- Email: [email protected]
W1309 CT Angiography and 24 Hours Tonometry: A Novel and Usefull Approach in the Diagnosis of Chronic Gastrointestinal Ischemia
1 patient with 3-vessel stenosis. Presenting symptoms were weight loss (80%), postprandial pain (75%) and diarrhea (20%). Treatment was performed in 18 patients (90%): PTA and stent placement in 13 and 5 patients had surgical revascularization. After a mean followup of 9 (1-24) months, 89% of patients were free of symptoms. Two patients were treated conservatively. The PPV of the consensus diagnosis is 89% with a NPV of 91%. Conclusions: The combination of 24hrTM and CTA provide a minimally invasive, reliable alternative diagnostic approach in patients suspected for CGI. This approach seems very useful in clinical practice and the main outcomes, in particular the association between the diagnostic test results and the outcome of treatment, are in line with earlier reports using the established approach. Consensus diagnosis CGI
The Role of Argon Plasma Coagulation (APC) in the Treatment of Chronic Radiation Proctitis Pierre Nel, Andrea Faris, Richmond G. Sy Radiation proctitis is a common complication of radiation treatment for pelvic malignancies. Approximately 5 to 20 % of patients who receive radiation treatment will develop chronic complications including bleeding, fistulae and stictures. To date there are no standard recommendations for the treatment of the chronic blood loss from radiation proctitis. Studied treatments, including hyperbaric oxygen, formaldehyde, 5-ASA have had varied results. Endoscopic treatment is gaining popularity in the treatment of radiation proctitis with both APC and bipolar heater probe being studied. A number of case reports suggest APC may be useful and safe in the treatment of chronic radiation proctitis. However none have utilized a validated scoring system for treatment effect.We plan to study both the endoscopic and the clinical response of APC in the treatment of rectal bleeding from radiation proctitis. Method: Patients referred from radiation oncology with chronic blood loss from suspected radiation proctitis were approached for consent to participate in this study. The patients baseline rectal bleeding was scored using a five point bleeding scale; the patient then underwent a colonoscopy to confirm the source of bleeding. The severity of radiation proctitis was scored using a validated scoring system - the rectal telangiectasia density grading score (RTG). Patients were then treated with APC and then re-evaluated in 8 weeks time. At this time, baseline bleeding score was obtained and RTG score evaluated with sigmoidoscopy. If further treatment was required the patient was again re-evaluated in 8 weeks time. Results: There were 19 patients enrolled in this study. Mean age was 72.1 (STD=8.0) and mean Hb is 134.2 g/l(STD=21.7). Three of them did not complete the study. Among the 16 patients who underwent the APC treatment, both the clinical bleeding score and RTG score were reduced after the treatment. The bleeding score reduced 0.93±1.34 (Mean ±STD), while the RTG score reduced 0.81±0.98 (Mean ±STD). The p-values for comparing the pre and post treatment bleeding and RTG scores were 0.02 and <0.01 (Wilcoxon signed ranked test) respectively. Conclusion: In this small prospective trial, APC treatment for radiation proctitis improves the clinical bleeding score and the endoscopic outcomes.
W1310 Relationship Between Colonic Motor Functions and Transit in Constipation. Karthik Ravi, Adil E. Bharucha, Michael Camilleri, Deborah L. Rhoten, Alan R. Zinsmeister The relationship between colonic transit and motility is incompletely understood. Aims To compare colonic motor functions in constipated patients with normal transit (NTC), isolated slow transit (STC), and pelvic floor dysfunctions without (PFD) or with (PFDSTC) delayed colonic transit. Methods - A barostat-manometric assembly was placed in the cleansed descending colon by endoscopy-fluoroscopy in 108 referred constipated patients without a known neuropathy or systemic disorder (102 F, age 38 ± 1 years; mean ± SEM). Colonic transit was assessed by scintigraphy. PFD was diagnosed by symptom criteria and 2 of 3 abnormal tests, i.e. anal resting pressure > 90 mmHg, abnormal rectal balloon expulsion, and defecography. Fasting colonic tone, tonic response to a 1000Kcal liquid meal (over 1 hour), and colonic pressure-volume relationships (balloon inflation from 0-44 mmHg in 4 mmHg increments at 1 min intervals) before and after neostigmine (1 mg i.v.)were measured. Analyses - Tonic response to a meal was analyzed as the symmetric percent change of post meal to pre-meal volume. Compliance curves were summarized by the Prhalf (the pressure at half maximum volume). Age-adjusted univariate and multiple logistic regression models were used to identify whether colonic compliance and tone were associated with abnormal colonic transit and/or pelvic floor dysfunctions, relative to the reference group (i.e., constipated patients with normal transit and anorectal functions). Results: Table shows summary data. The pre-neostigmine Prhalf was the only variable associated with abnormal colonic transit/anorectal functions by univariate and multiple variable analysis. A higher Prhalf was associated with a lower risk (OR, 0.73; 95% CI, 0.57 - 0.94) for PFDSTC, signifying that the Prhalf was lower (i.e., the colon was more compliant) in PFDSTC. Fasting colonic tone and colonic responses to a meal and neostigmine did not discriminate amongst categories. Conclusions: In constipation, there is considerable overlap in colonic motor functions amongst categories defined by colonic transit and anorectal functions. Colonic compliance was reduced, indicative of altered colonic biomechanical properties, in PFDSTC. Further studies are necessary to ascertain whether colonic motor dysfunctions in PFDSTC are reversible (e.g. after biofeedback therapy).
W1308 Small Bowel Disorders in Patients with Chronic Variable Immunodeficiency (CVID) - Capsule Endoscopy Findings Marc Karliova, Salama Abdulgabar, Verena K. Haas, Herbert Lochs, Winfried A. Voderholzer Background: The Chronic Variable Immunodeficiency (CVID) results from a currently undefined immune dysregulation, resulting in failed B cell differentiation with impaired secretion of immunoglobulins. It is characterized by markedly reduced serum levels of IgG (usually <400 mg/dL) and low IgA or IgM serum levels. Recurrent pulmonal infections, diarrhoea and malabsorbtion are typical clinical findings, however changes in small bowel morphology have not been adequately investigated. Patients and methods: Capsule endoscopy was performed (Olympus Endocapsule) in 10 consecutive patients (7 female, 3 male, age 50 (26-79) years) with CVID. All except one had a reduced IgG level (average 240mg/dl (700-1600)). In one patient only the subgroup IgG4 was reduced (3,5mg/dl (5-130)). In 7 patients IgA levels were reduced (average 9 mg/dl (70-400)) and in 5 patients also IgM levels were reduced (average 5 mg/dl (40-230)). All patients had a history of pulmonal infections, 7 had diarrhoea and 6 suffered from abdominal pain. In a subgroup of 5 patients intestinal permeability was determined by the lactulose/mannitol ratio. Results: A complete small bowel capsule endoscopy was possible in 9 out of the 10 patients. Six had lymphatic hyperplasia, in 3 patients aphtoid lesions similar to Crohn's disease could be seen, and one of them was eventually diagnosed Crohn's disease. Five patients had pinpoint lesions, and in another 5 cases lymphangiectasias were detected. One patient each showed erosions and a polyp. The intestinal permeability was increased in three patients. Most patients in our study population suffered from gastrointestinal symptoms. Small bowel capsule endoscopy revealed a high percentage of mucosal disorders. Conclusions: Different small intestinal lesions are a common finding in patients with CVID and may represent the morphological correlates of abdominal symptoms. The clinical relevance of these findings is unknown so far. However, there might be an association between Crohn's disease and CVID..
Values are Mean ± SEM
W1309
W1311
CT Angiography and 24 Hours Tonometry: A Novel and Usefull Approach in the Diagnosis of Chronic Gastrointestinal Ischemia Désirée van Noord, Peter B. Mensink, P. M. Pattynama, M. R. van Sambeek, E. J. Kuipers
The Anorectal and Colonic Functional Characteristics and the Effect of Biofeedback in Constipation with Spinal Cord Diseases Dong-Hoon Yang, Seung-Jae Myung, Kee Wook Jung, Benjamin Kim, Do Hoon Kim, Soon Man Yoon, Mi Young Do, In ja Yoon, Byong Duk Ye, Jeong-Sik Byeon, Hwoon-Yong Jung, Suk-Kyun Yang, Jin-Ho Kim
Background: The combination of duplex ultrasound, followed by conventional digital subtraction angiography of the abdominal arteries and gastric exercise tonometry (GET) is the established approach for patients suspected of chronic gastrointestinal ischemia (CGI). GET is cumbersome and impossible to perform in a considerable proportion of patients. Alternative diagnostic methods have recently been developed, in particular 24 hours gastric and jejunal tonometry (24hrTM) and computed tomography angiography (CTA). 24hrTM proved to be as accurate as GET for detection of CGI, while being less cumbersome and performable in every patient suspected of CGI. CTA seems a promising, minimally invasive technique to detect and define abdominal artery stenoses. Aim: We challenged the use of 24hrTM in combination with CTA as an alternative approach to evaluate patients suspected of CGI. Methods: Patients referred for evaluation of possible CGI were prospectively evaluated using CTA and 24hrTM. All patients were discussed in a multidisciplinary team (consisting of a vascular surgeon, interventional radiologist and gastroenterologist) and a consensus diagnosis was made. Patients with abdominal arterial stenosis on CTA and abnormal 24hrTM (i.e. GI ischemia) were advised to undergo treatment. The definitive diagnosis CGI was made after persistent symptom relief on follow-up. Results: Forty patients were enrolled; M/F 9/31, mean age 59 (20-87) yrs. A consensus diagnosis of CGI (Table) was made in 20 patients (87%): 11 patients with single vessel stenosis (celiac artery (CA) 9, superior mesenteric artery (SMA) 2), 8 with 2-vessel stenosis (CA+SMA 7, CA+inferior mesenteric artery 1) and
Background: Constipation is a major problem in spinal cord diseases often causing medically intractable condition. The aim of our study was to investigate the anorectal and colonic functional characteristics and the effect of biofeedback therapy in patients with spinal cord diseases. Patients and Methods: From June 2001 to June 2007, biofeedback therapy was done for 784 adults with constipation. Among these, 58 constipated patients with radiculopathy or myelopathy were enrolled as case group (mean age; 55.1±11.5 yrs). These patients were divided into myelopathy (n=16) and radiculopathy (n=42) group. The control group comprised 57 patients (mean age; 53.1±14.6 yrs) who fulfilled Rome III criteria for constipation without radiculopathy or myelopathy. They underwent colonic transit time (CTT), defecogram, and anorectal manometry (ARM) before biofeedback therapy. Before and after biofeedback therapy, all patients answered structured questionnaires on constipation derived from ROME III criteria. CTT results were described into normal, slow transit, pelvic outlet obstruction, and hindgut dysfunction. According to defecogram, patients were divided into normal, pelvic floor dysfunction, and hypertrophic anal sphincter. Results: CTT did not show significant difference between case and control group. However, rectosigmoid colonic transit time of myelopathy group was significantly delayed than those of radiculopathy and control group (myelopathy; 19.9±14.3 hr, radiculopathy; 13.1±11.5 hr, control; 10.9±12.2
A-677
AGA Abstracts
AGA Abstracts
W1307
The Role of Argon Plasma Coagulation (APC) in the Treatment of Chronic Radiation Proctitis Pierre Nel, Andrea Faris, Richmond G. Sy Radiation proctitis is a common complication of radiation treatment for pelvic malignancies. Approximately 5 to 20 % of patients who receive radiation treatment will develop chronic complications including bleeding, fistulae and stictures. To date there are no standard recommendations for the treatment of the chronic blood loss from radiation proctitis. Studied treatments, including hyperbaric oxygen, formaldehyde, 5-ASA have had varied results. Endoscopic treatment is gaining popularity in the treatment of radiation proctitis with both APC and bipolar heater probe being studied. A number of case reports suggest APC may be useful and safe in the treatment of chronic radiation proctitis. However none have utilized a validated scoring system for treatment effect.We plan to study both the endoscopic and the clinical response of APC in the treatment of rectal bleeding from radiation proctitis. Method: Patients referred from radiation oncology with chronic blood loss from suspected radiation proctitis were approached for consent to participate in this study. The patients baseline rectal bleeding was scored using a five point bleeding scale; the patient then underwent a colonoscopy to confirm the source of bleeding. The severity of radiation proctitis was scored using a validated scoring system - the rectal telangiectasia density grading score (RTG). Patients were then treated with APC and then re-evaluated in 8 weeks time. At this time, baseline bleeding score was obtained and RTG score evaluated with sigmoidoscopy. If further treatment was required the patient was again re-evaluated in 8 weeks time. Results: There were 19 patients enrolled in this study. Mean age was 72.1 (STD=8.0) and mean Hb is 134.2 g/l(STD=21.7). Three of them did not complete the study. Among the 16 patients who underwent the APC treatment, both the clinical bleeding score and RTG score were reduced after the treatment. The bleeding score reduced 0.93±1.34 (Mean ±STD), while the RTG score reduced 0.81±0.98 (Mean ±STD). The p-values for comparing the pre and post treatment bleeding and RTG scores were 0.02 and <0.01 (Wilcoxon signed ranked test) respectively. Conclusion: In this small prospective trial, APC treatment for radiation proctitis improves the clinical bleeding score and the endoscopic outcomes.
W1310 Relationship Between Colonic Motor Functions and Transit in Constipation. Karthik Ravi, Adil E. Bharucha, Michael Camilleri, Deborah L. Rhoten, Alan R. Zinsmeister The relationship between colonic transit and motility is incompletely understood. Aims To compare colonic motor functions in constipated patients with normal transit (NTC), isolated slow transit (STC), and pelvic floor dysfunctions without (PFD) or with (PFDSTC) delayed colonic transit. Methods - A barostat-manometric assembly was placed in the cleansed descending colon by endoscopy-fluoroscopy in 108 referred constipated patients without a known neuropathy or systemic disorder (102 F, age 38 ± 1 years; mean ± SEM). Colonic transit was assessed by scintigraphy. PFD was diagnosed by symptom criteria and 2 of 3 abnormal tests, i.e. anal resting pressure > 90 mmHg, abnormal rectal balloon expulsion, and defecography. Fasting colonic tone, tonic response to a 1000Kcal liquid meal (over 1 hour), and colonic pressure-volume relationships (balloon inflation from 0-44 mmHg in 4 mmHg increments at 1 min intervals) before and after neostigmine (1 mg i.v.)were measured. Analyses - Tonic response to a meal was analyzed as the symmetric percent change of post meal to pre-meal volume. Compliance curves were summarized by the Prhalf (the pressure at half maximum volume). Age-adjusted univariate and multiple logistic regression models were used to identify whether colonic compliance and tone were associated with abnormal colonic transit and/or pelvic floor dysfunctions, relative to the reference group (i.e., constipated patients with normal transit and anorectal functions). Results: Table shows summary data. The pre-neostigmine Prhalf was the only variable associated with abnormal colonic transit/anorectal functions by univariate and multiple variable analysis. A higher Prhalf was associated with a lower risk (OR, 0.73; 95% CI, 0.57 - 0.94) for PFDSTC, signifying that the Prhalf was lower (i.e., the colon was more compliant) in PFDSTC. Fasting colonic tone and colonic responses to a meal and neostigmine did not discriminate amongst categories. Conclusions: In constipation, there is considerable overlap in colonic motor functions amongst categories defined by colonic transit and anorectal functions. Colonic compliance was reduced, indicative of altered colonic biomechanical properties, in PFDSTC. Further studies are necessary to ascertain whether colonic motor dysfunctions in PFDSTC are reversible (e.g. after biofeedback therapy).
W1308 Small Bowel Disorders in Patients with Chronic Variable Immunodeficiency (CVID) - Capsule Endoscopy Findings Marc Karliova, Salama Abdulgabar, Verena K. Haas, Herbert Lochs, Winfried A. Voderholzer Background: The Chronic Variable Immunodeficiency (CVID) results from a currently undefined immune dysregulation, resulting in failed B cell differentiation with impaired secretion of immunoglobulins. It is characterized by markedly reduced serum levels of IgG (usually <400 mg/dL) and low IgA or IgM serum levels. Recurrent pulmonal infections, diarrhoea and malabsorbtion are typical clinical findings, however changes in small bowel morphology have not been adequately investigated. Patients and methods: Capsule endoscopy was performed (Olympus Endocapsule) in 10 consecutive patients (7 female, 3 male, age 50 (26-79) years) with CVID. All except one had a reduced IgG level (average 240mg/dl (700-1600)). In one patient only the subgroup IgG4 was reduced (3,5mg/dl (5-130)). In 7 patients IgA levels were reduced (average 9 mg/dl (70-400)) and in 5 patients also IgM levels were reduced (average 5 mg/dl (40-230)). All patients had a history of pulmonal infections, 7 had diarrhoea and 6 suffered from abdominal pain. In a subgroup of 5 patients intestinal permeability was determined by the lactulose/mannitol ratio. Results: A complete small bowel capsule endoscopy was possible in 9 out of the 10 patients. Six had lymphatic hyperplasia, in 3 patients aphtoid lesions similar to Crohn's disease could be seen, and one of them was eventually diagnosed Crohn's disease. Five patients had pinpoint lesions, and in another 5 cases lymphangiectasias were detected. One patient each showed erosions and a polyp. The intestinal permeability was increased in three patients. Most patients in our study population suffered from gastrointestinal symptoms. Small bowel capsule endoscopy revealed a high percentage of mucosal disorders. Conclusions: Different small intestinal lesions are a common finding in patients with CVID and may represent the morphological correlates of abdominal symptoms. The clinical relevance of these findings is unknown so far. However, there might be an association between Crohn's disease and CVID..
Values are Mean ± SEM
W1309
W1311
CT Angiography and 24 Hours Tonometry: A Novel and Usefull Approach in the Diagnosis of Chronic Gastrointestinal Ischemia Désirée van Noord, Peter B. Mensink, P. M. Pattynama, M. R. van Sambeek, E. J. Kuipers
The Anorectal and Colonic Functional Characteristics and the Effect of Biofeedback in Constipation with Spinal Cord Diseases Dong-Hoon Yang, Seung-Jae Myung, Kee Wook Jung, Benjamin Kim, Do Hoon Kim, Soon Man Yoon, Mi Young Do, In ja Yoon, Byong Duk Ye, Jeong-Sik Byeon, Hwoon-Yong Jung, Suk-Kyun Yang, Jin-Ho Kim
Background: The combination of duplex ultrasound, followed by conventional digital subtraction angiography of the abdominal arteries and gastric exercise tonometry (GET) is the established approach for patients suspected of chronic gastrointestinal ischemia (CGI). GET is cumbersome and impossible to perform in a considerable proportion of patients. Alternative diagnostic methods have recently been developed, in particular 24 hours gastric and jejunal tonometry (24hrTM) and computed tomography angiography (CTA). 24hrTM proved to be as accurate as GET for detection of CGI, while being less cumbersome and performable in every patient suspected of CGI. CTA seems a promising, minimally invasive technique to detect and define abdominal artery stenoses. Aim: We challenged the use of 24hrTM in combination with CTA as an alternative approach to evaluate patients suspected of CGI. Methods: Patients referred for evaluation of possible CGI were prospectively evaluated using CTA and 24hrTM. All patients were discussed in a multidisciplinary team (consisting of a vascular surgeon, interventional radiologist and gastroenterologist) and a consensus diagnosis was made. Patients with abdominal arterial stenosis on CTA and abnormal 24hrTM (i.e. GI ischemia) were advised to undergo treatment. The definitive diagnosis CGI was made after persistent symptom relief on follow-up. Results: Forty patients were enrolled; M/F 9/31, mean age 59 (20-87) yrs. A consensus diagnosis of CGI (Table) was made in 20 patients (87%): 11 patients with single vessel stenosis (celiac artery (CA) 9, superior mesenteric artery (SMA) 2), 8 with 2-vessel stenosis (CA+SMA 7, CA+inferior mesenteric artery 1) and
Background: Constipation is a major problem in spinal cord diseases often causing medically intractable condition. The aim of our study was to investigate the anorectal and colonic functional characteristics and the effect of biofeedback therapy in patients with spinal cord diseases. Patients and Methods: From June 2001 to June 2007, biofeedback therapy was done for 784 adults with constipation. Among these, 58 constipated patients with radiculopathy or myelopathy were enrolled as case group (mean age; 55.1±11.5 yrs). These patients were divided into myelopathy (n=16) and radiculopathy (n=42) group. The control group comprised 57 patients (mean age; 53.1±14.6 yrs) who fulfilled Rome III criteria for constipation without radiculopathy or myelopathy. They underwent colonic transit time (CTT), defecogram, and anorectal manometry (ARM) before biofeedback therapy. Before and after biofeedback therapy, all patients answered structured questionnaires on constipation derived from ROME III criteria. CTT results were described into normal, slow transit, pelvic outlet obstruction, and hindgut dysfunction. According to defecogram, patients were divided into normal, pelvic floor dysfunction, and hypertrophic anal sphincter. Results: CTT did not show significant difference between case and control group. However, rectosigmoid colonic transit time of myelopathy group was significantly delayed than those of radiculopathy and control group (myelopathy; 19.9±14.3 hr, radiculopathy; 13.1±11.5 hr, control; 10.9±12.2
A-677
AGA Abstracts
AGA Abstracts
W1307