger age (p=0.003). There was no significant difference between patients with and without hemophilia (p=0.197). On multivariate analysis, emergency case (p=0.01), the presence of HCC (p ,0.01), and younger age (p=0.01) were significantly associated with early bleeding. Conclusion: Under appropriate clotting factor replacement therapy, hemophiliac patients can be received endoscopic variceal treatment. Tu2054 BM=bowel movement Table 2. Summary of Intervention Trials
Shunt Surgery for Extra Hepatic Portal Venous Obstruction: Keeping It Simple Virandera P. Bhalla, Jagdish C. Vij, Ravindra Vats, Deep Goel Aim To present a simple cost effective and innovative approach for surgical shunting to lower portal pressures and compare the same with the more complex REX shunt. Background Beginning with the Eck fistula, surgical shunts for lowering portal pressures have always been an interesting proposition. During the 80's and 90's many centres had impressive series of portosystemic shunts. About this time endoscopic management strategies developed rapidly and proved invaluable in management of bleeding varices associated with portal hypertension (PHT) and interest in surgical shunting waned. Introduction of the REX shunt for bypassing an extrahepatic portal block by performing a mesenterico left portal shunt has again brought surgery for patients with extrahepatic portal obstruction with good liver function back into reckoning. The REX shunt was initially described for paediatric patients with extrahepatic obstruction. While it is a good shunt to lower portal pressure even while it maintains hepatofugal blood flow it is challenging to plan and technically demanding to learn and perform. Indian experience suggests that the proximal leinorenal shunt is a simpler shunt which is relatively easy to learn and do. There is no need for elaborate imaging studies to plan the shunt and often a simple abdominal ultrasonography has been used for planning surgery. Also pressure monitoring including wedge hepatic venous pressure gradient is possibly not essential in making management decisions for diagnosed PHT with good liver function. Compared to this the Rex shunt needs elaborate angiography and involves operating in the region of the porta hepatis often in the presence of collaterals. The left portal branch may also be involved by the extending main portal vein thrombus and there is a need for an interposition autologous or synthetic graft. Patients and methods The comparison with the REX shunt is based on a twenty year experience from 1993-2012 of 92 patients who underwent surgical shunting for portal hypertension with good liver function. The commonest causes of PHT were portal vein thrombosis and non cirrhotic portal fibrosis in 72/ 92 cases. GI bleeding in 66/92 patients was the commonest indication for shunting. Diagnosis of PHT in a patient with a GI bleed was based on the presence of splenomegaly on clinical examination and demonstrated esophageal varices on endoscopy. The abdominal ultrasound provided adequate information to plan surgery. The procedure performed was splenectomy with a Proximal Leino Renal shunt. No routine post shunt anticoagulation was used. No post shunt hepatic encephalopathy was encountered in this group. Shunt patency rate was 86% at one year follow up. Conclusion The simple management plan suggested may well be a better treatment option than the REX shunt.
BM = bowel movement Tu2056 Antibodies to Cytolethal Distending Toxin B and Auto-Antibodies to Human Vinculin Are Elevated in IBS Subjects Walter Morales, Emily Marsh, Zachary Marsh, Stacy Weitsman, Gene Kim, Christopher Chang, Mark Pimentel
Tu2055 Effect of Opioids on the Gastrointestinal Tract: A Systematic Review David Lin, Christopher Stave, Lauren B. Gerson
Recent data support that irritable bowel syndrome (IBS) can develop after gastroenteritis. In an animal model of post-infectious IBS, cytolethal distending toxin B (CdtB) appears to be important in the development of IBS and small intestinal bacterial overgrowth (SIBO). In this animal model, antibodies to CdtB bind neurological elements in the gut wall including interstitial cells of Cajal (ICC) and ganglia through a process of molecular mimicry/ autoimmunity. The protein on these nerves to which this mimicry occurs was found to be vinculin, and antibodies to vinculin predict SIBO in rats. In this study, we translate these antibody tests to humans to determine the titers of anti-CdtB and anti-vinculin antibodies in the serum of subjects with IBS and inflammatory bowel disease (IBD). Methods: Consecutive IBS subjects meeting Rome III criteria were recruited from a GI Motility clinic (n=45). In addition, 30 subjects with IBD were recruited from a tertiary care IBD clinic. Finally, 20 healthy controls were identified based on a negative symptom questionnaire. All subjects were consented and serum samples were obtained. An enzyme-linked immunosorbent assay (ELISA) was created by coating 96 well plates with either 0.4μg of recombinant vinculin or 0.4μg/mL of purified CdtB per well. Serum from each subject was added to the wells and incubated for 90 minutes. The wells were washed and then secondary antibodies were added to each well. The optical density (OD) measures were determined using a plate reader. Results: In plates coated with CdtB, the mean OD for IBS serum was 1.89±0.12. This was significantly greater than for subjects with IBD (1.35±0.22) (P ,0.05) or healthy controls (1.46±0.20) (P,0.05). In plates coated with vinculin, the mean OD for IBS serum was 0.53±0.07. This was significantly greater than for subjects with IBD (0.21±0.09) (P ,0.05). There was a trend for a difference from healthy controls (0.31±0.10) (P=0.11). There was no difference between IBS-C or IBS-D for either antibody. Conclusions: Both anti-CdtB and autoimmune anti-vinculin antibodies are detectable in IBS subjects and are seen to be elevated in IBS compared to controls and IBD. The detection of anti-CdtB and anti-vinculin suggest new clues to the diagnosis and pathophysiology of IBS. This is the first study to link acute gastroenteritis to an autoimmune process in IBS.
Background: The usage of opioids has been gradually increasing in the US, and narcotics are frequently prescribed for relief of chronic abdominal pain (Dorn, CGH 2012). Administration of opioids has been associated with narcotic-induced gastroparesis, small and large bowel dysfunction, and hyperalgesia syndrome. We performed a systemic review to determine the prevalence of these conditions and the effectiveness of available medical therapies. Methods: We performed a literature search using Pubmed (1950-present), SCOPUS (1823present), and the following search terms: "analgesics", "opioid/adverse effects", "nausea and /or vomiting", "hyperalgesia", "gastroparesis", "constipation", "bowel", "gastrointestinal disease" and "therapy." We used an evidence based approach to the literature using a standard grading system (Guyatt, BMJ 2008) where Evidence Level A was data from randomized controlled trials, and Level B from case-controlled studies. Results: Of the initial 600 publications, 416 remained after exclusion of duplications. The number of articles were excluded for the following reasons: Reviews and editorials (214), case reports/series (31), basic science or animal studies (64), or topic of post-operative ileus (11). Of the remaining publications, those pertaining to prevalence of opioid-induced bowel dysfunction and/or therapeutics targeting opioid-induced bowel dysfunction resulted in 26 articles. One article was excluded since it only listed prevalence of combined nausea and vomiting. Four case-control studies including 2592 opioid users described prevalence of gastrointestinal symptoms as shown in Table 1. Constipation was reported in approximately 49% of patients, abdominal pain in 45%, straining in 44% and bloating in 30%. No studies described prevalence of narcoticinduced gastroparesis, measured by gastric scintigraphy, however nausea was reported by a mean of 21% and vomiting in 9% of the cohort. Table 2 contains a summary of the intervention trials for narcotic-induced bowel dysfunction. Limited randomized controlled (RCT) data demonstrated efficacy for ondansetron and droperidol in the reduction of nausea and emesis. For constipation, the usage of alvimopan in 4 RCTs demonstrated efficacy compared to placebo for the percentage of patients reporting more than 3 BM/week (64±8% versus 43±11%, p=0.02). Subcutaneous methylnaltrexone in 6 clinical trials demonstrated efficacy compared to placebo regarding time to first bowel movement (mean 65%±30% versus 11%±20% for placebo, p=0.01). Conclusions: Significant gastrointestinal symptoms are reported in approximately 50% of subjects using opioids. The usage of opioid receptor antagonists have been shown to be beneficial for relief of narcotic-induced constipation. Therapies for upper gastrointestinal tract symptoms and narcotic-induced bowel dysfunction remain limited. Table 1. Prevalence of Gastrointestinal Symptoms in Opioid Users
AGA Abstracts
S-914