Introduction: Collagenous gastritis (CG) is an uncommon pathologic condition characterized by the presence of distinct subepithelial collagenous band within the gastric mucosa. The clinical presentation of CG can vary widely ranging from nonspecific gastrointestinal symptoms to severe anemia and nutritional deficiencies. We present a patient with CG to highlight management strategies and the subsequent clinical outcome. Through this patient case, we aim to contribute to existing knowledge surrounding CG and emphasize the importance of considering this rare condition when evaluating patient with unexplained anemia without typical gastrointestinal manifestations associated with this disease entity. Case Description/Methods: A 21-year-old man presented for outpatient evaluation of microcytic anemia. He denied any abdominal symptoms, weight loss, or overt GI bleeding. Physical examination revealed stable vital signs, normal gastrointestinal and cardiovascular findings. Labs revealed Hgb 10.3, MCV 66.1, ferritin 3, total iron 19, TIBC 489, calprotectin 6, CRP 0.7, negative workup for hemoglobinopathies and celiac disease. EGD showed diffuse nodular mucosa of the gastric body, patchy erythematous prepyloric mucosa. Biopsies of the gastric antrum/body showed increased eosinophils >50/hpf, thickened subepithelial collagen deposition and negative Helicobacter pylori immunostain. Duodenal biopsies were normal. Colonoscopy and subsequent MR enterography were unremarkable. Patient was diagnosed with collagenous gastritis and managed with pantoprazole 40 mg daily, iron supplementation, open capsule budesonide 3 mg three times daily for 4 months followed by a 2-month taper. Hemoglobin and iron studies normalized 2 months into treatment with budesonide (Figure 1). Discussion: Collagenous gastritis has been characterized as 2 different phenotypes, adult and pediatric. The symptomology of the pediatric type include abdominal pain and GI bleeding, while the adult type can present with chronic diarrhea, weight loss, and sequelae from associated nutritional deficiencies. This patient atypically had an asymptomatic presentation, with iron deficiency anemia being the only abnormal lab finding. Endoscopy revealed expected typical findings of nodular gastric mucosa and mucosal erythema. No standard therapy exist due to its rarity. Of the known treatment options, steroids, in particular open capsule budesonide, coupled with iron supplementation, helped our patient achieve quick and complete clinical resolution of his anemia.Figure 1.: Endoscopic view of the nodular gastric mucosa in Figure A. Histologic examination of stomach (body) biopsy, with hematoxylin and eosin (H&E) stain in Figure B, trichrome stain depicted in Figure C (200x magnification). The H&E stain (B) demonstrates expansion of the lamina propria by chronic inflammatory cells (stars) and increased eosinophils (arrow head) between the onxyntic glands (G). At the mucosal surface, the foveolar epithelium (FE) is degenerated, with loss of intracellular mucin vacuoles and detachment. The subepithelial collagen layer is markedly expanded and hyalinized (brackets), with embedded inflammatory cells. The trichrome stain (Figure C) highlights the thickened collagen layer (blue). There is no Helicobacter pylori, intestinal metaplasia or atrophy identified. The overall features are consistent with collagenous gastritis.

Chandra Chakinala, Raja MD1; Katchi, Tasleem MD1; Jolly, George P. MD1; Haq, Khwaja F. MD1; Solanki, Shantanu MD1; Barbash, Benjamin MD2 Author Information

Background and aims Cannabinoids are increasingly used for medicinal purposes, including neuropathy. Gastroparesis is a neuromuscular disorder and neuropathy plays a large role in its pathogenesis. It is thus reasonable that cannabinoids can serve a beneficial role in the management of gastroparesis. Our study evaluates the effect of cannabinoids on gastroparesis symptoms. Methods Twenty-four (n=24) patients with gastroparesis and refractory symptoms were selected from a single gastroenterology practice associated with a tertiary care medical center. The 'Gastroparesis Cardinal Symptom Index' (GCSI) and an analog scale rating abdominal pain were applied to prospectively assess the effect of cannabinoids, in the form of dronabinol and medical cannabis, on refractory gastroparesis symptoms. Patients completed a GCSI form and rated their abdominal pain, before and after treatment. There was a minimum of 60 days of cannabinoid use between reporting intervals. Total composite GCSI symptom scores, GCSI symptom subset scores, and abdominal pain scores were calculated before and after treatment. Results A significant improvement in the GCSI total symptom composite score was seen with either cannabinoid treatment (mean score difference of 12.8, 95% confidence interval 10.4-15.2; p-value < 0. 001). Patients prescribed marijuana experienced a statistically significant improvement in every GCSI symptom subgroup. Significant improvement in abdominal pain score was also seen with either cannabinoid treatment (mean score difference of 1.6; p-value < 0.001). Conclusions Cannabinoids dramatically improve the symptoms of gastroparesis. Furthermore, an improvement in abdominal pain with cannabinoids represents a breakthrough for gastroparesis-associated abdominal pain treatment, for which there are currently no validated therapies.

Introduction: Neuropathy plays a large role in the pathogenesis of gastroparesis. Neuropathic pain in gastroparesis is an often difficult—to—treat symptom of the disease, despite 80—90% of patients with gastroparesis reporting abdominal pain as a symptom. Treatment for gastroparesis—related pain is especially limited. Neuromodulators are used for this purpose despite a lack of evidence supporting their effectiveness. Cannabinoids, primarily delta—9—tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly utilized for medicinal purposes. In New York medical marijuana is approved for the treatment of neuropathy with severe pain. Similarly, Dronabinol (a synthetic THC analogue) has been used for nausea vomiting and anorexia for years. We showed that cannabinoids are effective in the treatment of gastroparesis—related abdominal pain. Methods: The effects of prescribed cannabinoids on gastroparesis symptoms were assessed in 24 patients (Table 1, baseline characteristics). All patients' symptoms were refractory to standard therapies for gastroparesis. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Patients who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Medical marijuana was prescribed as needed at varying THC: CBD ratios and was taken via vaporized inhalation or sublingual drops. Dosage of Dronabinol ranged from 2—10mg twice daily to four times daily. Patients filled out a ‘Gastroparesis Cardinal Symptom Index’ (GCSI) questionnaire before and after treatment. Additionally, patients rated their abdominal pain before and after cannabinoid use, using a 1—5 analog scale. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol followed by marijuana. Paired sample T—tests were performed and statistically significant improvement in abdominal pain score was seen in patients who received either cannabinoid treatment. When analyzed individually, both marijuana and Dronabinol showed statistically significant improvement in abdominal pain scores as well (Table 2, Figure 1).1204_A Figure 1. Baseline patient characteristics.Conclusion: Our study shows that cannabinoids may play an important role in the management of gastroparesis—related abdominal pain. There are currently no treatments shown to be effective for gastroparetic pain in clinical trials, and cannabinoids may serve a niche for this under—treated symptom.1204_B Figure 2. Paired sample t—tests and differences of the mean for abdominal pain analog score before and after cannabinoid treatment.1204_C Figure 3. Comparison of abdominal pain scores pre— and post— cannabinoid treatment. Results are shown for marijuana alone, Dronabinol alone and for any cannabinoid (either marijuana or Dronabinol).

Introduction: Cannabinoids, primarily delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly used for medical purposes. Medical marijuana is approved in New York for the treatment of neuropathy with severe nausea or pain. Neuropathy plays a large role in the pathogenesis of gastroparesis, a neuromuscular disorder of delayed gastric emptying. Dronabinol, a THC analogue, is used for nausea, vomiting and anorexia in HIV and cancer, and has been used for symptom management in gastroparesis. We previously demonstrated that both Dronabinol and medical marijuana dramatically improve symptoms of gastroparesis. We compared the difference in symptom improvement between medical marijuana and Dronabinol. Methods: The effects of cannabinoids on gastroparesis symptoms were assessed in 24 patients. All patients' symptoms were refractory to standard therapies. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Those who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Marijuana was prescribed as needed at varying THC: CBD ratios and taken via vaporized inhalation or sublingual drops. Dosage of Dronabinol ranged from 2-10mg twice daily to four times daily. Patients filled out a ‘Gastroparesis Cardinal Symptom Index’ (GCSI) form before and after treatment, and rated their abdominal pain before and after treatment using a 1-5 analog scale. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol then marijuana (baseline characteristics, Table 1). Pre- and post-treatment GCSI and abdominal pain scores were compared and unpaired sample t-tests were performed. Marijuana was superior to Dronabinol in improving all symptoms, with statistical significance seen in abdominal pain score (mean difference from baseline score in marijuana group 2.167 and mean difference from baseline score in Dronabinol group 0.929; p-value 0.007) and total symptom composite score (includes GCSI composite score and abdominal pain score; mean difference from baseline score in marijuana group 16.778 and mean difference from baseline score in Dronabinol group 11.429; p-value 0.036) [Table 2, Figure 1].2894_A Figure 1. Baseline patient characteristics.Conclusion: While both cannabinoid therapies dramatically improve gastroparesis symptoms, our analysis shows that marijuana is superior to Dronabinol, especially for improvement of abdominal pain and overall symptoms.2894_B Figure 2. Differences in composite symptom score and symptom subset scores before and after treatment with marijuana and Dronabinol. Unpaired sample t-tests were performed to assess differences in symptom improvement between the two groups. Statistical significance considered if p-value < 0.05.2894_C Figure 3. Comparing mean differences for each symptom category and total symptom composite score between marijuana and Dronabinol groups.

Introduction: Cannabinoids, primarily delta—9—tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly used for medicinal purposes. Dronabinol, a THC analogue, is used for nausea, vomiting and anorexia in HIV and cancer. Medical marijuana in New York is permitted to treat neuropathy with severe nausea. Gastroparesis is a neuromuscular disorder that causes many difficult—to—treat symptoms. Neuropathy plays a large role in its pathogenesis. We showed that cannabinoids significantly improve symptoms in patients with refractory gastroparesis. Methods: The effects of cannabinoids on gastroparesis symptoms were assessed in 24 patients. All patients' symptoms were refractory to standard therapies for gastroparesis including dietary modification, medications (prokinetics, antiemetics, neuromodulators), endoscopic therapy, and some patients had gastric stimulators. Patients were prescribed either Dronabinol, medical cannabis, or both for symptom management. Patients who received both treatments were prescribed them sequentially (Dronabinol then marijuana) if Dronabinol did not adequately relieve symptoms. Medical marijuana was taken via vaporized inhalation or sublingual drops and prescribed as needed at varying THC: CBD ratios. Dosage of Dronabinol ranged from 2—10mg twice daily to four times daily. All patients completed a ‘Gastroparesis Cardinal Symptom Index’ (GCSI), a validated symptom index for gastroparesis, before and after treatment. Results: Six patients were prescribed Dronabinol, ten were prescribed marijuana and eight were prescribed Dronabinol then marijuana. Baseline patient characteristics were collected (Table 1). Paired sample T—tests were performed and statistically significant improvement in GCSI total symptom composite score was seen in patients who received either cannabinoid treatment (mean score difference of 14.097, CI 11.487—16.707; p—value < 0.001). Patients prescribed marijuana experienced statistically significant improvement in every symptom subgroup, while the Dronabinol group experienced statistically significant improvement in all symptom subgroups except ‘bloating/distention’ (Table 2, Figure 1).1203_A Figure 1. Patient baseline characteristicsConclusion: Our study shows that cannabinoids significantly improve symptoms of gastroparesis, which is a notoriously difficult condition to manage. Therapeutic options for gastroparesis are limited, so cannabinoids can play an important role in the treatment of the condition, especially in patients with refractory symptoms.1203_B Figure 2. Paired sample T—tests and differences of the mean for composite symptom score and symptom subgroup scores before and after cannabinoid treatment [abbreviations: SD = Standard Deviation; SER = Standard Error of Mean]1203_C Figure 3. Comparison of composite symptom score and symptom subgroup scores before and after cannabinoid treatment (either marijuana or Dronabinol), marijuana treatment alone, and Dronabinol treatment alone

Introduction: Prior studies that evaluated the seasonal variation of upper gastrointestinal bleeding have led to no clear consensus. Some reports demonstrated seasonal variation, possibly with seasonal fluctuations in NSAID use, while other studies do not show a seasonal relationship. We reviewed the NIS database to assess seasonal differences in hospitalizations due to variceal bleeding. Methods: Method: We conducted a cross-sectional study using NIS data for years 2005 to 2014. We used single level CCS diagnosis code(153) to identify cases with GI hemorrhage and then used ICD-9-CM code (456.0 & 456.20: esophageal varices with bleeding) to identify cases with a primary or secondary diagnosis of variceal bleeding. We performed Chi-square analysis to study the demographics, and a multivariate to compare in-hospital mortality. Adjustments were made for the confoundings: age, gender, race, comorbidities, LOS, admission status and hospital factors including location and teaching status. All statistical analysis was performed with SPSS v25.0 (IBM Corp, Chicago, IL) Results: A total of 348,958 hospitalizations with variceal bleeding were reported between 2005 and 2014. The mean age of the entire cohort was 55.79 (SD:12.15), 69.1% were male. The mean LOS for the entire cohort was 6.35 days.The highest number of variceal bleed-related hospitalizations were reported in December (N=30,786; 8.8%) followed by March (N=30,492; 8.7%) and January (N=30,404; 8.7%). The lowest number of hospitalizations were reported in June (27,247; 7.8%). We calculated adjusted odds ratio for in-hospital mortality associated with months. Mortality was highest in January (Adjusted OR=1.268, 95% CI:1.194-1.345) The greatest number of esophagogastroduodenoscopy (EGD) for variceal bleeding were in December (N=25,940), out of which 77.5% (N= 20,129) involved endoscopic therapy for hemoastasis. The fewest EGD procedures were performed in June (N=22,849), out of which 75.1% (N=17,176) involved endoscopic therapy. In-hospital mortality for the patients undergoing EGD was 8.2%, while mortality was 21.5% for patients who did not undergo EGD. There was no significant difference in LOS or cost across seasons. Conclusion: There appears to be a seasonal variation in the incidence of variceal bleeding in the United States. The reasons for these variations remains unclear. This study is limited in that the analysis is based on the accuracy of diagnostic codes reported at the time of hospitalization.358_A Figure 1. Overall Monthly Incidence and Mortality of Variceal- Bleeding from 2005 to 2014358_B Figure 2. Graphical presentation of variation of in-hospital mortality with Esophageal variceal bleeding.358_C Figure 3. Multivariable regression analysis and adjusted Odds ratio for in-hospital mortality associated with each month.

Gastrointestinal (GI) tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms, making it difficult to discern from alternative disease processes. Although the ileocecal region is the most commonly affected site, tuberculous enteritis can involve any aspect of the GI tract. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of GI TB presenting as severe malnutrition and segmental colitis of the left colon.

Ulcerative jejunoileitis (UJ) is a rare condition that is difficult to diagnose and treat. We present a case of steroid-responsive UJ. A 62-year-old female presented with 3.5 months of diarrhea, abdominal pain, and pedal edema. Prior workup included an unremarkable EGD and colonoscopy (with unremarkable biopsies), and non-diagnostic MR enterography. Symptoms did not respond to a gluten-free diet. Physical examination revealed bibasilar crackles and anasarca. Laboratory results revealed a serum albumin of 1.4 g/dl and low immunoglobulin levels. Stool studies showed negative bacterial and acid-fast cultures, ova and parasites, helicobacter pylori antigen and C. Difficile toxin. Stool alpha-1-antitrypsin was elevated at 960mg/dl. Serum studies were negative for ESR, CRP, HIV, ANA, ANCA, tTG, CMV, Anti-Saccharomyces Cerevisiae IgA and IgG. Serum and urine protein electrophoresis was normal. Small bowel capsule endoscopy showed small bowel erosions and denuded villi. Push enteroscopy revealed patchy jejunal erythema, erosions and absent or mosaic-appearing villi. Jejunal biopsies showed focal partial villous blunting with loss of brush border without granulomas or dysplasia. T. whipplei PCR was negative. Prednisone 60mg by mouth daily was started, which led to resolution of her symptoms and improvement of her albumin. UJ is likely T-cell mediated and characterized by small bowel ulcerations and villous atrophy. Patients present with non-specific gastrointestinal complaints and signs of malabsorption or protein-losing enteropathy. It is highly associated with Celiac disease. Differential diagnosis includes Celiac and tropical sprue, Crohn's disease, lymphoma, infections, and infiltrative and rheumatologic disorders. Laboratory tests and biopsies ruled out these conditions in our patient. All imaging was negative prior to capsule endoscopy. Literature on UJ is scarce and limited to case series and reports. UJ is typically refractory to treatments including prednisone, azathioprine, cyclosporine, biologic agents and chemotherapy. Even after initial treatment success, the relapse rate is high- 90% in one case series. Prognosis is poor with up to 33% mortality rate within three years. Our patient represents a rare diagnosis of UJ and a rare case of steroid-responsiveness. Further research into the pathophysiology and treatment of this poorly understood and difficult-to-treat condition is warranted.Figure: Image demonstrating normal esophagus, gastroesophageal (GE) junction and stomach on push enteroscopy.Figure: Image demonstrating jejunal mucosa with erythema and erosions, seen on push enteroscopy.Figure: Microscopic examination of the small intestine demonstrating blunting of villi.

Introduction: Patients with inflammatory bowel disease (IBD) have many unique health maintenance needs and often require therapy necessitating close monitoring. Gastroenterologists often serve as the primary care provider for these patients and therefore must be familiar with the health maintenance needs of IBD patients in order to provide proper preventive care. While performance measures exist for quality care in IBD patients, it is unclear if these metrics are being adequately addressed in large urban centers that provide care for underserved patients with poor access to healthcare. Methods: A retrospective chart review was performed in 2013-2014 on 266 IBD patients at two GI clinics within a large, urban university-affiliated medical center to determine adherence to performance practice measures. Based on the quality measures outlined by the American Gastroenterological Association in 2011, adherence to the following parameters were assessed: pneumococcal and influenza vaccinations, bone health, assessment for latent tuberculosis (TB) and hepatitis B (HBV) status prior to starting an anti-TNF agent, and tobacco cessation counseling, in addition to others. For every patient, each health maintenance performance measure was given a score of 0 (not addressed), 1 (addressed), or N/A (irrelevant to subject). Mean, median, and standard deviations were calculated for the % of measures addressed overall and within each subgroup (Table 1). The % of subjects with specific measure addressed was also computed for each measure (Table 2).Table 1: Mean, Median, and Standard Deviation (s.d.) of % of Measures Addressed Overall Per Subject and Within Each SubgroupTable 2: of Subjects With Specific Measure AddressedResults: On average, 38% of all health maintenance performance measures and 33% of measures in the bone health subgroup were appropriately addressed. Smoking cessation was assessed in only 18% of subjects and influenza and pneumococcal vaccinations were addressed in 37% and 57% of subjects, respectively. 77% of subjects underwent evaluation for latent TB and HBV status prior to initiating anti-TNF alpha therapy, while only 41% had thiopurine S-methyltransferase testing prior to thiopurine therapy. Additionally, screening for skin, cervical and colon cancers was addressed in 26%, 47% and 87% of subjects, respectively. Conclusion: Adherence to IBD performance measures is inadequate in a large, urban and resourcelimited practice. Educational programs, resource allocation and a multidisciplinary approach may help gastroenterologists in this practice setting improve upon implementing guidelines to optimize the health of their patients with IBD.