ANNUAL SCIENTIFIC MEETING 6 - 8 - GIHep...GIHep 2018 | AOrganiser: Co-organiser: ANNUAL SCIENTIFIC MEETING 7 - 8 JULY 2018 Mandarin Orchard Singapore LIVE ENDOSCOPY WORKSHOP 6 JULY

GIHep 2018 | A

Organiser: Co-organiser:

ANNUAL SCIENTIFIC MEETING

7 - 8 JULY 2018

Mandarin Orchard Singapore

LIVE ENDOSCOPY WORKSHOP

6 JULY 2018

Tan Tock SengHospital

Programme Booklet

Supporting Societies:

2018July

6 - 8

ANNUAL SCIENTIFIC MEETING

B | GIHep 2018VONOPRAZAN

VONOPRAZAN

Strong, Sustained, Acid Suppression from the 1st dose1,2

ENV RONMENTOPT MAL ACID

Create the

TAKEDA PHARMACEUTICALS (ASIA PACIFIC) PTE. LTD.

21 Biopolis Road, Nucleos North Tower, Level 4, Singapore 138567Tel +65 6808 9500 | www.takeda.comSG/VCT/2018-00007

Reference: 1. Sakurai Y, et al. Clin Transl Gastroenterol 2015;6:e94. 2. Sakurai Y, et al. Aliment Pharmacol Ther 2015; 42:719-30.

Vocinti 10mg & 20mg Film-coated tabletsAbbreviated Prescribing Information (refer to full prescribing information for further details).Composition: Vocinti 10mg Film-coated tablets contain 10mg of vonoprazan, Vocinti 20mg Film-coated tablets contain 20mg of vonoprazan. Indications: Treatment of gastric ulcer (GU), duodenal ulcer (DU) and reflux esophagitis (RE) (erosive esophagitis EE); Maintenance treatment of reflux esophagitis (erosive esophagitis); Prevention of recurrence of gastric ulcer or duodenal ulcer during NSAIDs administration; Adjunct to Helicobacter pylori eradication. Dosage and Administration: Treatment of GU, DU and RE (EE): 20 mg of vonoprazan once a day. Administration should be limited to 8, 6 and 4 weeks respectively. Prevention of recurrence of GU or DU during NSAIDs administration: 10 mg of vonoprazan once a day. Adjunct to H pylori eradication: 20 mg vonoprazan + amoxicillin hydrate + clarithromycin/metronidazole, twice daily for 7 days. The doses of antibiotic should follow the respective label recommendations for H pylori eradication. Vonoprazan can be taken without regard to food or timing of food. Contraindications: Hypersensitivity. Special Precautions: Discontinuation is recommended in patients who have evidence of liver function abnormalities. Elevation of intragastric pH. Symptomatic response to vonoprazan does not preclude the presence of gastric malignancy. Increased risk of gastrointestinal infection caused by Clostridium difficile. Benign gastric polyps, Fractures and Hypomagnesemia have been observed in patient on long-term administration of PPIs. Undesirable Effects: Common: Diarrhoea and constipation. Drug-Drug Interactions: vonoprazan increased when concomitantly administered with clarithromycin. Storage conditions: Store at or below 30°C. Shelf-life: 36 months.

For Healthcare Professionals only

Vocinti 10mg & 20mg Film-coated tabletsAbbreviated Prescribing Information (refer to full prescribing information for further details).Composition: Vocinti 10mg Film-coated tablets contain 10mg of vonoprazan, Vocinti 20mg Film-coated tablets contain 20mg of vonoprazan. Indications: Treatment of gastric ulcer (GU), duodenal ulcer (DU) and reflux esophagitis (RE) (erosive esophagitis EE); Maintenance treatment of reflux esophagitis (erosive esophagitis); Prevention of recurrence of gastric ulcer or duodenal ulcer during NSAIDs administration; Adjunct to eradication. Dosage and Administration: 20 mg of vonoprazan once a day Administration should be limited to 8, 6 and 4 weeks respectively. Prevention of recurrence of GU or DU during NSAIDs administration: 10 mg of vonoprazan once a day Adjunct to H pylori eradication: 20 mg vonoprazan + amoxicillin hydrate + clarithromycin/metronidazole, twice daily for 7 days. The doses of antibiotic should follow the respective label recommendations for H pylori eradication. Vonoprazan can be taken without regard to food or timing of food. Contraindications: Hypersensitivity. Special Precautions: Discontinuation is recommended in patients who have evidence of liver function abnormalities. Elevation of intragastric pH. Symptomatic response to vonoprazan does not preclude the presence of gastric malignancy. Increased risk of gastrointestinal infection caused by Clostridium difficile. Benign gastric polyps, Fractures and Hypomagnesemia have been observed in patient on long-term administration of PPIs. Undesirable Effects: : Diarrhoea and constipation. Drug-Drug Interactions: vonoprazan increased when concomitantly administered with clarithromycin. Storage conditions: Store at or below 30°C. Shelf-life:

For Healthcare Professionals only

GIHep 2018 | 1

Contents

Welcome Message

Committees

Invited Faculty

Conference Information

Floor Plan

Programme @ a Glance

Programme Details

Lecture Abstract

Free Paper Oral Presentation

Free Paper Poster Presentation

Nursing Free Paper Oral Presentation

Nursing Free Paper Poster Presentation

Organisers

Acknowledgement

3

6

7

20

23

25

26

40

56

62

128

134

140

142

2 | GIHep 2018N8601099-032018

How Can NBI help in the Colon?Decrease Polyp Miss Rates

Horimatsu et al. 2015; Int J Colorectal Dis. 30(7):947-54

28%LOWER POLYPMISS RATES

Explore How NBI Drives a Significant

Improvement in The Detection of Colonic Polyps

A prospective multicenter randomized trial highlighted that screening with NBI can significantly

decrease the polyp miss rate by approximately 28% compared to white light endoscopy . The

miss rates did not differ between the examiners. More flat and depressed lesions were detected

by NBI, particularly in the right colon.

Olympus technologies help physicians raise quality of care by decreasing the polyp miss rates.

GIHep 2018 | 3

Welcome MessageDear Friends,

On behalf of the organising committee, it gives us great pleasure to extend a warm welcome and invitation to GIHep Singapore 2018, organised by the Gastroenterological Society of Singapore in collaboration with the Chapter of Gastroenterologists, Academy of Medicine Singapore and Tan Tock Seng Hospital.

GIHep Singapore, has been successful in attracting local and regional participation. Over the years the attendance has been growing, reaching more than 500 participants in recent years.

In GIHep Singapore 2018, we will bring together a group of prominent International and Regional experts in the field of Gastroenterology and Hepatology, and have prepared a 3-day programme which include Live Endoscopy Workshop, Plenary and State-of-the-Art Lectures, medical and nursing symposia.

GIHep is now in its 13th edition and it has been a decade of fostering and building friendships, of establishing collaborations and of witnessing progress in Gastroenterology and Hepatology. We would not have reached this stage without the support of the various healthcare institutions and societies, our industry partners and most importantly, the faculty and participants. We would like to take this opportunity to thank our faculty for spending their valuable time with us.

We hope that you will join our prominent international and regional experts from 6th to 8th July 2018 for an exciting and intellectually stimulating meeting, and that you will take time to enjoy our garden city as well!

Dr LING Khoon Lin

PresidentGastroenterological Society of Singapore

A/Prof Stephen TSAO

Director National Endoscopy Workshop

Dr WANG Yu Tien

ChairpersonAnnual Scientific Meeting Committee

4 | GIHep 2018

THE FIRST IL12/23 BLOCKER FOR THE TREATMENT

OF MODERATE TO SEVERE ACTIVE CROHN’S DISEASE

NOW AVAILABLE IN SINGAPORE

WITH UNRIVALLED COMBINED DOSINGSTELARA® is an intravenously-induced subcutaneous treatment, offering patients the power of

rapid response with IV induction combined with the convenience and proven durability of self-

administered SC maintenance treatment.2

RECOMMENDS STELARA AS FIRST LINE THERAPY FOR CROHN’S DISEASE PATIENTS WHO

FAILED CONVENTIONAL THERAPY1

INTRAVENOUSLY INDUCED, SUBCUTANEOUSLY MAINTAINED TREATMENT2

IV INDUCTION

× 1 single infusion

Number of vails by patient body weight:

• 2 vials / ≤55 kg

• 3 vials / >55 kg to ≤85 kg

• 4 vials / ≥85 kg

SC MAINTENANCE

With self-administration option

Recommended dosing interval:

Q8 weeks

POWER

AT WEEK 8

CONVENIENCE

GIHep 2018 | 5

6 | GIHep 2018

CommitteesGASTROENTEROLOGICAL SOCIETY OF SINGAPOREEXECUTIVE COMMITTEE (2016 – 2018)

President Dr LING Khoon Lin

President-Elect Dr CHUA Tju Siang

Hon. Secretary Dr David ONG

Hon. Treasurer Dr Damien TAN

Scientific Chair Dr WANG Yu Tien

Members Dr Daphne ANG Dr Stephen TSAO A/Prof LIM Wee Chian Dr Eric WEE Dr LOW How Cheng

Co-Opted Members A/Prof ANG Tiing Leong Dr Kenneth KOO

Board of Trustees Prof FOCK Kwong Ming Prof NG Han Seong Dr NG Pock Liok

GIHEP SINGAPORE 2018 ORGANISING COMMITTEESENDOSCOPY WORKSHOP COMMITTEE

Course Director A/Prof Stephen TSAO

Members Dr Mark CHEAH Dr CHEW Wei Da Dr CHEW Wei Hao Dr CHUA Tju Siang Dr Bhavesh DOSHI Dr Rahul KUMAR

ANNUAL SCIENTIFIC MEETING COMMITTEE

Chairperson Dr WANG Yu Tien

Members Ms Janet CHONG Dr CHUA Tju Siang Ms LEE Chuey Shan Ms LEE Hwei Ling Mr Peter LEE Dr LIM Wee Chian

Dr Andrew KWEKDr LEE Keat HongDr Damien TANDr THIAN Mann YieDr Benjamin YIP

Dr LING Khoon LinMs LOY Kia LanDr LUI Hock FoongDr David ONGDr Stephen TSAO

GIHep 2018 | 7

OVERSEAS FACULTY

Invited Faculty

A/Prof Anand SAHAIProfessor of Medicine

Chief, Service de Gastroentérologie

Centre Hospitalier de l’Université de Montréal (CHUM)

Canada

Ms Angelie ASHBYSenior Registered Nurse

Gastroenterology Department

Lyell McEwin Hospital

Australia

Prof Arjuna DE SILVAProfessor and Head

Department of Medicine

Faculty of Medicine

University of Kelaniya

Sri Lanka

Prof Carmelo SCARPIGNATOProfessor of Pharmacology and Therapeutics

Associate Professor of Gastroenterology

Head, Clinical Pharmacology & Digestive Pathophysiology Unit

Department of Clinical & Experimental Medicine, University of Parma

Italy

Dr Dadang MAKMUNHead

Division of Gastroenterology, Department of Internal Medicine

Universitas Indonesia/Cipto Mangunkusumo National General Hospital

Indonesia

Ms Dianne Mary JONESNurse Unit Manager

Endoscopy Unit

Logan Hospital

Prof Hiroyuki OSAWAHead

Department of Endoscopic Research and International Education

Jichi Medical University

Japan

Prof Ida HILMIProfessor and Consultant in Gastroenterology

University of Malaya

Malaysia

8 | GIHep 2018

Ms Joan HEATHERINGTONNurse Practitioner for Inflammatory Bowel Disease

IBD Unit

University of Calgary

Canada

Prof Jose SOLLANOProfessor of Medicine


University of Santo Tomas Hospital

Philippines

Prof Kentaro SUGANOProfessor Emeritus

Jichi Medical University

Japan

Prof Murdani ABDULLAHProfessor of Medicine

Head, Division of Gastroenterology

Department of Internal Medicine

Dr Cipto Mangunkusumo Hospital

Faculty of Medicine, Universitas Indonesia

Indonesia

Prof Noriya UEDOVice-Director

Department of Gastrointestinal Oncology

Osaka International Cancer Institute

Japan

Prof Nwe NIProfessor and Head

Department of Gastroenterology

Myanmar

Prof Ray KIMProfessor and Chief

Division of Gastroenterology and Hepatology

Stanford School of Medicine

USA

Prof Simon LODirector of Endoscopy and Pancreatic Diseases

F. Widjaja Family Chair in Digestive Diseases

Clinical Professor of Medicine

Cedars-Sinai Medical Center

USA

Prof Stefan SCHREIBERProfessor of Medicine

Director, Clinic of Internal Medicine I

Head, Institute for Clinical Molecular Biology

Christian-Albrechts-University

Kiel, Germany

GIHep 2018 | 9

Prof Stephen HANAUERProfessor of Medicine

Northwestern University Feinberg School of Medicine

Medical Director, Digestive Health Center

Northwestern Medicine

USA

Dr TAN Soek SiamConsultant Hepatologist

Department of Hepatology

Selayang Hospital

Malaysia

Prof Than Than AYEProfessor


Thingangyun General Hospital

University of Medicine 2

Myanmar

Dr Thein MYINTProfessor and Head


Yangon General Hospital

University of Medicine 1

Myanmar

Dr Varocha MAHACHAISenior Director, Bangkok Medical Center

Director, Digestive Wellness Center

BDHS GI & Liver Center, Bangkok Hospital

Thailand

A/Prof Yuichi MORIAssociate Professor

Digestive Disease Center

Showa University Northern Hospital

Japan

Prof Yves PANISProfessor of Digestive Surgery and Head

Department of colorectal surgery

Beaujon Hospital and University Paris VII

Department of colorectal surgery

France

10 | GIHep 2018

GIHep 2018 | 11

LOCAL FACULTY

Ms Alice ZHONGNurse Clinician

Endoscopy

Gleneagles Hospital

Dr Andrew KWEKSenior Consultant

Department of Gastroenterology and Hepatology

Changi General Hospital

Singapore

A/Prof ANG Tiing Leong Chief and Senior Consultant



Ms Annie Rose Addun ADDURUSenior Staff Nurse

Endoscopy Centre

Tan Tock Seng Hospital

Mr Azhar BIN MOHD Nurse Clinician

Ambulatory Endoscopy Centre

Singapore General Hospital

Dr Bhavesh DOSHISenior Consultant


National University Hospital

Ms CHAN Yoke Ling Advanced Practice Nurse Clinician

Nursing


Dr CHIA Chung KingConsultant Gastroenterologist

Mount Elizabeth Novena Specialist Centre

Ms CHIA Pei YuhNurse Clinician

Nursing


Ms CHIN Guey Fong Senior Nurse Clinician

Nursing Quality and Research, Department of Nursing Administration

Khoo Teck Puat Hospital

12 | GIHep 2018

Ms CHONG Shu HanDietitian

Nutrition & Dietetics


Dr CHOO Su PinSenior Consultant

Chief, Gastrointestinal Oncology Department

Division of Medical Oncology

National Cancer Centre Singapore

A/Prof CHOW Wan ChengChairman, Division of Medicine

Senior Consultant, Department of Gastroenterology and Hepatology


Dr Christopher CHIAConsultant



Dr Christopher KHOR Senior Consultant



Dr Christopher KONG Clinical Lead for Gastroenterology

Senior Consultant in Gastroenterology and Hepatology


Sengkang General Hospital

Ms CHUA Siew Huang Nurse Clinician

Nursing


Dr CHUA Tju SiangConsultant Gastroenterologist

Mount Elizabeth Medical Centre

Dr Constantinos ANASTASSIADESConsultant and Head

Division of Gastroenterology & Hepatology


Dr Damien TANSenior Consultant



GIHep 2018 | 13

Dr David ONGHead and Senior Consultant


National University Hospital, Singapore

Ms Eileen NGAIAdvanced Nurse Clinician



Ms Elaine CHANSenior Staff Nurse

Centre of Digestive and Liver Disease


Dr Eric WEESenior Consultant

Nobel Gastroenterology Centre

Mount Elizabeth Novena Specialist Centre

Ms FENG YingNurse Clinician

Nursing


Prof FOCK Kwong Ming Senior Consultant

Division of Gastroenterology


Ms GOOI Siao Ching Pharmacist


A/Prof GWEE Kok AnnAdjunct Associate Professor of Medicine

National University of Singapore

Dr HO Chun Loong Research Fellow

NUS Synthetic Biology for Clinical and Technological Innovation (SynCTI)

Department of Biochemistry

Yong Loo Lin School of Medicine

National University of Singapore

Ms HO Miew LingSenior Nurse Educator

Training & Practice, Nursing Service


14 | GIHep 2018

Ms HUANG Ya PingSenior Staff Nurse

Endoscopy Center


Dr Ivy YAPConsultant Gastroenterologist


A/Prof IYER Shridhar GanpathiHead & Senior Consultant

Division of Hepatobiliary & Pancreatic Surgery


Ms Janet CHONGNurse Clinician

Nursing


Dr Jimmy SOHead and Senior Consultant

Division of General Surgery (Upper Gastrointestinal Surgery)


Ms Josephine BOO Xue JunAssistant Nurse Clinician

Nursing


Mr Julian LIM Cong EnSenior Staff Nurse

Nursing


Ms Kalai SELVINurse Manager

Endoscopy Suite

Farrer Park Hospital

Ms Kathleen Barit BENJAMINSenior Staff Nurse II

Endoscopy Centre


Dr Kenneth KOODirector of Gastroenterology and Hepatology


Ng Teng Fong General Hospital

GIHep 2018 | 15

Dr Kewin SIAHConsultant



Ms KUU Meei TingNurse Manager

Nursing

Gleneagles Hospital

Ms Laarni Joy M ARREOLAStaff Nurse

Endoscopy Centre


Ms LAI Pei TingAssistant Nurse Clinician

Nursing


Prof Lawrence HO Khek YuSenior Consultant

Vision of Gastroenterology and Hepatology


Ms LEE Chuey ShanNurse Manager

Nursing


Ms LEE Hwei LingNurse Clinician

Nursing


Ms LEE Poh YinAdvanced Practice Nurse

Department of Psychological Medicine


A/Prof LEE Siu Yin Senior Advisor

Special Projects


Ms Lilian YEWChief Nurse

Raffles Hospital

Dr LIM Hsien JerConsultant Anaesthetist

Parkway Hospitals

16 | GIHep 2018

Dr LIM Li LinSenior Consultant



Mr LIM Teong GuanSenior Principle Pharmacist

Pharmacy


A/Prof LIM Wee ChianSenior Consultant



Ms LIN MeiSenior Staff Nurse

Nursing


Dr LING Khoon Lin Consultant

KL Ling Gastroenterology and Liver Clinic


Ms LIU GuoaiSenior Staff Nurse

Endoscopy Centre


Ms LOH Lee LengUGI Nurse

Nursing


Dr LOW How ChengSenior Consultant



Ms LOY Kia LanAdvanced Practice Nurse

Speciality Care


Dr LU WeiConsultant Gastroenterologist



GIHep 2018 | 17

Dr LUI Hock FoongConsultant

Gleneagles Hospital Singapore

Ms MOH Yoke PingNurse Clinician

Nursing

Sengkang General Hospital

Mr Mohamamad Alimmirza BIN SIDIKSenior Staff Nurse

Endoscopy Centre


Ms Naranderjit KAURNurse Clinician



Ms Nenny Suzanah BTE SELLAMATManager



Dr NG Pock LiokConsultant Gastroenterologist


Ms Norhayati BTE MD SHARIFFNurse Clinician

Endoscopy Centre


Ms Nur Aliffa BTE AYUBRegistered Nurse

Endoscopy Centre


Ms ONG Choo EngSenior Nurse Clinician

Nursing


Dr ONG Wai ChoungSenior Consultant



18 | GIHep 2018

Ms OO Fiona AisisSenior Staff Nurse

General Surgery


Dr OOI Choon JinConsultant Gastroenterologist

Gleneagles Medical Centre

Dr QUAN Wai LeongSenior Consultant Gastroenterologist

GI Endoscopy and Liver Centre @Royal Square

Dr Roland CHONGConsultant Gastroenterologist

Gleneagles Medical Centre

Dr Sivaramakrishnan Venkatesh KARTHIKSenior Consultant

Division of Paediatric Gastroenterology, Hepatology,

Nutrition and Liver Transplantation Services

Department of Paediatrics


Ms Sharon SEEEndoscopy Centre

Mount Elizabeth Hospital

Ms Siti Amalina BINTE KASANSenior Staff Nurse

Nursing


A/Prof Stephen TSAOSenior Consultant



Dr TAN Chun HaiConsultant

Department of General Surgery


Dr TAN Poh SengConsultant & Director of Clinical Services

Division of Gastroenterology and Hepatology University Medicine Cluster


GIHep 2018 | 19

Mr Thineseh Edward BALASINGAMSenior Staff Nurse

Gastroenterology & Hepatology


Ms Tina Bhagwandas NANKANIStaff Nurse

Endoscopy Centre


Ms WANG ChunhongSenior Staff Nurse

Endoscopy Centre


Dr WANG Yu TienConsultant



A/Prof YANG Wei LynHead and Senior Consultant



Dr YAP Chin KongSenior Consultant Gastroenterologist


Dr YEW Kuo ChaoConsultant



Dr YIM Heng Boon Senior Consultant Gastroenterologist and Hepatologist

Mount Elizabeth Novena Hospital

20 | GIHep 2018

CONFERENCE VENUE

Annual Scientific Meeting

Mandarin Orchard HotelLevel 6, Grand Mandarin Ballroom333 Orchard Road, Singapore 238867Tel: (+65) 6737 4411, Fax: (+65) 6732 2361Website: http://www.meritushotels.com/en/mandarin-orchard-singapore/index.html

CONFERENCE REGISTRATION COUNTER

Annual Scientific Meeting

The Registration Counter is located at the Foyer Area outside Grange Ballroom at Level 5. The counter will be opened daily from 0800 – 1700 hours.

CONFERENCE SATCHEL AND NAME BADGE

Upon registration you will receive a Conference satchel with your name badge. You are required to wear your name badge to all sessions and events. Should you lose your name badge, please contact the Conference Secretariat for a replacement. Please note that replacement fee applies.

EXHIBITION

A state-of-the-art exhibition on medical equipment and allied applications will be held at Level 6, Mandarin Grand Ballroom 3 from 0800 - 1630 hours, daily.

CME / CPE INFORMATION

(Applicable to Singapore registered Healthcare Professionals ONLY)

CME / CPE points will be accorded for attending the workshops and main sessions. Delegates are required to sign on the attendance record on a daily basis at the conference registration counter. Delegates are required to sign at the beginning of the day and during lunch time.

LOST AND FOUND

For lost and found items, please approach the Conference Registration Counter.

CONFERENCE LANGUAGE

English is the official language of this conference.

MESSAGE BOARD

There will be a message board next to the Conference Registration Counter. Please check this board regularly for messages.

LIABILITY

The Organisers are not liable for any personal accidents, illnesses, loss or damage to private properties of delegates during the Conference. Delegates are advised to arrange for appropriate insurance coverage during the conference period.

Conference Information

GIHep 2018 | 21

DISCLAIMER

Whilst every attempt will be made to ensure that all aspects of the Conference will take place as scheduled, the Organising Committee reserves the right to make appropriate changes should the need arises with or without prior notice.

SPEAKERS’ HOSPITALITY SUITE

The Speakers’ Hospitality Suite is located behind the Registration Counter at Level 6. All speakers should submit their presentations in Microsoft PowerPoint 2013 or earlier version in a USB Drive, at least 30 minutes prior to their session. Notebooks are also available in the room for editing.

POSTER PRESENTATION

Each presenter will be allocated a poster board (one side only) with an area of 1m x 2m. Each poster board will be marked with a poster panel number. Poster should be set up on 7 July 2018 between 0800 — 0900 hours and removed on 8 July 2018 after 1500 hours.

CONFERENCE SECRETARIAT

The Conference Secretariat is located at Level 8 during the Conference Period.

22 | GIHep 2018

GIHep 2018 | 23

Floor Plan (Annual Scientific Meeting)

MAIN

CONFERENCE

(Ballroom 1 & 2)

POSTERS

POSTER

EXHIBITIONS

AND FOOD

RECEPTION

(Ballroom 3)

24 | GIHep 2018

GIHep 2018 | 25

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Morning Afternoon Evening

26 | GIHep 2018

Day 2: Saturday, 7 July 2018

Medical TrackLevel 6, Mandarin Grand Ballroom 2, Mandarin Orchard

Time Topic Chairperson/Speaker

0830 – 0845 Registration

0845 – 0945 Free Paper Oral PresentationsWANG Yu TienLOW How Cheng

0845 – 0855Association Between Human Gut Microbiota and the Host Central Obesity

John Chen HSIANG

0855 – 0905Customising Polyethyleneimine (PEI) Polymer for Hepatitis B Virus Therapy in Cellular and Animal Models

LEE Guan Huei

0905 – 0915Use of Vibration Controlled Transient Elastography (Fibroscan) With or Without Platelet Count to Predict Presence of Large Oesophageal Varices

Abhimanrao M PAWAR

0915 – 0925Development and International Validation of a Survival Prediction Score for All Patients with Hepatocellular Carcinoma (HCC) at the Time of HCC Diagnosis Regardless of Therapy Eventually Received

TAN Chee Kiat

0925 – 0935Direct Antiviral Agent as First-Line Therapy for Genotype 3 Hepatitis C Virus in Singapore: Estimating the Optimal Cost Based on Real-World Experience

Yu Jun WONG

0935 – 0945Decoding Hepatitis B Viral Genome Mutations to Solve the Mystery of HBeAg-Negative Reactivation

LEE Guan Huei

0945 – 1100 Morning Tea Break and Viewing of Exhibits

1000 – 1040 Poster Round

1100 – 1230 HCC SymposiumIvy YAPProf Varocha MAHACHAI

1100 – 1120 Impact of Anti-viral Treatment on HCC Development Ray KIM

1120 – 1140 Advances in Locoregional Therapy for HCC TAN Poh Seng

1140 – 1200 Immunotherapy and Chemotherapy for HCC CHOO Su Pin

1200 – 1220 Surgery and Transplantation for HCC IYER Shridhar Ganpathi

1220 – 1230 Question and Answer Session

1230 – 1345 Lunch

1245 - 1315Lunch Symposium (Sponsored by DCH Auriga Singapore)

Evolution of Infliximab Biosimilar: CT-P13 Stefan SCHREIBER

Key Clinical Evidence of CT-P13: From Concept to Clinical Practice- 3.4 CD RCT (Switching Data for 54 weeks)- SC Trial

Stefan SCHREIBER

1315 – 1340 Lunch (continuation) and Viewing of Posters and Exhibits

1340 – 1400 Opening CHUA Tju Siang

1340 – 1345 Welcome Address by Scientific Chair, GESS WANG Yu Tien

1345 – 1350 Welcome Address by Chairman, Nursing Chapter, GESS LEE Chuey Shan

1350 – 1400 Opening Address by President, GESS LING Khoon Lin

1400 – 1500 Plenary SessionLOW How ChengJose SOLLANO

GIHep 2018 | 27

1400 – 1430Seah Cheng Siang Memorial Oration – Gastroenterology in Singapore – Evolving Challenges

YANG Wei Lyn

1430 – 1500 Plenary Lecture – The Evolving Treatment Algorithms and Treatment Targets for IBD in the Next Decade

Stephen HANAUER

1500 – 1520 Afternoon Tea Break and Viewing of Posters and Exhibits

1520 – 1700 IBD SymposiumNwe NILIM Wee Chian

1520 – 1600 New Drugs for IBD: How do We Fit Them into Our Treatment Algorithm

1520 – 1540 New Mesalazines and Steroids in the Treatment of Mild – Moderate UC Ida HILMI

1540 – 1600 New Biologic Agents for Moderate – Severe IBD OOI Choon Jin

1600 – 1620 The Role of the IBD Nurse in Patients on Biologic Therapy Joan HEATHRINGTON

1620 – 1700 Debate: EARLY Surgery or Isolated Ileocecal Disease Crohn’s Disease

Proposition: Yves PANISOpposition: Stephen HANAUER

1700 – 1800 GESS AGM (For GESS Members ONLY)

1730 – 1830 Pre-conference Dinner Cocktail

1830 – 2100 GIHep Evening Symposium and Conference Dinner

1830 – 1900 Evening Lecture Chow Wan Cheng

Looking Ahead: Treating Chronic Hepatitis B Virus Infection in 2020 Ray KIM

1900 - 1915 Prize and Award Presentation David ONG

Award Presentation – Medical Category NG Pock Liok

Award Presentation – Nursing Category LEE Chuey Shan

1915 - 2100 Conference Dinner

END OF DAY 1

28 | GIHep 2018

GIHep 2018 | 29

GP SymposiumLevel 5, Grange Ballroom, Mandarin Orchard



1300 – 1400Lunch Symposium (Sponsored by Pfizer Pte Ltd)

GWEE Kok Ann

1300 – 1345 Safe NSAIDs Use for Chronic Pain – Looking at GI and BeyondCarmelo SCARPIGNATO

1345 - 1400Lunch (continuation) and Viewing of Posters and Exhibitions(Level 6 Mandarin Grand Ballroom 1)

1400 – 1440 Luminal Symposium Christopher CHIA

1400 – 1420 Helicobactor Pylori – Is it Still a Problem? KENTARO SUGANO

1420 – 1440 Update in the Management of Stubborn Constipation Kewin SIAH

1440 – 1500 Probiotic GWEE Kok Ann

1500 – 1530Afternoon Tea Break and Viewing of Posters and Exhibits (Level 6 Mandarin Grand Ballroom 1)

1530 – 1630 Liver Symposium CHIA Chung King

1530 – 1550 Supplements and Drug Induced Liver Injury TAN Poh Seng

1550 – 1610 Fatty Liver – Is it Only Down to Diet and Exercise? YEW Kuo Chao

1610 – 1630 Doctor, is My Liver Ok? How to Assess Liver Function Accurately LU Wei

END OF GP SYMPOSIUM


Disclaimer: Whilst every attempt will be made to ensure that all aspects of the programme will take place as scheduled, the Organisers reserve the right to make appropriate changes should the need arise.

30 | GIHep 2018



0830 – 1000Liver Symposium - Practical Approach to Hepatology Referrals

LUI Hock Foong Murdani ABDULLAH

0830 – 0850“Please See for? Hepatorenal Syndrome – My Patient Has Abnormal LFT and Renal Impairment”

YANG Wei Lyn

0850 – 0910“Please See for? Hepatic Encephalopathy – My Drowsy Patient has Raised Serum Ammonia”

CHOW Wan Cheng

0910 – 0930“Should I Observe or Treat My 40 Years Old Patient with Chronic Hepatitis B, Normal LFT, Normal Fibrosis Test and Elevated HBV DNA”

TAN Soek Siam

0930 – 0940Presence of Steatosis Does Not Increase the Risk of HCC in Patients with Chronic Hepatitis B Over Long Follow-up

LIM Chong Teik

0940 – 0950Effect of Mobile Technology on Lifestyle Intervention and Weight Loss in Patients with Non-alcoholic Fatty Liver Disease: A Randomised Controlled Trial

LOO Wai Mun


1000 – 1030 Morning Tea Break and Viewing of Posters and Exhibits

1030 – 1200 Upper GI SymposiumKenneth KOOThan Than AYE

1030 – 1050Pathophysiology and Prevention of NSAID-enteropathy: Focus on Gut Microbiota

Carmelo SCARPIGNATO

1050 – 1110 Preventing Gastric Cancer through H. Pylori Eradication Kentaro SUGANO

1110 – 1130 Treatment of Refractory GERD FOCK Kwong Ming

1130 – 1150 Management of Anticoagulants During Endoscopy Lawrence HO


1200 – 1315 Lunch

1215 – 1245Lunch Symposium(Sponsored by Takeda Pharmaceuticals (Asia Pacific))Treatment of Helicobacter Pylori in 2018

Kentaro SUGANO

1245 – 1315 Lunch (continuation) and Viewing of Posters and Exhibitions

1315 – 1510 Gastroenterology and the Gut MicrobiomeArjuna DE SILVADr David Ong

1315 – 1335 Probiotics for GI Diseases GWEE Kok Ann

1335 – 1355 Microbiota-directed Therapies in Digestive DiseasesCarmelo SCARPIGNATO

1355 – 1415 Genetic Modification of Probiotic HO Chun Loong

1415 – 1435Serum Biomarkers for Detection of Gastric Cancer in a Singapore Chinese Population

Joy CHUA

Day 3: Sunday, 8 July 2018

Annual Scientific MeetingLevel 6, Mandarin Grand Ballroom 2, Mandarin Orchard

GIHep 2018 | 31



1515 – 1645 Endoscopy PotpourriThein MYINTEric WEE

1515 – 1535 POEM – The Singapore Experience Jimmy SO

1535 – 1555 Role of EUS in Portal Hypertension Anand SAHAI

1555 – 1615 Artificial Intelligence (AI) – Assisted Colonoscopy Yuichi MORI

1615 – 1635Strategies to Diagnose and Manage Complications of OGD and Colonoscopy

Simon LO


1645 – 1700 Closing

1645 – 1700 Closing Remarks by President, GESS CHUA Tju Siang

END OF MEETING


32 | GIHep 2018


1030 – 1130 Poster Round

1130 – 1230 Nursing Free Paper Presentation Lim Siew Geok

1130 – 1140Workflow (Version 2) For Standardization of Microbiological Surveillance of Endoscopes

1140 – 1150The Outcome and Cost of a Systematic Approach to Evaluate the Effectiveness of Flexible Endoscopes Reprocessing in NTFGH Singapore

1150 – 1200The Implementation of a Chronic Hepatitis B Telemedicine Program Reduced the Number of Clinic Visits Without Compromising Patient Safety.

1200 – 1210 Launch of Electronic Nursing Assessment Record (Enar)

1210 – 1220Enhancement of Peri-Endoscopy Nursing Care Checklist to Enhance Patients’ Safety, Suite Efficiency, And Staff Experience- A Case Study In A High-Volume, Endoscopy Setting

1230 – 1345 Lunch

1245 – 1315Lunch Symposium (Sponsored by Cantel Medical Asia/Pacific Pte Ltd)Traceability is Not the Answer for your Endoscopy Department

Peter BEERTEN

1315 – 1340 Lunch (continuation) and Viewing of Posters and Exhibitions

1340 – 1400 Opening Ceremony (Live Streaming from Medical Track) LEE Chuey Shan

1340 – 1345 Welcome Address by Scientific Chair, GESS WANG Yu Tien

1345 – 1350 Opening Address by President, Nursing Chapter, GESS LEE Chuey Shan

1350 – 1400 Opening Address by President, GESS LING Khoon Lin

1400 – 1500 Microbiological Surveillance SymposiumHO Miew LingAnnie Rose Addun ADDURU

1400 – 1425Microbiological Surveillance and Endoscope Storage Cabinet –Australia Perspective

Dianne JONES

1425 – 1450Microbiological Surveillance – Environment, Workflow and Processes – Singapore Perspective

Nenny Suzanah BTE SELLAMAT



1530 – 1700 Capsule Endoscopy Symposium Azhar BIN MOHD

1530 – 1550 Capsule Endoscopy – Indications and Complications ONG Wai Choung

1550 – 1610 What the Doctors are Looking For? ONG Wai Choung

1610 – 1630 Professional Value for Nurses Performing Capsule Endoscopy Dianne JONES

Nursing – Endoscopy TrackLevel 6, Mandarin Ballroom 3, Tower Block, Mandarin Orchard


GIHep 2018 | 33

1630 – 1650 The Role of Nurses Eileen NGAI


1700 – 1800 GESS AGM

1830 – 2100 GIHep Evening Symposium and Conference Dinner (By Invitation Only)

1830 – 1900 Evening Lecture CHOW Wan Cheng

Looking Ahead: Treating Chronic Hepatitis B Virus Infection in 2020

Ray KIM

1900 – 1915 Prize and Award Presentations David ONG

Award Presentation – Medical Category NG Pock Liok

Award Presentation – Nursing Category LEE Chuey Shan

1915 – 2100 Conference Dinner

END OF DAY 1 ANNUAL SCIENTIFIC MEETING


34 | GIHep 2018

Nursing – Endoscopy TrackLevel 6, Mandarin Ballroom 3, Tower Block, Mandarin Orchard




0830 – 1000 Deep Sedation and EndoscopySharon SEEAlice ZHONG

0830 – 0850New Trends and Challenges Faced in Private Sector for Patients Under Moderate to Deep Sedation

LIM Hsien Jer

0850 – 0910Proceduralist Administered Propofol (PAP) and His Challenges in Giving Moderate to Deep Sedation

YAP Chin Kong

0910 – 0930Nurse Sedationist Experience in Administer Sedation – Roles and Responsibilities

Angelie ASHBY

0930 – 0950Nurses Role in Assisting General Anaesthesia in Endoscopy Setting

Naranderjit KAUR


1000 – 1030 Morning Teabreak and Viewing of Posters and Exhibits

1030 – 1200 Role of Nursing in Therapeutic EndoscopyNorhayati BTE MD SHARIFFNur Aliffa BTE AYUB

1030 – 1050 Therapeutic EUS ANG Tiing Leong

1050 – 1110Role of Nurses in Preparation and Assisting Spyglass Cholangiosocopy

WANG ChunhongTina Bhagwandas NANKANI

1110 – 1130 Haemostasis Devices and the Role of Nurses LIU Guoai

1130 – 1150 Sengstaken Tube – Role in Modern Day Nursing Dianne JONES


1200 – 1315 Lunch

1215 - 1245Lunch Symposium(Sponsored by Erbe Singapore Pte Ltd)Expertise and Basics of Electrosurgery

Frtiz MAIER

1315 - 1345 Lunch (continuation) and Viewing of Posters and Exhibits

1315 – 1445 Special PopulationsMohamamad Alimmirza BIN SIDIKHUANG Yaping

1315 – 1445 Risk Management of Elderly Endoscopy PatientsLaarni Joy M ARREOLA

1340 – 1405 Risk Management of Paediatric Endoscopy Patients Venkatesh Karthik

1405 – 1430 Risk Management of Pregnant Endoscopy PatientsKathleen Barit BENJAMIN



GIHep 2018 | 35

1515 – 1645 Endoscopy Potpourri (Live Stream from Doctor Track) Peter LEE

1515 – 1535 POEM – The Singapore Experience JIMMY SO

1535 – 1555 Role of EUS in Portal Hypertension Anand SAHAI

1555 – 1615 Artificial Intelligence (AI) – Assisted Colonoscopy Yuichi MORI

1615 – 1635Strategies to Diagnose and Manage Complications of OGD and Colonoscopy

Simon LO


END OF MEETING


36 | GIHep 2018

Nursing – GI/IBD TrackLevel 8, Mandarin Meeting Suite 802, Tower Block, Mandarin Orchard




0830 – 1000 Gastrointestinal Symposium I LOY Kia Lan

0830 – 0850 Irritable Bowel Symptoms Kewin SIAH

0850 – 0910 Lower Anorectal Physiology Tests ZHANG Meng Meng

0910 – 0930 Mindfulness for Healthcare Providers in Our Daily Work LEE Poh Yin

0930 – 1000 Ostomy Dressings and Management LAI Pei Ting

1000 – 1030 Morning Tea Break

1030 – 1200 IBD Symposium Elaine CHAN

1030 – 1100What is the Impact of Professional Nursing on Patients' Outcomes Globally? An Overview of Research Evidence

Joan HEATHERINGTON

1100 – 1120 Wound and Stoma Issues – Management Strategies ONG Choo Eng

1120 – 1150 Nurse-Led Telephone Follow-Up of Patients with IBDJoan HEATHERINGTON


1200 – 1315 Lunch

1315 – 1445 IBD Workshop – Biologics Station LIN Mei

1315 – 1345 Understanding Biologics Therapy – What is it? LOY Kia Lan

1345 – 1415 Therapeutic Drug Monitoring of Biologics LIM Teong Guan

1415 – 1445Specialist Nurse Intervention in Biologic Service – Workshop on Various Biologic Management

Joan HEATHERINGTON

1445 – 1515 Afternoon Tea Break

END OF MEETING


GIHep 2018 | 37

Nursing – Liver TrackLevel 5, Grange Ballroom, Tower Block, Mandarin Orchard




0830 – 1000 Liver Cirrhosis……Better Care for our PatientsSiti Amalina BINTE KASAN

0830 – 0900 Understanding Our Patients with Hepatocellular Carcinoma LEE Hwei Ling

0900 – 0915 What is Indocyanine Green Test? HPB Nurses’ Perspective CHUA Siew Huang

0915 – 1000 The Surgery Code: Liver Resection in HCC Patients FENG Ying


1030 – 1200Updates on HCC……Super Easy Ways to Learn Everything About HCC Angiography Procedures

Siti Amalina BINTE KASAN

1030 – 1100 Radiofrequency Ablation (RFA) – Nursing Perspective Josephine BOO

1100 – 1130 Transarterial Chemoembolization (TACE) – Patient Education Oo Fiona AISIS

1130 – 1200 Selective Internal Radiation Therapy (SIRT) – Nurses’ Role Julian LIM Cong En

1200 – 1315 Lunch

1315 – 1445 Updates on HCC……Other ApproachesSiti Amalina BINTE KASAN

1315 – 1345 Educating Patients on Sorafenib CHIA Pei Yuh

1345 – 1405 Liver Cirrhosis and Related Complications – Nurses’ Perspective KUU Meei Ting

1405 – 1445 Case Studies…..Applying What We Learn into Practice

LEE Hwei LingFacilitator: Thineseh Edward BALASINGAM


END OF MEETING


38 | GIHep 2018

Nursing – Nutrition TrackLevel 8, Mandarin Meeting Suite 805, Mandarin Orchard




0830 – 1000 Nutrition Symposium I Lilian YEW

0830 – 0855Evaluation of Patients Outcome with Integrated Real-time Image System (IRIS) Technology Insertion of Naso-gastric Tube / Naso-gastricduodernal Tube

Janet CHONG

0855 – 0920 Nurse-led Discharge After Day Surgery PEG Insertion LOH Lee Leng

0920 – 0945 Management of Enteral / PEG in the Private Setting Kalai SELVI



1030 – 1200 Nutrition Symposium II Janet CHONG

1030 – 1055Monitoring the Glucose Roller Coaster: What’s New in Nutrition DM Management?

CHAN Yoke Lin

1055 – 1120 Insulin Myth of Patient on Enteral and Parenteral Nutrition GOOI Siao Ching

1120 – 1145Challenges in Setting Up Home Parenteral Nutrition Training for Nurses – Train the Trainer

Jocelyn Ubera BUNGUBUNG


1200 – 1315 Lunch

1315 – 1445 Nutrition Symposium III Moh Yoke Ping

1315 – 1345 Perioperative Nutrition Strategies for Patients Undergoing Surgery TAN Chun Hai

1345 – 1415 Nutrition and Wound Healing CHONG Shu Han

1415 – 1445Enteral Nutrition: - Gastric Residual Volume (GRV) Protocol - Early Recovery After Surgery (ERAS)

Janet CHONG


End of Meeting


GIHep 2018 | 39

40 | GIHep 2018

Lecture Abstracts

ENDOSCOPY LECTURE I

ENDOCYTOSCOPY – A PRIMERProf Yuichi Mori

Current advances in endoscopic imaging modalities, such as magnifying endoscopy and narrow-band imaging (NBI; Olympus, Tokyo, Japan), have changed conventional diagnostic approaches in colonoscopy. These imaging techniques, sometimes called “optical biopsies” have greatly improved the accuracy of diagnosis of colorectal neoplasms and allow on-site assessment of the histopathological features of lesions, obviating the need for a Bx. However, they allow only indirect assessment of the morphology of crypts or vessels, and their accuracies vary. Histopathology has therefore remained the gold standard for reliable pretreatment diagnosis.

Endocytoscopy (EC; CF-290ECI, Olympus Corp.), which involves a contact light microscopy system integrated into the distal tip of a conventional colonoscope, is a novel emerging endoscopic system. In contrast to other modalities, the ultra-magnification capability of EC enables on-site observation not only of structural atypia, but also of cytological atypia. Based on these advantages, EC has demonstrated good consistency in assessing the histopathology of lesions in the gastrointestinal tract and shown diagnostic accuracies between 94% and 100% for identifying adenomas(1-3). This special function also contributes to the high diagnostic accuracy in identifying massively invasive submucosal cancers (T1b cancers). Thus, EC is expected play an important role in improving the quality of endoscopic management of T1 cancers.

Specifications of an endocytoscope

The EC scope has a contact light microscopy system (520-fold magnification with a focusing depth of 35 μm and a field of view of 570 × 500 μm) integrated into the distal tip of a normal colonoscope (Figure 1). The EC scope can provide both standard white light and EC images under the NBI mode or the 1.0% methylene blue staining mode,using a hand-operated lever. Endoscopic treatment can be performed as with a traditional colonoscope.

Diagnostic performance of colorectal submucosal cancers using endocytoscopes

Over 10 clinical studies including one prospective trial(4) and one randomized trial(3) were conducted to clarify the potential of EC in diagnosis of colorectal lesions. In evaluating colorectal lesions by EC, the EC classification (Figure 2)(4) for the staining mode and the EC-V classification (Figure 3)(1) for the NBI mode are encouraged to be used. According to these trials, EC provided additional diagnostic values to conventional magnifying endoscopy in predicting the histology of T1b cancers; EC showed 95.7% accuracy with the NBI mode(1) and 96.3% accuracy with the staining mode(2) in diagnosis of these types of lesions. Therefore, EC has a potential of providing higher diagnostic performance in identification of T1b cancers than the previously available modalities such as magnified endoscopy.

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Figure 1

Figure 2

Figure 3

42 | GIHep 2018

GP SYMPOSIUM – LIVER

FATTY LIVER – DOWN TO ONLY DIET AND EXERCISE?Dr Yew Kuo Chao

Nonalcoholic fatty liver disease (NAFLD) / Nonalcoholic steatohepatitis (NASH) was once a disease spectrum that received little attention in the medical field but this is no longer the case. Its prevalence rises with increasing obesity associated with the modern lifestyle. NAFLD/NASH has always been described as the “hepatic manifestation of metabolic syndrome". The underlying truth may be more complex than commonly believed as NAFLD/NASH in non-obese patient has a more aggressive phenotype. The condition is gaining increasing recognition as it can lead to complications such as liver failure, cirrhosis and hepatocellular carcinoma which is certainly a significant health care issue. Lifestyle changes including weight reduction via dietary manipulation and aerobic exercise is beneficial but it is unlikely to be the ultimate answer to disease management especially when the beneficial effect of the mechanism remains unclear. A complementary multidisciplinary engagement is core in the NAFLD/NASH care model. It encompasses prevention and identification for significant liver fibrosis and its progression at an early stage and stopping or reversing fibrinogenesis and steatosis. The primary care physician plays an important role in performing periodical assessment and managing patient's cardiovascular risk factors such as hyperglycaenmia and hyperlipidaemia. They can also participate in identification of patients with significant fibrosis and initiate early referral to the specialist for liver biopsy, selection of suitable pharmacological intervention and bariatric surgery.

Fatty liver disease will remain an area of interest in hepatology in regards to diagnostic and therapeutic surveillance methodology and measurement (e.g. liver fat quantification), discovery of new inhibitor pathways, personalised risk re-modelling and most importantly the understanding of an old disease with a new face.

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UPPER GI SYMPOSIUM

TREATMENT OF REFRACTORY GERDProf Fock Kwong Ming

The third consensus on GERD in the Asia Pacific Region continues to clarify the epidemiology, investigation and treatment of gastro-oesophageal reflux disease which has been rising in incidence throughout the region.

Epidemiological data throughout the region showed that the prevalence of symptomatic GERD in the community is rising in the Asia Pacific Region although within each country there are regional differences. However, the severity of erosive esophagitis remains mild. Factors that have caused the increase in GERD and overweight.

Patients with refractory GERD symptoms (r-GERD) in Asia Pacific Region are more common in NERD than in ERD patients and the prevalence ranged between 16.7% - 64% depending on the duration of therapy. Upper GI endoscopy including NBI and HRM could differentiate between GERD and Non-GERD causes of Refractory GERD, symptoms including functional heartburn. Using the management algorithm in the AP consensus, a recent study showed that 52% of patients with refractory GERD symptoms were due to non-GERD causes. About 17% of r-GERD patients have inadequate acid suppression. Gastric cancer, eosinophilic oesophagitis and Barrett’s esophagus account for <1% of patients with refractory symptoms. The Asia Pacific Consensus has recommended that intestinal metaplasia is no longer required in the diagnosis of Barrett’s oesophagus. This is because 8 biopsies are needed to correctly diagnose IM with a yield of 70%. There is no value for screening for Barrett’s oesophagus in Asia Pacific region. In the absence of dysplasia, there is no benefit for surveillance of Barrett’s oesophagus.

44 | GIHep 2018

GASTROENTEROLOGY AND

THE GUT MICROBIOME

GENETIC MODIFICATION OF PROBIOTIC Dr Ho Chun Loong

Commensal microbes are known to regulate a healthy intestinal microbiota, translating to improved metabolism and immunity. Genetically engineered commensals have been studied for the treatment of inflammatory bowel disorders such as Crohn’s disease, ulcerative colitis, as well as for diseases linked to hyperactivity of the host immune system. These approaches have been used as well for targeting infections and as a biosensor help in disease diagnosis. Using the commensal microbes as a chassis, it is possible to add health benefiting properties that can enhance the gut conditions of the host. Herein, we discuss about the different methods microbial engineering have been used to tackle health issues. We will focus in particular to the engineered microbes to target infections and our recent work using engineered commensal microbes to target colorectal tumor leading to tumor regression. Our work demonstrates that our engineered microbes can potentially be deployed as a form of enhanced therapies for treating infections and cancer treatment, leading to reduced side effects on the patient thus improved patient recovery.

ENDOSCOPY POTPOURRI

ARTIFICIAL INTELLIGENCE (AI)-ASSISTED COLONOSCOPY Prof Yuichi Mori

Computer-aided diagnosis (CAD) for colonoscopy is a novel growing research area involving two general topics, namely polyp detection and polyp classification. Both detection and classification of colorectal polyps powered by CAD potentially improve the quality of colonoscopy by reducing the polyp miss rate and mischaracterization of detected polyps, which often occur as a result of human error or inexperience. To date, the research field of polyp detection remains in an experimental setting, however some researchers have succeeded in providing good sensitivity of over 90% for the detection in video-based analysis. With regard to polyp classification, real-time automated pathological prediction in a clinical setting has been realized for the differentiation of adenomas by several research groups. They provided excellent data of nearly 90% accuracies by using CAD combined with advanced imaging modalities like magnifying narrow-band imaging, endocytoscopy, and auto-fluorescence spectroscopy. The importance of these academic fields is strengthened by the fact that higher adenoma detection and accurate optical biopsy would be beneficial in terms of cancer protection and cost-savings of pathological examinations, respectively. Coupled with recent breakthrough of artificial intelligence like “deep learning”, CAD for colonoscopy is strongly expected to achieve major changes in routine colonoscopy in the next few years. In this lecture, I’d like to show both the clinical potential and the current limitation of CAD for colonoscopy.

GIHep 2018 | 45

NURSING SYMPOSIUM -

MICROBIOLOGICAL SURVEILLANCE

SYMPOSIUM

MICROBIOLOGICAL SURVEILLANCE AND ENDOSCOPE STORAGE CABINET – AUSTRALIA PERSPECTIVE Ms Dianne Jones

Quality control in the reprocessing of endoscopes was highlighted with the outbreak of infections caused by multi resistant organisms, in particular CPE. The use of microbiological surveillance cultures for that quality process has long been contentious, with some countries having long standing experience at incorporating these into their country standards whilst others have rejected the technique as not being appropriate. Australia and New Zealand have a standard for microbiological testing that incorporate flow charts to use to guide response to positive culture results. The FDA have now issued a protocol for collecting samples from the biopsy channel and the distal tip cap but only for microbial culture of duodenoscopes. However, the long standing experience in Australia of culturing all channels of all endoscopes has highlighted that biofilm formation occurs in all channels and all endoscopes. Current sampling techniques will identify planktonic bacteria in channels but may not identify bacteria embedded in biofilm. Reprocessing research has highlighted the problem of biofilm build up. A key step in reprocessing to prevent / limit biofilm is to ensure that the endoscope is totally dry. Cabinets have historically only served to store endoscopes but attention is now focussing on the use of channel purge drying within the cabinets.

46 | GIHep 2018

NURSING SYMPOSIUM - CAPSULE

ENDOSCOPY SYMPOSIUM

PROFESSIONAL VALUE FOR NURSES PERFORMING CAPSULE ENDOSCOPYMs Dianne Jones

Capsule endoscopy was first used in humans in 1999 using technology developed from equipment used by the Israel defence force. A commercially available capsule gained FDA approval in August 2001. The test rapidly was accepted by clinicians as a means for investigation of the “gut between two scopes”. Initial configuration required an array of sensors to gather the signals from the capsule and these needed to be well fixed to the patient for the duration of the test. Nurses were soon part of the team performing capsule endoscopy, initially as the clinician who set up the sensor array and then administering the capsule. Patient education was paramount to ensure that the full use of the capsule was realised. Subsequently nurses in some countries undertook training to be able to read the capsule data. This process that takes up to 90 minutes was seen as being suitable for experienced endoscopy nurses to complete training to be able to undertake this expanded independent role. There are a number of studies that have compared the accuracy of nurse interpretation of the capsule studies with other clinicians and determined that they are as capable as experienced physicians. Nurse-provided capsule services now exist in many countries.

GIHep 2018 | 47

NURSING SYMPOSIUM - DEEP

SEDATION AND ENDOSCOPY

NURSES ROLE IN ASSISTING GENERAL ANAESTHESIA IN ENDOSCOPY SETTING Ms Naranderjit Kaur

The aim of a high volume endoscopy unit is to provide high quality diagnostic and therapeutic endoscopy services and patient care. The facility shall provide a seamless flow across all functional areas. Patient safety and infection control were enhanced, while incorporating staff safety requirements, service quality, operational efficiency and optimal productivity. International and local standards and local regulatory requirements were integrated to ensure that the facility meets the highest standards. In addition, there is an ongoing challenge to manage competing nursing manpower needs within the organization and the overall healthcare landscape. The challenges presented in the internal and external environments, also brought about valuable opportunities for nursing innovation.

Endoscopy nurses are a highly specialized team of healthcare professionals. It takes approximately 1- 3 years to groom a highly competent and skilled endoscopy nurse capable of assisting in advanced and specialized endoscopy procedures. The Ambulatory Endoscopy Centre in SGH has a progressive model in molding highly specialized nurses with dual talents

The role of the endoscopy nurse has evolved in tandem with the demands for limited nursing manpower resources while ensuring overall operational efficiency. The dual role of an endoscopy nurse equipped with Anaesthetist - unit skills and competencies is a new paradigm for endoscopy service.

48 | GIHep 2018

NURSING SYMPOSIUM - ROLE

OF NURSING IN THERAPEUTIC

ENDOSCOPY

SENGSTAKEN TUBE – ROLE IN MODERN DAY NURSING Ms Dianne Jones

The catastrophic bleeding that can occur from oesophageal or gastric varices carries a high mortality rate. Prior to the development of the technique of oesophageal variceal sclerotherapy the use of an intragastric balloon device to apply compression to the vessels traversing the oesophageal hiatus of the diaphragm was the major intervention for achieving haemostasis. This pressure was achieved by applying traction on the intragastric balloon tube. In addition to this gastric balloon, a second balloon was inflated in the oesophagus to provide direct pressure laterally to the oesophageal wall if haemostasis was not achieved by the gastric balloon. Modern tubes have both balloons and drainage ports for oesophagus and stomach within the one tube. Sclerotherapy was followed by the development of oesophageal variceal banding and these interventions provided effective measures for control of oesophageal variceal bleeding, reducing the need for balloon devices, though they were still used for control of fundal variceal bleeding when gluing was not possible. Despite these haemostatic techniques and the use of vasoconstrictor agents such as Octreotide, balloon compression is still a valuable intervention to manage uncontrolled bleeding particularly from gastric varices. Nurses who are caring for patients with these tubes in-situ need to be conversant with the problems that may arise during use of the tube and the measures that they need to follow to avoid complications.

GIHep 2018 | 49

NURSING SYMPOSIUM -

GASTROINTESTINAL SYMPOSIUM

OSTOMY DRESSINGS AND MANAGEMENT Ms Lai Pei Ting

The presentation aims to give an overview of Ostomy care to healthcare professionals.Indication of stoma creation will be shared in the beginning. Factors to be taken into consideration for stoma site selection prior to surgery and the importance of stoma siting will be covered as well.

The goal of ostomy care to help patients and caregiver to familiarize with proper caring for their stoma so that they can maintain a quality standard of living after surgery. Understanding post-operative stoma assessment and care thus becomes essential for the patients.After which, knowing the types of ostomy appliances and accessories is necessary in order for us to provide the appropriate treatment. There are some important points to consider on the selection of an appropriate pouch for patients which will be covered in the presentation as well.

Lastly, there will be a discussion of the different stoma complications and management on each of them.

NURSING SYMPOSIUM - IBD

WORKSHOP – BIOLOGICS STATION

THERAPEUTIC DRUG MONITORING OF BIOLOGICS Mr Lim Teong Guan

Therapeutic drug monitoring (TDM) is an area of growing interest within the IBD area. It has emerged as a tool to understand and predict patient response to biologic treatment. TDM provides better guide on therapeutic decisions regarding biologic escalation, withdrawal or switch. Hence, it helps to optimize the biologic therapy and provide personalized treatment. Various factors affect TDM implementation in practice as well as results interpretation.

In this session, we will discuss the current strategy of using TDM in guiding IBD management, review biologics and antidrug antibodies interpretation, explain the treatment strategies based on the TDM results as well as to describe the practical challenges of using TDM in IBD.

50 | GIHep 2018

NURSING SYMPOSIUM - LIVER

CIRRHOSIS……BETTER CARE FOR

OUR PATIENTS

UNDERSTANDING OUR PATIENTS WITH HEPATOCELLULAR CARCINOMAMs Lee Hwei Ling

Hepatocellular Carcinoma incidence in Singapore is on the rising trend and in America it is currently the Third leading cause of cancer deaths worldwide. Prevalence and surveillance remains important to prevent late presentation. Patient education remains crucial hence as a healthcare professional we Nurses can play a vital role in patient education. Understanding the disease we can empower our patients through education.

NURSING SYMPOSIUM - UPDATES

ON HCC……OTHER APPROACHES

EDUCATING PATIENTS ON SORAFENIBMs Chia Pei Yuh

Hepatocellular Carcinoma (HCC) is the most common Primary Liver Cancer which originates from the liver cells called hepatocytes. According to the Singapore Cancer Registry, HCC is the fourth common cancer and the third leading cause of cancer-related death among Singaporean males from 2011-2015.

There are various risk factors that cause HCC, the most common causes are Hepatitis B, Hepatitis C and Cirrhosis. Many patients are diagnosed at late stage of the disease and the outlook for patients in advanced stage of HCC is dismal. Thus, regular surveillance of HCC is very important. With early detection of the disease, HCC can be curative.

In our Liver HCC Nursing Symposium, we will be sharing the various intervention and treatment options. In the next session, Pei Yuh will touch on the advanced HCC management; systemic therapy. She will share her experience in educating patients and caregivers on self-care and adverse effects management during systemic therapy.

GIHep 2018 | 51

NURSING SYMPOSIUM - UPDATES

ON HCC……SUPER EASY WAYS TO

LEARN EVERYTHING ABOUT HCC

ANGIOGRAPHY PROCEDURES

SELECTIVE INTERNAL RADIATION THERAPY (SIRT) - NURSES’ ROLEMr Julian Lim Cong En

Selective Internal Radiation Therapy (SIRT), also known as Radioembolization, is a way of using radiotherapy to control liver cancers that can’t be removed with surgery. SIRT is administered by a trained Interventional Radiologist specialist.

A microcatheter is used to deliver millions of radioactive tiny beads called microspheres into the main blood vessel that supplies blood to your liver (the hepatic artery). Each bead is smaller than the width of a human hair. They get lodge in the small blood vessels around the tumour.

Initial work-up for staging provides essential information on the patient's well-being, liver status, as well as the extent and location of disease, which are used in the assessment of a patient's suitability for treatment.The treatment goals are to:• Increase the time to progression• Extend overall survival• Potentially downsize or downstage tumors for liver resection, ablation or transplantation• Provide palliation of symptoms

Therefore, nurses are important advocators and educators for patients undergoing SIRT. We monitor patients’ progress throughout the treatment program. That includes treatment process, complications, side effects, post treatment care and radiation safety.

52 | GIHep 2018

NURSING SYMPOSIUM - NUTRITION

SYMPOSIUM I

EVALUATION OF PATIENTS OUTCOME WITH INTEGRATED REAL-TIME IMAGE SYSTEM (IRIS) TECHNOLOGY INSERTION OF NASO-GASTRIC TUBE / NASO-GASTRICDUODERNAL TUBE Ms Janet Chong

Enteral tube feeding is the delivery of nutritionally complete formulae via a Nasogastric Tube (NGT) into the stomach or Nasojejunal tube (NJT) into the small intestine.

NGT is mainly used for short-term support for patient with dysphagia related to neurologic and neuromuscular disorders and cancer. However, a gastrostomy feeding should be considered for patient requiring long term NGT feeding for more than 4 weeks.

NGT may be view as minimally invasive but its complications are undeniable such as accidental dislodgement, nasal irritation, unable to confirmation placement and incidental intubation into trachea or esophageal perforation which is detrimental.

As a Nutrition Support Specialist Nurse Clinician, I performed traditional beside insertion of NJT which routinely needed patient to lie on right lateral position for 4 hours post insertion to wait for tube to float pass the duodenum into the jejunum then followed by an abdominal X-ray (AXR) to confirm placement. It is often subject to adjustment and repeat AXR if NJT is not at the ideal location. This often causes delay in feeding and stress to patient/family. In Jan 2018, Integrated Real-time Image System (IRIS) advanced technology was brought into Singapore General Hospital. A total of 21 insertion of NGT/NJT was done in a 3 months trail period with outcome of 98% efficacy as evidence with CXR/AXR confirmation post insertion.

1 NGT, was located at the esophageal juncture which needed advancement of tube. The procedure takes 15 mins and patient almost can be fed immediately.

Real time image with IRIS technology increases clinical effectiveness by minimising and eliminating misplaced NGT or NJT and in turn may improve patient safety and reduced under feeding and reduces the prevalence of malnutrition in hospitalized patients. The device may also reduce the need for additional x-rays to confirm tube placement and reduce the length of stay in hospital due to complications as a result of misplaced tubes.

GIHep 2018 | 53


SYMPOSIUM II

INSULIN MYTH OF PATIENT ON ENTERAL AND PARENTERAL NUTRITIONMs Gooi Siao Ching

Hyperglycaemia is associated with a higher risk of mortality as well as poorer outcome in patients on nutrition support. It follows that reducing the variability of blood glucose level, avoiding hypo- and hyperglycaemia, is associated with better clinical outcome. This could be done by the appropriate adjustments in the content of nutritional feeds or parenteral nutrition. In addition, the judicious use of insulin regimen as well as proper timing in point of care glucose monitoring is of paramount importance. This lecture discusses how this could be achieved through a multidisciplinary team approach.

54 | GIHep 2018


SYMPOSIUM III

ENTERAL NUTRITION: GASTRIC RESIDUAL VOLUME (GRV) PROTOCOL AND EARLY RECOVERY AFTER SURGERY (ERAS)Ms Janet Chong

Gastric Residual Volume (GRV) is often used to evaluate Enteral Nutrition(EN) tolerance and feedings are often stopped unnecessarily and not advanced to goal, resulting in inadequate nutrition for patients. The practice of checking GRV is based on the belief that high GRVs are a marker of increased risk for regurgitation and aspiration, yet evidence does not exist in the literature correlating GRV with aspiration pneumonia.

GRV protocol is essential to assist medical clinicians and nurses’ interpretation and gain a better understanding of GRVs, offer strategies to improve EN tolerance when problems occur.

Understanding Gastric Physiology - stomach breaks food into smaller particles and mixing food with gastric acid and digestive enzymes. It acts as a reservoir, allowing slow emptying of approximately 5 to 15 ml at a time into the small bowel for continued digestion and absorption. When interpreting GRV, clinicians must keep in mind that the stomach has reservoir function and that the stomach fluid is a mixture of both the infused EN formula and normal gastric secretions.

EN feedings should not be stopped for a single high GRV if there are no other physical examination or radiography findings to show actual gastrointestinal dysfunction.

According to current American Society for Parenteral and Enteral Nutrition guidelines for nutrition support in patients who are critically ill, EN should not be stopped for a GRV of less than 500 mL unless there are other signs of feeding intolerance. GRVs ranging from 200 to 500 mL should prompt clinicians to implement methods to reduce aspiration risk, considering prokinectic therapy. Feeding intolerance includes emesis, abdominal distention, constipation, and, if the patient is awake and alert, complaints of uncomfortable fullness, abdominal pain, or nausea.

ERAS protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite evidence indicating that ERAS protocols lead to improved outcomes, there are still challenges in traditional surgical doctrine resulting slow compliance.

ERAS protocols represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

GIHep 2018 | 55

TAKEDA PHARMACEUTICALS (ASIA PACIFIC) PTE. LTD.

21 Biopolis Road, Nucleos North Tower, Level 4, Singapore 138567 Tel +65 6808 9500 | www.takeda.com

SG/EYV/2018-00011 | Print Date: June 2018For Healthcare Professionals Only

Y our decision to prescribe Entyvio®

can help change the next chapter of

your patients’ UC or CD treatment.

Entyvio® is the only gut selective biologic

for UC & CD,1–3 clinically proven to

provide long-lasting remission1,4–7 and

has a favourable safety profile1,8

References:1. ENTYVIO Prescribing Information, Singapore, November 2016.. 2. Soler D, Chapman T, Yang LL, et al. The binding specificity and selective antagonism of vedolizumab, an anti-α4β7 integrin therapeutic antibody in development for inflammatory bowel diseases. J Pharmacol Exp Ther. 2009;330(3):864–875. 3. Gilroy L & Allen PB. Is there a role for vedolizumab in the treatment of ulcerative colitis and Crohn’s disease? Clin Exp Gastroenterol. 2014;7:163–172. 4. Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2013;369(8):699–710. 5. Feagan BG, Rubin DT, Danese S, et al. Efficacy of vedolizumab induction and maintenance therapy in patients with ulcerative colitis, regardless of prior exposure to tumor necrosis factor antagonists. Clin Gastroenterol Hepatol. 2017;15(2):229–239.e5. 6. Sandborn WJ, Feagan BG, Rutgeerts P, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med. 2013;369(8):711–721. 7. Sands BE, Sandborn WJ, Van Assche G, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease in patients naïve to or who have failed tumor necrosis factor antagonist therapy. Inflamm Bowel Dis. 2017;23(1):97–106. 8. Colombel J-F, Sands BE, Rutgeerts P, et al. The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut. 2017;66(5):839–851.

Abbreviated Prescribing Information (refer to full prescribing information for further details).Composition: Vedolizumab 300mg/ vial Indication: Moderate to severe active ulcerative colitis & Crohn's disease in adult patients who have an inadequate response w/, lost response to, or intolerant to either conventional therapy or tumour necrosis factor-alpha (TNFα) antagonist. Dosage and administration: Ulcerative colitis & Crohn's disease - 300 mg IV infusion at 0, 2 & 6 wk, then every 8 wk thereafter. May be increased to 300 mg every 4 wk for patients who have experienced decrease in their response. Re-treatment: Consider dosing at every 4 wk. Contraindications: Hypersensitivity (eg, dyspnea, bronchospasm, urticaria, flushing & increased heart rate). Active severe infections eg, TB, sepsis, cytomegalovirus, listeriosis & opportunistic infections eg, progressive multifocal leukoencephalopathy. Special precautions: Observe patient for signs & symptoms of acute hypersensitivity reactions for approx 2 hr following completion of the 1st 2 infusions & approx 1 hr following completion of the infusion for all subsequent infusions. Discontinue immediately if severe infusion-realted & hypersensitivity reactions occur. Consider pre-treatment w/ antihistamines, hydrocortisone &/or paracetamol prior to next infusion for patients w/ history of mild to moderate infusion-related reactions. Potential increased risk of opportunistic infections. Patients w/ controlled chronic severe infection or history of recurring severe infections. Closely monitor for infections before, during & after treatment. Discontinue therapy in patients diagnosed w/ TB. Monitor new onset or worsening of neurological signs & symptoms. Discontinue permanently if progressive multifocal leukoencephalopathy is suspected. Increased risk of malignancy. Prior & concurrent use w/ biological drugs (eg, natalizumab or rituximab). Live & oral vaccines. May affect ability to drive or operate machinery. Women of childbearing potential. Pregnancy & lactation. Undesirable Effects: Nasopharyngitis, headache, arthralgia. Bronchitis, gastroenteritis, upper resp tract infection, influenza, sinusitis, pharyngitis; paraesthesia; HTN; oropharyngeal pain, nasal congestion, cough; anal abscess, anal fissure, nausea, dyspepsia, constipation, abdominal distension, flatulence, haemorrhoids; rash, pruritus, eczema, erythema, night sweats, acne; muscle spasms, back pain, muscular weakness, fatigue; pyrexia. Drug-Drug Interactions: Live vaccines should be used with caution with Entyvio. Storage conditions: Store between 2°C and 8°C. Protect from light. Shelf-life: 36 months.

56 | GIHep 2018

Free Paper Oral PresentationASSOCIATION BETWEEN HUMAN GUT MICROBIOTA AND THE HOST CENTRAL OBESITYKoo SH1, Chu CW2, Khoo JJ3, Cheong M4, Soon GH1, Ho EX2, Law NM5,

De Sessions PF2 , Fock KM5, Ang TL5, Teo EK5, Lee EJ1, Hsiang JC5

1 Clinical Trials and Research Unit, Changi General Hospital, Singapore2 GERMS Platform, Genome Institute of Singapore, A*STAR, Singapore3 Department of Endocrinology, Changi General Hospital, Singapore4 Department of Dietetic & Food Services, Changi General Hospital, Singapore5 Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore

Background/Aim:

Perturbance in the composition of human gut microbiota has been associated with metabolic disorders such as obesity, diabetes and insulin resistance. The objectives of this study are to examine the effects of ethnicity, central obesity and dietary components, on the human gut microbiome. We hypothesize that these factors have an influence on the composition of the gut microbiome.

Methods:

Healthy subjects of Chinese (n=14), Malay (n=10) or Indian (n=11) ancestry, median age 39 (range: 22-70 years old), were enrolled. They provided stool samples for gut microbiome profiling and completed a dietary questionnaire. Microbial DNA was extracted from the stool samples, followed by 16S PCR, library construction, Illumina sequencing, and data analysis. Central obesity was defined by waist circumference cut-offs of 90cm and 80cm, in Asian males and females, respectively.

Results:

There were no significant differences in Shannon alpha diversity for ethnicity and central obesity. The relative abundances of Anaerofilum and Gemellaceae (p=0.02), Streptococcaceae (p=0.03), and Rikenellaceae (p=0.04) were significantly lower in the obese group. From the principle coordinate analysis, the intake of fibre and fat/saturated fat pulled in opposing directions and there was clustering of obese individuals in the direction of fibre.

Conclusion:

The study demonstrated that there were differences in the gut microbiome in obese individuals. Suppression of the mentioned bacteria may play a contributory role to the aetiology of central obesity. Fibre and fat/saturated fat diet are not the key determinants of central obesity. The microbiome analysis with respect to body fat and insulin resistance is underway.

GIHep 2018 | 57

CUSTOMISING POLYETHYLENEIMINE (PEI) POLYMER FOR HEPATITIS B VIRUS THERAPY IN CELLULAR AND ANIMAL MODELSLee GH1,2, Aung MM2, Yang C3, Lai FSC4, Lim SG1,2, Chen Q4, Yang YY3.

1 Department of Medicine, National University Health System, Singapore2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore3 Institute of Bioengineering and Nanotechnology, Singapore3 Institute of Molecular and Cell Biology, Singapore

Background/Aim:

Polyethylenimines (PEI) polymers have been explored as a carrier for gene therapy. We modified the polymer to interrupt the interaction between HBV viruse and proteoglycans on cell membrane, a crucial step before viral entry. This pre-clinical study evaluates the anti-HBVl properties of a number of functionalized PEI polymers.

Method:

Antiviral effects of the polymers were studied in HepG2-NTCP infection model using 3000 MOI of virus produced from HepAD38 cells. To study HBV viral entry inhibition, polymers were added at the time of viral inoculation. We analyzed the parameters of HBV replication, core-associated HBV DNA quantification by qPCR method and HBsAg quantification by ELISA method. A mouse model humanized liver is also generated for direct HBV infection and drug testing.

Results:

Functionalized polymers reduced the HBV infection in HepG2 infection model in a dose dependent manner. Virus and cell binding assay also proved the significant reduction of viral replication intermediates after incubating virus or cells with functionalized polymers. Moreover, the polymers showed the additive effect of viral inhibition when being added together with Tenofovir. When added to cell culture medium after HBV entry had taken place (after day 1), the polymer prevents secondary spread of HBV to non-infected cells, as demonstrated by serial IF staining for intracellular HBcAg. With just 10 doses of treatment, H4 polymer results in 3 log reduction of HBV DNA (similar to tenofovir) compared with control mice, with antiviral effect lasting to week 12.

Conclusion:

Functionalized PEI polymers inhibit HBV entry into hepatocytes and have additive effect when combined with Tenofovir. As it also possesses the capacity to carry DNA, it may contribute to the development of HBV cccDNA-targeting therapies

58 | GIHep 2018

USE OF VIBRATION CONTROLLED TRANSIENT ELASTOGRAPHY (FIBROSCAN) WITH OR WITHOUT PLATELET COUNT TO PREDICT PRESENCE OF LARGE OESOPHAGEAL VARICESPawar AbhimanraoM1 , N Murugan2, MHariharan3

Department of Gastroenterology, Apollo Hospital, Chennai, Tamilnadu, India

Background/Aim:

Screening for Oesophageal Varices in cirrhosis is done by upper gastrointestinal endoscopy. Vibration Controlled Transient Elastography (Fibroscan) measures liver stiffness noninvasively and also correlates with portal hypertension. Liver stiffness >15 kPa are highly suggestive of compensated advanced chronic liver disease (cACLD). Aim is to study the utilityof Fibroscan with or without platelet count to predict large oesophageal varices in patients with cACLD in Indian population.

Methods:

88 patients with liver stiffness >10kPa who underwent upper gastrointestinal endoscopy and basic blood investigations were studied prospectively. Patients with ascites, Hepatocellular carcinoma, total bilirubin >5mg/dl and AST/ALT >5 times upper limit of normal were excluded. Endoscopic varices were graded into no varices, small varices or large varices.

Results:

Mean age was 51.07 years.69 were males, and 19 were females. Most common etiological factors were probable NASH(42; 47.72%) followed by HBV(18,20.45%), Alcoholic(12;13.63%), Others(10;11.36%), HCV(5;5.68%) and HBV+HCV(1;1.13%). Total 25(28.41%) patients had no varices, 36 (40.9%) patients had small varices and 27(30.68%) patients had large varices. A Cut-off liver stiffness of 20 kPa had 96.3% sensitivity and 45.9% specificity, 44.07% positive predictive value and 96.55% negative predictive value in predicting large oesophageal varices and when combined with a cut off platelet count of 150000, these values were 88.46%, 90%, 82% AND 93.75% respectively.

Conclusion:

Fibroscan has good sensitivity and negative predictive value, but limited specificity and positive predictive value in predicting large oesophageal varices, adding platelet count to it increases specificity and positive predictive value significantly with little change in sensitivity and negative predictive value in Indian population.

GIHep 2018 | 59

DEVELOPMENT AND INTERNATIONAL VALIDATION OF A SURVIVAL PREDICTION SCORE FOR ALL PATIENTS WITH HEPATOCELLULAR CARCINOMA (HCC) AT THE TIME OF HCC DIAGNOSIS REGARDLESS OF THERAPY EVENTUALLY RECEIVEDTan TJY1, Shen L2, Goh GBB1,3, Chang PE1,3, Tan CK1,3

1 Department of Gastroenterology and Hepatology, Singapore General Hospital2 Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore3 Duke-NUS Medical School

Background/Aim:

Survival of patients with hepatocellular carcinoma(HCC) is associated with several factors. Our aim was to develop and validate a survival prediction score(SPS) based on common clinical parameters and regardless of therapy received.

Methods:

The development cohort comprised 1,270 patients with HCC seen in our department. Prognostic parameters with p<0.1 on univariate analysis were included into a Cox regression with backward model selection. The SPS was derived based on coefficients estimated by Cox regression with selected parameters.

The SPS was then validated with two independent international cohorts of 220 patients from Imperial College(IC), University of London and 90 patients from Queen’s Mary Hospital(QMH), University of Hong Kong.

Results:

Based on coefficients estimated by Cox regression, points were allocated to the following 5 variables at the time of HCC diagnosis: ALBI grade, serum AFP level, portal vein invasion, ECOG status and TNM stage (see table). The total score i.e. SPS, identified 3 distinct survival risk categories of low, medium and high risk with median survival of 57.3(95%CI 44.9–69.8), 10.3(95%CI 8.7–12.0) and 2.1(95%CI 1.8–2.4) months respectively. The SPS was also able to stratify patients in the international validation cohorts from IC and QMH into distinct survival risk categories.

Conclusion:

We have formulated a survival prediction score to stratify HCC patients into distinct survival categories at the time of diagnosis regardless of subsequent therapy received. Thus it can prognosticate all HCC patients immediately at the time of diagnosis. The score was validated with international patient cohorts, portending its universal applicability.

60 | GIHep 2018

DIRECT ANTIVIRAL AGENT AS FIRST-LINE THERAPY FOR GENOTYPE 3 HEPATITIS C VIRUS IN SINGAPORE: ESTIMATING THE OPTIMAL COST BASED ON REAL-WORLD EXPERIENCEYJ Wong1, MHH Cheen2, JC Hsiang1, R Kumar1, J Tan1, EK Teo1, PH

Thurairajah1

1 Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore2 Department of Pharmacy, Singapore General Hospital

Background and Aim:

The prohibitively high treatment cost of direct acting antivirals (DAA) for hepatitis C virus (HCV) infection remains a barrier to treatment access in Singapore. We aimed to evaluate whether DAA as first-line therapy would be cost-effective for genotype 3 (GT3) HCV patients compared with peginterferon/ ribavirin (PR).

Methods:

We conducted a decision tree analysis simulated over 36 weeks to compare the costs and outcomes of DAA and PR as first-line therapy, followed by retreatment with DAA for treatment failure. Direct medical costs were estimated from the payer’s perspective using billing information from a restructured hospital in Singapore. We obtained health utilities from published literature. We report the incremental cost-effectiveness ratio (ICER) and quality-adjusted life year (QALY) gained as the unit of effectiveness. Willingness-to-pay threshold is set at 1-3 times per capita gross domestic product of Singapore.

Results:

In base case analysis, first-line therapy with DAA and PR yielded a QALY of 0.69 and 0.62, at a cost of $74,996 and $32,749 respectively. The resultant ICER (S$616,658/QALY) exceeded the willingness-to-pay threshold (S$73,167–S$219,501/QALY). DAA is the key factor influencing cost-effectiveness of HCV treatment. At current price, DAA as first-line therapy is not cost-effective, with or without consideration of retreatment. In order for DAA to be cost-effective as first-line treatment, the cost of a 12-week treatment course should range between S$18,480 and S$30,480.

Conclusion:

DAA as first-line therapy is not cost-effective compared with PR in GT3 HCV patients due to its high cost and optimistic SVR rates with PR.

GIHep 2018 | 61

DECODING HEPATITIS B VIRAL GENOME MUTATIONS TO SOLVE THE MYSTERY OF HBEAG-NEGATIVE REACTIVATIONChong HH1, Lee GH1,2, Khoo BWY1, Ng JWT1, Lim SG1,2

1 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore,

Singapore2 Department of Gastroenterology and Hepatology, National University Health System, Singapore.

Background/Aim:

HBV quasispecies and naturally occurring variants are hypothesised to play a crucial role in the pathogenesis of the viral disease. This study aimed to examine if specific viral strains have increased replication fitness and to determine if mutations in transcription factor binding sites can alter replication fitness.

Methods:

Full-length HBV DNAs from reactivation or inactive patients were transfected into Huh7 cells for functional analysis of their replication fitness. Core-associated HBV DNA, pgRNA and HBsAg were measured. The point mutations identified in the promoter and enhancer regions were further analysed using site-directed mutagenesis.

Results:

Remarkable variation of the viral replication was observed among the HBV clones. For reactivation patients, time-point-1 (before reactivation) clones produced lower amount of the extracellular viral DNA while some of the time-point-2 (during reactivation) clones produced a significantly higher amount of the extracellular viral DNA. In contrast, for inactive patients, no specific clones from time-point-2 produced a higher amount of the extracellular HBV DNA. These results were correlated to the phenotype of the reactivation patients, where the high viral load was observed during reactivation. Site-directed mutagenesis analysis showed that mutations in FTF binding site (1691T), HNF-1/ HNF-3 binding sites in the core promoter/enhancerII (C1723T, C1726A) and X promoter/enhancerI regions (A1122C+A1123C) reduced the amount of the extracellular HBV DNA levels (p=0.0001, T-test)

Conclusion:

Reactivation clones exhibited higher HBV production in Huh7 cells. Mutations A1122C+A1123C (X promoter/enhancerI region), 1691T, C1723T and C1726A (core promoter/enhancerII region) were shown to play an important role in HBV replication.

62 | GIHep 2018

Free Paper Poster PresentationA RETROSPECTIVE STUDY OF BUDD CHIARI SYNDROME (BCS) PATIENTS IN A SINGAPORE HOSPITALYang J1, Yang WL2, Punamiya S3

1,2 Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore 3 Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore

Background/Aim:

Primary BCS is uncommon and characteristics of affected Asian patients is unclear.

Methods:

We performed a single-centre retrospective study of BCS patients from 2010-2015. 5 cases(3 females, 2 males)were identified.

Results:

All patients presented with severe ascites;age at diagnosis ranged from 23-59 years old. Two had liver cirrhosis at diagnosis. Three had pro-thrombotic conditions(2-myeloproliferative disease, 1-antiphospholipid syndrome),one had no identifiable pro-thrombotic disorder. Information is lacking regarding the remaining patient.

Diagnosis was made with ultrasound-Doppler or computed-tomography abdominal scan. Four patients had hepatic vein(HV) involvement whilst one had combined inferior vena cava(IVC)/HV involvement. In contrast, other Asian studies showed predominantly IVC involvement.

All were initially managed with subcutaneous low-molecular-weight heparin, diuretics and underwent ascitic drainage. Four patients underwent subsequent radiological intervention(duration from start of medical therapy to intervention:two patients-unknown, 3rd-offered intervention after 3 months but only agreed after another 2 months, 4th-intervention after 1 month)after suboptimal response to medical therapy (worsening liver function tests and/or persistent ascites). Three underwent stenting/angioplasty for short-segment stenosis of involved veins. The fourth patient underwent transjugular-intrahepatic-portosystemic-shunt insertion(TIPS) due to long-segment HV thrombosis. One did not undergo intervention due to his poor premorbid condition.

Two patients(1st:TIPS,2nd:angioplasty with stenting)had normalization of their liver function tests and ascites resolution. The other 2 patients had no follow up data.

Conclusion:

Our cohort of patients responded poorly to medical therapy alone(severe symptoms/advanced liver disease at presentation)and decision for radiological intervention should be made earlier rather than later. This correlates with literature that patients who respond to medical therapy alone have milder symptoms/preserved liver function.

GIHep 2018 | 63

CHARACTERISTICS OF EXTRA-INTESTINAL MANIFESTATIONS (EIM) IN A LOCAL COHORT OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE (IBD) Lin HY, Lim WC

Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore Department

Background/Aim:

EIM involving musculoskeletal, cutaneous, ocular and hepatobiliary systems can occur in IBD patients. EIM can occur before or after IBD is diagnosed and is reportedly more common in smokers and in Crohn’s disease(CD) (compared to ulcerative colitis(UC)). Western populations have a higher prevalence of EIM (up to 41%) as compared to India (33%) and East Asia (6-14%).

We aim to determine the characteristics of EIM in IBD patients at our local centre.

Methods:

Electronic records of 247 adult patients with IBD treated at our centre from 2002-2017 were retrospectively reviewed.

Results:

18 patients(7.3%) displayed EIM. None exhibited EIM before IBD was diagnosed.

EIM occurred more frequently in CD (12 patients: 10.7%) compared to UC (6 patients, 4.4%), and in females (12.4%) more than males (4%). 22.2% (4 CD patients) had more than 1 EIM, 66.6% were non-smokers and 22.2% were Indian (comparable to the racial distribution)

The most common manifestations were spondyloarthritis (SpA), cutaneous and ocular. 8(3.3%) patients had SpA: 1 axial SpA, 7 peripheral SpA. 6(2.5%) patients had skin manifestations: 4 erythema nodosum, 1 pyoderma gangrenosum and 1 leukocystoclastic vasculitis. 5(2%) patients had ocular manifestations: 4 uveitis, 1 scleritis. There was only 1 CD patient with primary sclerosing cholangitis and 1 UC patient with primary biliary cholangitis.

Conclusion:

The prevalence of EIM (4.4% in UC, 10.7% in CD) in our cohort is comparable to other East Asian populations. EIM was more common in females, CD patients. However no strong association with smoking nor ethnicity; none presented with EIM before diagnosis of IBD.

64 | GIHep 2018

CLINICAL MANIFESTATIONS, TREATMENT AND PROGNOSIS OF WILSON’S DISEASE – OUTCOMES FROM A TERTIARY HOSPITAL IN SINGAPOREKuang J, Yang W L, Kaliyaperumal K

Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore.

Background/Aim:

Wilson’s disease is a rare defect of copper metabolism. We aimed to retrospectively evaluate all patients who were diagnosed with Wilson’s disease between 1987 and 2017 and characterise their clinical presentation, treatment, response to therapy and outcome.

Methods:

Patient data was retrieved from computerised outpatient and inpatient prescription records. We identified 12 patients who met diagnostic criteria for Wilson’s disease.

Results:

The most common mode of presentation was combined hepatic and neuropsychiatric(HNP) manifestations (n=7;58.3%) followed by hepatic(H) manifestations (n=2;16.7%) and then neuropsychiatric(NP) symptoms (n=1;7.7%). All patients in the HNP group had chronic liver disease (CLD) at the point of diagnosis. Oesophageal varices was the predominant complication of CLD(n=4;33%). Patients in the H group presented earlier than patients in the HNP group (16.5 years, IQR 1 versus 21.0 years, IQR 19;p=0.074). Patients in both the H and HNP groups were diagnosed later than their onset of symptoms (p=0.157 for H group and p=0.317 for HNP group). Penicillamine was the most common pharmacological treatment (n=7;58.3%) but 50%(n=6) of the patients had to switch to other drugs due to side effects.

Conclusion:

HNP manifestations was the most common presentation and all of them had CLD. However we did not find CLD to be associated with a poorer overall survival. Patients in both the H and HNP groups, had a lag time between onset of symptoms and diagnosis. Though not statistically significant, this highlights an important clinical scenario, where the diagnosis in young Wilson’s patients may missed or detected late.

GIHep 2018 | 65

PILOT FEASIBILITY ANALYSIS OF MINDFULNESS BASED COGNITIVE THERAPY (MBCT) FOR FUNCTIONAL DYSPEPSIA IN A TERTIARY REFERRAL CENTRE IN SINGAPORENg YK1, Ong AML1, Hao Y2, Doshi K3, Wang YT1

1 Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.2 Division of Medicine, Singapore General Hospital, Singapore.3 Department of Psychology, Singapore General Hospital, Singapore.

Background/Aim:

Our objective is to determine the feasibility of a group mindfulness based intervention in a tertiary care gastroenterology unit in patients with functional dyspepsia

Methods:

We recruited patients prospectively from the gastroenterology specialist outpatient clinic who have Rome-3 FD. Short Form Nepean Dyspepsia Index, EuroQOL VAS scale and Depression Anxiety Stress Scales-21 were administered. Ethics Board review was obtained. They were randomised to undergo Mindfulness Based Cognitive Therapy (MBCT) or to Treatment-as-Usual (TAU). The questionnaires were repeated at the end of the MBCT and at 3 months after. Subjects in the MBCT arm undergo weekly 2-hour-long standardised MBCT sessions for 8 weeks with 1 half-day retreat conducted by 2 accredited psychologists. We conducted the analysis at the end of the first cycle of intervention.

Results:

In a tertiary care gastroenterology unit in Singapore with an average outpatient attendance of 2000 per month, 53 patients were referred and 27 (59.9%) patients were recruited over 3 months. Amongst those who did not agree to recruitment, 10 were not fluent in English, 10 cited time constraints and unsuitability of the MBCT schedules, and 6 had no cited reasons. Of 27 patients, 21 (78%) completed the intervention. Of those who withdrew, 5 found difficulty in attending the intervention schedule due to time commitments, 1 had difficulty in following with the intervention instructions, 1 lost interest, and 2 were unable to complete “homework” due to time constraints.

Conclusion:

We conclude that it is feasible to conduct mindfulness based intervention in a tertiary gastroenterology unit. Modifications to design, such as a choice of session timing, having MBCT translated to other languages and simplying instructions, to address the patients’ concerns is likely to improve the acceptance and completion of the intervention.

66 | GIHep 2018

SAFETY OF CALCINEURIN INHIBITOR MONOTHERAPY CONVERSION IN LIVER TRANSPLANT RECIPIENTSSophia Lin De Lu Lin1, Thinesh Lee Krishnamoorthy2, Reina Tee-Gan Lim2

1 Faculty of Medicine, University of New South Wales, Sydney, Australia2 Department of Gastroenterology and Hepatology, Singapore

INTRODUCTION AND AIM

Conventional immunosuppression for liver transplantation is associated with various adverse effects. More patients are being treated with reduced-dose calcineurin inhibitors (CNIs) in combination with mycophenolate mofetil (MMF). The optimal timing for subsequent conversion to CNI monotherapy is not clearly defined and it is feared too early conversion would result in increased rates of acute cellular rejection. This study aims to evaluate the safety of conversion to CNI monotherapy after liver transplantation.

METHODS

This was a single-centre retrospective study of 90 consecutive patients who received CNI and MMF combination regimen immediately after liver transplantation at Singapore General Hospital from 2006 to 2017. Those who were subsequently converted to CNI monotherapy (group 1) were compared to those who were still on CNI and MMF, at 6 months (group 2) after transplantation. Patient demographics, clinical parameters and post-transplant complications (rates of liver graft rejection, de novo malignancy, cytomegalovirus (CMV) infection and renal impairment) were recorded.

RESULTS

Mean follow-up was 64.64 (+40.02) months. 18 (20%) out of 90 patients were weaned to CNI monotherapy within 6 months post-liver transplantation. Baseline characteristics of the two patient groups are outlined in Table 1. Overall patient survival was 95% and 83%, at 1-and 5-years post-transplant. There was no statistical difference in the rates of post-transplant complications including liver graft rejection (0% vs 16.67, p = 0.11), de novo malignancy (0% vs 8.33%, p = 0.34), CMV infection (5.56% vs 1.39%, p = 0.36) and renal impairment (27.78% vs 27.78%, p = 1.00) between the two groups.

CONCLUSION

Instituting CNI monotherapy within 6 months of liver transplantation is safe and does not adversely affect acute cellular rejection rates.

GIHep 2018 | 67

SCREENING AND BRIEF INTERVENTION IN PRIMARY CARE SETTING IN SINGAPORE: A MISSED OPPORTUNITY?Zhang Bei1, Vikneswaran Namasivayam1,2, Reina Tee-Gan Lim1,2

1 Duke-NUS Medical School, Singapore2 Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore

Introduction:

Alcohol-related medical problems are associated with increased morbidity and mortality globally. Primary care physicians (PCP) are in a unique position to recognize patients with potential alcohol problems and intervene when appropriate. Our aim was to assess current practice for alcohol problems in primary health care in Singapore.

Methods:

Survey questionnaires were distributed to 230 PCPs at a local PCP symposium. Participants’ demographic data, attitudes and screening practice were collected.

Results:

80 (35%) PCPs responded to the questionnaires. Baseline demographics of the participants are outlined in Table 1. Only 35% of PCPs screened patients for alcohol misuse and of these, 28% screened within the last 6 months. Locally trained PCPs(28%) were less likely to screen for alcohol misuse compared to overseas-trained PCPs (59%). Only 18% used a formal alcohol screening tool. The commonest barriers to screening identified were time constraint(21%), the lack of expertise in screening or counselling alcohol misuse felt by PCPs(21%) and the feeling that screening was irrelevant to the consultation(27%). Presentations with abnormal liver test(73%), domestic violence or frequent work absence(61%), and mental issues(65%) prompted screening amongst PCPs. 47% GPs felt confident in counselling hazardous drinkers and 53% referred their patients to the National Addictions Management Service (NAMS) or tertiary hospitals. 62% of PCPs felt that their intervention made a positive impact on patients.

Conclusion:

Formal screening and interventions for alcohol misuse were infrequent, indicating missed opportunities to reduce alcohol-related harm. Effective approaches are required to increase the screening rate of alcohol misuse in primary care.

68 | GIHep 2018

THE “ASSURANCE” IBD NEOPLASIA SURVEILLANCE SOFTWARE GUIDES PATIENT MANAGEMENT AND DATACOLLECTION: RESULTS FROM ASIA-PACIFIC. Kyaw MH1, Ong DE2*, Tan B2, So D1 , Li A1, Tang WY1, Ching JYL1, Yip C2,

Leong R3, Kamm MA4§, Ng SC1

1 The Chinese University of Hong Kong, Hong Kong2 National University Hospital of Singapore, Singapore

3 The University of Sydney, Australia4 St Vincent's Hospital and University of Melbourne, Melbourne, Australia

* Co-first author, § Co-senior author

Background/Aim:

Physician adherence to inflammatory bowel disease (IBD) cancer surveillance guidelines, including patient risk stratification and management, is poor. We developed an online, cloud-based software (ASSURANCE) surveillance tool to simplify neoplasia risk stratification, facilitate long-term individualized surveillance, and collect surveillance data from individual patients, hospitals, countries and internationally. As the incidence and prevalence of IBD has increased in Asia-Pacific so has the incidence of IBD-associated colorectal cancer. The aim of this study was to determine the effectiveness of implementing the ASSURANCE surveillance tool in Asia-Pacific.

Methods:

Since November 2015, participating centers in Singapore and Hong Kong have used the ASSURANCE surveillance tool when performing surveillance for IBD. Consecutive IBD patients were enrolled for surveillance colonoscopy if indicated according to international guidelines. Endoscopic modalities including white light endoscopy or dye-based chromo-endoscopy were used at the discretion of the endoscopist. A surveillance interval was recommended after risk stratification based on endoscopic findings and patient’s prior risk factors. We reviewed the prospective data captured by the ASSUARANCE surveillance tool up to November 2017 to determine detection rate of neoplasia, defined as low-grade dysplasia, high-grade dysplasia or adenocarcinoma, and patient outcomes.

Results:

212 IBD patients underwent surveillance colonoscopy (54.2% UC, 61.8% male; mean age 49 years) (Table). Neoplasia detection rate was 8.0% (17/212) at index surveillance colonoscopy. Among patients who received chromo-endoscopy, 13.2% (15/114) had neoplasia (14 low grade dysplasia, 1 adenocarcinoma) detected compared to 2.0% (2/98) of patients who received white light endoscopy (2 low grade dysplasia); with a significant difference in detection rate between modalities (P=0.003). Of the 16 patients with low grade dysplasia, 14 had visible dysplasia amendable to endoscopic resection. Three patients were referred for colectomy (2 visible dysplasia not amendable to endoscopic resection, 1 adenocarcinoma). 47.6% (101/212) of patients were stratified into moderate, high-risk or highest-risk groups, and were recommended for interval colonoscopy in 1 year, 6-months and 3-months respectively. Deviations from recommendation on surveillance colonoscopy occurred in 24 patients: 14 due to patient preference, 3 to doctor preference, and 7 for other reasons.

GIHep 2018 | 69

Conclusion:

The ASSURANCE surveillance tool is an effective clinical tool for entry risk stratification, aiding risk assessment based on endoscopic findings, and guiding management of patients with IBD-associated neoplasia. It has highlighted the benefit of chromo-endoscopy in real-world practice. Its application can be extended beyond Asia-Pacific.

70 | GIHep 2018

VEDOLIZUMAB HAS SIMILAR INCIDENCE OF CLOSTRIDIUM DIFFICILE INFECTION IN COMPARISON TO ANTI-TNF THERAPIES- A RETROSPECTIVE COHORT STUDYRangarajan Purushothaman1, Aaron Tau-Ming Gan1, Webber Pak Wo

Chan1,2, Cheng Yi Lee1, Choon Jin Ooi1, Sai Wei Chuah1,2, Brian John

Schwender1,2, San Choon Kong1,2, Wan Chee Ong3, Teong Guan Lim3,

Hang Hock Shim1,2.

1 Singapore General Hospital, Department of Gastroenterology and Hepatology, Singapore2 Duke-NUS Medical School, Singapore3 Singapore General Hospital, Department of Pharmacy, Singapore

Background/Aim:

It is unclear if vedolizumab has a different risk of clostridium difficile associated diarrhoea (CDAD) when compared to anti-TNF agents. We aim to study the risk of CDAD among vedolizumab and anti-TNF treated patients with inflammatory bowel disease (IBD).

Methods:

A retrospective review of case records was conducted for all IBD patients treated with vedolizumab and anti-TNF therapies at Singapore General Hospital from March 2010 to March 2018. Baseline characteristic, duration of treatment with biologics, incidence of CDAD and its associated risk factors (recent hospitalization within 3 months, proton pump inhibitor, antibiotics, steroid, immunomodulator or proton pump inhibitor use within 4 weeks) were collected. Risk of CDAD was compared using Fisher exact test.

Results:

Total of 102 patients were included in this study. [Table 1] There was no significant difference in CDAD incidence between both groups, vedolizumab (1/16, 0.063%) vs. anti-TNF (5/86, 0.058%), p=0.65. [Table 2] The single case of CDAD in the vedolizumab cohort was observed to be receiving prednisolone and proton pump inhibitor at time of diagnosis. For the 5 cases of CDAD from the anti-TNF cohort, majority (4/5, 80%) had minimum 1 risk factors, and 3/5 (60%) had minimum 2 risk factors. All patients were hospitalized and treated successfully for the CDAD infection with no recurrence reported.

Conclusion:

While our study has observed comparable incidence of CDAD among IBD patients who were treated with vedolizumab or anti-TNF therapies, they were confounded by additional risk factors. Larger studies will be required to confirm this observation.

GIHep 2018 | 71

A DURIAN SEED LODGED WITHIN THE OESOPHAGUSNg YC, Tsao S.

Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore.

Introduction:

Management of foreign body ingestion and food bolus impaction are common endoscopic challenges.

Background:

A 68-year-old chinese male with no known past medical history presented with acute onset dysphagia and vomiting immediately post meals. Oesophagogastroduodenoscopy revealed a large durian seed in the lower oesophagus with adjacent ulceration. The rest of the upper gastrointestinal tract was unremarkable. An overtube was inserted for airway protection. Initial attempts to extract the seed from the oesophagus via a roth-net and polypectomy-snare were unsuccessful. The seed was carefully negotiated into the stomach, however we could not capture it via a roth-net or a polygrab-tripod. Decision was made to postpone the procedure to allow healing of the oesophageal ulcer prior to further attempts. Patient was started on oral omeprazole. Further history revealed an accidental ingestion of a durian seed 3 weeks prior to presentation. Oesophagogastroduodenoscopy was performed 4 days later under monitored anaesthesia care. The oesophageal ulcer has healed and the seed was still in the stomach. A reusable lithotripter was used to capture the seed and removed whole via a therapeutic gastroscope. Patient's symptoms of dysphagia and vomiting resolved completely.

Discussion:

This case demonstrated both the pushing and extraction technique in successful retrieval of a non-digestible food bolus in the oesophagus. A prolonged history of food bolus ingestion increases the risk of pressure-induced mucosal surface ulcer and caution should be taken minimise perforation risk. The size and nature of food bolus should be considered when choosing the appropriate equipment for successful and safe extraction.

72 | GIHep 2018

LONG TERM OUTCOMES OF EARLY GASTRIC CANCER TREATED WITH ENDOSCOPIC SUBMUCOSAL DISSECTION(ESD) IN A TERTIARY CENTRE IN SINGAPORE Thian MY1, Chew W1, Morita Y2, Yamamoto H3, Tsao SKK1

1 Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore.2 Department of Gastroenterology, Kobe University Graduate School of Medicine, Japan3 Department of Gastroenterology, Jichi Medical University, Japan

Background/Aim:

A retrospective review of a single centre’s outcome post ESD for treatment of early gastric cancer

Methods:

Patients’ records from all gastric ESD cases performed in our institution were reviewed from May 2011 till March 2015. A total of 14 cases were performed and 5 cases without follow up endoscopy or low grade dysplasia were excluded.

Results:

A total of 9 patients were followed up with endoscopy post ESD for a median duration of 35 months (Range 20 – 61months). The site of lesions treated were antrum (n=4), incisura (n=4), body of greater curve (n=1) with a median size of 25mm (Range 20 – 40mm). En bloc resection rate was 89%. Histopathology results showed 56%(5/9) had high grade dysplasia and 44% (4/9) had adenocarcinoma. The majority of cases had associated intestinal metaplasia changes and 22% had Helicobacter pylori which were treated. Among the adenocarcinoma cases, 50% (2/4) had submucosal invasion with 1 involving resection margins, however both cases declined surgery. Local recurrence rate was 11% with one recurrence seen at 3 months with adenocarcinoma but declined surgery and with additional ESD treatment had no further recurrence seen endoscopically and on CT imaging at 61 months follow up. No disease specific deaths were noted during the follow up period for the whole cohort.

Conclusion:

Overall local recurrence rate remains low with good outcome seen at our centre.

GIHep 2018 | 73

TERLIPRESSIN USE IN HEPATORENAL SYNDROME - A CASE SERIES Clarence Kwan KW1, Jason Chang PE1,2, Tan CK1,2, Thinesh Lee

Krishnamoorthy1,2

1 Department of Gastoenterology and Hepatology, Singapore General Hospital2 Duke-NUS Graduate Medical School, Singapore

Background:

Terlipressin's efficacy in hepatorenal syndrome (HRS) treatment has been demonstrated in clinical trials, but real world data on adverse events and outcomes is scarce. We describe our experience of terlipressin use in HRS.

Methods:

We interrogated our hospital pharmacy database for terlipressin prescriptions between January 2006 - June 2012. Patients who received at least one dose of terlipressin and fulfilled the International Ascites Club HRS diagnostic criteria were included.

Results:

18 patients were identified, with baseline characteristics summarised in Table 1. Ten patients received terlipressin for more than 48 hours, with treatment response (serum creatinine reduction to <1.5mg/dL or to baseline) seen in 4 (40.0%) patients. Of the remaining 8 patients, 3 died within 48 hours of terlipressin commencement, 4 progressed to hemodialysis, and 1 developed bowel ischaemia necessitating treatment cessation. Four (22.2%) patients developed adverse events: bowel ischaemia (n=1), bowel and myocardial ischaemia (n=1), limb ischaemia (n=1) and congestive cardiac failure (CCF) (n=1). The overall 14-day survival rate was 52.9%, decreasing to 25.0% in patients where terlipressin treatment was delayed (beyond 72 hours post-diagnosis). The 90-day overall survival and transplant-free survival rates were 41.2% and 17.6% respectively, with 4 patients having undergone liver transplantation (at 2, 3, 69 and 115 days respectively after terlipressin initiation).

Conclusion:

Terlipressin should be administered promptly following diagnosis of HRS. For patients on terlipressin, clinicians should be vigilant to adverse events like end-organ ischaemia and CCF. Patients who respond to terlipressin retain an abysmal prognosis short of definitive treatment with liver transplantation.

74 | GIHep 2018

REAL-WORLD DATA ON THE EFFICACY AND SAFETY OF VEDOLIZUMAB THERAPY IN INFLAMMATORY BOWEL DISEASE IN AN ASIAN COHORTGan TA1, Purushothaman R1, Chan WPW1,2, Ooi CJ1, Ling KL1, Chuah

SW1,2, Schwender BJ1,2, Kong SC1,2, Ong WC1, Lim TG1, Shim HH1,2

1 Singapore General Hospital, Department of Gastroenterology and Hepatology, Singapore 2 Duke-NUS Medical School, Singapore

Background/Aim:

Real-world data on the use of vedolizumab in inflammatory bowel disease in Asian populations is lacking. We aim to report the efficacy and safety of vedolizumab in patients with Crohn’s disease (CD) and ulcerative colitis (UC) in Singapore.

Methods:

A retrospective review of case records was conducted for patients treated with vedolizumab at Singapore General Hospital between Mar 2015 and Mar 2018. Demographics, clinical disease activity indices, C-reactive protein (CRP), and adverse outcomes were collected at baseline and follow-up. The primary outcome measure was steroid-free clinical remission (SFCR) at weeks 14 and 24, defined by the absence of steroid use and a Harvey-Bradshaw index (HBI) <5 for CD or a partial Mayo Clinic score (pMCS) <2 for UC.

Results:

Sixteen patients [7(43.8%) CD and 9(56.3%) UC] were included, with 87.5% anti-TNF experienced. SFCR was achieved at weeks 14 and 24 in 42.9% and 71.4% of CD, and 88.9% and 77.8% of UC patients respectively. Endoscopic outcomes were available for 7/9 UC patients at week 24, amongst whom 2/7 (28.6%) achieved mucosal healing. Four (2 CD, 2 UC) patients (25%) lost response after 28-50 weeks of treatment requiring switch to ustekinumab or colectomy. Adverse effects were reported in 9(56.3%) patients – 4 had nasopharyngitis, 2 had transient mild rashes and 2 had deranged liver function tests (1 of whom received concomitant 6-mercaptopurine and herbal remedies). One serious adverse event occurred in a patient who was hospitalized for superimposed Clostridium difficile colitis after 26 weeks of vedolizumab.

Conclusion:

Our early experience with vedolizumab supports its efficacy and safety in the treatment of anti-TNF refractory disease, especially in patients with UC. Further studies to identify predictors of response to vedolizumab would aid in optimising biologic selection.

GIHep 2018 | 75

MODULATION OF GUT MICROBIOTA THROUGH MEDITERRANEAN DIET AS PREVENTIVE AND THERAPEUTIC AGENT FOR IRRITABLE BOWEL SYNDROMEFirdaus AG, Fahira A, Amin BF

Faculty of Medicine, Universitas Indonesia ([email protected]), Indonesia

Background/Aim:

Despite the fact that Irritable Bowel Syndrome (IBS) is one of the very most common forms of gastrointestinal disorder, its underlying pathogenesis has not yet known clearly. As it is a multi-factorial and intricate disease, finding a potential therapy breaking its pathological process is still beyond reach. With an increase founding on the success of gut microbiota modulation as a therapy to many other diseases, one should take into consideration the same potential in IBS. Therefore, this study focuses on exploring the possibility of dietary intervention as a new preventive and therapeutic agent for IBS, by modulating the gut microbiota composition, based on recent studies.

Methods:

The method used to assemble this study is by performing a systematic and comprehensive literature search with corresponding keywords in the period of June-August 2017.

Results:

The results show that gut microbiota modulation may affect the gut-brain axis, visceral hypersensitivity, motility of gastrointestinal system, intestinal epithelial permeability and immune system activation, all of which play a role in the pathophysiology of IBS. Mediterranean diet as a source of high plant-based food and low animal-based food can modulate intestinal microbiota through increasing good commensal bacteria as well as decreasing pathogenic bacteria, which in turn can prevent and relieve IBS symptoms.

Conclusion:

In conclusion, our findings support the link between high adherence to Mediterranean diet and gut microbiota composition, which in turn can prevent functional gastrointestinal problems lead to IBS.

76 | GIHep 2018

THE ANALYSIS OF GASTRIC MUCOSE HISTOPATHOLOGICAL FEATURE AND HELICOBACTER PYLORI FINDING OF GASTRITIS PATIENTS IN DR. WAHIDIN SUDIROHUSODO HOSPITAL IN 2016Iin Fadhilah Tammasse1, Upik Andriani Miskad2

1 Faculty of Medicine Hasanuddin University, Indonesia. 2 Patholgy Anatomy Departement of Hasanuddin University

Background/Aim:

Chronic gastritis has became a worldwide gastrointestinal problem. The prevalence of gastritis in Indonesia was 40,8%. Chronic gastritis is commonly caused by infection of Helicobacter pylori. H.pylori inflection may develop into the inflammation of gastric mucose. Histopathological biopsy of gastric mucose is the mainstay of diagnosis. 49% of normal endoscopy examination diagnosed as chronic gastritis by histopathological examination. This study aimed to analyze the correlation of Helicobacter pylori positivity and histopathological features of chronic gastritis in Dr. Wahidin Sudirohusodo hospital at 2016.

Methods:

This was a cross-sectional study on gastric biopsies from 162 patients who had been diagnosed as chronic gastritis by pathologist in Dr. Wahidin Sudirohusodo hospital from January 2016-December 2016. 162 archives slides from Laboratory of Pathology Anatomy was reviewed using Update Sydney System and statistically analyzed by Mann Whitney U test.

Results:

Among 162 biopsies, positive Helicobacter pylori was found in 10 biopsies (6,2%). Lymphocytes and neutrophils were detected in 100% and 77,1% of biopsies respectively. Glandular atrophy and Intestinal metaplasia were detected in 34% and 12,9% biopsies. Data analysis showed that a positive status of Helicbacter Pylori was associated with the presence of lymphocytes (2,20±0,79 vs 1,47±0,56), neutrophills (1,80±0,63 vs 0,80±0,50), and intestinal metaplasia (0,60±0,84 vs 0,16±0,50) with p value respectively (p=0,00;p=0,00 and p=0,008). While the negative status of Helicobacter Pylori was found with the glandular atrophy (0,50±0,71 vs 0,40±0,64) with (p=0,657).

Conclusion:

There was a significant differences among positivity of Helicobacter pylori densities and the degree of lymphocytes, neutrophils and intestinal metaplasia. Also there was a difference but statistically not significant among positivity of Helicobacter pylori and the degree of glandular atrophy.

GIHep 2018 | 77

GASTROINTESTINAL TRACT LYMPHOMA RECEIVING CHEMOTHERAPY: DOES PROPHYLACTIC TOTAL PARENTERAL NUTRITION AND BOWEL REST REDUCE RISK OF PERFORATION?Wong YJ1, Lum HM1, Tan CX1, Fook SC2, Lim ST3, Salazar E1

1 Department of Gastroenterology and Hepatology, Singapore General Hospital2 Health Service Research Unit, Division of Medicine, Singapore General Hospital3 Division of Medical Oncology, National Cancer Centre

Background and aim:

Gastrointestinal tract (GIT) lymphoma is associated with risk of perforation while receiving chemotherapy. The role of prophylactic total parenteral nutrition (TPN) and bowel rest in preventing perforation remained unknown. We aim to study the clinical outcome of prophylactic TPN and bowel rest in GIT lymphoma patient receiving chemotherapy.

Methods:

We review all patients with GIT biopsy-proven lymphoma in Singapore General Hospital between January 2009 and January 2017. We stratified patients into two groups, with and without prophylactic TPN and bowel rest during chemotherapy. Comparison of TPN and non-TPN group was done using Cox-regression for survival data and logistic binary regression for perforation and infection outcomes, adjusting for confounding factors.

Results:

Among 83 GIT lymphoma patients included, 47(56.6%) were started on prophylactic TPN and bowel rest. Mean (±SD) follow up duration was 34.7±31.5 months. Patients who received prophylactic TPN were younger (mean age 56.3 vs 64.8 years, p<0.05) and had lower baseline serum albumin (28.3 vs. 32.6 g/L, p<0.05). Perforation rate was similar for both groups (8.5% vs 8.3%, p=0.65). Infection rate was higher in TPN group (34% vs 11%, p<0.05). The length of stay and unscheduled 30-days readmission were similar in both groups. TPN group had better survival (HR 0.20, 95% CI 0.08-0.51) after adjustment for covariates (age, baseline albumin).

Conclusion:

Prophylactic TPN and bowel rest did not reduce the risk of GIT perforation. Instead, it was associated with higher risk of infection. Interestingly, overall survival was better in TPN group despite higher risk of infection.

78 | GIHep 2018

A 63-YEAR-OLD WOMAN WITH LIVER CIRRHOSIS AND A HYPER-VASCULAR EXOPHYTIC LIVER NODULETeh KJ1, Low SC2,3, Chang PE1,3, Tan CK1,3

1 Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore2 Department of Diagnostic Radiology, Singapore General Hospital, Singapore3 Duke-NUS Medical School, Singapore

Background/Aim:

Hemangiomas are the most common benign neoplasms of the liver. They are largely asymptomatic and are usually detected incidentally. Exophytic and pedunculated forms are rare. As surveillance is routinely performed on patients at risk of developing hepatocellular carcinoma (HCC), the discovery of an exophytic hypervascular lesion on a single imaging modality in a cirrhotic liver may prompt clinicians to treat it as a HCC without further diagnostic testing.

Methods/Results:

We report a case of a 1.1 cm hypervascular exophytic liver nodule detected on quadriphasic contrast-enhanced computed tomography (CT) imaging in a patient with Child-Pugh B liver cirrhosis. Despite the strong likelihood this being a hepatocellular carcinoma (HCC) in a patient with established cirrhosis, further evaluation was performed with magnetic resonance imaging (MRI) as per American Association for the Study of Liver Diseases (AASLD) recommendations. The MRI features of the nodule were those of a hemangioma but the CT features mimicked HCC.

Conclusion:

This case illustrates a pedunculated hemangioma masquerading as a HCC on CT in a patient with Child-Pugh B liver cirrhosis. In such cases MRI is useful to make a more accurate and correct diagnosis, highlighting the utility of a second imaging modality in the evaluation of suspicious liver nodules identified during HCC surveillance.

GIHep 2018 | 79

A CLINICAL SCENARIO BASED APPLICATION OF SPYGLASS DIRECT VISUALISATION SYSTEM – A CASE CONTROLLED STUDY FROM AN ASIAN TERTIARY CENTREQuan WL1, Ng WK1, Chen KP1, Vu KF1

1 Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore

Background/Aim:

We performed a retrospective descriptive analysis on procedures done in our centre between mid-2010 and mid-2017 using the SpyGlass DS System cholangioscope, which assisted in the management of difficult stones and indeterminate biliary strictures. We aim to identify factors that would yield benefit from early utilisation of cholangioscopy, which will reduce the need for multiple ERCPs.

Methods:

A retrospective analysis of all the patients recruited in our hospital cholangioscopy database was performed. We describe the demographics, indications, duration, cost, adverse events and the number of non-helpful ERCPs prior to the use of the cholangioscope. Our primary outcomes were success in establishing the diagnosis and impact on clinical management.

Results:

75 procedures in 61 candidates were analysed with stones comprising 68.9% (42/61) and strictures 26.2% (16/61) of the cases. Overall success rate was 91.8% (56/61), complication rate 14.8% (9/61). Subgroup analysis was also performed based, comparing success rates of cholangioscopy in relation to stone-duct-disproportion (SDD), amount, size and location of stone, while we describe the location and length for biliary strictures. A higher tendency of non-helpful ERCP attempts prior to use of the cholangioscope was observed to correlate with SDD (observed in 65.0% of cases with biliary stones, p<0.005), but interestingly not to stone size (Spearman’s � = 0.27, p = 0.091) nor stone load (p=0.666). However, there was a strong correlation between stones ≥20mm and presence of SDD (p= 0.007). The median length of biliary strictures observed was 13mm with the majority (11/16) located above the cystic duct insertion. 66.7% (10/15) had at least 1 while 46.7% (7/15) had 2 or more non-helpful ERCPs prior to the use of the cholangioscope. Cholangioscopy was successful at first attempt in 80% (12/15) of cases with biliary strictures.

Conclusion:

We propose the early use of cholangioscopy in select scenario, potentially reducing the number of invasive procedures, thus saving precious time, cost and effort.

80 | GIHep 2018

ACUTE PANCREATITIS DUE TO TAMOXIFEN INDUCED SEVERE HYPERTRIGLYCERIDAEMIATze Tong TEY, Kim Wei LIM, Chan Maung AYE, John Chen HSIANG

Dept of Gastroenterology & Hepatology


Case:

The patient was a 56 year old lady whose past medical history included hypertension and carcinoma of the right breast diagnosed in 2013. She underwent neoadjuvant chemotherapy followed by a mastectomy. Postoperatively she was started on tamoxifen 20mg daily since February 2014 and had been taking it for 4 years. She presented in January 2018 with a sudden onset of epigastric pain with radiation to the back. Laboratory tests revealed serum lipase 479 [10-60 U/L], amylase 221 [30-100 U/L]. A diagnosis of acute pancreatitis was made. An ultrasound of the abdomen showed no gallstones and the patient had no history of alcohol consumption. A fasting lipid panel was obtained which showed triglyceride level of 3883 mg/dL [0-150]. To treat the hypertriglyceridemia, she was given intravenous insulin infusion, oral fenofibrate, nicotinic acid, and atorvastatin. Her triglyceride levels rapidly decreased to 428mg/dL on day 2 of the admission. On day 4 of the admission, her epigastric pain had resolved completely and she was discharged. At her next oncology consult, tamoxifen was stopped permanently and she was prescribed letrozole 2.5mg once daily.

Discussion:

Tamoxifen is a selective oestrogen receptor modulator used as adjuvant therapy for breast cancer. There have only been 10 case reports in the literature on tamoxifen causing severe hypertriglyceridemia leading to acute pancreatitis. Patients on tamoxifen should have regular monitoring of their serum lipids. An alternative adjuvant drug to use instead of tamoxifen is letrozole: an aromatase inhibitor, which has no significant effects on serum lipid concentrations.

GIHep 2018 | 81

FIBROTOUCH T100 A NEW TOOL TO DETERMINE LIVER ELASTOGRAPHYYellapu Radha Krishna MD, DM, Yellapu Kiranmayi MD

Radha Krishna Liver and Gastrocenter, Visakhapatnam, South India

Introduction:

Liver Elastography is new tool to assess liver disease stage and quantification of liver fat. Liver Elastography ( Fibro Touch T100) is simple, pain less, non invasive, reproducible novel tool with instant results to assess liver fibrosis. Fibro Touch T 100 unique features include Single Probe for all patients irrespective of BMI and being cost effective.

Aim:

To study the performance of Fibrotouch T100 in day to day clinical practice and to compare with Fibroscan in assessment of Liver stiffness.

Methods:

The performance of Fibrotouch T 100 is compared to Fibroscan 402 in the present study. Head to head comparison was done at a single point of time ( February 2018). Liver Stiffness Measurement (LSM) was noted and other relevant clinical information noted.

Results:

A total of 90 subjects were assessed. Male to female ratio was 71:19, Mean Age was 40 years ( 20-74) Etiology : HBV (31), HCV (3) ,HBV+HCV (1), Alcohol (22), Fatty Liver (33). The rates of successful detection were 100% for Fibro Touch and 97 % for Fibroscan 402.

Conclusions :

Fibro Touch and Fibroscan have good consistency in evaluation of the degree of liver fibrosis. Fibrotouch has a higher rate of successful detection than Fibroscan in obese patients. Fibrotouch T 100 is not only efficient but cost effective .

82 | GIHep 2018

SOURSOP LEAF EXTRACT (ANNONA MURICATA L.) AS AN INNOVATION FOR ANTI- COLORECTAL CANCER TREATMENT IN INDONESIASa’diyah Isma Fadlilatus, Prayogi Geta Okta

Prof. Soemantri Brojonegoro Street, number 1, Gedung Meneng, Bandar Lampung 35145, Faculty

of Medicine, Lampung University, Indonesia.

Background/Aim:

Colorectal cancer is third-order cancer with 10.0% prevalence in men and 9.2% in women of all cancer patients in the world. In Indonesia colorectal cancer is a common malignancy after prostate and breast cancer with the percentage of 11.5% of all cancer patients in Indonesia. Management and treatment of colorectal cancer are multidisciplinary. The choice and recommendation of therapy depend on several factors. Therefore, we are innovating to create an alternative for colorectal cancer therapy from soursop leaf extract. Acetoginin compounds contained in soursop leaf acts as an inhibitor of energy sources for cancer cell growth. Acetogenin that enters into the body will stick to the cell wall receptors and serves to damage ATP in the walls of mitochondria. As a result, energy production in cancer cells stops and cancer cells will die.

Methods:

The methods used in this study such as, obtaining official licensing for drug manufacturing, collaborate with licensed laboratories, do a health promotion related to advantages and manufacturing procedures, provision of raw materials (Annona muricata), conducting pre-clinical trials and clinical trials according to standardization, procurement of drug-making facilities and infrastructure in accordance with a good practice method, consult to a physician and request an evaluation from a pharmacist.

Results:

The results of this research are Soursop Leaf Extract as anti-colorectal cancer which has been tested clinically and get official permission to be disseminated.

Conclusion:

Soursop Leaf Extract (Annona muricata) can be used as a Colorectal Anticancer that results in the decrease of Colorectal Cancer mortality rate in Indonesia.

GIHep 2018 | 83

POST-ERCP PANCREATITIS: MINIMIZING ROLE OF PANCREATIC DUCT STENTING WITH NON-INVASIVE COMBINATION THERAPY IN DIFFICULT CASES.Ho JL, Chia CTW, Chuah KB.

Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore

Background/Aim:

Double-guidewire technique (DGT) is a salvage technique frequently used when standard cannulation technique (SCT) is unsuccessful. Instrumentation of the pancreatic duct (PD) has been associated with increased risk of post-ERCP pancreatitis (PEP).

Methods:

A total of 258 ERCP cases between July to December 2017 was retrospectively retrieved and analysed. We seek to determine the safety of DGT and role of PD stenting in prevention of PEP in the setting of failed SCT.

Results:

Out of the 258 ERCP cases, 13.5% (35 cases) failed SCT and required DGT to facilitate successful biliary access. Out of the DGT cases, rectal NSAID was administered in 65%, PD stenting was performed in 23%, and intravenous Lactated Ringer’s (LR) was initiated in 83% as PEP prophylaxis. DGT cannulation rate following failed SCT was 83%. The incidence of PEP, infection, significant bleeding and perforation were 2.9%, 17.1%, 0% and 0% respectively. The rate of PEP in the subgroup without PD stent placed was only 3.7%. Impact of PEP prophylaxis was found to be significant for rectal NSAID (p<0.01), PD stenting (p=0.039) and LR hydration (p<0.01). There was no PEP witnessed when at least 2 PEP prophylactic measures were instituted.

Conclusion:

Our data demonstrated PEP rates remained low despite performing DGT for difficult biliary access and PEP risk may be minimized even without PD stenting if at least 2 other PEP prophylactic measures are undertaken. This suggests PD stenting may not be critical in this situation. A larger prospective study is indicated to evaluate this finding.

84 | GIHep 2018

PERIAMPULLARY DIVERTICULUM: BOON OR BANE FOR THE ERCP ENDOSCOPIST?Ho JL1, Seneviratna A2, Anastassiades C3, Yip CHB3

1 Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore2 Clinical Research Unit, Clinical Research & Innovation Office, Tan Tock Seng Hospital, Singapore3 Division of Gastroenterology and Hepatology, Khoo Teck Puat Hospital, Singapore

Background/Aim:

The prevalence of periampullary diverticulum (PAD) ranges from 9 to 33% in patients who undergo ERCP. It remains unclear if the presence of PAD impacts the success, difficulty and complication rates of ERCP.

Methods:

The aim of the study is to investigate differences in ERCP indication, procedure outcome and complication rate between patients with and without PAD. A single centre cross sectional study was conducted. Out of 548 ERCP procedures performed at our endoscopy centre from 2015 to 2016, 357 procedures (351 patients) were analysed after excluding patients with previous ERCP, inability to locate the ampulla or abandoned procedure. Patients with PAD were further analysed according to location of PAD in relation to ampulla and size of PAD.

Results:

116 (32.5%) were found to have PAD. The ampulla was located within the diverticulum in 8.9%, on the edge in 38.9% and near in 52.2%. PAD was large in 64.3% and small in 35.7%. Patients with PAD were significantly older (p<0.001) and more likely to undergo ERCP for choledocholithiasis (p=0.007). There was no significant difference in success rate, procedure difficulty and complication rate between the groups. Multivariate logistic regression showed that younger age was a predictor of cannulation success (p=0.023), while older age (p=0.010) and indication other than choledocholithiasis (p=0.038) were predictors of cannulation difficulty.

Conclusion:

ERCP in the presence of PAD, regardless of size or location, is as successful, easy and safe as ERCP for patients without PAD. Older age and procedure indication other than choledocholithiasis may increase the difficulty of the procedure

GIHep 2018 | 85

AN UNCOMMON CAUSE OF SEVERE INTRACTABLE DIARRHEA IN A PATIENT WITH A MALIGNANT THYMOMAYang J1, Chau C2, Chuah KB1

1 Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore2 Department of Pathology, Tan Tock Seng Hospital, Singapore

Background/Aim:

A 55 year-old Chinese lady with Myasthenia Gravis and metastatic malignant thymoma with previous thymectomy presented with a 3-week history of diarrhea.

Methods/Results:

Stool studies were negative for infectious organisms. She continued to have severe diarrhea despite empirical treatment with antibiotics and anti-diarrheal agents. A stool fat globule test was normal. Serum Immunoglobulin A and chromogranin A levels were normal. Colonoscopy revealed colonic erythema and biopsies revealed an increase in apoptosis. A gastroscope showed corpus gastritis and biopsies revealed acute inflammation. Video capsule endoscopy was normal. After discussion with the pathologist, the possibility of thymoma-associated multi-organ autoimmunity (TAMA) was raised. Repeat colonoscopy performed 1 month later showed an endoscopically normal colon. Repeat biopsies revealed more apoptotic bodies compared to previous biopsies and was consistent with TAMA. Stains for Cytomegalovirus were negative.

She subsequently developed pneumonia. It was decided, after discussion with Neurology, to administer intravenous immunoglobulin and steroids. Splenic biopsy was performed (to exclude a lymphoproliferative disease as splenic deposits were noted on a computed tomography scan) and histology demonstrated features compatible with a thymoma. She was continued on steroids with resolution of her diarrhea.

Conclusion:

Our patient presented a diagnostic challenge as histology of her colonic biopsies were interpreted as normal till the suspicion of TAMA was raised. Also, there is no well-defined treatment for this TAMA which presents with intractable diarrhea. In our case, immunosuppression was started despite her pneumonia as her diarrhea was severe and there was clinical suspicion of a myasthenia gravis flare, in addition to TAMA.

86 | GIHep 2018

SINGLE CENTRE INITIAL EXPERIENCE OF EUS-GUIDED GALLBLADDER DRAINAGE FOR CHOLECYSTITIS USING A LUMEN APPOSING METAL STENTS (LAMS) FOR NON-SURGICAL CANDIDATESAdeel Urrehman, Christopher JL Khor , Yung Ka Chin, Ravishankar

Asokkumar, Damien MY Tan

Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.

Aim:

EUS guided gallbladder (GB) drainage is now becoming a viable alternative to percutaneous GB drainage with favourable clinical success rates and potentially fewer adverse events.

Methods:

Patients with cholecystitis who were not surgical candidates underwent EUS guided GB drainage in a single centre. LAMS 15mmx10mm with electrocautery-enhanced delivery system were used in all patients.

Results:

A total of 6 patients underwent endoscopic GB drainage. Median age was 65 years (range, 58-93). Three patients had severe cardiovascular disease and rest had advanced hepatobiliary malignancy. Cholecystitis was graded moderate in three patients and mild in three per the Tokyo guidelines. Out of the six GB drainage cases; three were performed as primary GB drainage and three were performed as endoscopic internalisation of prior percutaneous biliary drainage. LAMS deployment was technically successful in four patients. Two patients had contrast extravasation on initial filling of GB via percutaneous drain and after needle puncture respectively. As the GB was not distended in each case, the respective procedures were aborted and referred for surgical management. Of the four deployed stents, one had the proximal flange obstructing the pylorus and this was treated with another LAMS deployed at the pylorus to prevent gastric outlet obstruction. There was no periprocedural complication. Median duration of the successful procedures was 33.5 min (20-83). Three patients had advanced malignancy, so the LAMS was left permanently. One patient had transmural stone extraction through the LAMS and it removal at one month after placement. One patient had severe abdominal pain due to post-procedure bile leak and was treated conservatively with intravenous antibiotics. The overall success rate was 67% (4/6). Of the four successfully deployed LAMS, clinical success was observed in all.

Conclusion:

GB drainage using LAMS with electrocautery-enhanced delivery system is technically feasible in non-surgical candidates with cholecystitis.

GIHep 2018 | 87

EUS-GUIDED GASTROJEJUNOSTOMY USING A LUMEN APPOSING METAL STENT IN PATIENTS WITH SYMPTOMATIC GASTRIC OUTLET OBSTRUCTIONAdeel Urrehman, Christopher JL Khor , Yung Ka Chin, Ravishankar

Asokkumar, Damien MY Tan


Aim:

EUS gastrojejunostomy (GJ) is emerging as an alternative novel technique in patients with symptomatic gastric outlet obstructions (GOO) who have advanced malignancy. Recent studies have shown that the EUS-guided approach has less adverse events and is more cost-effective compared to laparoscopic GJ. We share our experience of 5 patients who underwent EUS Guided GJ with favourable outcomes.

Methods:

5 patients with symptomatic gastric outlet obstruction underwent EUS-guided GJ interventions from May. 2017 to Nov. 2017. Patients were informed of the potential risks of this novel procedure and informed consent was taken. Technical success was defined as successful deployment of lumen apposing metal stents (LAMS); while clinical success was the ability to tolerate diet.

Results:

Median age was 61.5 (Range 53-83) years. GOO was secondary to advanced pancreatic malignancy (4) and duodenal malignancy (1). Two patients had altered anatomy from previous post bilroth gastrectomy and Roux-en-Y hepaticojejunostomy. For all five patients with GOO, LAMS 15mm diameter with electrocautery-enhanced delivery system was used to create the GJ anastomosis. Identification of the distal jejunal limb was done with an inflated balloon catheter and this was use as a target for direct puncture with a 19G needle. All five interventions had technical success with median procedure time of 80min (38-163 range). All stents were dilated up to their corresponding diameters. Duration of stay after procedure was 3-7 days and there were no adverse events post procedure such as bleeding or perforation. There were no stent migrations and stents were left in place for the rest of their life expectancy. One patient developed intermittent vomiting four weeks after stent deployment. This was possibly secondary to proximal stomach deployment, as repeated endoscopy showed a patent stent. The rest of the patients had clinical success and could tolerate diet on discharge. Range of follow up time was 1-6 months and at time of analysis GOO did not recur in all 5 patients. Three patients died due to disease progression with no symptoms of GOO prior to terminal event.

Conclusion:

EUS guided GJ is a novel procedure with favourable outcomes in patients with symptomatic GOO. Further prospective studies with larger number of patients are required to compare this new technique against the gold standard laparoscopic approach.

88 | GIHep 2018

HICCUPS AND VERTEBRAL ARTERY DISSECTING ANEURYSM: AN UNCOMMON PRESENTATION Tee Nicholas Chin Hock, Wang Yu Tien


Background/Aim:

Hiccups are involuntary spastic contractions of the respiratory muscles against a closed glottis, producing the characteristic “hic” sound. Hiccup is usually benign and self-limiting. Pathological causes should be considered if it persists beyond 48 hours by evaluating the potential physical or chemical insults along the hiccup reflex arc pathway

Case Presentation:

An 80 year old gentleman presented to the Gastroenterology outpatient clinic with a 2 year history of persistent bouts of hiccups. The frequency of hiccups progressively increased from a few times a day to every few minutes. He has dysphagia to solid and liquid during a bout but remains relatively well in between. Physical examination was unremarkable without any focal neurological signs. Patient had an oesophago-gastroduodenoscopy (OGD) which showed mild oesophagitis and gastritis. Despite a trial of proton pump inhibitor, his hiccups persisted. A computer tomography (CT) chest scan was also unremarkable. A magnetic resonance imaging (MRI) brain was then organized, which revealed a large (12mm) dissecting aneurysm of the left vertebral artery compressing on the left vagus nerve. Subsequent CT and digital subtraction angiography reported a largely self-thrombosed aneurysm, leaving behind a residual calcified lumen of 3mm. Patient reported diminished frequency of hiccups and no further intervention was undertaken apart from a scheduled 6 months surveillance scan.

Conclusion:

This is an uncommon case of a large vertebral aneurysm compressing on the vagus nerve which forms part of the hiccup reflex arc and illustrates the methodical approach to evaluate persistent hiccups.

GIHep 2018 | 89

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PRESENTING AS ABDOMINAL PAIN AND ENTERITIS Sim MJH1, Law YM2, Wang YT1

1 Department of Gastroenterology, Singapore General Hospital, Singapore2 Department of Diagnostic Radiology, Singapore General Hospital, Singapore

Background:

SLE can present in a variety of ways, occasionally without cutaneous manifestations, which makes diagnosis challenging.

We report a case of a female patient in her mid-20s with no significant past medical history presenting with abdominal pain and lupus enteritis as a first presentation of occult SLE. The patient was admitted to our gastroenterology unit as a diagnostic dilemma after recurrent presentations for abdominal pain and vomiting. Blood and stool microbiology were negative and she failed to improve with antibiotics. Inflammatory bowel disease was initially considered as a leading differential diagnosis however certain atypical features and computer tomography (CT) findings prompted the suspicion of mesenteric vasculitis and eventually the diagnosis of lupus enteritis.

In our report, we highlight the clinical features and the cardinal computer tomography (CT) findings that aid in the diagnosis of this case and discuss the management of lupus enteritis. We urge gastroenterologists to maintain a high index of suspicion for atypical causes of abdominal pain.

90 | GIHep 2018

A GLOBAL SURVEY OF GASTROENTEROLOGISTS’ TRAVEL ADVICE AND MANAGEMENT OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE ON IMMUNOSUPPRESSIVE AGENTS TO TUBERCULOSIS ENDEMIC AREAWebber Chan1,2, Hang Hock Shim2, Siew C. Ng3, Asia–Pacific Crohn's

and Colitis Epidemiologic Study (ACCESS) Study Group, Jeffrey Liu1,

Christian Inglis1, Kay Greveson4, Brandon Barathy1, Craig Haifer1, Rupert

W. Leong1

1 Concord Repatriation General Hospital, Sydney, Australia2 Singapore General Hospital, Singapore3 The Chinese University of Hong Kong4 Royal Free Hospital, London, UK.

Background/Aim:

With increasing use of biological therapies and immunosuppressive agents, patients with inflammatory bowel disease(IBD) have improved clinical outcome and international travel is common. Adequate pre-travel advice is important. We aim to determine the proportion of gastroenterologists who provided pre-travel advice, and to assess their management strategies for patients on biological therapies visiting tuberculosis(TB)-endemic areas.

Methods:

A 57-question survey was distributed to IBD physicians in 22 countries in five continents. We collected physicians’ demographics, and using a standardized Likert scale, assessed physicians’ agreement with stated treatment choices.

Results:

A total of 305 gastroenterologists met inclusion criteria. Overall, 85% would discuss travel-related issues: travellers’ diarrhoea(TD), travel-specific vaccines, medical care and health insurance abroad, and TB. They were more likely to advise patients not to travel to TB-endemic area if on both anti-tumor necrosis factor(TNF) and azathioprine, than if on vedolizumab and azathioprine(47% vs 17.6%, p<0.01). More physicians would continue anti-TNF monotherapy then vedolizumab monotherapy(58.2 % vs 42.6%, p<0.01). Two-thirds would continue all IBD treatments and not cease any medications. Chest X-ray and Interferon-gamma-release assay were the preferred methods to assess for active and latent TB infection. The knowledge on vaccines among IBD physicians was inadequate (survey mean scores 10.76(±6.8)). However, they were more familiar with the societal guidelines on management of VTE and TD(mean scores 14.9 (±5.3) and 11.9 (±3.9) respectively) .

Conclusion:

Most IBD specialists would provide pre-travel advice to IBD patients and would advise continuing all IBD medications even when travelling to TB-endemic areas. More education on vaccinations would be particularly helpful for IBD physicians.

GIHep 2018 | 91

HERPES SIMPLEX ESOPHAGITIS: AN UNCOMMON COMPLICATION FOLLOWING REACTIVATION OF HERPES SIMPLEX ESOPHAGITISWong Yu Jun1, Tracy Loh Jiezhen2, Piotr Maciej Chlebicki3, Damien Tan

Meng Yew1

1 Department of Gastroenterology and Hepatology, Singapore General Hospital2 Department of pathology, Singapore General Hospital3 Department of Infectious Disease, Singapore General Hospital

Clinical history:

A 77-year old lady was referred for iron deficiency anemia (Haemoglobin 6.0g/L). She had herpes simplex virus (HSV) encephalitis 3 years ago which was complicated with post-encephalitic syndrome. She was afebrile upon presentation. No genital ulcers or vesicles were seen. Following blood transfusion, she underwent gastroscopy which revealed exudative oesophagitis (LA grade D) with hiatus hernia. Colonoscopy was unremarkable.

Differential diagnosis:

Reflux oesophagitis with hiatus hernia, HSV oesophagitis (HSVE)

Investigations:

Human immunodeficiency virus and diabetic screen were negative. Oesophageal biopsy revealed ulceration with multinucleated giant cell with intranuclear inclusions positive for HSV-1 and HSV-2 staining.

Final diagnosis:

HSVE following reactivation of HSV encephalitis

Difficulty of case:

Endoscopy findings were atypical of HSVE. Proton pump inhibitor (PPI) alone may result in suboptimal response, potentially subjecting the patient to various risks of extended PPI therapy.

Therapeutic approach:

She received 10 days of oral acyclovir 400mg TDS and 8 weeks of oral esomeprazole 40mg BD. Repeat gastroscopy showed complete resolution of oesophagitis with a Schatzki ring at distal oesophagus (Figure 1). She tolerated orally well and haemoglobin improved to 11g/L.

Point for discussion:

Although HSVE is rare among immunocompetent host, perforation and bleeding has been reported. 79% of HSVE in immunocompetent host had reactivation from prior HSV exposure. Severe esophagitis with prior HSV infection should prompt endoscopists on HSVE, even in absence of typical endoscopic findings. Esophageal biopsy has important diagnostic role in severe esophagitis. To our knowledge, it is the first reported case of HSVE following reactivation of HSV encephalitis in an immunocompetent host.

92 | GIHep 2018

UPPER GASTROINTESTINAL BLEEDING IN A PATIENT WITH CONCOMITANT BULLOUS PEMPHIGOID AND ACQUIRED FACTOR 8 DEFICIENCYKuang J, Chew WD


A 67 year old Indian female presented with a 1-month history of blistering skin lesions over her body. She was diagnosed with bullous pemphigoid and started on oral steroids. One week into admission, she developed melena with hypotension. Her pre-endoscopy blood tests revealed normal platelet and international normalized ratio(INR), but a prolonged activated partial thromboplastin time(APTT) of 78.2-seconds that was not correctable with a mixing study. Haematology was consulted and acquired Haemophilia A was diagnosed as there was low Factor 8 levels secondary to an inhibitor.

In view of active bleeding, Haematology advised for ‘Novo7’(recombinant factor VIIa) and ‘Factor Eight Inhibitor Bypassing Activity’(FEIBA) infusions to be administered before endoscopy. It was imperative that these medications were administered at an appropriate timing to ensure their peak onset of action during endoscopy.

During gastroscopy, the entire length of the oesophagus appeared necrotic with friable mucosa. Post-endoscopy the patient was continued on intravenous(IV) proton pump inhibitor and was given oral sucralfate. IV hydrocortisone and cyclophosphamide were administered for the management of bullous pemphigoid and Haemophilia A. She was started on parenteral nutrition to allow for oesophageal recovery. There were no further episodes of melena. A repeat gastroscopy 9 days later showed healing of the oesophageal mucosa.

The findings on initial endoscopy were unexpected. The differential diagnoses were oesophageal involvement in bullous pemphigoid and acute oesophageal necrosis. This case illustrates the importance of being vigilant for underlying coagulopathy and highlights the challenges in managing a patient with a rare coagulopathy presenting with gastrointestinal bleeding.

GIHep 2018 | 93

HEALTHCARE AND MEDICATION UTILISATION IN SINGAPORE ADULT INFLAMMATORY BOWEL DISEASE PATIENTS RECEIVING IMMUNOMODULATORS AND BIOLOGICSGan E.L.1, Ng K.Y.1, Ong W.C.1, Chan P.W.2,3, Schwender B. J.2,3, Kong

S.C.2,3, Shim H.H.2,3, Ling K.L.2,3, Chuah S.W.2,3, Lim T.G.1,3

1 Department of Pharmacy, Singapore General Hospital, Singapore2 Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore3 Duke-NUS Medical School, Singapore

Background/Aim:

Due to the chronic nature of the disease, inflammatory bowel disease (IBD) patients consume substantial healthcare resources. We aim to analyse healthcare and medication utilisation in Singapore IBD patients receiving immunomodulators and biologics, and identify factors associated with greater utilisation.

Methods:

All IBD patients followed-up at Singapore General Hospital IBD Clinic in 2015 were retrospectively screened. Patients were recruited if they received at least one dose of biologic or immunomodulator in 2015. Healthcare utilisation was measured using the number of annual IBD-related hospitalisations, and medication utilisation was measured using pattern of IBD medication use and annual IBD-related medication costs.

Results:

Out of 490 IBD patients screened, 156 patients were recruited. Mean number of annual IBD-related hospitalisations did not differ between patients with Crohn’s Disease(CD) and ulcerative colitis(UC) (0.63 vs 0.33,p=0.131). Significant factors (p<0.05) associated with increased hospitalization were female (0.82 vs 0.32), biologic-use (1.22 vs 0.22), infections (2.22 vs 0.43), non-clinical remission (0.94 vs 0.42) and non-biochemical remission (0.74 vs 0.25). Biologic-use was significantly higher in CD than UC (42.9% vs 9.8%) while 5-ASA was used more in UC than CD (90.2% vs 57.1%). Significant factors associated with high annual drug costs were CD patients(SGD$S8,159.30 vs SGD$2,675.61), steroid-use (SGD$10,314.97 vs SGD$5,484.95) and biologic-use (SGD$18,184.25 vs SGD$1,101.36).

Conclusion:

This study suggests that in our IBD patients receiving biologics and immunomodulators, those with suboptimal controlled disease, infections and on biologics had higher healthcare utilization. Further studies measuring cost saving of biologics and immunomodulators to achieve remission would assist in treatment decision in Asian IBD patients.

94 | GIHep 2018

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PRESENTING AS ABDOMINAL PAIN AND ENTERITIS Sim MJH1, Law YM2, Wang YT1

1 Department of Gastroenterology, Singapore General Hospital, Singapore2 Department of Diagnostic Radiology, Singapore General Hospital, Singapore

Background:

SLE can present in a variety of ways, occasionally without cutaneous manifestations, which makes diagnosis challenging.

We report a case of a female patient in her mid-20s with no significant past medical history presenting with abdominal pain and lupus enteritis as a first presentation of occult SLE. The patient was admitted to our gastroenterology unit as a diagnostic dilemma after recurrent presentations for abdominal pain and vomiting. Blood and stool microbiology were negative and she failed to improve with antibiotics. Inflammatory bowel disease was initially considered as a leading differential diagnosis however certain atypical features and computer tomography (CT) findings prompted the suspicion of mesenteric vasculitis and eventually the diagnosis of lupus enteritis.

In our report, we highlight the clinical features and the cardinal computer tomography (CT) findings that aid in the diagnosis of this case and discuss the management of lupus enteritis. We urge gastroenterologists to maintain a high index of suspicion for atypical causes of abdominal pain.

GIHep 2018 | 95

PATTERNS OF ENDOSCOPIC FINDINGS IN PATIENTS WITH UPPER GASTROINTESTINAL BLEEDING AT PATEL HOSPITAL, KARACHI.Samad A , Farrukh Z , Siddiqui A , Niaz SK , Haqqi SA

Department of Gastroenterology, Patel Hospital Karachi, Pakistan.

Background:

Upper gastrointestinal bleeding (UGIB) is a common medical emergency associated with significant morbidity and mortality. The most common causes of UGIB are Esophageal Varices (EV) and Peptic Ulcer Disease (PUD). Upper gastrointestinal endoscopy is the preferred investigative procedure for UGIB because of its accuracy, low rate of complication, and its potential for therapeutic interventions.

Objectives:

This study is carried out to identify the different patterns of endoscopic findings in patients with UGIB and its frequency according to age, gender and symptoms in our setup.

Study Design: It is a single centered retrospective analysis.

Setting: Endoscopy Unit of Patel Hospital Karachi

Period: January 2015 to December 2016

Materials and Methods:

Two Hundred and thirty six patients came to Emergency Department with UGIB during the study period and were subjected to endoscopy to identify the etiology. Data was collected from the endoscopy records on demographics (age and gender) and history of UGIB. The endoscopic findings were then evaluated.

Results:

Out of total 236 patients. 61% were males (144) and 39% were female (92); male to female ratio was (1.38:1). The mean age of patients was 55.06 ± 17.22. (41.1%) had melena (38.6%) had hematemesis, (20.8%) had both hematemesis and melena. The most common cause of UGIB was portal hypertension related (Esophageal and gastric varices) seen in 37.3% of patients followed by peptic ulcer-related bleed (32.2%), esophagitis (6.9%), gastritis (3.8%) and gastric erosions (2.1%). The malignant conditions (gastric, duodenal and esophageal cancers) contributed to 2.5%. Other less frequent causes of UGIB were hiatus hernia (2.1%), GAVE (0.4%), dieulafoy lesion (0.4%). Normal endoscopic finding was 6.8% in patients who had UGIB.

Conclusion:

EV was the commonest cause of UGIB in our setup, as compared to the western world, where PUD was more common. Probable reason could be the high prevalence of liver cirrhosis in our population. A good number of patients had a normal endoscopy, suggesting physicians to obtain detailed history prior to the procedure.

96 | GIHep 2018

INCIDENCE AND OUTCOMES OF ACUTE SEVERE ULCERATIVE COLITIS (ASUC) – A RETROSPECTIVE COHORT STUDY IN A SINGAPORE TERTIARY INSTITUTIONChen K1, Chan PWW1,2, Ooi CJ1, Chuah SW1,2, Schwender BJ1,2, Kong

SC1,2, Ong WC3, Lim TG3, Shim HH1,2

1 Singapore General Hospital, Department of Gastroenterology and Hepatology, Singapore2 Duke-NUS Medical School, Singapore3 Singapore General Hospital, Department of Pharmacy, Singapore

Background/Aim:

Incidence and outcomes of acute severe ulcerative colitis (ASUC) in Asia countries especially Singapore is unclear. This study aims to report the incidence, outcomes and predictors of ASUC at a tertiary hospital in Singapore.

Methods:

A retrospective review of medical record from 2000 to 2015 was performed for patients with ulcerative colitis (UC) in Singapore General Hospital. ASUC was defined as per Truelove and Witt’s criteria. Baseline patient characteristics, needs for salvage therapy (infliximab, ciclosporin) and surgery were collected and analysed using IBM® SPSS® software.

Results:

A total of 143 UC patients were reviewed with 19/143, 13.3% had ASUC. For those with ASUC, they are predominantly male (57.9%); had pancolonic disease (68.4%) and had a median age of 53 years at presentation (ISQ 17 years). Only 1/19 (5.3%) of ASUC patients required infliximab salvation after failed course of corticosteroid therapy during first presentation. However, despite corticosteroid therapy and infliximab, 6/19, 31.6% of ASUC patients, readmitted for flare, including 2 with further ASUC who responded to infliximab and adalimumab respectively.

We observed 1/19 (5.3%) patients had superimposed clostridium difficile, 3/19 (15.8%) patients had superimposed cytomegalovirus colitis upon ASUC presentation. Three out of 19 (15.7%) eventually underwent colectomy with staged ileopouch anal anastomosis creation, 2 during ASUC admission, and 1 within 1 year of admission. Only extent of disease (pancolitis) were found to have significantly higher risk of ASUC (OR 3.25, p = 0.015). Age of UC diagnosis, duration of disease and gender were not found to be significant.

Conclusion:

In out cohort of UC patients, significant number of patients had ASUC and eventually required biologics and colectomy. Larger numbers will be required to confirm this observation.

GIHep 2018 | 97

FACTORS AFFECTING THE DEVELOPMENT OF EARLY CHRONIC KIDNEY DISEASE AFTER LIVER TRANSPLANT Tan TJY1, Fook-Chong SMC2, Tan HK1

1 Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore2 Health Services Research Unit, Division of Medicine, Singapore General Hospital, Singapore

Background/Aim:

Liver transplantation is the curative treatment for end-stage liver disease. Calcineurin inhibitors (CNI) are the main immunosuppression used for the prevention of allograft rejection in liver transplantation. Long-term use of CNI results in progressive decline in renal function due to nephrotoxicity, and some patients develop end stage renal failure requiring dialysis

The aim of this study was to identify risk factors for the development of early CKD after a Liver Transplant, including amount of CNI exposure

Methods:

All patients who had liver-only transplantation in SGH up to December 2014 and received Tacrolimus based immunosuppression were included. The primary endpoint was the development of early CKD (eCKD), as defined by an eGFR of <60 persisting for more than 3 months, occurring in the first 12 months post transplantation

Known risk factors for CKD were analysed with univariate logistic regression. Significant variables were then included in a multivariable logistic regression

Results:

A total of 57 patients were analysed, of which 73.7% were male and the median MELD score and GFR at time of transplant (eGFRT) were 16 and 85.9 respectively

eGFRT was the only statistically significant predictor of eCKD with an AUC of 0.825 (95%CI 0.720-0.930). The optimal cutoff was 89.7ml/min/1.73m2 with a sensitivity of 78.1% and specificity of 68%. Patients below this eGFR threshold had an odds ratio of 7.59 (95%CI 2.32-24.87) of developing eCKD

Conclusion:

eGFRT is a significant predictor of eCKD in post-liver transplant patients. Amount of tacrolimus exposure was not significant with regards to risk of eCKD.

98 | GIHep 2018

ALCOHOL RELATED HEALTHCARE BURDEN IN SINGAPORE GENERAL HOSPITAL BETWEEN 2006 AND 2016Lim KW1, Cheen MHH2, Lim RTG3

1,3 Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore2 Department of Pharmacy, Singapore General Hospital, Singapore

Background:

In Singapore, the prevalence of alcohol use disorder is 1.9%. However, the impact of excess alcohol consumption on healthcare resource utilization is poorly understood. We sought to assess temporal trends of alcohol related healthcare burden.

Methods:

We analyzed cross-sectional data of 7,580 Singaporeans admitted to Singapore General Hospital for alcohol-related medical problems from 2006 to 2016. Temporal trends in hospitalizations and emergency visits were assessed using Pearson correlation. We compared mean length of stay (LOS) and costs using linear regression. Annual proportion of inpatient mortality was compared using logistic regression. We compared mortality rates between alcohol-related diagnoses using Cox proportional hazards regression, with adjustments for age, gender and ethnicity. In addition, we also compared outpatient visit and medications cost using linear regression.

Results:

From 2006 to 2016, the number of hospitalizations (883 to 841; p=0.071) and emergency visits (533 to 620; p=0.987) remained stable. Among those who were hospitalized, there was no significant change in mean LOS (6.7 ± 9.3 to 5.9 ± 15.3; p=0.392). There were significant increases in mean cost of hospitalization (S$5,460 ± S$8,385 to S$7,666 ± S$21,244; p=0.022) and emergency visits (S$235 ± S$68 to S$313 ± S$127; p<0.001) after adjusting for inflation. Inpatient mortality remained unchanged (3.9% to 3.3%; p=0.313). A total of 1,592 (21.0%) patients died during the study period. Mortality risk was higher among patients with alcoholic liver disease compared with alcohol use disorder (HR 1.73, 95% CI 1.52 – 1.96; p<0.001). There were also significant increases in mean outpatient visit cost (S$ 245.40 to S$1001.37; P< 0.001) and mean outpatient medications cost (S$ 236.57 to S$ 1191.15; P<0.001) after adjusting for inflation.

Conclusions:

Over the past 11 years, the number alcohol-related hospitalizations and emergency visits remained stable. Inpatient mortality did not improve and costs of inpatient and outpatient care have increased substantially.

GIHep 2018 | 99

DOES EUS-GUIDED FRANSEEN DESIGN FINE NEEDLE BIOPSY (FNB) PROVIDE MORE TISSUE THAN FINE NEEDLE ASPIRATION (FNA): A RANDOMIZED STUDY Ravishankar Asokkumar, MBBS, MRCP,1 Chin Yung Ka, MBBS,

MRCP,1 Tracy Loh, MBBS, MRCP,2 Damien Tan, MBBS, MRCP, FAMS,1

Christopher Khor, MBBS, MRCP,1 Tony Lim, MBBS, FRCPath, FRCPA,2

Roy Soetikno, MD, MS, MSM1,3

1 Department of Gastroenterology and Hepatology, Singapore General Hospital2 Department of Pathology, Singapore General Hospital3 Duke- NUS Graduate Medical School

Introduction:

Recently, a new Franseen design EUS-FNB needle was developed with the premise to provide more tissue for histology. We compared the tissue adequacy rate of 22G EUS-FNB vs. 22G EUS-FNA, in solid gastrointestinal and extra-intestinal lesions. (Clinicaltrials.gov, NCT03109639).

Methods:

We conducted a randomized cross-over study and recruited 36 patients with solid lesions. We performed three passes for pancreatic lesions and two passes for other lesions, using each needle. We blinded the pathologist to the needle assignment. We compared the length of histological tissue, diagnostic tissue, and desmoplastic stroma (DS) length specifically in lesions with carcinoma. We examined the ROSE and cell-block diagnostic yield of the two needles.

Results:

The lesions included 20 (55%) pancreatic masses, 6 (17%) gastric sub-epithelial lesions, 5 (14%) lymph nodes and 5 (14%) other abdominal masses. The mean ±SD size of the lesion was 3.8 ± 2.0cm. The final diagnosis was malignancy in 27 (75%) and benign in 9 (25%). We found EUS-FNB provided significantly more histological tissue than EUS-FNA (23.71 ± 16.25mm vs. 15.09 ± 14.19mm, p<0.001), but the diagnostic tissue length was similar (14.86 ± 16.75mm vs. 11.89 ± 13.98 mm, p=0.136). In lesions diagnosed as carcinoma, EUS-FNB provided significantly more DS than EUS-FNA (11.04 ± 11.35mm vs. 1.69 ± 2.53mm, p<0.001). We did not find a difference in the ROSE or cell-block diagnostic yield between the needles.

Conclusion:

EUS-FNB provides more histological tissue with DS, but the same amount of diagnostic tissue as EUS-FNA. In this study, the 22G EUS-FNB performed similarly to 22G EUS-FNA.

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THE USE OF OVER-THE-SCOPE-CLIP (OTSC) IMPROVES THE OUTCOMES OF HIGH-RISK ADVERSE OUTCOME (HR-AO) NON-VARICEAL UPPER GI BLEEDING (NVUGIB) Ravishankar Asokkumar, MBBS, MRCP,1 Roy Soetikno, MD, MS, MSM,1,2

Andres Sanchez-Yague, MD, PhD3, Lim Kim Wei, MBBS, MRCP,1 Ennaliza

Salazar, MBChB, MRCP,1 Jing Hieng Ngu, MBChB, FRACP, Ph.D.,1,2

1 Singapore General Hospital2 Duke Graduate School of Medicine - National University of Singapore3 Hospital Costa del Sol, Marbella, Spain

Introduction:

Endoscopic treatment of NVUGIB with HR-AO lesions has a high-risk of failure. We studied the safety and efficacy of OTSC to treat these lesions.

Patients and Methods:

We included patients who were treated using OTSC for NVUGIB from January 2015 to October 2017. We studied the rebleeding and mortality rates and used the Rockall data and our institution’s prior data for comparison. We used descriptive and chi-square statistics.

Results:

We studied 18 patients with 19 bleeding lesions: 9 (47%) duodenal ulcers, 4 (21%) Dieulafoy’s lesion, 3 (16%) gastric ulcer, and 3 (16%) bleeding after gastric biopsy, gastric polypectomy and EUS-FNA of peri-gastric mass. We applied OTSC as the first-line treatment in 10 (53%) and as the second-line treatment in 9 (47%) bleeding lesions. Continued bleeding after OTSC occurred in six patients, but we treated it successfully and achieved complete hemostasis in all patients. We found OTSC use significantly decreased (0% vs. 53%, p<0.01) and reduced (0% vs. 24%, p=0.08) the rebleeding rate in our high-risk (RS≥8) and the intermediate-risk (RS= 4-7) Rockall score patients as compared to the rates reported by the Rockall study, respectively. When compared to our institution’s prior study, we found a decrease in the rebleeding rate with OTSC (0% vs. 21%, p=0.06) in our intermediate-to-high risk Rockall score patients (RS ≥4). There was no difference in mortality rates as compared to both control studies.

Conclusion:

The use of OTSC is safe, efficacious and appears superior to standard treatment for HR-AO NVUGIB. OTSC should be considered as first-line treatment for HR-AO bleeding.

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RECURRENT ULCER BLEED IN A PATIENT WITH HENOCH-SCHONLEIN PURPURA (HSP) AND CYTOMEGALOVIRUS (CMV) INFECTIONKuang J, Yang, J


A 70 year-old Chinese male with newly diagnosed HSP with renal involvement, presented with melena. He was started on oral prednisolone 30-milligrams daily for 3 days prior. 2 months before, he underwent surgical endovascular repair for a Stanford B aortic dissection and was on aspirin.

Initial oesophagogastroduodenoscopy(OGD) showed a Forrest 1B ulcer in the second portion of the duodenum(D2) and multiple Forrest 2C/3 ulcers in the rest of D2 and D3. Adrenaline injection and Hemospray were applied to the Forrest 1B ulcer. Steroid therapy was re-started for his HSP. Subsequently, his melena recurred and a repeat OGD revealed the same bleeding D2 ulcer requiring adrenaline injection and clip application. Ulcer biopsies showed equivocal positivity for CMV. He was started on intravenous Ganciclovir and steroids tapered down. However, he re-bled due to a different Forrest 1B D2 ulcer. An over-the-scope clip was applied as the ulcer continued to bleed despite various hemostatic measures. A push enteroscopy revealed scattered ulcers in the proximal jejunum. Biopsies showed focal nuclear inclusions staining positive for CMV. The bleeding stopped subsequently.

In conclusion, this case presents a diagnostic and therapeutic challenge in someone with recurrent bleeding duodenal ulcers. In view of his HSP, we initially thought it was due to his vasculitis. Furthermore, he was immuno-competent prior to presenting with melena, hence the lower suspicion for CMV-related ulcers. The difficulty faced was in diagnosing the etiology of his ulcers and achieving a balance between the immunosuppression required for his HSP and treatment of the CMV infection.

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EARLY DIAGNOSIS OF HELICOBACTER PYLORI INFECTION IN VIETNAMESE PATIENTS WITH ACUTE PEPTIC ULCER BLEEDING: A PROSPECTIVE STUDYQuach DT1,2, Luu MN1,2, Hiyama T3, To HTT4, Bui QN4, Tran TA4, Tran BD4,

Vo CHM2, Tanaka S5, Uemura N6

1 Department of Internal Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam2 Department of Gastroenterology, Gia Dinh People’s Hospital, Ho Chi Minh City, Vietnam3 Health Service Center, Hiroshima University, Higashihiroshima, Japan4 Department of Endoscopy, Gia Dinh People’s Hospital, Ho Chi Minh City, Vietnam5 Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan6 Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine,

Ichikawa, Japan

Background/Aim:

To investigate H. pylori infection rate and evaluate a combined set of tests for H. pylori

infection diagnosis in Vietnamese patients with acute peptic ulcer bleeding (PUB).

Methods:

Consecutive patients with acute PUB admitted between September 2015 and April 2016 were enrolled prospectively. Rapid urease test (RUT) with 3 biopsies (one from the antrum, two from the lower and middle portion of the corpus in greater curvature) was carried out randomly.

Patients without RUT or with negative RUT result received urea breath test (UBT) and serological and urinary H. pylori antibody tests. H. pylori infection was considered positive if RUT or any non-invasive test was positive. In case of having prior history of H. pylori

eradication, only RUT and UBT results were used for H. pylori infection diagnosis.

Results:

171 patients were enrolled in this study: 111 in group A (RUT plus non-invasive tests) and 60 in group B (only non-invasive tests). The overall H. pylori infection rate was 94.2% (161/171). Group A and B had no differences in demographic characteristics, bleeding severity, endoscopic findings and proton pump inhibitor use. H. pylori-positive rate in group A was significantly higher than that in group B (98.2% versus 86.7%, p = 0.004). The positive rate of RUT was similar at each biopsy site but significantly increased if RUT results from 2 or 3 sites were combined (p < 0.05).

Conclusion:

H. pylori infection rate in Vietnamese patients with acute PUB is high. RUT is an excellent test if at least 2 biopsies are taken.

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NEW ONSET ULCERATIVE COLITIS FOLLOWING RESECTION OF SIGMOID CANCER: A CASE REPORTKrishnasamy Balasubramanian JK1, Asokkumar R1

Department of Gastroenterology and Hepatology, Singapore General Hospital

Introduction:

Long standing ulcertaive colitis (UC) increases the risk of developing advanced neoplasia and colorectal cancer (CRC). However, occurrence of new onset UC after CRC resection is largely unknown. We describe a case of UC that developed after resection of sigmoid colon cancer.

Case:

A 68-year-old female presented with abdominal pain, vomiting and constipation for one week. Examination showed features of intestinal obstruction. A CT-scan revealed 3.8cm obstructing tumor in the sigmoid colon with solitary hepatic metastasis. She underwent sigmoidectomy with primary bowel anastamosis and resection of hepatic metastasis. Histology confirmed a moderately-differentiated adenocarcinoma. Postoperatively she was given capacetabine/oxaliplatin.

During chemotherapy, she developed frequent episodes of non-bloody diarrhoea. Colonoscopy showed extensive colitis which was attributed to chemotherapy. The symptoms persisted for a year even after discontinuation of chemotherapy. A repeat Ileo-colonoscopy showed erythema, mild friability, decreased vascularity affecting the rectum and extending in a continuous fashion till caecum. Multiple Paris-IIa non-polypoid lesions with distinct borders (NP-CRN) were identified in the proximal colon. Histopathology from the colitic segment showed features confirming UC and those from NP-CRN showed adenomatous change with low-grade dysplasia. She was treated with mesalamine and the diarrhoea resolved.

The mechanism for UC development after CRC resection is unclear. We believe an ischemic change and altered mucosal-barrier function induced by chemotherapy may be the etiology for development of UC. The NP-CRN likely represent synchronous lesions that were missed during initial endoscopy than related to new onset UC

Conclusion:

UC, although rare, may develop after resection and chemotherapy for CRC. A meticulous endoscopic evaluation prevents missing synchronus lesion after resection of obstructive CRC.

104 | GIHep 2018

ASSOCIATION BETWEEN HELICOBACTER PYLORI INFECTIONS WITH SERUM GASTRIN-17 LEVELS IN DYSPEPSIA PATIENTSSari Y.M1, Nusi I.A1, Maimunah U1, Setiawan P.B1, Sugihartono T1, Kholili

U1, Widodo B1, Vidyani A1, Thamrin H1, Miftahussurur M1.

1 Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Indonesia.

Background/Aim:

Helicobacter pylori infection known to interfere with gastric acid secretion. One of the most potent gastrointestinal hormones in triggering gastric acid secretion is gastrin. However, the role of Helicobacter pylori in increasing serum gastrin levels remains controversial. This paper’s objective is to determine the relationship between Helicobacter pylori infection with serum gastrin-17 levels in dyspepsia patients in the Endoscopic Unit Department of Internal Medicine, Dr. Soetomo General Hospital Surabaya.

Methods:

This study used a cross-sectional method that enrolled thirty of dyspepsia patients underwent endoscopy and gastric biopsy in the endoscopic unit of the Department of Internal Medicine Dr. Soetomo General Hospital Surabaya. The patients were divided into two groups, i.e., fifteen patients infected with Helicobacter pylori and not. Determination of Helicobacter pylori infection was using histopathological examination. In the other hands, gastrin-17 fasting serum levels were measured by ELISA method.

Results:

The results showed median of gastrin-17 serum levels in the H. pylori-infected group (3.97 (0.54-19.43)} were higher than the uninfected group {1.28 (0.62- 2.71)}. From the statistical test, there was a significant difference between the two groups (p = 0.002) with the medium-value relationship between Helicobacter pylori infection and gastrin-17 serum levels (� = 0.478).

Conclusion:

There was a relationship between Helicobacter pylori infection with increased of gastrin-17 serum levels in dyspeptic patients.

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PERIPANCREATIC TUBERCULOSIS LYMPHADENOPATHY: THE ROLE OF ENDOSCOPIC ULTRASOUND FOR DIAGNOSISVirly Nanda Muzellina1, Hasan Maulahela1, Achmad Fauzi1

Division of Gastroenterology, Department of Internal Medicine, Medical Faculty University of Indonesia

/ Cipto Mangunkusumo National General Hospital

Corresponding author: Achmad Fauzi MD, Division of Gastroenterology, Department of Internal

Medicine, Medical Faculty University of Indonesia / Cipto Mangunkusumo National General Hospital.

Email: [email protected]

Abstract:

Pancreatic and peripancreatic tuberculosis is a rare abdominal tuberculosis. Diagnosis for pancreatic tuberculosis can be challenging. Conventional imaging tools may show mass or malignancy in the pancreas. Endoscopic ultrasound (EUS) is an excellent tools for evaluating pancreas and peri pancreas region. It also allows us to obtain tissue sample for cytology and histopathology. Here we present a case of peripancreatic tuberculosis lymphadenopathy that mimic pancreatic mass. His symptoms were also nonspecific (weight loss, epigastric pain, and irregular fever). From EUS evaluation we found that there was no mass but multiple lymphadenopathy around the pancreas and then performed FNA. The result of the cytology was granuloma inflammation and caseous necrosis which is compatible with tuberculosis infection. From this case illustration we conclude that EUS is an important diagnostic tool for pancreatic lesion to avoid unnecessary surgery.Keywords : Pancreas; tuberculosis; lymphadenopathy; endoscopic ultrasound

Introduction:

Tuberculosis is still endemic in Indonesia but abdominal tuberculosis especially pancreatic and peripancreatic tuberculosis is a very rare disease. Pancreatic and peripancreatic tuberculosis is difficult to diagnose. It can mimic mass or other malignancy in the pancreas. Patient usually come to doctor with symptoms of gastrointestinal malignancy (e.g. weight loss, loss of appetite and chronic abdominal pain) and the imaging are often non-conclusive. Patient usually diagnosed with pancreatic tuberculosis after surgical resection. Endoscopic ultrasound (EUS) is non-invasive tool that allow us to evaluate more detail in the pancreas and surrounding tissue. We can also obtain tissue sample for cytology or histopathology diagnosis using EUS.

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NATIONAL CANCER REGISTRY – EPIDEMIOLOGY OF COLORECTAL CANCER IN THE NORTHERN REGION OF MALAYSIAMuhammad Radzi bin Abu Hassan¹, Shafarul Halimi bin Mohamed¹,

Fitgerald Henry², Nik Raihan Nik Mustapha³

¹ Medical Department, Hospital Sultanah Bahiyah

² Surgical Department

³ Pathology Department, Hospital Sultanah Bahiyah.

Introduction:

The National Cancer Registry – Colorectal Cancer is a multi-centre and multidisciplinary project which aims to systemically collect data on all aspects of colorectal cancer (CRC) relevant to its prevention, management and treatment evaluation in Malaysia.

Methodology:

Data from years 2008 to 2014 on prevalence, incidence, clinical aspects and treatment modalities of CRC were collected from all public and private hospitals in the northern region of Malaysia. Data crosscheck for consistency and reliability was performed with cancer database of northern state registries of Perlis, Kedah, Penang and Perak.

Result:

Incidence and mortality: Overall CRC crude incidence rate and mortality rate were 53.2 cases per 100,000 and 23.1 cases per 100,000 respectively.

Demographic:

Majority of patients were Chinese (55.5%), followed by Malays (37.8%), Indian (5.9%) and others (0.8%). The mean age of CRC patients was 63.1 years; the peak was at the age of 60-64 and 65-69 years.

Risk factors and clinical presentation: 21.7 % of CRC patients had diabetes mellitus, 13.1% were active smokers, 20.5% were former smokers, and 7.2% had a positive family history of CRC. Altered bowel habit was the most common presentation of CRC (21.7%) followed by abdominal pain (18.1%), blood in stool (16.6%), anemia (4.9%), loss of appetite (4.8%) and intestinal obstruction (3.5%).

Primary diagnosis and final staging: The most common site of CRC was rectum (35%). 61.3% presented late at Stage III and IV, only 12.2% were diagnosed at Stage I. Histologically, 92% of CRC patients had adenocarcinoma while 1.7% were categorized into other type. 83.4% patients had moderately differentiated tumors, followed by 10.7 % of differentiated tumors and 5.9% of poorly differentiated tumors.

Treatment modalities: 2619 patients underwent surgery; 1104 patients had adjuvant chemotherapy and biological therapy. 22 patients opted for complementary / alternative treatment. The 5 most commonly performed surgeries were low anterior resection (15.5%), right hemicolectomy (15.4%), sigmoid colectomy (6.9%), high anterior resection (6.2%)

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and left hemicolectomy (6%). Most patients underwent chemotherapy with De Grammont regime (13.3%) followed by FOLFOX (13.1%) and XELOX (10.7%). There were 345 patients who did not receive any of the therapies.

Conclusion:

This report should be able to serve as a guide to health providers, no-governmental organizations (NGOs) as well as policy makers in order to improve CRC prevention, management and control.

108 | GIHep 2018

PREVALENCE OF ASYMPTOMATIC DIVERTICULAR DISEASE AND HAEMORRHOID IN PATIENTS WHO UNDERWENT SCREENING COLONOSCOPY IN HOSPITAL KUALA LUMPUR FROM 2009 TO 2017Lai Teck Gew¹, Eng Soon Tan¹, Karina Koh²

¹ Gastroenterology Unit, Medical Department, Hospital Kuala Lumpur

² Clinical Research Centre, Hospital Kuala Lumpur

Background/Aim:

Prevalence of hemorrhoidal disease and diverticular disease thought to be changes with modern lifestyle changes. Locally, the prevalence of these asymptomatic bowel diseases is unknown. Examining the endoscopy findings in healthy clients who had undergone screening colonoscopy may be able to shed light on this discrepancy of knowledge.

Methods:

1525 patients who had undergone screening colonoscopy in Hospital Kuala Lumpur from 2009 to 2017 were identified. 961 patients with age ≥50 years old (501 males, 460 females) were included in analyses after those with poor bowel preparation and incomplete colonoscopy were excluded. Proportion of colonoscopy with findings of haemorrhoids and diverticular diseases were calculated annually. An attempt to observe a trend in such findings, alongside with the association of the lesions with gender and ethnicity were done.

Results:

The findings of asymptomatic diverticulum demonstrate an overall increasing trend (from 8.5% in 2009 to 18.0% in 2017) while haemorrhoids shows a fall in number (from 29.8% in 2009 to 14.1% in 2017). The figures of both incidental findings of diseases fluctuate over the years. 72.1% of the diverticular disease involved the right colon, 35.6% involved the left side and 7.7% involved both sides of the colon. There was statistically significant association of haemorrhoid lesion with Chinese and Malay ethnicity. Statistical analysis did not show preponderance of the asymptomatic diverticular disease in any gender or ethnicity.

Year and number of patient

2009(n=47)

2010(n=77)

2011(n=77)

2012(n=125)

2013(n=72)

2014(n=58)

2015(n=98)

2016(n=152)

2017(177)

Mean age 64.8 62.6 61.8 63.6 64.4 63.4 63.0 62.6 63.7

Haemorrhoid 29.8% 26.7% 29.9% 23.2% 27.8% 20.7% 19.4% 27.5% 14.1%

Diverticular Disease

8.5% 16.9% 14.3% 19.2% 20.8% 25.9% 30.6% 25.7% 18.0%

Conclusion:

Though with some degree of fluctuation, the proportion of incidental findings of hemorrhoidal had in screening colonoscopy showed a general decreasing trend, where as diverticular disease had shown a rising trend. Similar to other Asia countries, majority of the diverticular diseases involved right side of the colons.

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INTRAHEPATIC CHOLESTASIS IN PREGNANCY: A CASE REPORT Kok VSL, Ooi BH, Tan ES

Gastroenterology Unit, Medical Department, Hospital Kuala Lumpur, Malaysia

Abstract:

Although it is one of the most common pregnancy-related liver disorder during the third trimester, intrahepatic cholestasis in pregnancy is underdiagnosed. These women present with pruritus, with or without abnormal liver functions tests, and elevated bile acid levels. There is an increased risk of perinatal complications, but pruritic symptoms resolve after delivery with favourable maternal prognosis. We report a case of intrahepatic cholestasis in a 32-year-old primigravida Malay lady at 30 weeks and six days gestation. A multidisciplinary approach, including gastroenterologist input is required to identify and diagnose these patients early to alleviate patients’ symptoms and reduce the risk of perinatal morbidity and mortality.

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IMPROVING TIME TAKEN TO ADMINISTER FIRST DOSE ANTIBIOTIC (STAT) OF ANTIBIOTIC IN SEPSIS PATIENT IN HEPATOLOGY WARD1 ADNAN SD, 2 AHMAD ROSDI H, 3 KAMARUZAMAN AA, 1 KAMARUDDIN

MA, 1 YEOP HASHIM N

1 Dept. of Hepatology2 Clinical Research Centre, Ministry of Health Malaysia3 Dept. of Pathology

Hospital Selayang, Ministry of Health Malaysia

Background/Aim:

Sepsis is a life-threatening organ dysfunction. Delay of administration of antibiotics stat dose will lead to increase rate of morbidity and mortality of sepsis patient. In our Hepatology ward, 66% of death is contributed by sepsis based on census. Factors that contributed to delay stat dose antibiotics include delay in taking blood culture, insufficient staff, no intravenous access, patient not in bed and poor communication among staff. According to the literature review, administer effective intravenous antimicrobials within the first hour of recognition of septic shock (Grade 1c) and severe sepsis(Grade 1c) should be made as the goal of therapy.

Methods:

We conducted a cross sectional study from March 2017 until October 2017. Multiple strategies for change have been implemented by involving the ward’s staff which include continuous medical education to the medical officers and nurses, assure prescription availability especially during ward rounds, visual aid: special stamp and awareness poster (i.e. on mouse pad, badge).

Results:

From the remedial measures, the percentage of patient who received stat dose antibiotic within 1 hour has increased from 55% to 83% and ABNA has reduced from 47% to 17%. Improving time taken to administer STAT dose antibiotics has also been shown to reduce sepsis related mortality.

Conclusion:

Sepsis is a major issue in Hepatology ward and contributing factor to patient’s mortality. By improving time taken to administer stat dose antibiotic to sepsis patient has been proven to improve patient survival.

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PRELIMINARY APPLICATION OF ENDOSCOPIC ULTRASOUND, USING ROSEMONT CLASSIFICATION, IN DIAGNOSIS OF CHRONIC PANCREATITIS IN VIETNAMTran Van Huy1, Vinh Khanh2, Phan Trung Nam2, Nguyen Cong Quynh2

1 Hue University of Medicine and Pharmacy2 Hue UMP hospital.

Background and aims:

To evaluate the efficacy of endoscopy ultrasound for diagnosis chronic pancreatitis by Rosemont criteria

Patients and methods:

57 patients of suspected chronic pancreatitis were enrolled. A cross - sectional study was conducted on patients undergoing clinical and laboratory examination, abdominal US, CT Scan and endoscopic ultrasound (EUS). Rosemont classification by EUS was used to diagnose chronic pancreatitis.

Results:

The lesions of chronic pancreatitis on endoscopic ultrasound: the hyperechoic foci without shadowing and stranding were found in 82.5% and hyperechoic foci with shadowing in 70.2%, cyst and pseudocyst in 15.8%. Main pancreatic duct dilation was found 71.9%, hyperechoic main pancreatic duct wall was found 70.2%, main pancreatic duct stones were found in 45.6% of all patients.Rosemont classification in diagnosis of chronic pancreatitis: Consistent with chronic pancreatitis by 1 major A feature (+) ≥ 3 minor features was 69.4% and 2 major A features was 30.6%. Suggestive of chronic pancreatitis by over 5 minor features was 100%. EUS was more sensitive than CT in detecting early chronic pancreatitis.

Conclusions:

Endoscopic ultrasound is a highly effective method in diagnosis of chronic pancreatitis, especially of early chronic pancreatitis, in Vietnamese patients.

Key words: Chronic pancreatitis, EUS, Rosemont criteria

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EFFICACY OF FLEXIBLE SPECTRAL IMAGING COLOR ENHANCEMENT COMBINED WITH MAGNIFYING COLONSCOPY IN THE DIAGNOSIS COLORECTAL POLYPSPham B.N, Vu T.K, Dao V.L

Gastroenterology and Hepatology Department at Bach Mai Hospital, Viet Nam

Background/Aim:

The magnifying endoscopy with flexible spectral imaging color enhancement (FICE) is an image-enhanced endoscopy that allows to characterize the fine supertificial capillary pattern of nomal mucosa and of colorectal polyps. This study evaluated the endoscopic distinction of the capillary pattern of colorectal polyp might contribute to the differential diagnosis among neoplasia and non - neoplasia.

Methods:

The total of 194 polyps of 164 patients endoscopically or surgically resected were prospectively examined from May, 2016 to December, 2017. After identified by white light endoscopy, polyps continued to be evaluated by magnifying endoscopy (x 100 times) with FICE. The capillary pattern was devided into 5 subtypes according to the number, morphology, and distribution of the fine blood vessels. Capillary patterns I and II were characterize by a few short, straight, and sparsely distributed vessels; typ III, IV and V were of nummerous, and tortuous capillaries irregularly distributed. The results according to classification of capillary pattern was compared with histopathological results after biopsy.

Results:

The number of neoplastic polyps was 158 with 139 adenoma polyps and 19 cacinoma polyps. The sensitivity of the capillary pattern classification for distinguishing neoplastic lesions was 97.47%, the specificity was 83.33%. The overall diagnostic accuracy for distinguishing neoplastic from nonneoplastic lesions was 94,84%.)

Conclusion:

The magnifying endoscopy with flexible spectral imaging color enhancement (FICE) according to capillary pattern classification is an accurate method of distinguishing neoplasia and predicting the histopathologic findings.

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BEYOND CONVENTIONAL FACTORS AFFECTING THE VALIDITY OF LIVER STIFFNESS MEASUREMENT AND REPORT QUALITY Ching SY, Cher GLY, Yew KC

Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore

Background:

Indirect liver stiffness measurement (LSM) has been developed in an attempt to replace liver biopsy. Factors such as operator experience, patients’ physical characteristics and liver parenchymal conditions contribute to LSM reproducibility.

Methods:

We performed LSM using M and XL probes. Multi-point assessment was performed in cross section. M probe assessment was conducted at 2 points along the right intercostal spaces. If a reading was unobtainable, the XL probe was then used, provided patient’s BMI was >30kg/m2.

Results:

303 patients had readings with the M probe. Variability of readings were categorised into <2 kPas (n=217, 71.62%), 2-5 kPas (n=73, 24.09%), >5-10 kPas (n=11, 3.63%), >10kPas (n=2, 0.66%). Simple and multiple linear regression analysis was performed on possible contributory factors. Age (p=0.039), hepatitis B (p=0.009), and cryptogenic liver disease (p=0.001) were found contributory. BMI was found not significant. We proceeded with subgroup analysis of patients with BMI < 30kg/m2. Age (p=0.038), hepatitis C (p=0.031), alcohol (p=0.021) and cryptogenic liver disease (p=0.016) were associated with result variability. For subjects with thoracic perimeter > 75cm, operator perception of skin thickness and alcohol consumption were contributory. IQR/Median was not associated with report variability, limiting our ability to identify a different cut-off value from the conventional 30%.

Conclusion:

Fibrinogenesis may not occur homogeneously within the liver. This may be due to varying disease aetiology. It is important to understand the effects of various factors on LSM. Using elastography assessment of a 4 cm column of liver parenchyma for the generalisation of liver stiffness needs caution.

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RADIOFREQUENCY ABLATION OF HEPATOCELLULAR CARCINOMA: LONG-TERM OUTCOMES AND PROGNOSTIC FACTORSNam Thanh Nguyen, Hang Viet Dao, Khanh Truong Vu, Long Van Dao

Gastroenterology Department of Bach Mai Hospital

Purpose:

To evaluate the long-term outcomes of RFA and to determine the prognostic factors.

Subject and Methods:

A retrospective study on HCC patients with tumors ≤ 50mm treated by RFA in Gastroenterology Department of Bach Mai Hospital from January 2012 to December 2015. 151 patients (Non-cirrhotic liver, Child-Pugh class A and B, 5, 133 and 13 patients, respectively) with 205 tumors were performed 431 RFA sessions, among whom 33 patients with the history of treatment with other methods (Resection, PEI, TACE), 118 patients without the history of treatment.

Results:

During follow-up time (35.7 ± 14.4 months), 45 patients (29.8%) died, 9 patients (6%) had local recurrence, 37 patients (24.5%) had new lesions, 6 patients (4%) had portal vein thrombosis, 11 patients (7.4%) had metastasis. The estimated 1- 2- and 3-year overall survival rates of the group with the history of treatment were 90.1%, 75.2%, and 61.5% respectively. The estimated 1- 2- and 3-year overall survival rates of the group without the history of treatment were 92.4%, 84.5%, and 71.8% respectively. At multivariate analysis, initial AFP concentration (p< 0.001) had correlation with overall survival, while tumor size, tumor number, the history of treatment had no correlation with overall survival.

Conclusion:

RFA is a safe and effective method for treating HCC up to 50mm in diameter, especially for patients with a low serum AFP level, and well-preserved liver function.

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TIME TO VIRAL SUPPRESSION DOES NOT IMPACT SVR IN PATIENTS TREATED WITH GLECAPREVIR/PIBRENTASVIR FOR 8 WEEKSChristoph Sarrazin1 , Douglas E. Dylla2, Jordan J. Feld3, Sanjeev Arora4,

David Victor III5, Yiran B. Hu2, Stanley Wang2, Federico J. Mensa2, David

Wyles6

1 JW Goethe University Hospital, Frankfurt, Germany and St. Josefs-Hospital Wiesbaden2 AbbVie Inc., North Chicago, Illinois, United States3 Toronto Centre for Liver Disease, University of Toronto, Toronto, Ontario, Canada4 University of New Mexico, Albuquerque, New Mexico, USA5 Houston Methodist Hospital, Houston, Texas, United States6 Denver Health Medical Center, Denver, Colorado, United States

Background/Aim:

The co-formulated direct-acting antiviral glecaprevir/pibrentasvir (G/P) is an 8-week treatment approved for HCV genotypes (GT) 1 to 6. Historically, with interferon (IFN)-containing treatments, achieving week 4 viral suppression was a predictor of cure. With shortened duration DAA regimens, the relevance of viral kinetics is unclear; concerns remain that failure to suppress HCV RNA quickly may lead to relapse. 8-week G/P treated patient data was analyzed to investigate factors impacting time to viral suppression and relapse.

Methods:

Analysis of five phase 2 and 3 studies included non-cirrhotic, treatment-naïve or experienced (IFN or pegIFN ± ribavirin (RBV), sofosbuvir + RBV ± pegIFN), HCV GT1-6-infected patients on once-daily, 8-week oral G/P (300mg/120mg). Data from the following patients were excluded: 1) those with missing SVR12 data or lost to follow-up (n=13) and 2) those with on-treatment virologic failure (n=2).

Results:

Of 950 patients in the trials, majority were white, male, and treatment-naïve. Among 942 patients included in this analysis, 906 (96%) had HCV RNA<LLOQ at week 4, and 899/906 (99%; 95% CI 98.4–99.6) achieved SVR12; Table 1 shows subgroup results. No baseline factor besides male sex (5/7, 71%) was predominantly observed among relapsed patients. Of 36 with week 4 HCV RNA>LLOQ (median baseline HCV RNA 6.7 log10 IU/mL; range 5.2–7.6 log10 IU/mL), 100% (95% CI 90.4–100.0) achieved SVR12.

Conclusion:

Failure to suppress HCV RNA by treatment week 4 was not predictive of treatment outcome, suggesting that treatment extension in patients eligible for 8-week regimens based on this milestone is not warranted.

116 | GIHep 2018

LONG-TERM EFFECTIVENESS AND SAFETY OF ADALIMUMAB BASED ON CROHN’S DISEASE DURATION: RESULTS FROM THE PYRAMID REGISTRYLoftus, Edward V.1, Reinisch, Walter2, Panaccione, Remo3, Berg, Sofie4,

Bereswill, Mareike5, Kalabic, Jasmina5, Skup, Martha6, Petersson, Joel

H.6, Robinson, Anne M.6, D'Haens, Geert R.7

1 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States.2 Medical University of Vienna, Vienna, Austria.3 Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, AB, Canada.4 AbbVie AB, Solna, Sweden.5 AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany.6 AbbVie Inc., North Chicago, IL, United States.7 Academic Medical Center, Amsterdam, Netherlands.

Background/Aim:

PYRAMID was a real-world, multinational registry of adult patients with Crohn’s disease (CD) treated with adalimumab (ADA). This study evaluates the relationship between CD duration at registry enrolment (baseline [BL]) and treatment outcomes in ADA-naïve patients.

Methods:

Adults (≥18 years) with moderate to severe CD, newly prescribed or already receiving ADA were followed for ≤6 years. Effectiveness was evaluated in ADA-naïve patients with ≥1 ADA dose and ≥1 post-enrolment measurement. Change in Harvey-Bradshaw Index (HBI), Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and Work Productivity and Activity Impairment (WPAI) questionnaire scores was evaluated at BL and yearly, irrespective of ADA-use at time of assessment.

Results:

Of 5025 registry patients, 2057 (40.9%) were ADA-naïve; CD duration was available for 1980 ADA-naïve patients: <2 years: 373; 2–<5 years: 334; 5–<10 years: 512; ≥10 years: 761). Mean total HBI, SIBDQ, and WPAI scores improved in all subgroups at year 1; these improvements were generally maintained. The numerical improvements in WPAI score were greater in patients with CD duration <5 vs ≥5 years. Generally, improvements in SIBDQ and WPAI scores were clinically meaningful. Rates of any infection (7.4–9.0 E/100 per 100 patient-years (PYs)), and serious infection (4.4–6.4 E/100 PYs) were similar across subgroups.

Conclusion:

Initiation of ADA treatment improved patient-reported quality of life and work-related activities. These improvements were maintained for up to 6 years across CD duration subgroups.

The safety profile for ADA-naïve patients was generally similar across subgroups and comparable with safety data previously reported for the overall registry population.

GIHep 2018 | 117

FACTORS DRIVING TREATMENT ESCALATION IN CROHN’S DISEASE IN THE CALM TRIALReinisch, Walter1; Panaccione, Remo2; Bossuyt, Peter3; Baert, Filip J.4;

Armuzzi, Alessandro5; Hebuterne, Xavier6; Danese, Silvio7; Sandborn,

William J.8; Schreiber, Stefan9; D'Haens, Geert R.10; Berg, Sofie11; Zhou,

Qian12; Petersson, Joel H.12; Neimark, Ezequiel12; Robinson, Anne M.12;

Colombel, Jean Frederic13

Affiliations 1 Medical University of Vienna, Vienna, Austria.2 University of Calgary, Calgary, AB, Canada.3 Imelda General Hospital, Bonheiden, Belgium.4 AZ Delta , Roeselare-Menen, Belgium.5 Presidio Columbus, Fondazione Policlinico Gemelli Università Cattolica, Rome, Italy.6 Service de Gastroentérologie et Nutrition Clinique, Nice, France.7 Istituto Clinico Humanitas, Milan, Italy.8 University of California San Diego, La Jolla, CA, United States.9 University Hospital Schleswig-Holstein, Kiel, Germany.10 Academic Medical Center, Amsterdam, Netherlands.11 AbbVie AB, Solna, Sweden.12 AbbVie Inc., North Chicago, IL, United States.13 Icahn School of Medicine at Mount Sinai, New York, NY, United States

Background/Aim:

Patients with Crohn’s disease (CD) from the tight control (TC) group of CALM, whose treatment was escalated based on symptoms (CD Activity Index (CDAI), prednisone use) and biomarker (C-reactive protein (CRP), faecal calprotectin (FC)) criteria, achieved better endoscopic outcomes than patients whose treatment was escalated based on symptoms alone.1 We report treatment escalation decisions based on symptoms and biomarker criteria in more detail.

Methods:

Patients (n=122) naïve to biologics and immunosuppressants, ± prior prednisone use, were randomized to the TC group. Adalimumab (ADA) dose was escalated if at least one of the following criteria was met: CDAI≥150, CRP≥5mg/L, FC≥250mg/g, prednisone use. At randomization, patients who met at least one criterion received treatment with ADA induction 160/80 mg and then 40 mg every other week. At 12, 24, and 36 weeks after randomisation, patients who met at least one criterion were escalated to ADA 40 mg every week [EW], then ADA 40 mg EW+2.5 mg/kg azathioprine. At each time point, we report the dose escalation criteria for all patients who received escalated treatment.

Results:

Over 70% of patients who qualified to receive ADA at randomisation met ≥three criteria . After randomisation, most patients were escalated based on one criterion. Prednisone use was the least frequent criterion for escalation.

118 | GIHep 2018

Conclusion:

Data from CALM suggest that biomarkers are important for guiding treatment decisions in patients with early CD after their symptoms are controlled by treatment. These results underscore the importance of monitoring symptoms and biomarkers to achieve better clinical and endoscopic outcomes.

References:

1. Colombel J-F et al., The Lancet, 2017, published online on October 31.

GIHep 2018 | 119

GLECAPREVIR/PIBRENTASVIR IN PATIENTS WITH HEPATITIS C AND PRIOR TREATMENT EXPERIENCE: AN INTEGRATED PHASE II/III ANALYSISFred Poordad1, Stefan Zeuzem2, Armen Asatryan3, Graham R Foster4,

Edward Gane5, David L Wyles6, Stanislas Pol7, Maria Buti8, Paul Kwo9,

Tarik Asselah10, Kris Kowdley11, Christophe Hézode12, Kosh Agarwal13,

Stanley Wang3, Neddie Zadeikis3, Teresa I Ng3, Tami Pilot-Matias3, Yang

Lei3, Jens Kort3, Chih-Wei Lin3, Federico J Mensa3

1 The Texas Liver Institute, University of Texas Health, San Antonio, TX, USA2 Goethe University Hospital, Frankfurt, Germany3 AbbVie Inc, North Chicago, IL, USA4 Queen Mary University of London, Barts Health, London, United Kingdom5 Liver Unit, Auckland City Hospital, Auckland, New Zealand6 Denver Health Medical Center, Denver, CO, USA7 Groupe Hospitalier Cochin-Saint Vincent De Paul, Paris, France8 Vall d’Hebron University Hospital and CiBERHED del Instituto Carlos III, Barcelona, Spain9 Stanford University Division of Gastroenterology and Hepatology, Palo Alto, CA, USA10 Centre de Recherche sur l’Inflammation, Inserm UMR 1149, Université Paris Diderot, Service

d’hépatologie, AP-HP Hôpital Beaujon, Clichy, France11 Swedish Medical Center, Seattle, WA, USA12 Hôpital Henri Mondor, Université Paris-Est, Créteil, France13 Institute of Liver Studies, Kings College Hospital, London, United Kingdom

Background/Aim:

Patients with hepatitis C virus (HCV) infection who failed prior therapy generally have decreased response to subsequent therapy. We evaluated the efficacy and safety of Glecaprevir/Pibrentasvir (G/P) in patients with prior treatment experience.

Methods:

Data from nine phase II and III clinical trials were analysed including patients who had prior treatment with at least one of the following regimens: interferon or pegylated interferon (pegIFN) + ribavirin (RBV), sofosbuvir + RBV (±pegIFN), or a regimen that contained either an NS3/4A protease inhibitor (PI) or an NS5A inhibitor, but not both, and received a European EMA and/or US FDA label-recommended duration of G/P treatment (8, 12, or 16 weeks) based on genotype, prior treatment history, and cirrhosis status. Safety was assessed in all patients who received at least one dose of G/P; the primary efficacy endpoint was the percentage of patients with SVR12.

Results:

362 patients with prior treatment experience were treated with G/P. Baseline characteristics are summarized in Table 1. Overall, 97% (350/362) of patients achieved SVR12; 2% (9/362) experienced virologic failure (Figure 1). Presence of NS3 or NS5A baseline substitutions was not predictive of virologic failure. Adverse events (AEs) occurring in ≥10% of patients were headache and fatigue. There were no study-drug related serious AEs; <1% of patients had grade ≥3 increases in total bilirubin, none had post-nadir grade ≥3 increases in alanine aminotransferase.

Conclusion:

HCV retreatment with G/P demonstrated a high overall rate of SVR12 (97%), including in patients with prior NS3/4A PI or NS5A inhibitor experience, and was well tolerated.

120 | GIHep 2018

A RACE OF TRUE DIAGNOSIS: HEPATIC ENCEPHALOPATHY OR PSYCHOSIS? Ching SY, Yew KC

Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore

Background:

The diagnosis of hepatic encephalopathy (HE) is important for in preventing permanent cerebral cognitive defects. HE presents as a spectrum of neuropsychiatric abnormalities including defects in cognitive, emotional, behavioural and psychomotor functions. Differentiation from psychosis can be challenging as both may present with symptoms of paranoia.

Methods:

We present a case study of a 55 year old lady with Child B8 hepatitis B cirrhosis who underwent transjugular portosystemic shunt placement in March 2017 for variceal bleeding. Her condition was stable despite raised bilirubin 60 micromol/L (MELD 15). She was admitted in January 2018 for caustic substance ingestion and persecutory delusions. MRI brain and EEG were unremarkable. The psychiatrist noted fluctuating inattentiveness and disordered thoughts without auditory hallucinations, in keeping with delirium. She was subsequently managed as HE and received laxatives followed by rifaximin. Her HE progress was measured using the number connection test (NCT), EncephalApp Stroop test and serum ammonia, after exclusion of confounding factors in interpretation.

Results:

There was a correlation between HE improvement and NCT and Stroop test assessment, but no relation with serum ammonia levels. Lag time between introduction of rifaximin and resolution of HE was estimated to be about 2 weeks.

Conclusion:

Multidisciplinary input from a psychiatric colleague can assist in the diagnosis of atypical HE. Absence of hallucinations and unclassifiable “psychiatric manifestations” are good exclusion criteria for psychosis. Tests exploring psychomotor speed and cognitive flexibility should be employed in HE assessment and surveillance. Serum ammonia alone is unreliable as a diagnostic criterion for HE.

GIHep 2018 | 121

SYSTEMIC LUPUS ERYTHEMATOSUS OR AUTOIMMUNE HEPATITIS: THE CLINICAL UTILITY OF LIVER BIOPSYChing SY, Lin HY

Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore.

Background:

Autoimmune hepatitis (AIH) is characterised by ongoing hepatocellular necrosis and inflammation which may progress to cirrhosis/liver failure. The revised original scoring system of the international autoimmune hepatitis group (IAHG score) suggests that clinical criteria are sufficient to diagnose AIH.

Methods:

We report a case of suspected AIH with a high pre-biopsy aggregate score but discordant liver biopsy histology.

A 40-year old Malay female, with a family history of systemic lupus erythematosus (SLE), presented with recurring self-limiting febrile episodes, significant transaminitis and urticarial exanthem, but had no other clinical symptoms suggestive of SLE. She denied any drug/alcohol use. Blood tests revealed leukopenia and thrombocytopenia, ALP:ALT ratio < 1.5, raised Immunoglobulin G and Antinuclear antibody titres (1:160). Viral markers were negative. Coagulation studies were abnormal hence anti-phospholipid antibodies were done which were positive.

Results:

Her pre-biopsy IAHG score was 16, suggesting a definite diagnosis of AIH. A liver biopsy was performed to confirm this. However, histology showed mild lobular and portal inflammation, granulomas in the lobules with focal necrosis– features not consistent with AIH. Stains for tuberculosis and lymphoma were negative.

She was reviewed by Rheumatology in view of her positive autoantibodies and family history, and diagnosed with atypical SLE with antiphospholipid syndrome.

Conclusion:

The diagnosis of AIH is challenging in SLE patients due to similar clinical/laboratory findings. AIH score without histological evidence is insufficient for diagnosis. Liver biopsy proved crucial to distinguish lupus hepatitis from AIH in this previously undiagnosed SLE patient because of the difference in medical therapy and outcome.

122 | GIHep 2018

AN OBSERVED CHANGE IN LARGE VOLUME PARACENTESIS PRACTICE IN A TERTIARY MEDICAL CENTRE IN SINGAPORENah CY, Tan D, Ang D, Yew KC

Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore

Background:

Large volume paracentesis (LVP) is a procedure commonly performed especially for portal hypertension related ascites. There are differences in the local practices of LVP across different institutions in Singapore. We describe the observation on the LVP practice in our department.

Methods:

We reviewed the medical records of 117 bedside LVPs performed from 2nd January to 10th July 2017.

Results:

62 patients underwent bedside LVP and 26 (42%) patients had repeat LVPs.There were 23 female and 39 male patients. Average age was 68.4 years (male 63.9 years; female 76 years). 56 (90.3%) patients had liver cirrhosis and most had advanced cirrhosis.Advanced cirrhotic patients required repeated LVP (Child's A, n=1; B/C , n=21, no information, n=1). The junior doctor preferred to use ultrasonography guidance. Most would choose the 16-gauge cannula (n=91, 77.8%) over the Rocket set (n=26, 22.8%). This can be partly explained by a lack of experience in using the Rocket set. The 16-Gauge cannula had an issue of tube kinking leading to suboptimal ascitic drainage. The average dwell time was 9.92 hours and majority of physicians were unable to predict the actual volume to be drained.

Conclusion:

This observation demonstrated LVP could be performed at bedside, saving the waiting time for appointments from Radiology department. There is a change in practice amongst junior doctors, who are now more comfortable with ultrasonography guided LVP than blind percutaneous insertion. Accreditation in performing Rocket drain insertions can be explored. Proper decisions in LVP management will affect patient's care and the quality of life.

GIHep 2018 | 123

LONG TERM OUTCOMES, EARLY EXPERIENCE AND CHALLENGES OF ESTABLISHING ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) IN A TERTIARY CENTRE IN SINGAPOREChew WD* 1, Thian MY1 ,Yoshinori Morita2, Takashi Toyonaga2, Hironori

Yamamoto3, Stephen Tsao1

1 Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore2 Gastroenterology, Kobe University Graduate School of Medicine, Japan3 Gastroenterology, Jichi Medical University, Japan

Background/Aim:

ESD has played an increasingly important role in management of gastrointestinal(GI) lesions since its development in Japan in 1990s. This is a retrospective review of a single’s centre long term outcomes of our early experience in ESD.

Methods:

Patients' records from all ESD cases performed in our institution were selected from May 2011 to Dec 2013 with follow up endoscopy were reviewed. All cases was done by a single endoscopist with the guidance of visiting Japanese experts.

Results:

A total of 22 patients underwent ESD (14 colon, 7 gastric and 1 esophageal) where the average age was 66.9 years(53-81). The most common site of lesions was rectum (7/14) and incisura (4/7). The mean duration time was 208 minutes(60-429) and resection velocity was 42min/ cm2 for the first 10 cases vs 35min/cm2for next 11. The en-bloc resection rate was 85.7%(6/7) for gastric and colonic ESD 64.3%(9/14) with time/fibrosis as the limiting factors. The overall complication rate was 9.5% (2/21) with no mortality. 18/22 had a follow up endoscopy post ESD at an average of 207 days (6.5months). Recurrence at 6months was (2/4, non en-bloc) vs (1/14, en-bloc) and the longest follow up is at 5.2 years (no recurrence).

Conclusion:

ESD will play an important role in management of early malignant GI lesions in view of its minimal invasiveness and safety with comparable efficacy in a fast aging population. En-bloc, recurrence and complication rate will improve with case volume, refinement in technique/equipment and proper patient selection.

124 | GIHep 2018

PHANTOM RECTAL SYNDROME AFTER ABDOMINOPERINEAL RESECTION …A UNIT BASED RETROSPECTIVE STUDY.TH Pathirana, P Samarathunga, S Wimalarathne, S Kumarage

Background:

Phantom rectal syndrome(PRS) is a rare and a poorly understood area where patients with a background of Abdominoperineal resection (APR)/similar dissection develop symptoms arising from the resected bowel. Symptoms are either painful or non-painful. This descriptive study attempts to explore the prevalence and the burden of these symptoms.

Methods:

This descriptive study was conducted at Colombo North Teaching Hospital amongst patients who underwent APR .Interviewer based questionnaire was administered to a total of 30 surviving patients within past 5 years .

Results:

Out of the 30 patients, 33% had sensation arising from the resected distal bowel. And out of those with symptoms, 80% of patients had painless symptoms and only 20% of patients had intermittent painful rectal symptoms.

All patients who had such symptoms had undergone the surgery at an age less than 55 years Laparoscopic surgery had 35% risk of PRS compared to pure open procedure which is 30%.

80% patients are staged II B Only 20% of patients with symptoms have seeked emergency medical attention and symptoms objectively halved with regular analgesics.Reassurance at clinic level was received by all patients and the perturbations to activities of daily living was minimal afterwards.

Conclusion:

Phantom Rectal Syndrome is a common but poorly addressed complication of perineal surgery in APR. And the likelihood increases with younger age group, perirectal involvement.We feel a thorough explanation of the possibility of phantom rectal symptoms preoperatively and post operatively is required and will improve symptoms.

GIHep 2018 | 125

ECONOMIC IMPACT OF SINGLE OPERATOR DIGITAL CHOLANGIOSCOPE IN THE TREATMENT OF PANCREATOBILIARY DISORDERS: SINGLE CENTER EXPERIENCE IN SINGAPORE Yvonne Lee1, Ng Wee Khoon2, Chen Kok Pun2, Charles Vu2, Michael

Cangelosi1, Quan Wai Leong2

1 Boston Scientific2 Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore

Objectives:

Single operator digital cholangioscope (SO-DC), has allowed endoscopists to visualize the biliary and pancreatic ducts to perform diagnostic or therapeutic procedures. We aim to evaluate the economic impact of this system from the perspective of a Singaporean, Medisave and Medishield-unsubsidized patient.

Methods:

An economic assessment of the medical device was performed using a patient budget impact analysis (BIA). A cost calculator was developed on an interactive platform to facilitate patient and healthcare provider/facility education. The BIA calculations included an estimate of the eligible population, and costs of: inpatient and outpatient procedures, surgery, and medical device(s). Data required to populate the model were provided by Tan Tock Seng public hospital and hospitalization cost data were extracted from Ministry of Health published reports.

Results:

We projected cost savings of approximately SGD $3,000 (rounded to nearest 50 SGD) in making definitive diagnosis for indeterminate strictures, SGD $1050 in avoiding repeat endoscopic retrograde cholangiopancreatography (ERCP) procedures and SGD $26,500 in avoiding unnecessary surgeries due to the use of the SO-DC for each unsubsidized patient. The potential government annual net savings for this individual, representative public hospital is projected to be approximately SGD $191,000.

Conclusions:

SO-DC is designed to increase diagnostic accuracy, reduce the need for exploratory surgery, manage indeterminate strictures and large stones in the biliary system, when conventional ERCP had been unsuccessful or deemed inappropriate. These findings demonstrate that these clinical improvements associated with the use of SO-DC can additionally manifest as reduced patient out-of-pocket expenditure with improved patient outcome.

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GIHep 2018 | 127

Nursing Free Paper Oral PresentationWORKFLOW (VERSION 2) FOR STANDARDIZATION OF MICROBIOLOGICAL SURVEILLANCE OF ENDOSCOPES Gu HW, Galapon LMJ, Beh XT, Toh BLA, Morales KM, Ilano LMSA,

Tatlonghari CT, Lyons DSR, Foo ML, Leong FW Alice, Chua CP Rachel,

Tay BH Serene

Endoscopy Centre, Khoo Teck Puat Hospital, Singapore

Laboratory Medicine, Khoo Teck Puat Hospital, Singapor

Infection Control, Khoo Teck Puat Hospital, Singapore

Background:

Endoscopes microbiological surveillance (MS) are conducted on a regular basis based on a MS schedule. There are several occasions where the endoscope MS results turned out to be positive. Staff are unclear on how to handle positive MS results with High Concern Microorganisms. Thus, they seek advice from Infection Control department and Microbiologist of the Laboratory Medicine, rendering the need for a more specific guidelines in treating endoscopes with High Concerned and Low Concerned Microorganisms results.

Aim:

The main purpose of this project is to revise and standardize the workflow for endoscopes microbiological surveillance across all Perioperative departments in Khoo Teck Puat Hospital (KTPH) and Admiralty Medical Centre (AdMC), who uses endoscopes and carry out MS. This revision and standardization will provide a clear guideline for staff in handling positive endoscopes MS result effectively.

Methods:

Inter-departmental discussions and meetings were conducted among the stakeholders, Endoscopy Nurses, MOT Nurses, Microbiologist of the Clinical Laboratory as well as Infection Control department in charge.

Results:

A revised workflow with clear instructions is established to guide Nurses handling positive endoscope MS results. For all positive MS results, cleaning and disinfecting process will be investigated, staff will need to restrict the use of endoscope, repeat the disinfection process together with microbiological surveillance until it is negative. Technique on reprocessing and conducting MS need to be evaluated if consecutive three positive results are received. Endoscopes should also be evaluated by manufacturer. Furthermore, patient recall might be needed for high-concern microorganism. Conclusion:

This revised workflow provides a clear guideline for staff handling endoscopes with positive culture result during microbiological surveillance. This practice has allowed standardization across Perioperative services in KTPH and AdMC

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THE OUTCOME AND COST OF A SYSTEMATIC APPROACH TO EVALUATE THE EFFECTIVENESS OF FLEXIBLE ENDOSCOPES REPROCESSING IN NTFGH SINGAPOREWang, C., Zhang, R., Idris, R.

Department of Endoscopy, Ng Teng Fong General Hospital, Singapore.

Background/Aim:

Endoscope-associated nosocomial has caused significant concern. Outbreaks due to inadequate cleaning and disinfection are mostly reported. Therefore, a systematic microbiology culturing programme was established in NTFGH endoscopy unit to render safe use of flexible endoscopes for patients. This aim of the study is to report the outcome and cost of the programme.

Methods:

A microbiology surveillance culture (MSC) threshold was developed by the hospital microbiologists. Both qualitative and quantitative MSC were carried out for all flexible endoscopes in the unit: 1) periodical culturing post high level disinfection with different frequency, 2) random testing during storage, 3) follow up evaluation for positive result and after repair, and new endoscopes, 4) ad-hoc culturing after used for Carbapenem-Resistant Enterobacteriaceae patients. Associated endoscopes and AERs were restrained from clinical circulation before the MSC result and remained quarantined if the result is positive.MSC data was reviewed and analysed. Cost for time of staff, sampling accessories and consumables, culturing charge and reprocessing was calculated.

Results:

Firstly, there was no outbreak related to endoscopy procedure in NTFGH. Secondly, during this program from January 2017 to April 2018, total 230 MSC were performed and 33 MSC (14%) had positive result. Total 200 endoscopes were screened and 21 (10.5%) endoscopes had positive result. Those endoscopes with positive MSC result were quarantined, reprocessed and underwent repeated testing. 5 endoscopes were found to have inner lining scratches/ damage/ stains, thus repair was required. Thirdly, the total cost for this programme is 34,078 Singapore dollars.

Conclusion:

A considerable positive culture result was found during this sixteen months programme. We conclude that systematic culturing is necessary to deliver safe endoscopes to prevent nosocomial and the cost is modest.

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THE IMPLEMENTATION OF A CHRONIC HEPATITIS B TELEMEDICINE PROGRAM REDUCED THE NUMBER OF CLINIC VISITS WITHOUT COMPROMISING PATIENT SAFETYLim LT1, Lee GH1,2, Chong CF1

1 Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital.2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore,

Singapore;

Background/Aim:

Patients with chronic hepatitis B infection on high potency antiviral agents are typically follow-up at 6-monthly interval for routine ultrasound scan and blood tests to monitor of their liver condition. This amounts to medical costs, time loss from work, and inconvenience to family members of patients with mobility challenges. We implemented a telemedicine program aimed at reducing the number of clinic visit to one per year, without compromising patient care and treatment.

Methods:

The respective doctors first select suitable patients to participate in the program. The alternate clinic visits were substituted by a dedicated nurse tracing the test results in the background, and making sure that they are vetted by the primary physician, and conveyed to the patients by a telephone call. If the test results were abnormal, or that the patient developed new symptoms, an interval clinic session will be arranged. The participating doctors and patients were asked to voluntarily complete a satisfaction survey after one year for audit purpose.

Results:

Ten doctors referred a total of 153 patients to the NUH HBV Telemedicine Program. To date, the median follow-up duration is 24 months. Seven patients were lost to follow up. A total of nine patients were recalled for abnormal test results or additional tests. Four patients were taken off the program by the doctors for non-HBV treatment. All the doctors surveyed expressed strong confidence and satisfaction with the program. Amongst the 48 subjects who responded to the survey, 47 patients expressed satisfaction with the service, although 20% preferred to see their doctors every 6 months for various reasons.

Conclusion:

The HBV Telemedicine Program reduces patient waiting time, medical costs and number of clinic visits. The standard of care is maintained with both the doctors and patients expressing high levels of satisfaction.

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LAUNCH OF ELECTRONIC NURSING ASSESSMENT RECORD (ENAR)Joseph AK, Li Y, Zhao XF, Teo BB, Quinto C, Marron SG, Diangkinay A,

Nasrun K, Chua CP Rachel, Tay BH Serene, Leong FW Alice, John RA

Acopio and Iliyan C Zith

Endoscopy Centre, Khoo Teck Puat Hospital, Singapore

Nursing Administration, Khoo Teck Puat Hospital, Singapore

Background:

For cases that are admitted as same day admission (SDA), Nurses are required to manually fill up multiple forms during admission, handover and discharge to inpatient ward. This has led to multiple transcription with similar information on multiple forms and checklist. This whole process of documentation takes up to 40 minutes to complete. With different individuals documenting the same set of information, reports and post procedure instructions are easily misinterpreted and misunderstood during handover. Nurses in the ward has to resort to flipping multiple documents in the case folder in search of post procedure instructions and information. Thus giving rise to delay in continuation of care to the patient.

Aim:

This project aims to achieve Patient-Centered Standards – International Patient Safety Goal (IPSG) 2: Effective Communication, between Endoscopy nurses and Inpatient ward nurses with electronic Nursing Assessment Record (eNAR) on SCM. A standard post procedure instruction template on eNAR was created to increase time saving and reduce transcription error which enables the patients to have access to care and continuity of care post ERCP procedure in the ward.

Methods:

There were collaborations between Endoscopy Centre, Nursing Informatics department and In-patient departments. Discussions and meetings were conducted with Nursing Informatics and In-patient departments on specification and design of post ERCP template. Roadshows were done in Endoscopy Centre for Nurses to be familiarised with the use of SCM, eNAR and the post ERCP template before the roll out.

Results:

There was a big reduction on the time used for documentation with the implementation of eNAR. Documentation time used was reduced from 40 minutes to 12 minutes for each SDA patient. This time saved were effectively used for cases turnaround, thus reducing waiting time for other patients. This implementation has also resulted in reduced consumptions of paper – hardcopies of checklist, continuation sheet, fall risk assessment etc etc. Nurses in Endoscopy Centre were able to achieve clear, precise and standardized documentation with the use of post ERCP template on SCM eNAR. Handover of post procedure instructions to ward Nurses were made hassle free and the continuity of care of patient were improved with the use of one centralized electronic Nursing Assessment Record.

Conclusion:

With eNAR inter-departmental communication has improved, nursing time has been used effectively to provide quality care to the patients. Precise and accurate post ERCP documentation were achieved with the use of eNAR.

GIHep 2018 | 131

ENHANCEMENT OF PERI-ENDOSCOPY NURSING CARE CHECKLIST TO ENHANCE PATIENTS’ SAFETY, SUITE EFFICIENCY AND STAFF EXPERIENCE - A CASE STUDY IN A HIGH-VOLUME, ENDOSCOPY SETTINGNg, RM, Elizabeth SS Christopher, Samantha Ng Qi Li, Sui Cer Chin,

Nenny Suzanah (faciliatator), Chua PH, Azhar Mohd

Ambulatory Endoscopy Centre, Singapore General Hospital, Singapore

Background :

A comprehensive peri-endoscopy nursing care checklist is an essential tool to ensure the completeness of pre- procedure review, and enhance patient safety, suite efficiency and staff experience in a high volume, fast-paced endoscopy centre. The aim of this study is to review, optimize and enhance the current pre- procedure checklist.

Aim:

Enhancement of peri-endoscopy nursing care checklist to enhance patients’ safety, suite efficiency and staff experience- a case study in a high-volume, endoscopy setting

Method:

• Pre-survey of current pre procedure tasks and processes performed by nurses in AEC.• Implementation of an improved peri-endoscopy nursing care checklist in a pilot study.• Conduct a post outcome survey.

Results:

• Suite efficiency-reduction of time taken for endoscopy procedures to commence when using a more comprehensive peri endoscopy nursing checklist.

• Enhanced patient safety - Negate number of near miss events with regards to patients’ medical history

• Enhanced staff experience- Minimised unnecessary staff movement to pre-procedure counters to clarify patient’s information.

Conclusion :

Enhancement of the peri-endoscopy nursing care checklist has enhanced patients’ safety and satisfaction through their journey in AEC.

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Nursing Free Paper Poster PresentationENHANCED PATIENT AND STAFF EXPERIENCE AND EFFICIENCY FOR THE POST- PROCEDURE RECOVERY AND DISCHARGE PROCESS IN AN ENDOSCOPY SETTINGNg, Valleri, Jia Xin, Lee MH, Ren Jing, Wu Ying, Thazin, Nenny Suzanah

(facilitator), Azhar Mohd, Chua PH


Aims:

To enhance patient and staff experience during recovery and discharge process in the endoscopy setting

Method:

• Root cause analysis was conducted • A pre- post implementation survey was collated form staff and patients

Result:

A qualitative survey from discharge nurse indicates that disruption in workflow was significantly reduced and waiting time of patient in discharge has improved.

134 | GIHep 2018

ENHANCEMENT OF PERI-ENDOSCOPY NURSING CARE CHECKLIST TO ENHANCE PATIENTS’ SAFETY, SUITE EFFICIENCY AND STAFF EXPERIENCE- A CASE STUDY IN A HIGH-VOLUME, ENDOSCOPY SETTINGNg, RM, Krizen Cueto, Nenny Suzanah (faciliatator), Chua PH, Azhar

Mohd, Mohd Nabil Fadhil


Aims:

Efficient scheduling of quality assurance test for microbiological culture meet service demands in a high-volume, fast –paced, endoscopy setting with optimized equipment inventory.

Background:

Ambulatory Endoscopy Centre (AEC) at present is attending to up to 30,000 procedures annually. Despite its high volume, the centre has a low and optimised inventory for endoscopes, Microbiological culture is done on selected endoscopes to maintain quality assurance weekly. This reduces up to 10% to 20% of available endoscopes inventory for use. It is imperative that the scheduling pattern of culture for endoscopes is efficient so as to meet service demands

Methods:

• A review of daily patient volume against available endoscope inventory is conducted.• Pattern and trending is done on available inventory• A pre and post implementation survey is done to evaluate effectiveness of the planned

scheduled for microbiological culture.

Results:

• Hourly supply of endoscopes meets the demand of lists• Results of survey is positive for staff, especially stakeholder experiences

Conclusion:

Endoscopes use remained optimal with the aid of an efficient schedule for microbiological culture despite having a low stock inventory.

GIHep 2018 | 135

IMPLEMENTATION OF AN ENHANCED PATIENT EXPERIENCE WORKFLOW FOR GA-ASSISTED ENDOSCOPY PROCEDURES- A CASE STUDY IN AN AMBULATORY ENDOSCOPY CENTRE SETTINGMa, XY, Nenny Suzanah, Li LX, Goh Atikah, Tan, MY,), Chua PH, Azhar

Mohd, Naranderjit Kaur


Introduction:

Implementation of a New Workflow for GA-Assisted Endoscopy Procedures: A Case Study In An Ambulatory Endoscopy Centre Setting.

Background:

Traditionally, GA assisted endoscopic cases are performed adhoc according to the availability of the anaesthetist, endoscopy suites, GA support team from OT. This results in complexities in planning or arranging for endoscopic cases that require GA support. To optimise and smoothen workflow to negate and reduce complexities, the workflow was reviewed. A stakeholder discussion of departments involved was conducted and a new workflow was implemented.

Methods:

• Root cause analysis was used to investigate the causes using a fish bone diagram. • The efficacy of the new workflow was reviewed and a survey was conducted among the

stakeholders.

Results:

Results were positive. Complexities were reduced.

Conclusion:

The enhanced workflow implemented creates a standardised foundation for listing GA endoscopic cases that are reduced in complexities.

136 | GIHep 2018

PREVENTING MISSING HP ONE SPECIMENIdris, R., Xue, F., Wang, C., Kumaran, T., and Koo, Y. H.

Department of Endoscopy Center, Ng Teng Fong General Hospital, Singapore

Background/Aim:

In Ng Teng Fong General Hospital (NTFGH), a commercial rapid urease test kit (HP ONE) is used to detect Helicobacter pylori infection. From Apr 2016 to Apr 2017, 4 incidents of missing specimen occurred and had caused delay in patients’ treatment. Therefore, a project team was formed and aimed to prevent further incidents.

Methods:

Three Plan-Do-Study-Act (PDSA) cycles was used to test the changes. 1st PDSA cycle was started in Apr 2017, while it was tried the 5th incident occurred. Hence in May 2017, the 2nd PDSA cycle was immediately executed.

During the 2nd PDSA cycle, the Model for Improvement (Langley et al, 2009) was introduced to guide the project. Scientific measures and run charts were established. Effective tools such as SMART, SIPOC, root cause analysis, Pareto chart and Impact vs Implementation matrix were applied. Based on the root causes identified, the 3rd change was carried out in Nov 2017; keep the specimen in the standard biohazard specimen bag into the patient’s thin folder till patient discharge, and modifying the specimen recording file to record handover process and witnessing the discard of the specimen.

Results:

The 3rd PDSA change was effective and spread on from Feb 2018. By 24 April 2018, NTFGH Endoscopy department had achieved 328 days of incident-free.

Conclusion:

Systematic approach is needed to achieve sustainable change. The Model for Improvement is recommended for healthcare quality improvement projects.

GIHep 2018 | 137

REDUCED RATES OF REPAIR, REDUCED EQUIPMENT DOWNTIME AND ENHANCED COST EFFECTIVENESS WITH A MULTI-PARTY AND MULTI- LEVEL STRATEGY- THE EXPERIENCE IN A HIGH- VOLUME ENDOSCOPY CENTRENenny Suzanah, Mohd Nabil Fadhil, Noor Azlina, Pawandeep Kaur,

Elizabeth Sashi Devi, Ng Ll Samantha, Azhar Mohd


Aims:

To minimize rates of repair, and down-time attributed to equipment repair and servicing in high volume endoscopy center with optimal inventory

Background:

• High volume centre uses a model of a batch reprocessing of endoscope, with an optimal inventory of endoscopes

• There was an increase in rates of repair over a period of 12 months.• Increased occurrence of repair results in longer in long down-time and build-up of

inventory out for servicing

Methods:

• Root cause analysis was conducted on the causes for damage. • Pattern and trending of damage and repair occurrences were initiated• Multi party- collaboration and multi-pronged strategy was implemented • Outcome was measured

Outcome:

• Lesser incidence of repair reported within 2 months.• Decrease in repair costs • Positive outcomes noted.

138 | GIHep 2018

TO ALLAY PATIENT’S ANXIETY WHILE WAITING IN A PRE- PROCEDURE LOUNGE OF A HIGH VOLUME ENDOSCOPYNg Valleri, Jia Xin, Lee MH, Thazin, Renjng, Wu , Nenny Suzanah

(Facilitator), Azhar Mohd, Chua Puay Hoon, Naranderjit Kaur


Objectives:

Establish an interactive platform for patient to understand the whole journey in endoscopy centre.

Method:

• Root cause analysis was conducted• A pre- and postimplementation survey was conducted

Result:

Feedback from nurses have shown that patients feel less anxious after being oriented through a video demonstrating the journey in endoscopy centre.

Conclusion:

Educating your patients is vital in every ounce of our nursing care. Not only does it improve the patient’s compliance and knowledge but also ensures the clearance of any doubts and allayment of fears. Interactive educational tool are essential tools in minimizing patient discomfort while waiting.

GIHep 2018 | 139

N8601096-032018

Explore How NBI and Zoom Endoscopes Contribute

to Improved Detection and Characterization

The Head and Neck RegionUp to 92% higher sensitivity

Up to 22% higher accuracy

The EsophagusUp to 42% higher sensitivity

Up to 32% higher accuracy

How Can NBI Help

in the Head and Neck Region and Esophagus?

NBI with magnification can help physicians significantly improve detection and characterization rates in

the head and neck region, as well as the esophagus.

The latest study shows that compared to WLI, Olympus technologies can detect 92% more superficial

cancer and increase diagnostic accuracy up to 22% in the head and neck region. Detection is 42%

higher and accuracy up to 32% higher in the esophagus.

Olympus technologies help physicians raise quality of care by driving detection rates and accuracy.

Muto et al. 2010; J Clin Oncol.28(9):1566-72

140 | GIHep 2018

GIHep 2018 | 141

Gastroenterological Society of Singapore

c/o Wizlink Consulting Pte Ltd2 Venture Drive #16-16Vision ExchangeSingapore 608526URL: http://www.gastro.org.sg

Chapter of Gastroenterologists

College of Physicians, Singapore81 Kim Keat Road, #11-00 NKF CentreSingapore 328836URL: http://ams.edu.sg/colleges/CPS/chapter-of-gastroenterologists


11 Jalan Tan Tock SengSingapore 308433URL: http://www.ttsh.com.sg

Wizlink Consulting Pte Ltd

2 Venture Drive #16-16Vision ExchangeSingapore 608526Tel: (+65) 6774-5201Fax: (+65) 6774-5203Email: [email protected]

Organiser

Co-Organisers

Supporting Societies

Conference Secretariat

142 | GIHep 2018

AcknowledgmentThe GIHep Singapore 2018 Organising Committee will like to thank the following for their kind and generous contributions:

DIAMOND:

PLATINUM:

BRONZE:

GOLD:

EXHIBITORS:

GIHep 2018 | 143

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Documents

ANNUAL SCIENTIFIC MEETING 6 - 8 - GIHep...GIHep 2018 | AOrganiser: Co-organiser: ANNUAL SCIENTIFIC MEETING 7 - 8 JULY 2018 Mandarin Orchard Singapore LIVE ENDOSCOPY WORKSHOP 6 JULY