A series of AGA Postgraduate Course breakout sessions on Saturday, June 2, at DDW^® 2018 featured case-based discussions covering a variety of common, as well as some uncommon, clinical scenarios.

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Case 1: Celiac disease

In the session, Approaches to Celiac Disease and Non-Celiac Gluten Sensitivity, Sheila E. Crowe, MD, AGAF, professor in the division of gastroenterology at the University of California, San Diego, and Guy Weiss, MD, leader of the celiac disease program in the department of digestive diseases at UCLA, presented the case of a 45-year-old woman who presented with iron deficiency anemia (IDA).

The patient was a practicing vegan for 15 years who reported no rectal bleeding or black tarry stools and normal menses. Her past medical history includes hypertension and Hashimoto’s thyroiditis. She was worried about cancer and reported that her father died of small bowel cancer at the age of 65.

“In this patient, we proceeded with an upper endoscopy, during which we saw lots of scalloping and loss of folds in the distal duodenum and a colonoscopy, which was non-contributory,” Dr. Weiss said.

The next step would be a biopsy, he said, noting that the 2013 American College of Gastroenterology (ACG) guidelines recommend taking one or two biopsies from the duodenal bulb and at least four from the distal duodenum.

“We do know from studies that the more biopsies we take, the yield of diagnosis is higher,” Dr. Weiss said. “Interestingly, we did a study at UCLA which suggested that only about 60 percent of physicians actually follow those guidelines.”

When approaching a diagnosis, Dr. Weiss cautioned physicians to be aware of other conditions that mimic celiac disease, such as peptic duodenitis and H. pylori infection, as well as the potential of false negative biopsies.

“Further, to screen for celiac disease, we test the antibodies EMA IgA and tTG IgA, both of which have specificity and sensitivity of more than 95 percent,” he said. “The general consensus from a cost-effectiveness standpoint is that we check tTg IGA and, in some instances total IGA, because we know that our celiac patients are more prone to have IGA deficiency, almost 10 times more than the general population.”

In this patient, Dr. Weiss said that celiac disease turned out to be the right diagnosis and, in a follow-up visit, the patient underwent celiac serology to have baseline levels to follow and was referred to a GI-dietitian for further counseling for a gluten-free diet and nutrient evaluation.

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Case 2: Pancreatic necrosis

In the session, Treatment of Infected Pancreatic Necrosis, Antibiotics, Drains, Hoses or the Knife?, Andrew Ross, MD, FASGE, head of the section of gastroenterology and director of the Therapeutic Endoscopy Center of Excellence at Virginia Mason Medical Center, Seattle, WA, and Gregory Cote, MD, MS, AGAF, associate professor at the Medical University of South Carolina, Charleston, explored the management principles of infected pancreatic necrosis.

Looking at percutaneous management, they presented the case of a 70-year-old female with a history of acute relapsing pancreatitis, pancreas divisum and a possible small branch duct intraductal papillary mucinous neoplasm (IPMN) who underwent an ERCP and minor papilla sphincterotomy. An unflanged pancreatic duct stent was placed and indomethacin 100mg PR was administered. After an uneventful overnight stay, at one-hour post-discharge the patient complained of abdominal pain and lipase levels were minimally elevated.

Ultimately, the patient was re-hospitalized and required antibiotics for worsening clinical course before being discharged to rehab. She returned to hospital one week later with a white blood cell count of 30,000 and fevers. Percutaneous drains were placed and the patient underwent aggressive percutaneous debridement.

“Our thinking was that doing a direct endoscopic necrosectomy was probably not going to be super helpful in this situation, just due to the size and extension deep into the pelvis and along the paracolic gutter,” Dr. Ross said. “Certainly, you could have chosen a surgical intervention, but what you’re trying to do is get control over these collections that are now driving this patient’s infectious process and, in my experience, these patients can be managed with a percutaneous drainage catheter.”

The key in this situation, he noted, is taking a multidisciplinary approach to treating this patient.

“You’ve got the hospitalist, the intensivist, the gastroenterologist and sometimes surgeons, involved, but if you’re going to be embarking on percutaneous drainage of this patient, you need your interventional radiologist,” Dr. Ross said. “But you need them to be more than interventional radiologists — you need them to be active participants in the care of these patients.”

Ultimately, he added, timing is a crucial factor in the failure or success of percutaneous drainage

“We have learned that patients do better the longer you wait, but it can be really hard sometimes to convince the intensivists of this,” he said. “The longer you wait, the shorter the duration of the drainage and the better they do, but you really have to make decisions based on the patient’s clinical course.

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Case 3: Irritable bowel syndrome

In another session, Clinical Pearls in Managing IBS and Chronic Abdominal Pain, Joanne Wilson MD, AGAF, professor of medicine at the Duke University School of Medicine, Durham, NC, and Douglas Drossman, MD, AGAF, professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine, Chapel Hill, presented the complex case of a 53-year-old female referred to a GI tertiary care program due to years of constant abdominal pain; infrequent, hard stools; and diarrhea with some fecal leakage.

The symptoms have progressed over 35 years. There is a history of childhood physical/sexual abuse and she has a psychiatric diagnosis of PTSD with suicidal thoughts. Over the past year, oxycodone use has become more frequent and increased from 30mg to over 100mg/day. However, this increase has made the pain and constipation worse.

“This woman is a complicated problem, further complicated by her psychiatric overlay,” Dr. Drossman said. “She has constipation that is being impacted on by the opioids, which has led to more fecal retention. The diarrhea that she’s having is really leakage around a colon full of stool — get the colon empty from stool and the diarrhea should stop or at least become very infrequent.”

The likely diagnosis in this patient, he said, is narcotic bowel syndrome, which occurs in about 5 percent of people on opioids.

“She has centrally mediated abdominal pain and, unlike IBS, it is not relieved by defecation and not made worse with eating or other factors — it’s a central phenomenon,” Dr. Drossman said. “We have to look at this as a failure of the brain to downregulate incoming visceral signals. This patient needs neuromodulators and detoxification and psychological treatment could be of value if the patient is willing to engage in it.”

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