Background: We aimed to examine the relationship between disease symptoms and disease phenotype in a large Canadian cohort of persons with Crohn’s disease (CD). Methods: Adults (n=1515) with CD from 14 Canadian centers participated in the Mind And Gut Interactions Cohort (MAGIC) between 2018 and 2023. Disease activity was measured using the 24-item IBD Symptom Inventory-Short-Form (IBDSI-SF). We compared the symptoms commonly associated with active versus inactive disease, and explored symptoms patterns in relation to disease phenotype, based on the Montreal Classification. To assess psychological status the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were used. Results: The mean disease duration was 15.6±11.8 years. The 5 most common symptoms were similar for those with active disease, although at higher prevalence (89% to 98%) versus those with inactive disease (47% to 79%), and included fatigue, diarrhea, gas, bloating, and urgency. The intensity of symptoms was higher in those with active than inactive IBDSI-SF scores. The rank order and relative distribution of the symptoms and intensity of the symptoms reported were similar between those with different disease phenotypes B1, B2, and B3 and L1, L2, and L3. Persons with active IBDSI-SF had a higher prevalence of anxiety (24.6%) and depression (38.2%) versus persons with inactive IBDSI-SF (6.3% and 8%, respectively) Conclusions: Individuals with CD with active and inactive disease by IBDSI, experience similar symptoms, but the prevalence of symptoms and their intensity is greater in persons with active IBDSI. Persons with inactive IBDSI report many symptoms. There was no difference in symptom reporting by disease behavior or location.

BACKGROUND:The Inflammation, Microbiome, and Alimentation: Gastro-Intestinal and Neuropsychiatric Effects Strategy for Patient Oriented Research Network (IMAGINE) has conducted a 5-year multicenter prospective observational cohort study, Mind And Gut Interactions Cohort (MAGIC) in 14 centers across Canada from 2018 to 2022. Herein, we investigated the relationship between ulcerative colitis (UC) phenotypes, demographics and other relevant outcomes, and symptom reporting. METHODS:At baseline, participants answered surveys assessing disease activity, medications and complementary therapies, lifestyle factors, psychological status, and comorbidities. UC phenotypes were classified by the Montreal Classification. Herein, we describe the association between phenotypes and demographics, medications used, comorbidities, and symptoms experienced in adults with UC. The Inflammatory Bowel Disease Symptom Inventory (IBDSI) was used to assess symptoms. RESULTS:The maximal extent phenotypic distribution based on chart review was E1 (proctitis) n=261 (14.5%), E2 (left-sided colitis) n=671 (37.2%), and E3 (subtotal or pancolitis) n=794 (44.0%). More males had E3. Different phenotypes did not lead to differences in the use of complementary therapies. There was greater likelihood of primary sclerosing cholangitis but a lower likelihood of hypertension in E3. Among the 25 different symptoms queried in the IBDSI, there was no difference across phenotypes, except among persons with overall active IBDSI, there was more waking for urges for bowel movements in persons with E3. CONCLUSIONS:Overall, there was no difference in symptom reporting based on extent of UC except for cohort with overall active IBDSI there were some differences in nocturnal waking based on disease extent.

Objective:Proton pump inhibitors (PPIs) are widely prescribed but inappropriate indications and concerns over long-term side effects have led to recommendations to deprescribe PPIs in certain patients. We previously found a 4-fold increase in PPI deprescription in patients with esophageal strictures. This study aims to assess the PPI deprescription rate in patients with upper gastrointestinal bleeding (UGIB). Methods:All patients from 2 gastroenterology practices who received endoscopic treatment for UGIB during the years of 2015-2022 were identified using physician billing codes. We defined PPI deprescription as either a 50% dose reduction, frequency reduction, or complete medication discontinuation at the time of endoscopic intervention compared to the established PPI therapy from the 3 months prior. We compared the rate of PPI deprescription between 2 time periods 2015-2018 (group 1) and 2019-2022 (group 2). Results:Three hundred one UGIB managed with endoscopy were analyzed. Patients in group 2 had a significantly higher rate of PPI deprescription than group 1 (15% vs 4%; P < .002). Patients with peptic ulcer disease (PUD) had a significantly higher PPI deprescription during the second time period (16% vs 0%; P = .028). Among patients with repeat UGIB, 10% had their PPI deprescribed. Conclusions:Proton pump inhibitor deprescription in patients with UGIB treated with endoscopic intervention was more common in the second time period. This corresponds to when PPI deprescription guidelines were distributed. Physicians should ensure the appropriate application of PPI deprescription guidelines and continuation of PPI therapy for patients with strong indications.

BACKGROUND & AIMS:Nonvariceal, nonpeptic ulcer bleeding, arising from etiologies such as malignant tumors, Mallory-Weiss tears (MWTs), Dieulafoy's lesions, and gastric antral vascular ectasia, constitutes a significant and increasing proportion of upper gastrointestinal bleeding cases. These evidence-based guidelines, developed by the Canadian Association of Gastroenterology with international collaboration, are the first to specifically address the endoscopic management of these conditions, aiming to support patients, clinicians, and others in making informed decisions. METHODS:The Canadian Association of Gastroenterology formed a guideline panel with a balanced representation to minimize potential bias from conflicts of interest. The Cochrane Gut Group supported the guideline-development process, including conducting literature searches and performing systematic reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation approach was used, including developing the Grading of Recommendations Assessment, Development and Evaluation Evidence-to-Decision frameworks, which underwent public comment. RESULTS:The panel formulated 19 conditional recommendations for adult patients with nonvariceal, nonpeptic ulcer bleeding due to malignant tumors, MWTs, Dieulafoy's lesions, and gastric antral vascular ectasia. CONCLUSIONS:For patients with active bleeding from malignant tumors, the panel suggested topical hemostatic agents over conventional endoscopic hemostatic therapy; it also suggested the administration of oncologic therapy after the endoscopic intervention. In patients with active bleeding from MWTs (oozing and spurting), the panel suggested endoscopic band ligation or endoscopic through-the-scope clip over epinephrine injection alone. For nonbleeding MWTs with visible vessels, adherent clots, flat pigmented spots, or clean-based ulcers, the panel suggested against endoscopic hemostatic therapy. For Dieulafoy's lesions, the panel suggested mechanical modalities with endoscopic band ligation or through-the-scope clip, contact thermocoagulation, or injection of sclerosants over epinephrine injection alone. For patients with gastric antral vascular ectasia, the panel suggested endoscopic band ligation over argon plasma coagulation. GUIDELINE ENDORSEMENT:This guideline has been formally endorsed by leading international endoscopy societies: the American Society for Gastrointestinal Endoscopy, the European Society of Gastrointestinal Endoscopy, the Sociedad Interamericana de Endoscopía Digestiva, and the World Endoscopy Organization, as well as by the American Gastroenterological Association.

Abstract Background Proton Pump Inhibitors (PPIs) are commonly used for various indications, including prophylaxis of upper GI bleeding. We aimed to assess if there has been more PPI deprescription in recent years in patients treated for Upper GI Bleeds (UGIB). Aims Our study aimed to assess the frequency of PPI deprescription in patients treated with endoscopic therapy for UGIBs. We hypothesized that there was a higher rate of PPI deprescription in recent years. Methods This retrospective cohort study analyzed patients who received endoscopic treatment for UGIB between the years 2015-2022. All patients who were treated with endoscopic therapy for an UGIB from two academic GI practices were included. PPI deprescription was defined as a 50% dose reduction, frequency reduction or complete medication discontinuation in the past 3 months or longer in established PPI users. To assess trends, the cohort was divided into group 1 (2015-2018) and group 2 (2019-2022). Data were analysed using SPSS and chi-squared testing was used to compare categorical variables. Results Data were collected from 301 UGIB treated endoscopically. The mean age was 66.4 ± 13.5 years with 64% males and 36% females. Patients from group 1 had a deprescription rate of 2% (2/101 cases). Patients from group 2 (2019-2022) had a deprescription rate of 16% (32/200 cases) (pampersand:003C0.001). Conclusions There was a higher rate of PPI deprescription in patients treated for UGIB in the second time period. Reasons for the increased rate of PPI deprescription require further investigation. Chi-Squared of PPI Deprescription for entire cohort Fisher Exact test: P value ampersand:003C0.001 Funding Agencies None

Abstract Background Gastrointestinal (GI) endoscopic procedures may need to be performed emergently on hospitalized patients. Current short-term mortality rates following emergent GI endoscopic procedures are attributed to their indication and vary by geographic area, ranging from 1.89% to as high as 10%. Recent studies describing clinical outcomes and mortality of non-scheduled GI endoscopic procedures are limited. Aims This study aimed to describe the 30-day mortality and clinical outcomes of patients who received endoscopic intervention as an add on, non-scheduled procedure over a 2-month period across 2 tertiary hospitals, in St. John’s, Newfoundland and Labrador. Methods We retrospectively reviewed the charts for all patients between July 1, 2021, and August 31, 2021, who received an esophagogastroduodenoscopy (EGD), colonoscopy, sigmoidoscopy, and percutaneous gastrostomy (PEG) across 2 tertiary hospitals in St. John’s, Newfoundland and Labrador. Endoscopic procedures on hospitalized patients that were added to the emergency endoscopy list were included. Procedures were done during working hours on weekdays or outside working hours at night-time, and during the weekend. Data on demographics, endoscopic findings, treatment outcomes, and 30-day mortality, were collected through electronic chart review. Descriptive statistics were conducted for data analysis. Results Of the 258 add on procedures performed on 213 patients, 17 patients (8.0%) died within 30 days of having had the procedure. The most frequently performed procedure was EGD, and the mortality associated with it was 9.4% (12/127), followed by sigmoidoscopy (1/29, 3.4%), colonoscopy (0/18, 0%), PEG (3/9; 33.3%). One patient who died had both EGD and colonoscopy (1/25, 4%). No patients died from both EGD and sigmoidoscopy (0/5, 0%). The median time between the procedure and death was 15 days. The median age was 72 years old. Most patients received endoscopic intervention for suspected bleeding. The major causes of death were cardiac, GI, malignancy, respiratory, and other. Conclusions Hospitalized patients are a distinct cohort with competing risks that need to be considered when planning endoscopic procedures. Further investigation is necessary with a larger patient cohort over multiple years. Funding Agencies Summer Undergraduate Research Award (Memorial University of Newfoundland)

Background We aimed to establish a cohort of persons with Crohn's disease (CD) enrolled from 14 Canadian centers to describe the contemporary presentation of CD in Canada. Methods All enrollees were at least 18 years old and underwent chart review for phenotype documentation by Montreal Classification at time of enrollment, comorbidities, inflammatory bowel disease (IBD) and other surgeries, and use IBD and other therapies. Results Of 2112 adults, 59% were female, and the mean age was 44.1 (+/-14.9SD) years. The phenotype distribution was B1 = 50.4%, B2 = 22.4%, B3 = 17.3%, and missing information = 9.9%. Perineal disease was present in 14.2%. Pertaining to disease location, 35.2% of patients had disease in L1, 16.8% in L2, 48% in L3, and 0.4% in L4. There was no difference in phenotype by gender, anxiety score, depression score. Disease duration was significantly different depending on disease behavior type (B1 = 12.2 +/- 10.1; B2 = 19.4 +/- 12.9; B3 = 18.9 +/- 11.8, P < .0001). Isolated colonic disease was much less likely to be fibrostenotic or penetrating than inflammatory disease. Penetrating disease was more likely to be associated with ileocolonic location than other locations. Perineal disease was most commonly seen in persons with B3 disease behavior (24%) than other behaviors (11% B1; 20% B2 disease, P < .0001) and more likely to be seen in ileocolonic disease (L3;19%) vs L2 (17%) and L1 (11%; P < .0001). Surgery related to IBD occurred across each behavior types at the following rates: B1 = 23%, B2 = 64%, and B3 = 74%. Inflammatory bowel disease-related surgery rates by location of disease were L1 = 48%, L2 = 21%, and L3 = 51%. Conclusions In exploring this large contemporary CD cohort we have determined that inflammatory disease is the main CD phenotype in Canada and that CD-related surgery remains very common.

Abstract Background Recent recommendations to reduce proton pump inhibitor (PPI) usage may cause uncertainty for clinicians and patients. We have shown increased PPI discontinuation rates in patients with esophageal strictures in recent years. Purpose: We aim to determine the appropriateness of PPI discontinuation in patients undergoing esophageal dilation for symptomatic strictures. Purpose We aim to determine the appropriateness of PPI discontinuation in patients undergoing esophageal dilation for symptomatic strictures. Method All patients from two gastroenterology practices who received dilations to treat symptomatic esophageal strictures in 2015-2021, (group 1: 2015-17 and group 2: 2019-21) were identified using physician billing codes for this retrospective study. Patient demographics, medications, and previous GI diagnoses were collected using endoscopy reports, nursing reports and medication records from the local hospital database. We defined PPI discontinuation as either a 50% dose reduction, 50% frequency reduction or complete medication discontinuation at the time of endoscopic dilation compared to the established PPI therapy. Next, we defined inappropriate PPI discontinuation as a patient who discontinued their PPI medication with a past history of 1. esophageal stricture, 2. Barrett’s esophagus 3. grade C/D esophagitis, or 4. experienced symptom reoccurrence after PPI discontinuation. We selected these criteria as they are consistent with both Canadian and American Gastroenterology Society GERD management guidelines. This information was coded on a standard data sheet and entered into SPSS for analysis. Result(s) In total, 223 patients were identified with an average age of 58.7 and a sex ratio of (125:98, M:F). 26 patients discontinued their PPI medication prior to esophageal stricture dilation. The most frequent type of event was complete PPI discontinuation at 58% (15/26 cases). Followed by frequency reduction at 27% (7/26), dose reduction at 8% (2/26), and both dose and frequency reduction at 8% (2/26). The 26 patients with PPI discontinuations had an average length of 13 months between PPI discontinuation and esophageal stricture dilation. 57% (15/26 cases) of patients meet our criteria for inappropriate PPI discontinuation (table 2). The proportion of inappropriate PPI discontinuation are as follows: Group 1: 33% (3/9 cases) inappropriate PPI discontinuations and Group 2: 70% (12/17 cases) inappropriate PPI discontinuations, (P=0.06) upon Chi-squared analysis. Table 2- Inappropriate PPI discontinuations Previous Stricture: 10/26 Barrett’s Esophagus: 0/26 Grade C/D Esophagitis: 1/26 Symptom Reoccurrence: 4/26 Total inappropriate discontinuations: 15/26 = 57% Total appropriate discontinuations (no PMH): 11/26 = 43% Conclusion(s) Compete PPI discontinuation was the most common type of PPI discontinuation event. There was a trend toward more inappropriate PPI discontinuations in the second time period. Physicians should carefully consider indications for PPI use prior to discontinuation. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest K. Kecskemeti: None Declared, M. Borgaonkar Consultant of: $10K, Speakers bureau of: $20K, J. McGrath: None Declared

Introduction: Patients with decompensated cirrhosis have increased hospitalizations causing a higher risk of acquiring infections caused by multi-drug resistant organisms (MDRO). MDRO lead to delayed appropriate treatment causing increased morbidity, and mortality in the cirrhotic population. We aimed to determine the prevalence of MDRO and extrapolate the implication this may have on empiric antimicrobial treatment in cirrhotic patients hospitalized in Newfoundland and Labrador (NL). Methods: Patients with a history of cirrhosis and antimicrobial resistant cultures admitted to an acute care facility in the Eastern Health Region of NL between 2016-2021 were included in this study (n=142). Cirrhosis was defined as evidence of advanced liver fibrosis seen on ultrasound, CT-scan or MRI. Each patient was then grouped into non-MDRO or MDRO based on their microbiology culture report. Non-MDRO group was defined as patients with positive microbiology cultures showing resistance to 1 or 2 antimicrobials. Whereas the MDRO group was defined as patients with positive microbiology cultures showing resistance to 3 or more antimicrobials. Microbiology cultures included in this study were, ascitic fluid, blood, pleural fluid, sputum, urine, and wound cultures. Microbiology culture collection date was then cross-referenced with date of admission to determine if their infection was diagnosed upon presentation to hospital or a hospital-acquired infection (HAI). Results: On review of 142 cirrhotic patients with resistant microbiology cultures, MDRO accounted for 54.7% of all resistant organisms in the cirrhotic patient population through 2016-2021 with the most common MDRO being Escherichia Coli (32.1%) and Enterococcus Faecium (23.5%). Urine cultures were found to be the most common source of MDRO (32.4%), followed by blood cultures (10.8%) and ascitic fluid cultures (4.1%). HAI associated MDRO accounted for 31.0% of all resistant organisms throughout this study time period. Conclusion: These data indicate that in hospitalized cirrhotic patients with drug resistant infections, over 50% have MDRO. These findings could have implications for initial antibiotic choice in this patient population.

Objective:There have been concerns about the widespread usage of proton pump inhibitors (PPIs), leading to recommendations to deprescribe PPIs in certain patients. This study aims to determine if PPI deprescription in patients with symptomatic esophageal strictures was consistent with published guidelines and to compare the rate of PPI deprescription between two-time points.Methods:All patients from two gastroenterology practices who received endoscopic dilation to treat symptomatic strictures between the years of 2015-2017 and 2019-2021 were identified using physician billing codes. We defined inappropriate PPI deprescription as: a patient who was deprescribed their PPI with a past medical history of esophageal stricture, Barrett's esophagus, grade C/D esophagitis, or who had experienced symptom recurrence after PPI deprescription. Furthermore, we analyzed the rate of PPI deprescription between two time periods 2015-2017 (group 1) and 2019-2021 (group 2).Results:Two hundred twenty-three esophageal dilations were analyzed. Twenty-six patients in the sample were deprescribed their PPI, with the majority (57 percent) meeting the criteria for inappropriate PPI deprescription. There was a trend towards more inappropriate deprescription in the second time period. (71 percent vs. 33 percent; P = 0.06). Patients in group 2 had a higher rate of PPI deprescription (23.9 percent) than group 1 (6.0 percent; P < 0.001).Conclusions:PPI deprescription in patients treated for symptomatic esophageal strictures appears to be more common in the second time period. Most patients were defined as inappropriate deprescription. Physicians must apply guidelines carefully when considering deprescribing PPIs.

Background Colonoscopy exposes endoscopists to awkward postures and prolonged forces, which increases their risk of musculoskeletal injury. Patient positioning has a significant impact on the ergonomics of colonoscopy. Recent trials have found the right lateral decubitus position is associated with quicker insertion, higher adenoma detection rates, and greater patient comfort compared to the left lateral decubitus position. However, this patient position is perceived as more strenuous by endoscopists. Methods Nineteen endoscopists were observed performing colonoscopies during a series of four-hour endoscopy clinics. Durations of each patient position (right lateral decubitus, left lateral decubitus, prone, and supine) were recorded for all observed procedures ( n = 64). Endoscopist injury risk was estimated by a trained researcher for the first and last colonoscopies of the shifts ( n = 34) using Rapid Upper Limb Assessment (RULA), an observational ergonomic tool that estimates risk of musculoskeletal injury by scoring postures of the upper body and factors such as muscle use, force, and load. The total RULA scores were compared with a Wilcoxon Signed-Rank test for patient position (right and left lateral decubitus) and time (first and last procedures) with significance taken at p < 0.05. Endoscopist preferences were also surveyed. Results The right lateral decubitus position was associated with significantly higher RULA scores than the left lateral decubitus position (median 5 vs. 3, p < 0.001). RULA scores were not significantly different between the first and last procedures of the shifts (median 5 vs. 5, p = 0.816). 89% of endoscopists preferred the left lateral decubitus position, primarily due to superior ergonomics and comfort. Conclusion RULA scores indicate an increased risk of musculoskeletal injury in both patient positions, with greater risk in the right lateral decubitus position.

Introduction: Recent studies have shown increasing usage of antiplatelet medication to treat a variety of chronic conditions. Although these medications improve survival in certain conditions, antiplatelet agents increase the risk of upper GI bleeds (UGIBs). This study aimed to assess the prevalence of antiplatelet therapy and their medical indications in patients who had UGIBs at our institution. Methods: This retrospective cohort study recruited all patients from a single academic tertiary gastroenterology practice who received endoscopic treatment for upper GI bleeds during the years 2015-2022. Patients were identified using physician billing codes for endoscopic treatment for upper GI bleeds. Information regarding demographics, medications, and previous GI diagnoses were collected using endoscopy reports and medication records from the local hospital medical database. We documented antiplatelet medication status at time of endoscopic treatment for UGIB. We assessed medical indication for the antiplatelet therapy based on the Canadian Cardiovascular Society guidelines on antiplatelet therapy1. We analyzed the patient’s physician narrative reports for these conditions and the documented rationale for first prescribing the medication. Furthermore, we defined a recent medication prescription as any therapy that was initiated 3 months prior to the UGIB. All the information was coded using a standardized data sheet and entered into SPSS for data analysis. Results: Data were collected from 102 upper GI bleeds. The average patient age of the sample was 62.9 years old. The sample consisted of 70 males (68%) and 32 females (31%). In total, 27 patients were prescribed antiplatelet therapy at time of the UGIB. The most common medical indications for antiplatelet therapy were previous PCI with 33%, CABG with 15% and stroke with 11% (Table 1). Meanwhile, 30% of all patients prescribed antiplatelet therapy had no clear medical indication for therapy. 33% of patients began their antiplatelet therapy within 3 months of their UGIB. Conclusion: At the time of endoscopic treatment for upper GI bleed, a third of patients on antiplatelet medications had no clear medical indications. This may place patients at risk of UGIBs without gaining reciprocal benefits from therapy. Research at other centers involving compressive patient datasets can help further investigate this phenomenon. Resources: 1-https://pubmed.ncbi.nlm.nih.gov/21640290/ Table 1. - Medical Indications for Antiplatelet Therapy Medical Indications Number of Patients Percentage PCI 9 33.3 CABG 4 14.8 Stroke 3 11.1 ACS 2 7.4 No clear indication 8 29.6 Total 27 100.0 PCI (percutaneous coronary intervention), CABG (coronary artery bypass graft), ACS (acute coronary syndrome).