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Long-standing inflammation leads to esophageal remodeling with stricture formation in patients with eosinophilic esophagitis (EoE). The ability of proton pump inhibitors (PPI) to reverse endoscopic features of fibrosis is still unknown.To investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal fibrosis in EoE patients.Cross-sectional analysis of the EoE CONNECT registry. Patients who received PPI to induce EoE remission were evaluated. Endoscopic features were graded using the EoE Endoscopic Reference Score (EREFS), with rings and strictures indicating fibrosis. Results were compared to those from patients treated with swallowed topic corticosteroids (STC).Clinico-histological remission was achieved in 83/166 adult patients treated with PPI (50%) and in 65/79 (82%) treated with STC; among responders, 60 (36%) and 57 (72%) patients respectively achieved deep histological remission (5 eosinophils/hpf). At baseline, mean±SD EREFS was lower in patients treated with PPI compared to those who received STC (p 0.001). Short term treatment significantly reduced EREFS scores in patients treated either with PPI or STC as well as rings and strictures. Among patients treated with PPI, deep histological remission (5 eosinophils/hpf) provided further reduction in total EREFS score.Effective PPI therapy for EoE significantly reduced endoscopic esophageal fibrosis in the short term.

Background & Aims Topical steroids, proton pump inhibitors (PPIs), and dietary interventions are recommended first- and second-line therapies for eosinophilic esophagitis (EoE). We investigated differences in their effectiveness in a real-world, clinical practice cohort of patients with EoE. Methods We collected data on the efficacy of different therapies for EoE (ability to induce clinical and histologic remission) from the multicenter EoE CONNECT database—a database of patients with a confirmed diagnosis of EoE in Europe that began in 2016. We obtained data from 589 patients, treated at 11 centers, on sex, age, time of diagnosis, starting date of any therapy, response to therapy, treatment end dates, alternative treatments, and findings from endoscopy. The baseline endoscopy was used for diagnosis of EoE; second endoscopy was performed to evaluate response to first-line therapies. After changes in treatment, generally because lack of efficacy, a last endoscopy was performed. The time elapsed between endoscopies depended on the criteria of attending physicians. Clinical remission was defined by a decrease of more than 50% in Dysphagia Symptom Score; improvement in symptoms by less than 50% from baseline was considered as clinical response. Histologic remission was defined as a peak eosinophil count below 5 eosinophils/hpf. A peak eosinophil count between 5 and 14 eosinophils/hpf was considered histologic response. We identified factors associated with therapy selection and effectiveness using χ2 and multinomial logistic regression analyses Results PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%). Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%). Among the 344 patients who switched to a second-line therapy, dietary interventions were selected for 47.1% of patients, followed by PPIs (for 29.1%) and topical steroids (for 18.6%). Clinical and histologic remission or response was achieved by 80.7% of patients treated with topical steroids, 69.2% of patients given PPIs, and 41.7% of patients on empiric elimination diets. Multivariate analyses found the stricturing phenotype of EoE to be associated with selection of topical steroids over PPIs as the first-line therapy; lack of fibrotic features at initial endoscopy was associated with selection of elimination diets over topical steroids as a second-line therapy. The recruiting center was significantly associated with therapy choice; second-line treatment with topical steroids or PPIs were the only variables associated with clinical and histologic remission. Conclusions In an analysis of data from a large cohort of patients with EoE in Europe, we found topical steroids to be the most effective at inducing clinical and histologic remission, but PPIs to be the most frequently prescribed. Treatment approaches vary with institution and presence of fibrosis or strictures.

Atezolizumab is an IgG1 isotype monoclonal antibody against the protein programmed cell death-ligand 1 (PD- L1). PD-L1 may be highly expressed in some tumors and is believed to inhibit immune cells that recognize and attack tumor cells. Inhibition of PD-L1 can remove its inhibitory effect and provoke an anti-tumor response. In October 2016, the Food and Drugs Administration (FDA) approved atezolizumab for the treatment of patients with metastatic non-small cell lung cancer after disease progression during or following platinum based chemotherapy. We present the case of a 43-year-old male with stage IV lung adenocarcinoma in progression, despite standard chemotherapy.

Brunner's gland hamartoma is a polypoid lesion typically composed of an increased quantity of normal-appearing Brunner's glands, accompanied by a variable proportion of smooth muscle. Most of these masses are asymptomatic and behave as benign tumors. Occasionally tumoral growth can provoke gastrointestinal problems which, together with the possibility of malignant transformation, will require resection after a broad differential diagnosis has been made with solitary duodenal mass. Both clinical and radiographic studies are nonspecific and often do not allow diagnosis of these tumors. Basic endoscopic studies (upper endoscopy) with adequate characterization of the lesion by endoscopic ultrasound (EUS) can establish a high diagnostic suspicion and determine the best therapeutic option (endoscopy or surgery). We present a case of giant Brunner's gland hamartoma. The initial manifestation was iron-deficiency anemia with no evidence of bleeding. After adequate characterization of the lesion, EUS allowed complete and safe endoscopic resection, avoiding more invasive surgical treatment.

Objective The use of colonoscopy as a primary screening test for colorectal cancer (CRC) in average risk adults is a subject of controversy. Our primary objective was to build a predictive model based on a few simple variables that could be used as a guide for identifying average risk adults more suitable for examination with colonoscopy as a primary screening test. Methods The prevalence of advanced adenomas was assessed by primary screening colonoscopy in 2210 consecutive adults at least 40 yr old, without known risk factors for CRC. Age, gender, and clinical and biochemical data were compared among people without adenomas, those with nonadvanced adenomas, and those with any advanced neoplasm. A combined score to assess the risk of advanced adenomas was built with the variables selected by multiple logistic regression analysis. Results Neoplastic lesions were found in 617 subjects (27.9%), including 259 with at least one neoplasm that was 10 mm or larger, villous, or with moderate-to-severe dysplasia, and 11 with invasive cancers. Advanced lesions were more frequent among men, older people, and those with a higher body mass index (BMI). These three variables were independent predictors of advanced adenomas in multivariate analysis. A score combining age, sex, and BMI was developed as a guide for identifying individuals more suitable for screening colonoscopy. Conclusions Age, gender, and BMI can be used to build a simple score to select those average risk adults who might be candidates for primary screening colonoscopy.

Eosinophilic oesophagitis has emerged as a common cause of oesophageal symptoms.To document practice variation in care provided to eosinophilic oesophagitis patients in Spain and to assess adherence to available guidelines.A prospective survey-based registry including data from all patients receiving care from gastroenterologists and allergists throughout Spain was developed.Data from 705 patients (82% adults, male:female ratio 4.1:1) were collected from 26 Spanish hospitals. 42.7% received care in teaching hospitals. Adults presented dysphagia and food impaction more frequently; vomiting and weight loss predominated in children (p0.01). A mean diagnostic delay of 54.7 and 28.04 months was documented for adults and children, respectively. Normal endoscopic exams were reported in 27.6% and directly related to the experience in managing the disease (p0.05). Paediatric patients, non-teaching hospitals and greater experience in managing eosinophilic oesophagitis were associated with increased frequency in eosinophil count reports and with taking gastric and duodenal biopsies (p0.001). Initial therapy consisted of topical steroids (61.7% of patients), proton pump inhibitors (52.4%), dietary modifications (51.26%) and endoscopic dilation (7.2%). Referrals to allergy units occurred more frequently in teaching hospitals (p = 0.003) where food restrictions generally followed allergy test results (p0.001).Availability of facilities and the physician's experience constituted the most important factors in explaining differences in patient management.

For colorectal cancer screening, the predictive value of distal findings in the ascertainment of proximal lesions is not fully established. The aims of this study were to assess distal findings as predictors of advanced proximal neoplasia and to compare the predictive value of endoscopy alone vs. combined endoscopic and histopathologic data. METHODS: Primary colonoscopy screening was performed in 2210 consecutive, average-risk adults. Age, gender, endoscopic (size, number of polyps), and histopathologic distal findings were used as potential predictors of advanced proximal neoplasms (i.e., any adenoma > or =1 cm in size, and/or with villous histology, and/or with severe dysplasia or invasive cancer). Polyps were defined as distal if located in the descending colon, the sigmoid colon, or the rectum. Those in other locations were designated proximal. RESULTS: Neoplastic lesions, including 11 invasive cancers, were found in 617 (27.9%) patients. Advanced proximal neoplasms without any distal adenoma were present in 1.3% of patients. Of the advanced proximal lesions, 39% were not associated with any distal polyp. Older age, male gender, and distal adenoma were independent predictors of advanced proximal neoplasms. The predictive ability of a model with endoscopic data alone did not improve after inclusion of histopathologic data. In multivariate logistic regression analysis, the predictive ability of models that use age, gender, and any combination of distal findings was relatively low. The proportion of advanced proximal neoplasms identified if any distal polyp was an indication for colonoscopy was only 62%. CONCLUSIONS: A strategy in which colonoscopy is performed solely in patients with distal colonic findings is not effective screening for the detection of advanced proximal neoplasms in an average-risk population

colonoscopy was not different in the Prepsystem (19 3 min) and the PEG (22 1 min) groups. Blood electrolytes were not significantly modified after bowel cleansing in both groups. Patient satisfaction was good to excellent in all cases in the Prepsystem group. Conclusion: The Prepsystem water infusion protocol appeared as effective as the splitted PEG protocol for bowel cleansing before colonoscopy. Patient tolerance of the Prepsystem was good. Further studies should evaluate the benefit of this protocole in patients with contraindications or poor tolerance to PEG cleansing or in ambulatory patients. Su1550 Establishing the Learning Curve for Achieving Competency in Performing Colonoscopy: a Systematic Review Neal Shahidi*, George Ou, Jennifer J. Telford, Robert a. Enns Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada Background: Training in colonoscopy (CSPY) is a difficult but an integral part of gastroenterology and surgical training programs. However, the number of procedures required to achieve competence is not well established, leading to significant heterogeneity among current guidelines. Aims: To assess the learning curve for achieving competency in performing CSPYs during gastroenterology and surgical training. Methods: Two investigators (NS and GO) independently searched MEDLINE (1946 June 2013) and the grey literature (bibliographies of included studies, pertinent review articles and guidelines) to identify relevant citations. Subsequently, after full-text review, studies meeting inclusion underwent data extraction with discrepancy among investigators resolved by consensus. A threshold of 90% independent cecal intubation rate (ICIR) was used as a minimum reference for competence. Results: 18 unique study populations, encompassing 38,000 CSPYs were included in our analysis. When stratifying by markers of competence: 10 studies used ICIR; 6 studies used ICIR with a cecal intubation time (CIT) limit; 1 study used ICIR with a procedural time limit; and 2 studies provided more comprehensive definitions of competence. Among the 10 studies that solely quantified ICIR, 4 studies were able to reach the reference competence estimate during analysis (90% ICIR), with trainees reaching competence between 140 to 305 CSPYs. In studies additionally setting a CIT (15 minutes 30 minutes) limit, competence was reached in 5 studies between 100 to 300 CSPYs. Of the 2 studies who provided more comprehensive estimates of competence, their reference competence thresholds were reached between 275 to 467 CSPYs. Conclusions: Our results suggest that as the definition of competence becomes more robust (i.e. acceptable for clinical practice) and incorporates more than just ICIR and CIT that the threshold to achieve competency continues to rise well above current recommendations. With newer levels of competence being promoted, present guidelines need to reassess the level of training required to adequately train endoscopists. Su1551 Split-Dose Sodium Picosulfate and Magnesium Citrate Preparation for Colonoscopy: Cleansing Effectiveness and Residual Gastric Volume and pH CeSar Prieto*, RAMoN AngoS, Maria Teresa BeteS, Susana De La Riva, Iago RodriGuez Lago, Cristina Carretero, Maite Herraiz, Alejandra Alzina Perez, Miguel a. MUnOz-Navas Gastroenterology, Clinica Universidad de Navarra, Pamplona, Spain Background: Split dose bowel preparations result in superior bowel cleanness. Although there is evidence that smaller residual gastric volumes (RGV) are obtained with fasting times of 2-4 hours when compared with more than 4 hours, and the relationship between fasting times for clear liquids and risk of pulmonary aspiration has not been demonstrated, there is still concern about the increased risk of aspiration when using a split-dosing regimen. Low-volume bowel preparation containing sodium picosulfate and magnesium citrate (PMC) has shown to be better tolerated, and at least as effective, as other cleansing agents. Aim: To compare the cleansing efficacy, RGV, gastric pH and tolerabilty between a PMC split-dose regimen and a traditional evening-before-procedurecomplete PMC regimen. Methods: Patients aged 18 to 80 ys. requiring elective gastroscopy (EGD) and colonoscopy in the same day were invited to participate. Exclusion criteria were: known gastroparesis, gastric outlet obstruction, hiatal herniaO4 cm, previous gastrointestinal resections excluding appendicectomy, renal insufficiency, active inflammatory bowel disease, and elevated anesthesic risk (ASA III-IV). Patients were distributed to split-dose group (1) or traditional regimen group (2) exclusively depending on the hour and date of medical visit. Group 1 patients were instructed to take a PMC sachet at 19:00 the evening before the procedure, and a second sachet 4 hours before the procedure. Group 2 patients were instructed to take 1 sachet at 15:00 and second sachet at 20:00 both the evening before the procedure. Tolerability was assesed by completing a questionnaire just before the procedure. Colonoscopy was performed immediately after EGD. Total gastric volume was suctioned off and collected in a graded AB318 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 specimen trap. Colon cleansing efficacy was assesed by Ottawa Bowel Preparation Scale (OBPS). Results: 206 patients were included (group 1: 116; group 2: 90). There were no significant differences in patient characteristics between the two groups. Mean time interval ( SD) between last reported ingestion was 3.63 hours ( 1.02) (range 2-6 hours) in the split-dosing group, and 11.59 ( 1.64) in the traditional regimen group. Mean RGV was significantly lower in group 1 than in group 2 (11.65 vs.17.50 ml; p!0.005). pH of RGV in group 1 was slightly higher than group 2 (2.06 vs.1.45; ns). Total, mid-colon and right-colon OBPS scores were significantly bettter in group 1 than in group 2 (3.47 vs 4.38, p!0.01; 1.18 vs 0.91, p!0.05; 1.16 vs 1.67 p!0.001, respectively). No significant differences in tolerabilty were found. No patient had evidence of aspiration. Conclusions: Patients receiving split-dose regimen of PMC have lower residual gastric volumes and superior cleansing levels, specially in right colon, than those receiving traditional regimen, suggesting an efficacy and safety adventage. SPLITDOSING (n[116) Mean (± SD) TRADITIONAL REGIMEN (n [ 90) Mean (± SD)

A 72-year-old woman was admitted to our hospital with abdominal pain, fever, and weight loss. Physical examination revealed tenderness in the epigastrium. Laboratory data showed a white blood cell count of 12,600 10/L (normal range, 4800-10,800 10/L) and increases in the serum levels of amylase (379 IU/L; normal

Physicians involved in care of migraine patients should make a considerable effort to educate themselves and their patients. It is fundamental that doctors, patients and their families understand the causes of migraine, and know the different treatment strategies available to improve migraine care. Mallory-Weiss tears are lacerations in the region of the cardioesophageal junction due to vomiting. We report a case of Mallory-Weiss tear secondary to migraine that could had been reasonably avoided had the patient been treated with triptans since the first attack, according to the stratified care strategy. This case illustrates that inadequate management can cause serious medical consequences. It also proves that it is necessary to improve education about migraine for both patients and doctors.

Aims: To establish independent predictive risk factors for APA in averagerisk population. Methods: From 1988 to 1998 screening total colonoscopy was performed in consecutive average-risk people, with strict exclusion criteria. Clinical, biochemical, endoscopic and histologic data were recorded. The term advanced was used for adenomas with villous component, moderate-severe dysplasia or ≥1cm. Adenomas were defined as distal if they came from the descending colon or distally. Univariate comparisons were assesed using the Chi2 Test and logistic regression. Backward stepwise logistic regression was used for multivariate analyses. Results: APA were detected in 125 of 2210 subjects (5.66%); 56 (44.8%) had no index distal adenoma. Independent predictors for presenting APA, after adjustment for the endoscopist who performed the endoscopy, are shown in the table. Conclusions: Almost half cases with APA did not present a distal index lesion. Distal polyp characteristics which were independent risk factors for APA were villous component and moderate-severe dysplasia.This multivariate model offers guidelines for clinicians in the approach to patients with distal tubular adenomas.

Evidence from controlled trials suggest that removing adenomatous polyps reduce the incidence of colorectal cancer. Nowadays, it is clear that only a small proportion of adenomas go on to develop into cancer. Advanced adenomas (AA; adenoma ≥ 1 cm in size, with villous component, or with moderate to high-grade dysplasia) are associated with an increased risk of malignancy. Aims: To establish independent predictive factors of AA in average-risk asymptomatic population. Methods: From 1988 to 1998 screening total colonoscopy was performed, as a part of a routine medical checking, in 2210 consecutive average-risk asymptomatic people, in whom strict exclusion criteria were applied. Clinical, biochemical, endoscopic and histologic data were recorded. Univariate comparisons were assessed using the Chi2 test and logistic regression. Backward stepwise logistic regression was used for multivariate analysis. Results: Colonic polyps were detected in 885 of 2210 patients and neoplastic lesions in 617 (27.9%). 11 subjects (0.5%) presented malignant polyps or carcinoma. AA were found in 268 patients (12.1%). The variables selected by univariate analyses to enter the multivariate model were: age (p