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were entered into a multivariable logistic regression model with forward stepwise selection to determine
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Abstracts
1334
3D High Resolution Anal Manometry (3DHRAM) on Squeeze Estimates Anal Sphincter Length and
Lengths Correlate With Symptoms of Constipation and Fecal Incontinence
Sonali Palchaudhuri, MD1, Shreya Raja, MD2, Frances U. Onyimba, MD3, Danielle Hoo-Fatt, MD4,
Francis Okeke, MD, MPH1, Sameer Dhalla, MD, MHS5, John O. Clarke, MD2, Jiande Chen6, Patricia
Garcia, MD7, Monica Nandwani, CRNP8, Ellen Stein, MD9. 1. Johns Hopkins Bayview Medical Center,
Baltimore, MD; 2. Johns Hopkins University, Baltimore, MD; 3. Johns Hopkins University, Columbia,
MD; 4. Johns Hopkins Bayview Medical Center, Perry Hall, MD; 5. Johns Hopkins School of Medicine,
Baltimore, MD; 6. Johns Hopkins Medicine, Baltimore, MD; 7. Johns Hopkins Hospital, Baltimore, MD;
8. Johns Hopkins, Baltimore, MD; 9. Johns Hopkins University, Elkridge, MD.
Introduction: Constipation and fecal incontinence (FI) are common anorectal disorders, affecting 20%
and 8% of the population respectively. Anorectal manometry is a diagnostic modality that assesses func-
tion of the anorectum. Addition of 3D HRAM may improve diagnostic value by better illustration of
sphincter function and integrity. There is some evidence that 3D manometry catheters, a fixed type of
catheter, differ from traditional catheter measurements. We explored value of 3D images in estimating
anal sphincter length. Our hypothesis is that the estimated length of anal sphincter is related to symp-
toms, and that FI patients would have shorter sphincters.
Methods: We obtained IRB approval for a retrospective review of 3D-HRAM of clinical studies con-
ducted between Jan 2013 and May 2015 for either FI or constipation, at Johns Hopkins Motility Cen-
ter. We recorded demographic data. We analyzed 30 3DHRAM studies using ManoView ® software to
sequentially review 3D images through baseline, rest, squeeze and bear down. We estimated the length of
anal sphincter by measuring the maximum number of sensors with pressure greater than 80 mmHg on
3D imaging during squeeze frame, and multiplying by the distance between sensors (0.4cm).
Results: Anal sphincter length for constipated patients on average was 3.85 cm and for those with FI
was on average 2.69. This was statistically significant (p value = 0.013). Similarly, mean resting HPZ was
4.13cm for constipated subjects vs 2.85 cm for FI subjects (P value < 0.001). There was no significant dif-
ference in age distribution between the groups (correlation factor 0.12) or height (-0.15).
Conclusion: The anal sphincter is involved in control of bowel habits, and the size and continuity of
the anal sphincter likely related to strength and function. Shorter length of anal sphincter on 3D view
during squeeze appears to be correlated with symptoms of FI, and longer length appears to be correlated
with constipation. The true value of 3D anorectal manometry is under investigation, but this pilot study
offers a glimpse at the role of 3D HRAM in interpretation of anorectal disorders. Further research can
determine if this correlation is predictive of patient symptoms.
1335
Predictors of Failure After Fecal Microbiota Transplantation (FMT) for the Therapy of Clostridium
difficile Infection (CDI)
Monika Fischer, MD, MS1, Shama Mehta, MD1, Tracey Martin2, Gwendolyn Cook, MS3, Emmalee Phelps3,
Brian Sipe, MD 4, Huiping Xu, PhD, MS5, Colleen Kelly, MD 6. 1. Department of Medicine, Indiana
University, Indianapolis, IN; 2. Alpert Medical School of Brown University, Providence, RI; 3. Indiana
University, Indianapolis, IN; 4. Central Indiana Gastroenterology Group, Indianapolis, IN; 5. Department
of Biostatistics, Indiana University, Indianapolis, IN; 6. Women’s Medicine Collaborative, Alpert Medical
School of Brown University, Providence, RI.
Introduction: FMT is a highly effective treatment for recurrent or therapy refractory CDI; however,
10-20% of patients fail to achieve cure after a single FMT. Factors associated with FMT failure in the
treatment of CDI are not known.
Methods: Demographics, patient characteristics, clinical variables, and FMT outcomes data for patients
treated with FMT between 2011 and 2015 at two tertiary referral centers were collected by review of elec-
tronic medical records. FMT success was defined as complete resolution of symptoms and/or negative C.
difficile PCR testing at 3 months post-FMT without the need for further anti-CDI therapy or repeat FMT.
Characteristics of patients with FMT success and failure outcomes were compared using the Wilcoxon rank
sum test for continuous variables and Fisher’s exact test for categorical variables. All potential risk factors
[1335A] Figure 1.
The American Journal of GASTROENTEROLOGY
the final predictors for FMT failure. Patients’ risk scores were constructed based on coefficients of final
predictors and risk groups were created to indicate low, moderate, and high risk patients for FMT failure.
Results: Of 345 patients, 71.8% (n= 248) were females with the mean age of 61.9± 19.1 years, 18.5%
(n=64) had IBD, and 24% (n=83) were immunosuppressed. The indication for FMT was recurrent CDI
in 74.2% (n=244) and refractory in 25.8% (n=85) with severe or severe/complicated in 13.3% (n=44).
FMT was performed as inpatient in 16.7% (n=54). The stool source was from patient-directed donors
in 40% (n=138) of cases. The FMT failure rate at 3 months was 23.7%. Results of the univariate analy-
sis are shown in the table. In the multivariable analysis, risk factors significantly associated with a
greater risk of FMT failure at 3 months include: inpatient status during FMT (OR 6.9, 95% CI:2.9-16.3);
immunosuppressed state (OR 3.5, 95% CI:1.7-2.8); and previous CDI-related hospitalization (OR 1.45,
95% CI:1.2-1.8); with each additional hospitalization, the odds of failure increased by 45%. Risk scores
ranged from 0 to 12, with 0 indicating low risk, 1-3 indicating moderate risk, and 4 or more indicating
high risk. FMT failure rates were 12.8% for low risk patients, 17.1% for moderate risk patients, and 43.8%
for high risk patients.
Conclusion: Inpatient status during FMT, immunosuppressed state, and previous CDI-related hospital-
izations, are strongly associated with failure of a single FMT for CDI.
1336
Ischemic Colitis Affects Right Colon More Often in Patients With Chronic Kidney Disease
Salih Samo, MD1, Muhammed Sherid, MD2, Humberto Sifuentes, MD2, Samian Sulaiman3, Husein
Husein, MD4, Jigar Bhagatwala, MBBS, MPH2, Subbaramiah Sridhar, MBBS, MPH, FACG2. 1.
Northwestern University Feinberg School of Medicine, Chicago, IL; 2. Georgia Regents University, Augusta,
GA; 3. Medical College of Wisconsin, Wauwaosa, WI; 4. Seton Hall University, Trinitas Regional Medical
Center, Elizabeth, NJ.
Introduction: Chronic Kidney disease (CKD) is a risk factor for ischemic colitis (IC); however, the char-
acteristics of IC in the setting of CKD have not been studied extensively. The aim of this study was to
investigate the characteristics of IC in CKD patients and to identify the risk factors and outcomes.
Methods: Medical records of patients with IC from January 2007 to January 2013 were reviewed. The study
was conducted in two hospitals after IRB approval. Demographic details, clinical & lab data, imaging,
endoscopy & histology, co-morbidities, concomitant medications, surgery, length of hospital stay & death
within 30 days of admission, were collected. Patients were divided into two groups: patients with IC who
had CKD (CKD-IC group) and patients with IC who did not have CKD (non-CKD-IC group). The diagno-
sis of IC was made based on clinical features consistent with IC with negative stool studies for infections &
at least one diagnostic study consistent with IC (CT scan, colonoscopy, or histology). Exclusion criteria: age
< 18, pregnancy, positive studies for gut pathogens, colonic ischemia due to trauma or mechanical causes,
chronic bowel ischemia, acute flares of inflammatory bowel disease & evidence of diverticulitis.
Results: A total of 118 patients with IC were identified (mean age 69.4±15.07 years, 83% females). One
case was excluded because of lack of documentation of CKD status. CKD-IC group comprised 12.8%
of study pool compared to 87.2% in non-CKD-IC group. Right colon was involved in 35.7% in CKD-
IC group compared to 12.4% in non-CKD-IC (p=0.023). The statistical differences were present when
divided into individual segments. The cecum, ascending colon, and hepatic flexure were more com-
monly involved in CKD-IC group compared to non-CKD-IC group (28.6% vs. 9.3%, p=0.036; 35.7% vs.
9.3%, p=0.005; 28.6% vs. 5.2%, p=0.003, respectively). CKD-IC group had more associated comorbidities
including hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, peripheral vas-
cular disease, deep venous thrombosis, and abdominal aortic aneurysm (p).
Conclusion: More than one third of patients with CKD who developed IC had the right colon involved,
which occurred more often in patients with multiple cardiovascular comorbidities.
1337
Bolus Lukewarm Saline With Sequential Posture Change: A New Mechanism of Gastrointestinal
Lavage
Vijaypal Arya, MD1, Shashank Agarwal, MD2, Shikha Singh, MD2, Kalpana Arya Gupta, MD2, Ashok
Valluri, MD3. 1. Wyckoff Heights Medical Center, Middle Village, NY; 2. Vijaypal Arya MD PC, Middle
Village, NY; 3. Blessing Hospital, Middle Village, NY.
Introduction: Gastrointestinal Lavage (GIL) is necessary to clean the colon before a colonoscopy
procedure. GIL can be done using laxatives classified as – 1) Osmotic (holding water inside the bowel
lumen) -2) Stimulant (inhibition of water absorption or stimulation of secretion and colonic motility
-3) Balanced electrolyte solutions administered in a volume of 2-4 L. We propose to introduce a new
mechanism of GIL using Bolus Lukewarm Saline (BLS) with Sequential Posture Change (SPC). This
method is inspired by an ancient yogic process - Shankh prakshalana that uses lukewarm saline water and
a series of five simple asana, or postures, to clean the intestinal tract.
Methods: This method involves drinking of BLS which is prepared by mixing 9gm of salt to 32 oz of
lukewarm tap water. The solution is then consumed as a bolus (16oz) combined with SPC. The efficacy
has been proved by our pilot study and randomized study. To implore the mechanism of action of this
process – we have published a gastric emptying(GE) study and a perfusion study.
Results: NA
Conclusion: The gastric emptying of lukewarm saline follows the ‘First order kinetics’ – 50 % of the
volume empties out in 8-18 minutes. A larger volume of intake leads to faster GE, stimulating a strong
gastro-colic reflex. The SPC further complements faster GE which can be labeled as ‘specific’ to enhance
GE for several reasons. Arm elevation in normal subjects increases end-inspiratory gastric and trans-dia-
phragmatic pressure. All postures are associated with auditory–vestibular stimulation, which is known
to affect GE. The SPC used in this study are mild to moderate intensity exercises (MET: 3–5) which
also enhances GE as opposed to strenuous exercises which is known to delay GE. The SPC Inputs from
sensory sources are modified by cognition and effect, and then integrated in the central nervous system
(CNS), autonomic nervous system (ANS) and enteric nervous system (ENS) with an outcome of effects
on gastro-intestinal (GI) motility, secretion and blood flow. Deep breathing stimulates the parasympa-
thetic nervous system via the vagus nerve, which is also known to increase the gastrointestinal motility.
A Multi-Centered Randomized Study has been planned and designed to assess the safety and efficacy
of this novel approach.
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