Patient outcomes related to percutaneous endoscopic gastrostomy placement.

Although many aspects of percutaneous endoscopic gastrostomy (PEG) have been addressed in the literature, attention to psychologic and social outcomes of PEG has been limited. Our goal was to assess a range of physical, psychologic, and social outcomes related to PEG feeding. This study is a follow-up survey of patients undergoing PEG and/or their surrogates. Data were collected by semistructured interviews in two tertiary hospitals in Alberta, Canada. Measurements consisted of PEG status at 1-year follow-up, quality of life, impact on caregivers, and opinions about long-term support via PEG. We included 71 patients in the study. Of all 39% of patients died, 32% had the PEG still in place, and for 28% the PEG was removed at the end of the 1-year follow-up. The prognosis of the attending physician at the initial visit and the underlying disease were significantly related to the outcome (p < 0.05). After 1 year, 85% of all patients whose PEGs were still in place, were not working or studying or managing their own household in any capacity, 67% were not managing personal care, and 19% were feeling very ill. Fifty-two percent of the caregivers spent 15 hours or more per week visiting and caring for the patient. At the 1-year follow-up, all ten surviving patients who could be interviewed agreed they would have a PEG again. Seventy percent of the caregivers said that they would want the same decision to be made. Although a majority of patients and caregivers did not regret the decision to place a PEG, this did not necessarily mean enhanced quality of life. Developing strategies to select patients who will benefit from long-term nutritional support could improve patient outcomes.

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding.

OBJECTIVE: This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding. METHODS: One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus. RESULTS: In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids. CONCLUSIONS: In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.

How are decisions made about the use of percutaneous endoscopic gastrostomy for long-term nutritional support?

OBJECTIVE: We sought to study the process by which decisions to commit individuals to long-term nutritional support via percutaneous endoscopic gastrostomy (PEG) are made. METHODS: A semistructured questionnaire was administered to surrogates and patients in 73 cases of persons undergoing PEG. RESULTS: Such decisions are often made with inadequate information regarding the PEG and its possible impact on the future clinical course, sometimes with an overly optimistic view of the prognosis. Several factors may influence this process. In cases in which the underlying illness was severe, 30% of surrogate decisionmakers expressed some uncertainty that a right decision was made. CONCLUSIONS: The decision to commit patients to long-term nutritional support via PEG is often difficult and the implications of such a commitment may have major implications for patients and their families. Strategies to optimize this decisionmaking process are recommended.

The utility of endoscopy in the management of patients with gastroesophageal reflux symptoms.

OBJECTIVE: The utility of endoscopy in the management of patients with symptoms of gastroesophageal reflux disease (GERD) is unclear. The purpose of this prospective study was to assess the impact of endoscopy on the subsequent management of patients with uncomplicated reflux symptoms. METHODS: A total of 742 patients underwent endoscopy for symptoms of GERD. Endoscopists recorded the therapy before endoscopy, the findings of endoscopy, and the treatment recommendations after endoscopy. RESULTS: There was no difference in pre-endoscopy therapy or grade of esophagitis in subjects undergoing endoscopy for failed therapy versus GERD symptoms alone. After endoscopy, the most common strategy for patients taking omeprazole was to maintain or increase the dose. For those taking an H2 blocker before endoscopy, the most common outcome was to switch the patient to omeprazole, independent of the grade of esophagitis. CONCLUSIONS: Most patients undergoing endoscopy for symptoms of GERD were switched to omeprazole regardless of the endoscopic findings. No esophageal cancer was identified and the incidence of Barrett's esophagus was low. It appears that endoscopy itself did not change the management of patients receiving H2-blocker therapy. A trial of a proton pump inhibitor before endoscopy should be considered.

Endoscopists' opinions of indications for upper gastrointestinal endoscopy.

OBJECTIVE: To determine whether endoscopists and general internists agreed with the characterization of appropriateness for endoscopy of various clinical scenarios, as previously reported by the RAND Corporation. DESIGN: Mail survey. STUDY SAMPLE: All endoscopists in western Canada and a random sample of general internists who did not perform endoscopy. METHODS: Questionnaires were sent to 179 endoscopists in western Canada who were asked to rate the 53 scenarios for endoscopy on a nine-point scale ranging from most appropriate to most inappropriate. A similar questionnaire was sent to 39 general internists practising in the province of Alberta. RESULTS: Response rate was 72% of endoscopists (n = 128) and 64% of general internists (n = 25). Among the endoscopists, there was agreement with the RAND classification for 32 scenarios. All 18 indications previously thought to be appropriate were considered to be appropriate. However, endoscopists agreed with only six of 16 equivocal and eight of 19 indications considered inappropriate. Discrepancies were reviewed by five experienced endoscopists and most appeared to be related to a concern regarding possible malignancy linked in part with the definition of failure to respond to medical therapy; and to a refusal to request a barium meal before endoscopy. Among general internists, there was agreement with RAND in 26 scenarios. When the appropriateness rankings of endoscopists and general internists were compared, there was agreement in 40 of 53 scenarios. Significant discrepancies in ratings were identified in scenarios in which barium studies were described as being normal, known or not done. CONCLUSIONS: The equivocal and inappropriate ratings developed by the RAND Corporation are not uniformly accepted by the endoscopy community or general internists. Use of the RAND indications for assessing quality assurance can be challenged.

Decision-making and outcomes for percutaneous endoscopic gastrostomy: a pilot study.

We undertook a retrospective review of 25 patients who had undergone percutaneous endoscopic gastrostomy (PEG). Data regarding the clinical courses were collected, and a questionnaire was administered to patients when possible; in most cases the individual responsible for care answered questions. We pinpointed concerns relevant to the decision-making process. In a substantial proportion of cases, the clinical courses subsequent to PEG were poor. Of 21 surrogates interviewed, 33% were uncertain that proceeding to nutritional support via PEG had been the right decision. Findings indicate a need to improve the process by which decisions to treat by PEG are made, ideally including better prognostic information.

Segmental colitis complicating diverticular disease.

Two cases of idiopathic colitis affecting the sigmoid colon in elderly patients with underlying diverticulosis are presented. Segmental resection has permitted close review of the histopathology in this syndrome which demonstrates considerable similarity to changes seen in idiopathic ulcerative colitis. The reported experience with this syndrome and its clinical features are reviewed.

A simple, non-invasive marker of gastric damage: sucrose permeability.

Disaccharides do not cross intact gastrointestinal mucosa to any appreciable extent unless there is damage to the epithelium. Furthermore, since sucrose is rapidly broken down in the small intestine, the absorption of intact sucrose implies damage to proximal epithelium. We have reported that measurement of sucrose permeability detects gastric damage in animals. Whilst such a non-specific test could not replace endoscopy, it might represent a clinically useful technique to identify patients who would benefit from endoscopy. 189 patients underwent endoscopy and assessment of sucrose permeability to evaluate the effectiveness of increased sucrose permeability in the prediction of endoscopic findings. The endoscopist was blinded to results of the sucrose assay. Gastric damage, particularly ulcers and severe gastritis, was successfully detected with this technique. Increased sucrose permeability, however, did not reliably detect mild gastritis, oesophagitis, or duodenal disease. The sensitivity of the test for gastric ulceration was 84% and specificity in predicting an abnormal endoscopy was 96%. Measurement of sucrose permeability is a simple way of screening for gastric damage. It has a sensitivity similar to that for upper gastrointestinal radiology and provides a new way to effectively screen large populations at risk of gastric damage.

Comparing peer and faculty evaluations in an internal medicine residency.

PURPOSE: To compare in-training evaluations of residents by their peers with evaluations by faculty preceptors in an internal medicine residency. METHOD: The study group consisted of 22 residents enrolled in the core (three-year) internal medicine program at the University of Calgary in 1989-90 and 1990-91. At the end of each rotation, ratings of the residents were requested from faculty preceptors and from peers for several categories of clinical competence. The peer ratings were paired with faculty ratings, for a total of 74 pairs of ratings. The Wilcoxon matched-pair signed-rank procedure was used to compare the paired ratings. One-way analysis of variance was used to compare the peer and faculty ratings with the residents' scores on three other kinds of evaluation used by the residency. RESULTS: While there was no significant difference between peer and faculty ratings for overall competence or for several components of competence, there were significant differences for some components, with faculty tending to rate higher than peers. The latter components were physical examination, team relationships, industriousness and enthusiasm, teaching, physician-patient relationships, and case presentations. External validation of the ratings by comparing them with other kinds of evaluation yielded little meaningful information. CONCLUSION: That the faculty ratings were significantly higher than the peer ratings for some components of clinical competence suggests that there were differences in the quality of evaluation between the peers and faculty, or differences in the standards or expectations of the two groups.

Inflammatory bowel disease.

An increasing number of options are available for the treatment of inflammatory bowel disease; the selection depends on the extent and severity of the disease. Experience with sulfasalazine and corticosteroids has led to a proliferation of 5-aminosalicylic acid (5-ASA) compounds and experimentation with alternative corticosteroid preparations. Given rectally 5-ASA is particularly effective in the treatment of distal ulcerative colitis, and experience is accumulating with several oral formulations. Metronidazole is useful in some cases, and immunosuppressive agents have a role in some patients with chronic refractory disease. A variety of measures, such as nutritional therapy, surgery and psychosocial support, are important elements of therapy. Further therapeutic innovations are expected as the etiology and pathogenesis are clarified.

Pilot study of cyclosporin A in patients with symptomatic primary biliary cirrhosis.

The purpose of this pilot study was to determine whether daily administration of cyclosporin A to symptomatic patients with primary biliary cirrhosis for 1 yr would lead to a significant and sustained improvement in liver enzyme abnormalities. Twelve adult patients (11 female, 1 male; aged 52.6 +/- 8.9 yr, mean +/- SD) with serologic and histologically defined primary biliary cirrhosis were randomized to receive either oral cyclosporin A or vehicle placebo. Cyclosporin A was administered at sufficient dosages to maintain serum radioimmunoassay trough levels between 100 and 200 ng/ml (starting dosage, 2.5 mg/kg.day). After 1 yr of therapy, significant changes from pretreatment values were seen only in recipients of cyclosporin A. These included a 37% decrease in mean serum alkaline phosphatase and a 43% decrease in gamma-glutamyltransferase (controls +3% and -14%, respectively). Mean serum bilirubin and albumin levels and prothrombin times remained unaltered in the two groups, as did the extent of inflammation and fibrosis and the histologic staging of liver biopsy specimens. Although mean serum creatinine levels increased by 51% in recipients of cyclosporin A (+2% in controls), there were no associated changes in diastolic blood pressure or creatinine clearance values. Other side effects including thrombocytopenia, hirsutism, headaches, tremor, and parasthesiae were common in the treated group but not of sufficient severity to warrant adjustment in the dosage or discontinuation of therapy. The observed changes in hepatic, renal, and hematologic tests tended to return to baseline after discontinuation of therapy. Two patients, both placebo recipients, died of liver failure during the study period. The results of this study indicate that in symptomatic primary biliary cirrhosis, cyclosporin A administration is associated with a significant improvement in cholestatic liver enzyme abnormalities that persists for the duration of therapy. A progressive rise in serum creatinine levels and a high incidence of side effects raise concerns regarding the long-term safety of this agent in primary biliary cirrhosis.