OBJECTIVES:Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly utilized procedure in pediatric populations. A lack of dedicated pediatric research has led endoscopists to extrapolate adult risk factors and preventative strategies to children. The aim of this multisite, retrospective study was to identify risks for adverse events, procedure failure, and prolonged courses in pediatric patients undergoing ERCP.METHODS:Pediatric patients who had an ERCP at one of our academic centers were identified by query of their electronic medical records. Pre-procedure and post-procedure data were collected with ERCP-related adverse events defined according to the consensus criteria developed by Cotton et al 2010.RESULTS:Between January 2004 and January 2021, 287 children had a total of 716 ERCPs. The procedure success rate was 95.5% with no mortality and an adverse event rate of 12.7%. Younger age was associated with increased case complexity, increased adverse events, and an increased rate of repeat ERCP. Case complexity score correlated with increased procedure time ( P < 0.001) and increased adverse events (tau 0.24, P < 0.01); stent removal and pancreatic stenting were more likely to precede an adverse event. Pancreatitis, pancreatic divisum, and pancreatic stricture/stenosis were associated with increased adverse events and rates of repeat ERCP.CONCLUSIONS:Pediatric ERCP adverse event rates are higher than adults. The complexity grading system proposed by the Cotton et al appears to have applicability to pediatric patients. Young age and interventions affecting the pancreatic duct are associated with adverse ERCP outcomes in pediatrics.

Introduction: Obstructive jaundice in young patients generally prompts a focused differential based on distal biliary obstruction, but proximal obstructions require a more extensive workup. Here, we present a perplexing case of proximal biliary obstruction in a young man. Case Description/Methods: A 34-year-old male industrial worker with IBS-D but no significant personal/family history presented with epigastric abdominal pain, weight loss, and jaundice. Labs were significant for AST 95 U/dl, ALT 221 U/dl, Total bilirubin 4.9 mg/dl, and ALP 277 U/L. Toxicology and testing for HIV, Hepatitis A/B/C, extractable nuclear antigen antibodies, ANCA, autoimmune hepatitis, Wilson’s, A1AT deficiency, and hereditary hemochromatosis were unrevealing except for an IgG4 of 133 mg/dl and a CA 19-9 of 133 U/ml. Phase CT liver and MRI showed a 2.8 x 2.8 cm mass at the left/right liver lobe confluence with significant intrahepatic biliary ductal dilatation but were nondiagnostic for hepatocellular carcinoma (HCC), cholangiocarcinoma, or lymphoma (Figure 1, left). Multifocal lymphadenopathy in the porta hepatis was also noted and suspicious for inflammatory pseudotumor. ERCP showed a right-sided hepatic duct inflammatory stricture that was sampled and stented (Figure 1, middle). Lymph node pathology showed malignant gland-forming cells with intracytoplasmic mucin and staining compatible with cancer of hepatobiliary origin (CK19 and CDX2 positive, CK7 and CK20 negative). Bile duct brushings were benign. PET-CT revealed hypermetabolic retroperitoneal, supraclavicular, and left mediastinal lymphadenopathy concerning for metastases (Figure 1, right). Given the lack of criteria to satisfy the diagnosis of HCC, cholangiocarcinoma, or lymphoma, he is undergoing initiation with FOLFOX chemotherapy for a working diagnosis of cancer of unknown primary. Discussion: Pseudoinflammatory tumor from IgG4 disease, supported by his imaging and serologies, was initially our working diagnosis1-6. IgG4 disease, given its nonspecific presentation and rarity, is misdiagnosed as cancer2,3,5. Alternatively, cholangiocarcinoma, feared for its variable presentation in the absence of primary sclerosing cholangitis (PSC), was also considered. We pondered whether the patient’s IBS had been misdiagnosed ulcerative colitis with PSC8. This patient illustrates that consideration of both common and obscure diagnoses is crucial in evaluating obstructive jaundice, especially in young adults without risk factors for liver disease or malignancy.Figure 1.: Figure 1, left. MRI Contrast (A-B) CT Liver Triple Phase (C) Images showing ill-defined mass (arrows) at left/right hepatic lobe confluence causing intrahepatic biliary dilatation, as seen on MRI T2 Coronal (A) and Axial (B) views, and iterative model reconstruction coronal CT Liver view (C). Figure 1, middle. ERCP showing inflammatory stricture occupying right and common hepatic duct (A-C), also visualized on fluoroscopy(D). Figure 1, right. PET CT image showing multifocal liver lesions surrounding central mass in left liver lobe, as well as distant hypermetabolic activity in the retroperitoneal mediastinal, and supraclavicular lymph nodes (arrows) concerning for distant metastasis.

Introduction: Aicardi-Goutières syndrome (AGS) is a rare autosomal recessive genetic disorder resulting from mutations of genes encoding multiple proteins, including DNA 3’ repair exonuclease 1 (TREX1). This form of leukodystrophy is characterized by increased interferon-alpha in the cerebrospinal fluid and serum leading to immune dysfunction primarily targeting white matter myelin in the brain. Late onset AGS can affect other organs, including liver, kidneys, heart, and lungs. Hepatic inflammation is associated with the neonatal form of AGS, but the incidence of hepatitis across other ages remains unknown. To our knowledge, there have been no reported cases of nodular regenerative hyperplasia in adults with Aicardi-Goutières syndrome. Case Description/Methods: A 63-year-old man was evaluated for proteinuria and microscopic hematuria. Laboratory workup was unrevealing and renal ultrasound was normal. Family history was significant for father with kidney transplant for unknown renal disease and brother with recurrent bilateral vitreous hemorrhage. Subsequently, the patient and brother had kidney biopsies that showed findings consistent with thrombotic microangiopathy (TMA). Familial TMA prompted whole genome sequencing that revealed a mutation in TREX1 in all three family members. Following nephrology workup, the patient was incidentally found to have a nodular hepatic contour suggestive of cirrhosis. Physical exam was absent of stigmata of liver disease, and he denied a history of alcohol use. A focused laboratory workup was unrevealing (Table 1). MRCP revealed a nodular liver consistent with fibrosis and no intrahepatic or extrahepatic biliary dilation. MR elastography showed F2-F3 fibrosis without evidence of hepatic steatosis or iron overload. Ultimately, a percutaneous liver biopsy demonstrated nodular regenerative hyperplasia (NRH) (Figure 1). Discussion: NRH has been associated with autoimmune conditions such as systemic lupus erythematosus (SLE) and is thought to be caused by blood vessel inflammation within the liver leading to an overcompensated replication of hepatocytes. The finding of NRH in this patient is representative of the phenotypic overlap between AGS and SLE related to the common underlying feature of IFN-α up-regulation. As seen in this patient, NRH typically does not cause any overt signs or symptoms of liver disease. However, given it can eventually lead to the development of non-cirrhotic portal hypertension, further monitoring of this patient is warranted.Figure 1.: Percutaneous liver biopsy with nodular regenerative hyperplasia. (A, B) Liver biopsy, reticulin stain, low power ×40. Focal compression of reticulin framework with alternated areas of sinusoidal dilatation which gives rise to a vague nodular appearance in the absence of fibrosis, suggestive of NRH. (C, D) Liver biopsy, H&E stain, low power ×40. Intact hepatic architecture with focal hepatocyte atrophy and hepatocyte plate compression with areas of sinusoidal congestion. There is no significant hepatocyte apoptosis or necrosis. Hepatic lobules show mild reactivity with occasional lymphocytic inflammation. There is no significant steatosis, ground glass cells or viral inclusions. Table 1. - Focused Laboratory Results AST/ALT Total Bilirubin Alkaline Phosphatase Viral Hepatitis Serologies (HAV, HBV, HCV) Serum Total Protein Serum Albumin Ceruloplasmin Anti-Smooth Muscle Antibody Alpha-Fetoprotein Alpha-1 Antitrypsin 14/21 units/L 0.4 mg/dL 92 units/L Non-reactive 7.4 g/dL 3.4 g/dL 24.6 mg/dL 11 units 1.0 ng/mL 126 mg/dL

Introduction: Generally of pulmonary origin, small cell cancer is a locoregionally aggressive malignancy that can infrequently arise from the integumentary, upper respiratory, genitourinary, lymphatic, and gastrointestinal tracts. Rectal SCC (RSCC) is particularly rare, accounting for < 0.2% of large bowel cancer. Prognosis is dismal with a median survival of 6-12 months. Here we present a case of RSCC presenting as a rectal ulcer in a patient evaluated for hematochezia. Case Description/Methods: A 75-year-old male with atrial fibrillation on rivaroxaban and a remote history of prostate cancer status-post radiotherapy presented with 24 hours of hematochezia, rectal tenesmus, and diarrhea, but denied weight loss or abdominal pain. Hemoglobin trended from a baseline of 13.5 g/dL 5 months earlier to 11.9 g/dL upon presentation. Diagnostic colonoscopy revealed a firm 3 cm ulcerative rectal mass with heaped borders and friability 2 cm from the anal verge. Pelvic MRI showed the mass abutting the prostate without evidence of extension into adjacent tissues. Brain MRI was negative for intracranial metastasis, and whole-body PET CT showed abnormal uptake in the perirectal, posterior pelvic, right and left inguinal lymph nodes without intrathoracic uptake. Histopathological analysis revealed RSCC with strong CD56 expression, weak expression of synaptophysin and chromogranin, and absent CD45 expression. FNA of the right inguinal lymph node confirmed lymphatic spread, establishing a final staging of T3a-T4bN2aM0 (group IIIC). Given his history of prostate radiation, he was not a candidate for further radiotherapy. He was induced on etoposide/carboplatin and is being considered for either abdominoperineal resection or pelvic exenteration (Figure). Discussion: Colorectal cancer (CRC) is relatively common, with 151,030 new cases of large bowel cancer diagnosed annually in the United States, with 52,580 deaths per year. RSCC is often metastatic, portending a poor prognosis. Primary RSCC is particularly rare, though radiotherapy and chemotherapy can be an effective in neoadjuvant, adjuvant, and palliative contexts when combined with surgery. Though radiotherapy significantly increases survival in RSCC, our patient’s close tumor proximity to his prostate cancer radiotherapy site precluded further radiotherapy. Overall, the prognosis for RSCC remains dismal, with mean relapse of 1 year, even in treated patients. Although rare, our case highlights how RSCC should remain on the differential for both CRC and hematochezia.Figure 1.: Top Left: Rectal mass biopsy under hematoxylin-eosin stain shows dense clusters of oval or round cells (red arrows) with round or oval nuclei, high nuclear/cytoplasmic ratios, prominent mitoses, and conspicuous necrosis that are characteristic of small cell cancer. Bottom Left: Colonoscopy image of a large, ulcerative, friable rectal mass with heaped up borders unlike the typical appearance of adenocarcinoma, which more often presents with a polypoid mass or obstructing lesion. Right: PET-CT slice showing significant radiotracer uptake at site of large rectal mass on colonoscopy (red arrow) and numerous perirectal, posterior pelvic, and inguinal lymph nodes (white arrows).

Introduction: Due to its proven efficacy, endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly used modality in pediatric populations, with utility extending to recurrent pancreatitis (the most common indication in children), chronic pancreatitis, and gallstone disease. However, little is known about long-term ERCP outcomes in pediatric patients. The goal of this project was to assess long-term quality-of-life outcomes in pediatric ERCP using a questionnaire previously validated for patients with chronic pancreatitis. Methods: Adult patients who had an ERCP performed as a child at one of our 3 academic centers were contacted to assess their willingness to participate in the survey. A telephone script was utilized to reduce bias in the posing of questions. The questionnaire incorporated parts of pancreatitis quality of life instrument (PANQOLI), which has primarily been validated for chronic pancreatitis, as well as unique questions designed to evaluate distinctive problems posed by pancreatic and bile duct manipulation. Results: 26 patients completed the questionnaire, with 46.15% reporting complete satisfaction with their health. Though only 23.08% recounted that their presenting symptoms were cured by ERCP (Table 1), the majority of patients (69.23%) perceived no effect of the prior ERCP on their overall health as adults. 34.61% of patients needed at least one additional ERCP, and a diagnosis of chronic pancreatitis was described by 42.31% of surveyed patients. Spearman correlation testing identified that increasing severity of nausea (rs = −0.84231) and weight loss (rs = −0.59523) correlated with decreases in patient health satisfaction (Figure 1A). 23.08% of patients continued to require pancreatic enzyme replacement into adulthood, and 4 of the 26 patients had prescriptions for opiate pain medication related to chronic abdominal pain. Very frequent stress and very frequent frustration were reported by 23.08% and 19.23% of patients, respectively (Figure 1B). Conclusion: This study offers a glimpse into the long-term physical, social, and emotional states of patients who underwent ERCP in childhood. Though we found that chronic symptoms related to ERCP contribute to decreased health satisfaction, further study is needed to assess risk factors for long-term complication in pediatric ERCP. A limitation of this study is the questionnaire’s reliance on patient recall, considering that many of these procedures were performed during childhood many years prior. Table 1. - Survey Results Not at all Slightly Unsure Mostly Completely Overall Health Satisfaction 15.38% 11.54% 11.54% 15.38% 46.15% Cured by ERCP 11.54% 30.77% 19.23% 15.38% 23.08% Unsure No Yes Yes, multiple Additional ERCP 7.69% 57.69% 7.69% 26.92% Subsequent Surgery 0.00% 65.38% 23.08% 11.54% Acute Pancreatitis 0.00% 50.00% 15.38% 34.62% Chronic Pancreatitis 0.00% 57.69% 42.31% 0.00% None Mild Moderate Severe Diarrhea 61.54% 23.08% 15.38% 0.00% Vomiting 84.62% 7.69% 3.85% 3.85% Nausea 57.69% 19.23% 11.54% 11.54% Bloating 46.15% 30.77% 11.54% 11.54% Weight Loss 65.38% 15.38% 7.69% 11.54% Never Very Infrequently Infrequently Sometimes Frequently Very frequently Diarrhea 53.85% 11.54% 3.85% 26.92% 3.85% 0.00% Vomiting 84.62% 0.00% 3.85% 3.85% 3.85% 3.85% Nausea 57.69% 7.69% 7.69% 3.85% 15.38% 7.69% Of the 26 patients that completed our survey, only 23.08% reported that ERCP completely cured their presenting condition. 42.31% of patients reported chronic pancreatitis as a diagnosis after their ERCP, with 26.92% reporting an additional ERCP needed to address their presenting condition. The most common persistent symptoms were nausea, bloating, and weight loss. Figure 1.: Likert Scale showing response rates for reported symptom severity (A) and long-term effects from prior ERCP (B). Symptom severity scale (A) includes Spearman correlation coefficients which identified a correlation between increasing severity of nausea and weight loss and decreasing overall health satisfaction. A sizable number of patients reported stigmatization, anger, frustration, depression, or stress attributable to their prior disease course. There were also post-procedure limitations in the ability to work, participate in sexual activity, participate as a caregiver, and spend time with friends or family.

Background This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates. Methods The Kids’ Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4. Results Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant. Conclusions ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.

Introduction: Benign recurrent intrahepatic cholestasis (BRIC) is a part of a spectrum of familial intrahepatic cholestatic disorders (FIC) characterized by recurrent episodes of cholestasis, jaundice, and pruritus. BRIC type 2 is associated with an ABCB11 mutation that leads to elevations in alkaline phosphatase (ALP) and bilirubin with notable normalization of these levels between episodes. ABCB11 mutation is also associated with progressive familial cholestasis type II (PFIC2), a more severe form of FIC. BRIC in pregnancy has been poorly described. Here we report a case of a 30-year-old woman with BRIC 2 who presented with worsening liver function during two pregnancies necessitating preterm deliveries. Case Description/Methods: A 30-year-old pregnant female with a history of BRIC type 2 presented for 1.5 months of worsening fatigue, pruritus, and jaundice. This mirrored a presentation 5 years prior, at which time she underwent preterm delivery at 28 weeks due to fetal distress in the setting of presumed intrahepatic cholestasis of pregnancy (ICP). After her first pregnancy, she presented twice more for cholestasis and was eventually diagnosed with BRIC type 2 based on her relapsing, remitting medical course, and a noted heterozygous ABCB11 mutation. She was lost to follow-up for 2 years and this admission presented at 13 weeks gestation with fatigue and pruritus. Abnormal liver function tests (LFTs) (Table 1) were noted, and she was managed with ursodiol and rifampin prior to discharge. She was readmitted at 27 weeks gestation with recurrent symptoms and a cholestatic enzyme pattern before treatment with ursodiol, fat-soluble vitamins, and steroids, which had previously resolved her symptoms at the time of initial BRIC diagnosis. She reported mild symptom improvement but no decrease in LFTs. At 34 weeks, she returned in labor with fetal distress and worsening LFTs. She was taken for emergent delivery, and her liver enzymes improved modestly post-partum. Discussion: There are no specific guidelines outlining the management of familial cholestasis in pregnancy. Guidelines for management of ICP recommend consideration of preterm delivery or termination of pregnancy with worsening liver function. As seen in our patient, BRIC type 2 may similarly cause worsening cholestasis, though it typically presents earlier in pregnancy than ICP. Therefore, pregnancy in BRIC 2 patients should warrant more aggressive management and closer follow-up, as pregnancy may serve as a catalyst for progression of BRIC2 to PFIC2.Table 1.: Progression of liver function tests during pregnancy in a patient with BRIC 2.Figure 1.: Liver biopsy with arrows above showing feathery degeneration, a phenomenon occurring in periportal hepatocytes due to the detergent-like action of bile acids in intrahepatic cholestasis. Arrowheads demarcate bile deposition in the setting of bile stasis.

Introduction: Despite increasing ERCP usage, there remains a paucity of information regarding demographic differences and complication rates in pediatric populations, with published evidence only encompassing small sample sizes or lacking head-to-head comparisons. This study aims to aid in risk assessment in pediatric ERCP candidates by utilizing a national pediatric database with a large sample to assess how ERCP demographics affect complication rates. Methods: The KID is a sample of pediatric discharges from community hospitals in states participating in the Healthcare Cost and Utilization Project (HCUP). Demographic information, hospital region, hospitalization duration, and mortality information were provided by the database for individual hospitalizations. ICD-10 codes were also used to determine the hospitalization indication, and subsequently coded ERCP indicated a repeat ERCP within the hospitalization. ERCP complication rate was ascertained via complication codes (K91.89, K91.81). All statistical analysis was performed using SAS 9.4. Results: This analysis captured a large Hispanic population, specifically in the South and West regions (Table 1). Procedure complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. Of pediatric patients with documented ERCP during the hospitalization, 30.0% required a repeat ERCP during the same hospitalization. Repeat ERCP was not associated with increased rate of complication. Calculus of the gallbladder, acute, and chronic cholecystitis were more likely to occur in the female group (Figure 1), though there was no difference in complication between genders (p = 0.3). A higher percentage of hospitalized patients in the age 10-17 age group were female (52.7% vs 72.2%, p < 0.01) and Hispanic (22.7% vs 33.4%, p < 0.01) compared to the age 0-9 group. Age 0-5 was associated with a lower routine home discharge rate and a longer length of stay (Table 2). Complications also occurred at a higher rate in this age group, though the difference was not statistically significant. Conclusion: ERCP is a safe procedure for pediatric populations with relatively low complication rates and exceedingly rare associated mortality. We found significant differences in the procedure indications between pediatric age groups, races, and genders. Though no statistical difference was found in complication rates between groups, age < 5 yo and male gender were associated with longer lengths of stay and decreased likelihood of routine home discharge.Figure: Table 1.: Over 6 million hospitalizations were included in the overall sample, and we restricted to live births with at least one ERCP, giving n=4484 for ages 0 to 20 and n=1934 for ages 0 to 17. A large percentage of the captured patients came from the older age groups, indicating that this is an uncommon procedure in patients age < 10. A high percentage of hospitalized patients in the age 10-17 age group were female (52.7% vs 72.2%, p < 0.001) and Hispanic (22.7% vs 33.4%, p < 0.001) compared to the age 0-9 group. Differences in admission primary diagnosis between genders are also depicted. Females had statistically higher rates of calculus of the gallbladder/bile duct (p = 0.03) and chronic cholecystitis (p = 0.02). Males had higher rates of traumatic injury (p < 0.001), obstruction of the bile duct (p < 0.001), cholangitis (p = 0.002), and primary sclerosing cholangitis (p = 0.02).Table 2.: ERCP Age Group Comparison. A large percentage of the dataset if comprised of patients age >10, indicating that this is an uncommonly performed procedure in younger age groups. The common primary diagnoses for age 10 were more often Hispanic. There was no statistical difference in rates of repeat procedure or complication between age groups. The HCUP database prohibits reporting patient counts < 10.

Introduction: Endoscopic submucosal dissection (ESD) is a novel, minimally invasive method for the removal of malignant and premalignant gastrointestinal lesions. Literature has been published establishing the safety and efficacy of ESD and its potential as a replacement for invasive surgery in some patients. Due to a lack of procedure-specific Current Procedural Terminology (CPT) codes many hospitals are challenged with adopting this intricate procedure in a cost-effective manner. The aim of this study was to evaluate the financial metrics from our first three years of ESD practice and gain insight into how to provide this service more cost-effectively. Methods: Financial data was reviewed from ESDs performed at our tertiary care center from 4/2018 to 3/2021 including insurance status, direct costs, charges per case, payments per case, and contribution margin. Pearson’s correlation test was utilized to assess whether charges, payments, and margins correlated within the cohort. Results: A total of 57 procedures were included, of which 7 were performed inpatient (12.2%) and 50 were outpatient (87.8%). Eleven [19.3%] had commercial insurance, 4 [7.0%] had Medicaid, 34 [59.6%] had Medicare, 4 [7.0%] had federal assistance, and 4 [7.0%] utilized a local repayment assistance program. Total charges [median, range] were $1,718,349 [$17,364, $249,687]. Total direct costs were $409,572 [$4,682, $57,446]. Total payments were $217,488 [$1,199, $50,138]. The total contribution margin was -$183,024 [-$3,334, $21,269]. Increasing charges and costs were associated with increased institutional payments while none were associated with contribution margins. Conclusion: The data depicts an overall net loss for nearly all performed ESDs. Notably, only four of the 57 ESDs yielded a positive contribution margin with three of the most recent seven ESDs netting an average of $6,538 per case. This potentially indicates increased financial viability as more experience was gained with both performing and billing ESDs. Standard deviations exceeded the mean in all fields, indicating a significant degree of variability between procedures. Until standardized CPT codes are established, ESD must be undertaken with a cost-conscious and outcomes-focused mindset to reduce institutional losses.Figure 1.: Top: Depicts relation between costs per case in relation to payments showing a strong correlation. Bottom Left: Relation between charges per case and contribution margin (CM). Bottom Right: Relation between payments per case and CM. It is notable that both bottom figures do not have statistically significant correlations. However, if outliers are not considered, there appears to be a clear negative trend in CM with increasing charges and costs per case.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly utilized procedure for pediatric populations. A lack of dedicated pediatric research has forced endoscopists to extrapolate adult risk factors and preventative strategies to children despite population-based studies suggesting significant differences in common indications and demographic characteristics. The aim of this multi-institutional, retrospective observational study was to characterize risk factors for complication and ERCP failure in pediatric populations. Methods: Between 2004 and 2021, 288 pediatric patients were identified to have received an ERCP under age 18 at one of our academic centers (University Hospital, Children’s Hospital of San Antonio, Christus Santa Rosa). Once a patient’s initial ERCP data was extracted via chart review, subsequent ERCPs were each recorded as a repeat instance with collection of each ERCP’s indication, interventions, complications, and rates of repeat procedure. ERCP-related complications were defined and graded based on severity according to the consensus criteria developed by Cotton et al, 2010. All statistical analysis was performed using R version 4.0.5. Results: 716 procedures were identified. Though average case complexity was higher than other studies, the overall success rate was 95.5% with no mortality and a 12.7% complication rate (Table 1). Repeat ERCP correlated with increasing rates of complication (p < 0.001) (Figure 1). Younger age was associated with increased case complexity (p = 0.001), complications (p = 0.009), and rates of repeat ERCP (p < 0.001) (Figure 2). Increasing case complexity scoring on initial ERCP led to increased procedure times (p < 0.001), increased complications (p < 0.01), and a decreased technical success rate (p = 0.04) (Figure 3). Interventions associated with increased complications and rates of repeat ERCP were stent removal and pancreatic stenting, while implicated diagnoses were recurrent pancreatitis, chronic pancreatitis, pancreatic divisum, and pancreatic stricture/stenosis (Figure 4, 5). Conclusion: Interventions on the pancreatic side of the pancreaticobiliary system and pancreatic disease affecting pancreatic anatomy are particular risk factors for adverse ERCP outcomes in pediatrics. Cases for younger patients (especially under age 5) are more likely to be complex and result in complication. This study also suggests the complexity scoring previously proposed by Cotton et al, 2011 is applicable to pediatric populations.Table 1.: Retrospective Cohort of ERCPs Performed at University Hospital, CHRISTUS Santa Rosa, and Children's Hospital of San Antonio. Table shows the breakdown of patient demographics and types of complications associated with ERCP in pediatrics. Though the average case complexity was higher than other studies, the overall success rate was 95.5% with no mortality and a complication rate of 12.7%. Notably, abdominal pain attributed to procedure was included as a complication for this dataset, as this had been previously included in the Cotton et al, 2010 study that was referenced for complication classification (+). We can also see the differences in initial ERCP diagnoses vs repeat ERCP diagnoses. Recurrent pancreatitis, chronic pancreatitis, diagnosis of pancreatic divisum, and anatomic stenosis/stricture are increasingly common diagnoses in the repeat ERCP group. This table also shows that ERCPs for choledocholithaisis or cholangitis rarely require repeat ERCP (+)2.Figure 1.: This graph displays the lifetime rate of ERCP complication when comparing patients receiving a single ERCP (11%) vs at least one repeat ERCP (36.8%).Figure 2.: This table shows how younger patients had more complex cases, increased rates of complication, and increased rates of repeat ERCP.Figure 3.: Procedure complexity scoring was derived from Cotton et al, 2011(A)-Grade 1(easiest) to Grade 4(most difficult). Here a significant inverse relationship appears between technical success rate and procedure complexity. Procedure duration (p <0.001) was also longer in the more complex group with a positive relationship between complexity and rates of complication (tau 0.24, p < 0.01).Figure 4.: Shows frequencies of interventions performed during initial ERCPs. The most common interventions (sphincterotomy, stone removal, and balloon sweep) are typically performed for stone disease and did not correlate with increased rates of complication. Pancreatic stenting was associated with the highest correlation with complication and rates of repeat ERCP.Figure 5.: Shows the most frequent initial procedure diagnosis was choledocholithiasis. Diagnoses associated with increased complication are ones sometimes seen with pancreatic anatomic abnormalities, such as recurrent pancreatitis, chronic pancreatitis, pancreatic divisum, and pancreatic strictures. Utilized statistics 1.Kendall Rank Correlation. 2. Fisher’s Exact Test. 3. ANOVA (A).1

INTRODUCTION: Esophagogastroduodenoscopy (EGD) is an important tool for assessing the resolution of high-risk varices, ulcers, and esophagitis. At our institution, the process of scheduling surveillance EGD has proven inconsistent. This quality improvement study is designed to improve rates of short-term follow-up EGD (4-12 weeks) via standardization of the scheduling process, a change we hope will increase early detection rates of high-risk lesions and facilitate rapid management of threatening conditions. METHODS: We retrospectively reviewed 191 EGDs from 1/1/19-4/30/19. Collected variables included recommended follow-up timeframe, whether repeat EGD was performed within the recommended period, evidence of a consult being placed, and the presence or absence of a visit being scheduled. Scheduling was then standardized via a newly created form, filled out by fellows/faculty and given directly to scheduling staff. Afterwards, an additional 69 charts were reviewed from 1/1/20-1/31/20, and pre and post-intervention rates were compared using chi squared testing. RESULTS: Of the pre-intervention cases, 103 had follow up EGD recommended within 4-12 weeks. Only 47.6% had an appointment properly scheduled, while 32.0% had an EGD within the recommended timeframe. Of the post-intervention cases, 38 patients had a follow up EGD recommended within a 12 week period. Of these patients, 81.6% had a visit made after initial EGD, demonstrating a dramatic improvement in the overall rate of properly scheduled appointments (P = 0.01) (Figure 1). When controlling for follow-up indication there was significant improvement in scheduled visits for high-risk varices (P = 0.02), ulcers (P = 0.04), and esophagitis (P = 0.028) (Figure 2). Follow-up EGD was actually performed in the recommended period for 42.1% of post-intervention patients (P = 0.27), When excluding the 10 patients with cancelations due to COVID 19 (3/25-5/3), this number increases to 57.1%, representing a statistically significant increase in EGDswithin the recommended time period (P = 0.01). Conclusion: Clinical expertise plays a large role in identifying high-risk lesions, and the ability to repeat EGDs in a timely manner remains a critical aspect to facilitating excellent patient care. As seen in this project, the standardization of logistic processes can have a dramatic effect on follow-up rates for high-risk lesions. While our data is affected by COVID 19 cancelations, our increase in successful surveillance indicates a positive shift in scheduling effectiveness.Figure 1.: Here we see how both rates of EGD within recommended time frame (A) and rates of appropriately scheduled follow up visits (B) were affected by the standardization of scheduling by a simple form accompanied by practitioner education. It is notable that the previous process of scheduling, whereby it was left to primary teams or the fellow to place a consult, resulted in low rates appointments even being scheduled properly (47.6%).Figure 2.: The breakdown of appointment scheduling rates by indication shows that the failure of these patients to follow up was not limited to a single indication, but rather a process deficiency. Once the process was standardized, dramatic improvements in the rates of scheduled visits and follow ups is seen across each indication.Figure 3.: Variceal bleeding is seen as the most frequent reason for recommended repeat EGD within 12 months. Esophagitis, ulcers, and Barrett’s esophagus remain frequent indications, as these lesions sometimes be a sign of underlying malignancy.

INTRODUCTION: Microscopic colitis (MC) is a diarrheal illness difficult to differentiate from other gastrointestinal disorders. Historical cues and understanding of disease prevalence are critical to the evaluation of MC patients experiencing continued symptoms despite adequate treatment or histologic improvement. This study examines the prevalence of concomitant small intestine bacterial overgrowth (SIBO) and carbohydrate malabsorption in a MC population. METHODS: Records were reviewed from 6/2015 to 6/2020 at a single-center private gastroenterology practice. Patients with MC were identified by ICD10 codes and grouped into either collagenous (CC) (K52.831), lymphocytic (LC) (K52.832), or other microscopic colitis (K52.839). Patient demographics, surgical history, disease activity, medications, fecal calprotectin, date of initial diagnosis, and breath testing results were recorded in a HIPAA compliant dataset. Data were analyzed using chi-squared, Fisher’s exact, Pearson correlation, and T testing where indicated. RESULTS: 223 MC patients were reviewed with 67 included based on the presence of SIBO hydrogen (H2) breath testing: 50 with LC, 10 with CC, 4 with CC and MC, and 3 indeterminate. The average age at MC diagnosis was 64.9 ± 14.6, with a higher prevalence of females (73.1%) and whites (78.9%). SIBO positive rates were 19/54 (35.2%) in the LC group and 5/14 (35.7%) in the CC group (P = 0.97) (Figure 1). There was no difference in SIBO positivity between age groups (< 70 vs > 70, P = 0.82), genders (P = 0.33), or ethnicities (P = 0.35). SIBO rates in patients with active MC (defined as > 3 watery bowel movements daily) did not differ from patients in remission (30.6% vs 28.6%, P = 0.89). The average fecal calprotectin (FC) in the SIBO positive group was 84.4 mg/mg, compared to 262.6 mg/mg in the SIBO negative group (P = 0.31) (Figure 2). Concurrent carbohydrate malabsorption was observed in 47.4% of SIBO positive patients, compared to 61.1% in the SIBO negative group (P = 0.33) (Figure 3). CONCLUSION: This retrospective cross sectional study illustrates rates of SIBO positivity in the MC population are similar to symptomatic patients in the general population (Figure 1). There was no difference in positive rates between the LC and CC groups, limited by a small CC sample size. Furthermore, carbohydrate malabsorption was frequently superimposed on the MC diagnosis, highlighting the need to consider H2 breath testing for both SIBO and carbohydrate malabsorption in symptomatic MC patients who are unresponsive to therapy.Figure 1.: Similar rates of SIBO positivity were observed between collagenous and lymphocytic colitis (35.2% vs 35.7%, P = 0.97). Rates of bacterial overgrowth in the general population are estimated 2-22%, though our study’s rates of positive SIBO breath testing correlate with rates from a Vizuete et al, which found SIBO positivity in 32.9% of patients with “flatulence, eructation, and gas pain”. No statistical difference in SIBO positivity was seen between age groups (39.1% (< 70) vs 36.4% (> 70), P = 0.82), genders (27.8% (M) vs 40.8% (F), P = 0.33), or ethnicities (43.3% (white) vs 25.0% (non-white), P = 0.35).Figure 2.: There was no difference in SIBO positive rates between patients with active microscopic colitis (described as at least 3 bowel movements per day) versus patients in remission (30.6% vs 28.6%, P = 0.89). When comparing SIBO positive to negative patients, there was no difference in the percentage of patients on steroid therapy at the time of breath testing (12.0 vs 14.3%, P = 0.79).Figure 3.: Carbohydrate malabsorption was frequently observed in all tested patients (56.4%). Positive rates of fructose/lactose/sucrose intolerance were observed more frequently in the SIBO negative group (47.4% vs 61.1%, P = 0.33). There was no observed difference between collagenous colitis patients (CC) and lymphocytic colitis patients (LC) with regard to rates of individual carbohydrate malabsorption.

INTRODUCTION: Despite increasing endoscopic retrograde cholangiopancreatography (ERCP) usage in pediatrics, there remains a paucity of information regarding ERCP outcomes in children. Thus, providers are forced to extrapolate adult risk factors and preventive strategies to children, who are a unique population entirely. This pilot study aims to quantify the healthcare burden of pediatric ERCP and to define how outcomes differ amongst pediatric age groups. METHODS: Pediatric patients (age < 18) who underwent ERCP from 3/1/18 to 3/1/20 were identified. All historical and subsequent ERCPs were reviewed. The cohort was divided into two age groups: preadolescent (age 0–13) and adolescent (age 14–17). Descriptive and comparative statistics were performed, and continuous variables were compared via two-sided T-tests. RESULTS: A cohort of 25 patients (total of 74 ERCPs) was identified. 17 (68%) patients were female with no difference with regard to male and female age (P = 0.86), and mean BMI was 25.7 ± 8.5. The most common initial ERCP indications were pancreatitis (32%) and recurrent biliary colic (32%) (Table 1). Females had a higher percentage of biliary stones removed compared to males (41.2% vs 25%, P = 0.43) on initial ERCP but a lower percentage of biliary stents placed (47.1% vs 87.5%, P = 0.05). Repeat ERCPs were most commonly performed for the removal or replacement of biliary stents (55.1%). Among patients requiring multiple ERCPs, preadolescents had a higher number of subsequent ERCPs (5.6 vs 2.1, P = 0.06). Also, the relationship between BMI and number of procedures appears to be inversely proportional; however, this was not statistically significant (r = −0.28, P = 0.18) (Figure 1). There was no difference between age groups with regards to complications (P = 0.87), procedure times (P = 0.25), pre-procedure length of stay (LOS) (P = 0.21), post-procedure LOS (P = 0.70), or opiate utilization (P = 0.08)(Figure 2). CONCLUSION: The trend toward increased subsequent ERCPs among preadolescent patients compared to adolescents suggests that younger pediatric patients may exhibit a more complicated and prolonged overall course. Children suffering from pancreaticobiliary disease have high rates of morbidity, evidenced by the high rates of repeat hospitalization, ED visits, and opiate utilization. BMI was inversely associated with procedure number - possibly due to multiple hospitalizations, decreased oral intake, and malabsorptive syndromes due to pancreatic insufficiency and recurrent biliary outflow obstructions.Table 1.: Females were found to have higher BMIs in this sample and represent a larger percentage of the patients presenting with pancreatitis and biliary colic. ERCP complication rates were low, occurring in only 4.1% of total performed ERCPs. Post-ERCP pancreatitis was defined as new or worsened abdominal requiring a new hospitalization or extension of hospital stay with a lipase or amylase at least three times the upper limit of normal within 24 hours of the procedure. Though there was no mortality seen in the sample, these 25 patients endured a staggering 60 procedures after initial ERCP including a total pancreatectomy, an islet cell transplant, a Whipple procedure, and 2 cases of severe, recurrent abdominal pain that required celiac blocksFigure 1.: There was no difference between age <13 and >14 years when comparing complication rates, rates of outpatient opiate utilization, and rates of repeat ERCP after initial. However, when accounting for every performed ERCP; including repeats, there was a statistically significant increase in the likelihood of having another ERCP. Rates complications and opiate discharges did not differ when comparing initial ERCPs and repeats, suggesting that there is no increase in individual procedure outcomes when ERCP repeat is required.Figure 2.: Our patients requiring multiple procedures tended to have lower body mass indices (BMI) (kg/m2), likely due to malabsorption due to chronic pancreatitis, biliary abnormalities, and recurrent hospitalizations with inability to tolerate PO nutrition. 2 of the 3 individuals most frequently receiving ERCP had increases in BMI with subsequent interventions, suggesting some improvement in either intake or absorptive capacity with repeat therapeutic intervention.

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a mature endoscopic technique that can spare patients surgical removal of luminal gastrointestinal lesions too large for endoscopic mucosal resection. The safety and feasibility of ESD has been established; however, outside of Japan and other East Asian countries, technique adoption has been gradual due to a steep learning curve, prolonged procedure times, procedure risks, and a lack of qualified ESD providers. This quality improvement study is designed to examine the challenges of the rapid adoption of ESD by a single practitioner and to provide insight into the expected safety metrics during its incorporation into practice. METHODS: ESDs performed from 4/2018 to 5/15/19 were compared to cases from 5/16/19 to 1/31/20 to assess complication rates, resection type (en bloc vs piecemeal), presence of positive margins, lesion recurrence, and success rates with regard to lesion location, lesion size, and presence or absence of prior endoscopic intervention. Pearson’s correlation testing was utilized to assess whether lesion size correlated with procedure duration in before and after groups. RESULTS: 41 patients were included in the final ESD dataset (20 prior to 5/15/19, 21 after 5/16/2019). The late procedure group was found on Fisher's exact testing to have a statistically significant increase in en bloc resections (P = 0.040) and decrease in lesion recurrence rates (P = 0.048) (Figure 1). Complications, consisting of one perforation and one post-procedural bleed, were exclusively observed in the early ESD group (Figure 2). There was no statistically significant change in complications (P = 0.232) or ESD success rate (P = 0.598), though decreases in these outcomes were identified after the initial 20 cases. Average ESD procedure times was 143.7 ± 52.0 min, and increasing lesion size was associated with increased procedure times (Figure 3), positive margins, and complications. CONCLUSION: The statistically significant increase in en bloc compared to piecemeal resections is an important benchmark for rapid adopters of ESD, indicating a shift in practitioner proficiency after the first 20 cases. A significant decrease in lesion recurrence also points to improved ability with the number of performed cases, and subgroup analysis of positive margin rates implicated the esophagus as an area of particular difficulty. Complication rates were shown to decrease early in ESD adoption, demonstrating the safety of an experienced endoscopist undertaking ESD.Figure 1.: Shows the differences in rates of en bloc resection (a), recurrence (b), positive margins (c), and complications (d) between the first 20 ESDs and the subsequent 21 ESDs. Complications identified in 1c were a bowel perforation while removing a 6.2 cm2 GIST from the posterior stomach and an episode of subsequent bleeding requiring repeat EGD with endoscopic cautery. In 1d, reasons for unsuccessful resections were poor prep, sigmoid bowel spasms, and a procedure with difficultly positioned well-differentiated neuroendocrine tumor in the gastric antrum requiring hybrid ESD/EMR.Figure 2.: Shows incidence rates compared to pathology results. Excluded are 2 procedures performed for therapeutic relief, 2 with unsuccessful resections resulting in no tissue, and 5 for benign pathology (hyperplastic polyps, inflammatory polyps, and a large submucosal lipoma). None of these 9 procedures resulted in complications or lesion recurrence, and the resections were all achieved en bloc. Recurrence was heavily associated with piecemeal resection, with all but one lesion recurring in the setting of piecemeal resection (all in the early ESD group).Figure 3.: Depicts linear regression modeling of lesion size and procedure duration. While early resections showed a minimal size correlation with procedure times (R = -0.29, P = 0.449), Pearson correlation testing identified resections after 5/16/2019 start to form a correlation between increasing lesion size and ESD procedure times (R = 0.24, P = 0.337). On average, the largest lesions were identified in the descending colon (3.875 cm), compared to the smallest lesions in the esophagus (1.71 cm). Despite this, rates of positive resection margins were highest in the esophagus (57.1% of procedures with positive margins were lesions in the esophagus), indicating that this is a difficult area to achieve full resection.

INTRODUCTION: Autoimmune hepatitis (AIH) can present almost identically to drug-induced liver injury (DILI). While 90% of drug-induced AIH worldwide is due to nitrofurantoin and minocycline, several medications have been implicated making differentiating DILI and AIH difficult (Figure 1). We present a case of AIH due to para-aminobenzoic acid (PABA), a previously undescribed cause of drug-induced AIH. CASE DESCRIPTION/METHODS: A 37 year-old female with ulcerative colitis on mesalamine presented with 2 weeks of jaundice. She reported initial eye yellowing and intense pruritus 2 days after starting a hair supplement containing PABA. An outside ER prescribed oral prednisone which improved the pruritus, but despite stopping the PABA, she developed fatigue, malaise, and nausea in the setting of worsening conjunctival icterus. Aspartate (AST) and alanine transaminase (ALT) were 1570 U/L and 2315 U/L, respectively, with a bilirubin (TB) of 7.9 mg/dl (direct bilirubin (DB) 5.4 mg/dl) (Figure 2). Liver ultrasound revealed patent hepatic vasculature without anatomic disease, and viral hepatitis serologies were negative. She received camphor/menthol lotion for pruritus as liver enzymes peaked at AST 2310/ALT 3061 and TB 12.5/DB 7.6 on hospital day 2. A liver biopsy performed on hospital day 4 showed acute, non-specific panlobular hepatitis (Figure 3). Smooth muscle antibody (anti-SMA) and serum IgG were elevated at 39:1 and 1623 mg/dL, respectively. ANA, HSV, CMV, HIV, and EBV serologies were negative with normal levels of Anti-LKM Type 1, alpha 1 antitrypsin, and mitochondrial antibodies. LFTs downtrended, and she was discharged on hospital day 8 with an AST 1361/ALT 1577 (TB 6.7). Her LFT elevation persisted one month later, and she was started on prednisone and 100 mg of daily azathioprine which normalized AST, ALT, and TB. Azathioprine was increased to 125 mg daily at 6 months due to another episode of fatigue with LFT elevation. One year later, she remains asymptomatic on azathioprine. A second liver biopsy confirmed resolution of acute hepatitis, now with grade 2 chronic hepatitis. DISCUSSION: PABA is a sunscreen ingredient marketed as a dietary supplement for skin disease and hair loss prevention. Overdose can cause DILI, which we initially believed to be the diagnosis in this case. However, the elevated anti-SMA, characteristic liver biopsy, persistent lab abnormalities, and subsequent steroid response strengthens the diagnosis of type 1 AIH—a finding that should prompt caution with future use of this supplement.Figure 1.: Numerous medications have been linked to autoimmune hepatitis, though the most frequent causative medications are minocycline and nitrofurantoin. Notably, statins can be a cause of drug induced liver injury and AIH, and a small number of DILI cases can share features with AIH or trigger overt AIH.Figure 2.: Here we see the LFT response over time. AST and ALT peaked in the hospital and decreased prior to discharge, though it was not until prednisone and azathioprine were started that the LFTs and bilirubin returned to normal range. 6 months after presentation, LFTs increased with accompanying fatigue and she was diagnosed with AIH flare which required restarting a short course of prednisone and increasing her daily azathioprine.Figure 3.: Liver biopsy showing areas of interface hepatitis (arrows) with a lobular necro-inflammation consistent with acute hepatitis (a). High magnification of the portal tract shows abundant plasma cells along with lymphocytes and scattered eosinophils (b). Acute hepatitis with prominent plasma cell infiltration is compatible with autoimmune hepatitis, though other features that can be found in AIH are not seen.

Hepatolithiasis is a disease characterized by intrahepatic stone formation. In this article, we review the features of this disease and explore the established and emerging treatment modalities. Recent reports show an increasing prevalence of hepatolithiasis, likely owed to increased immigration and shifts in the Western diet. New pharmacotherapy options are limited and are often only supportive. Endoscopic intervention still cruxes on removal of impacted stones, though new techniques such as bile duct exploratory lithotomy and lithotripsy continue to advance management. Although hepatectomy of the effected portion of the liver offers definitive therapy, alternative less invasive modalities such as combined endoscopic/interventional radiology modalities have been utilized in select patients. Additionally, liver transplant serves as an option for otherwise incurable hepatolithiasis with coexisting liver dysfunction. Multiple emerging pharmacologic and procedural interventions may provide novel treatment for hepatolithiasis. While definitive therapy remains resection of affected liver segments, these modalities offer hope for less invasive approaches in the future.

ABSTRACT Benign recurrent intrahepatic cholestasis represents a rare class of autosomal recessive chronic cholestasis disorders, usually presenting with recurrent episodes of intense pruritus and jaundice. We report a 27-year-old woman presenting with benign recurrent intrahepatic cholestasis type 2 due to heterozygosity in ABCB11. Interestingly, she was also found to be heterozygous in cystic fibrosis transmembrane conductance regulator, NPHP4, and A1ATD (SERPINA1), which may explain the severe nature of her disease expression because heterozygosity in each of these genes has been associated with cholestasis. Finally, she exhibited a response to steroids that may have implications for future treatment of bile salt export pump-related diseases.

INTRODUCTION: Ulcerative colitis (UC) is a chronic inflammatory bowel disease with symptoms of persistent diarrhea and abdominal pain. Small intestinal bacterial overgrowth (SIBO) can appear concurrently with UC with similar symptoms, and differentiating between the two can be difficult, particularly in patients whose UC is thought to be in remission. Data concerning prevalence rates of SIBO among UC patients has not previously been described. METHODS: Electronic health records from 6/2015 to 6/2020 at a single-center private gastroenterology practice were reviewed retrospectively by 3 independent investigators. UC patients were identified by ICD10 codes (K51.91) and included if they also underwent hydrogen (H2) breath testing. Patient demographics, surgical history, disease severity, medications, fecal calprotectin (FC), and breath testing results were recorded in a deidentified, HIPAA compliant dataset. Data were analyzed using chi-squared tests, Fisher’s exact tests, and T testing where appropriate. RESULTS: 520 UC patients were identified, with 67 (49.2% male, 50.7% female) tested for SIBO and included in the analysis (Table 1). 21 patients (31.3%) tested positive for SIBO (increase of H2 at least 10 ppm on breath test) with no difference in SIBO positivity across patient demographics including gender (P = 0.77), race (white vs non-white, P = 0.86), and age (> 65 vs < 65, P = 0.41) (Figure 1). When excluding patients with prior intestinal surgery, SIBO rate was 29.3% without demographic differences. The average FC at the time of SIBO testing was 93.3 mg/mg with no statistical FC difference in SIBO positive patients compared to negative (77.9 vs 116.5 mg/mg, P = 0.53), and UC treatment was unrelated to SIBO rate (P = 0.96). Breath testing for carbohydrate malabsorption in this UC population identified 24/55 (43.6%) with at least one of lactose/fructose/sucrose intolerance. SIBO positive patients did not have statistically different rates of carbohydrate malabsorption (Figure 2), though lactose intolerance was exclusively observed in the SIBO negative group (0/10 vs 7/32, P = 0.16). CONCLUSION: Estimates of SIBO prevalence vary widely from 4 - 78% in various populations. It is well established that patients with IBD often have concomitant functional bowel disease. In this large UC population, SIBO was detected in nearly a third of tests, arguing that breath testing is a logical step that can facilitate the diagnosis and treatment of patients with UC and persistent symptoms.Table 1.: Differentiating between uncontrolled inflammatory bowel disease and other causes of abdominal symptoms and diarrhea can be difficult. Our population represents a real-world community population, with an even gender mix, diversity of ethnicity, and a number of patient with prior intestinal surgery (9/67). The fecal calprotectin at the time of SIBO testing is low on average, indicating that breath testing was generally performed in patients with controlled UCFigure 1.: Rates of positive SIBO testing were more than general population estimates (2-22%) but were found to be similar to SIBO rates confirmed in symptomatic patients. Fecal calprotectin was not associated with changes in SIBO results, indicating that disease activity did not necessarily correlate with the incidence of positive SIBO testing. *Control data acquired from a similar population in “Vizuete J, et al. The differential diagnosis of gas and bloating. Am J Gastro 2013; 108:S92–S106.”Figure 2.: Rates of fructose intolerance differed little between SIBO positive and negative groups. The fact that lactose intolerance was exclusively observed in the SIBO negative group, despite being statistically insignificant (P = .16), is interesting in that it may hint that the presence of anomalous bacteria can affect lactose absorption.