Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an accepted method of placing a feeding tube to enable enteral feeding in patients with swallowing difficulties. However, the factors associated with complications and death after PEG have not been studied in detail. We describe the largest audit of deaths after PEG tube insertion. OBJECTIVE: Our purpose was to determine the factors associated with death after PEG tube insertion. DESIGN: Deaths occurring within 30 days after PEG tube insertion in the United Kingdom between April 2002 and March 2003 were identified and a questionnaire was sent to the consultant endoscopist for completion. PATIENTS: A total of 719 patients (391 male, median age 80 years, range 26-98 years) who died within 30 days after PEG insertion were identified for this study. SETTING: United Kingdom hospitals. MAIN OUTCOME MEASUREMENT: Cause of death. RESULTS: A total of 97% of the identified patients had coexistent neurologic disease. PEG tubes were inserted by specialized GI physicians in 522 cases (73%). Seventy-two patients (10%) required reversal agents after sedation. After PEG tube insertion, 309 patients (43%) died within 1 week. Death was due to cardiovascular disease (n = 175), respiratory disease (n = 508), central nervous system disease (n = 358), renal disease (n = 38), and hepatic failure (n = 11). In 136 cases (19%) the National Confidential Enquiry into Patient Outcome and Death expert panel regarded the procedure as futile. LIMITATIONS: Retrospective review of case records. CONCLUSIONS: Mortality and morbidity rates after PEG tube insertion are not insignificant. Selection of patients is paramount to good patient outcomes. Multidisciplinary team assessment should be performed on all patients being referred for PEG tube insertion.

Who follows up patients after PEG tube insertion?

BACKGROUND: Community follow-up is often inadequate for patients discharged from hospital following commencement of PEG tube feeding. OBJECTIVE AND METHODS: We performed a postal questionnaire to assess if patients/carers were trained in the care of the PEG tube pre-discharge and whether appropriate community follow-up was in place. RESULTS: Of 166 PEG tubes inserted during the study period, 66 patients were alive at least 6 months following PEG tube insertion. Response rate was 44% (29 of 66 patients). Of the 29 respondents, 21 (72%) had been taught how to manage the tube, feeds and feeding pumps prior to discharge; 17 (59%) had their swallow re-assessed following PEG tube insertion and 16 (55%) patients were able to take some food or liquids by mouth. Twenty-four (83%) patients had had dietetic assessment following discharge. Fifteen patients had encountered problems with the PEG tube, 14 of whom knew who to contact in the event of a problem, all of which were resolved. In six of the 14 cases the respondent felt that the experience was not satisfactory for the patient/carer and that the resolution of PEG-related problems could be improved. In 9 (31%) cases the PEG tube had been removed. CONCLUSIONS: Over two-thirds of patients/carers had been trained regarding PEG tube care. As expected, dietetic follow-up was in place for the majority of patients. Approximately one third of patients had had their PEG tube removed. Ongoing PEG tube feeding may not be required in all of the remaining patients. Most PEG tube problems were resolved although there is still scope to improve the PEG follow-up service.

Diagnostic criteria for coeliac disease: time for change?

A spectrum of histological changes may be seen in coeliac disease. Interpretation of duodenal biopsies can be problematic due to inadequate specimens or difficulties in detecting the minimal histological lesion. If serology is negative but clinical suspicion is high, a duodenal biopsy should always be performed. A combination of histology, serology, morphometry and HLA typing may be helpful in equivocal cases. Small intestinal histology is the current gold-standard diagnostic test for coeliac disease. Serological tests, immunohistochemistry and HLA typing may also have a role in the diagnostic algorithm. IgA antigliadin antibodies have mainly been replaced by IgA antiendomysial antibodies and IgA antitissue transglutaminase antibodies. The high sensitivity and specificity of these new markers have been used to challenge the necessity of obtaining a duodenal biopsy to confirm the diagnosis. It is widely recognized that relying on duodenal biopsies may be problematic. In equivocal cases where the biopsy material cannot be relied on accurately, further diagnostic tests are necessary. Quantitative morphometry and immunohistochemistry may be of value in identifying intraepithelial lymphocytes and a specific subset bearing the gamma/delta receptor. HLA-DQ2 may have a role in excluding the diagnosis in equivocal cases, its main limitation being its high frequency in the normal population. Each diagnostic test, namely histology, serology or genetic typing has limitations. A combination of these diagnostic tests should be used to clarify the full breadth of the gluten sensitivity spectrum, in particular, in those cases where duodenal histology may be equivocal.

Quality of life in screen-detected and typical coeliac disease and the effect of excluding dietary gluten.

OBJECTIVE: It is widely recognized that 'asymptomatic' patients with coeliac disease often feel better after commencing a gluten-free diet. The aim of this study was to determine a measure of the quality of life in patients diagnosed as having coeliac disease detected both by screening and those with typical clinical symptoms. METHODS: Quality of life (QoL) was measured using the SF36 questionnaire. This was completed prospectively by all subjects who agreed to undergo duodenal biopsy as a follow-up to a serological screening programme. Seventeen typical coeliac patients who presented clinically also completed the QoL assessment at diagnosis. Both coeliac groups were compared to healthy controls. SF36 questionnaires and coeliac serology were repeated in coeliac patients after 1 year on a gluten-free diet. RESULTS: There were no significant differences between the eight SF36 parameters when the screen-detected coeliac patients were compared to controls, and at 1 year follow-up compared to their baseline data. Two QoL parameters (general health, vitality) improved significantly in the typical coeliac patients at 1 year follow-up compared to their baseline data. General health with reference to 1 year previously significantly improved in typical coeliac patients (3.8 vs 2.2; P = 0.0004) but not screen-detected coeliac patients (2.9 vs 2.4; P = 0.08). CONCLUSIONS: Quality of life in screen-detected coeliac patients did not differ significantly compared to controls. Two of eight QoL parameters improved significantly in typical coeliac patients compared to baseline data. Dietary gluten exclusion in typical coeliac patients led to a significant improvement in health at 1 year follow-up, in contrast to screen-detected coeliac patients.

Intra-epithelial T cells in coeliac disease.

Coeliac disease is an enteropathy associated with dietary gluten which occurs in individuals with a genetic predisposition. The pathogenesis remains obscure although it is clear that only certain parts of the gliadin molecule are toxic and there is considerable evidence of immunological activity, including antibody production. In this issue of European Journal of Gastroenterology and Hepatology Carton et al. present evidence in favour of an inherent depletion of CD4CD8 T cells, which could result in a loss of oral tolerance to ingested gliadin. Using flow cytometry they also demonstrated that the classic T-cell infiltration of coeliac disease is not due to an increase in T cells but is an apparent increase associated with a relative decrease in enterocytes as a result of the change in architecture of the mucosa. These could be important fundamental observations in helping to unravel the pathogenesis of coeliac disease.

A comparison of antibodies to tissue transglutaminase with conventional serological tests in the diagnosis of coeliac disease.

BACKGROUND: Tissue transglutaminase is now recognized as the autoantigen for antiendomysial antibodies. Antibodies to tissue transglutaminase have been proposed as a valuable test for coeliac disease. OBJECTIVE: To determine the value of antibodies to tissue transglutaminase in the diagnosis of coeliac disease in our outpatient population. METHODS: Patients who underwent serological tests for coeliac disease during the first 18 months of the tissue transglutaminase antibody assay were retrospectively identified from the regional serology laboratory database. Patients' symptoms were noted, along with serological results and duodenal histology in those patients who underwent duodenal biopsy. RESULTS In total, 586 patients were identified as having been serologically tested for coeliac disease, of whom 92 patients (33 men; mean age 51.7 years) had been followed up with duodenal biopsies. Of these 92 patients, 29 (31%; 14 men; mean age 52.5 years) had histological features of coeliac disease. The 63 patients with normal histology (19 men; mean age 51.8 years) acted as controls. Weight loss was more frequent in coeliac disease patients compared to controls (7 vs 5; P = 0.04) whereas the frequency of anaemia (P = 0.85) and diarrhoea (P = 0.74) did not differ significantly between the two groups. The sensitivity and specificity of tissue transglutaminase antibodies (86%; 84%) were compared to those for antiendomysial antibodies (90%; 98%) and antigliadin antibodies (76%; 79%). CONCLUSIONS: The diagnostic value of tissue transglutaminase antibodies was intermediate between that of antiendomysial antibodies and antigliadin antibodies. However, duodenal biopsy remains the gold standard diagnostic test for coeliac disease.

Acute onset dysphagia associated with an intramural oesophageal haematoma in acquired haemophilia.

A 78-year-old man presented with a 5-day history of epistaxis and spontaneous bruising, and a 2-day history of acute dysphagia. Barium swallow, computerized tomography scan of the chest and upper gastrointestinal endoscopy were suggestive of an upper oesophageal tumour, although biopsies failed to confirm this. Investigations including a raised activated partial thromboplastin time led to the detection of an inhibitor causing functional factor VIII deficiency. Following treatment with intravenous human immunoglobulin, oral prednisolone and oral cyclophosphamide, the patient's dysphagia resolved. There was a resolution of the findings seen at the initial endoscopy and on computerized tomography scan of the chest, consistent with an oesophageal haematoma. Follow-up endoscopy failed to detect recurrence or an aetiological factor.

Cardiovascular morbidity and mortality after orthotopic liver transplantation.

BACKGROUND: Hyperlipidemia and hypertension have been reported in liver allograft recipients and contribute to an increased risk of ischemic heart disease (IHD) after orthotopic liver transplantation (OLT). The aims of the study were (1) to determine the prevalence of risk factors for IHD in these patients and (2) to compare the observed incidence of cardiovascular events and related mortality in allograft recipients with a matched population. METHODS: One hundred ten consecutive adults (50 male) who attended for review after OLT (median follow-up 3.9 years; range 0.1-17.9) were assessed for cardiovascular risk factors using current blood pressure, diabetic status, and smoking history and measurements of total cholesterol, high-density lipoprotein cholesterol, and triglyceride concentrations. Cardiovascular events and cardiovascular mortality data were collected from the prospective database of all adult liver allograft recipients and compared to matched data from myocardial infarction registries and Office for National Statistics data, respectively. RESULTS: Raised serum cholesterol (>5.0 mmol/L) was found in 48 (44%) patients (18 male), and systolic hypertension (>140 mmHg) was found in 69 (63%) patients (27 male). The relative risk of ischemic cardiac events was 3.07 (95% [confidence interval] CI, 1.98-4.53) and the relative risk for cardiovascular deaths was 2.56 (95% CI, 1.52-4.05) in allograft recipients compared to an age-matched population without transplants. CONCLUSIONS: Liver allograft recipients have a greater risk of cardiovascular deaths and ischemic events than an age- and sex-matched population. The prevalence of raised cholesterol concentrations in patients after OLT is similar to those in previous reports. Moderate hypertension and hyperlipidemia may be more detrimental in patients after OLT compared to non-transplant patients without these risk factors.