When is feeding via a percutaneous endoscopic gastrostomy indicated?

PURPOSE OF REVIEW: This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS: There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY: Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.

In Praise of Richard Asher (1912-1969).

This essay aims to stimulate a reawakening of interest in the writings of the physician Richard Asher (1912-1969), who is now best known for coining the term "Munchausen's syndrome." Asher's essays are as relevant now as when first published. His articles were a model of clarity, wit and elegance: he argued consistently for precision in thought and expression, for logic in clinical thinking, and for evidence in treatment.

Ethereal and material gain: unanticipated opportunity with illness or disability.

When caregivers address the positive aspects of illness or disability, there is a risk of patronising the sufferer. It is equally problematic when secondary gain is judged in a negative light and impedes an effective doctor-patient relationship. Changing attitudes, and particularly the negative perception of a patient's gain from illness, are reflected in biographies of artists, philosophers and other creative individuals. In contrast, some memoirs about illness feature a retrospective discussion of the positive features of the experience - from one who is now free from the ordeal. The experience of continual sufferers may be more instructive. We examine contemporary examples of unanticipated advantage or gain arising from ongoing disability or illness. The contribution of disability/illness to remarkable achievement promotes enhanced self-appreciation for patients and may foster in others a better understanding of what it means to suffer and live with disability.

Against narrative medicine.

This essay aims to provoke debate on how and what the medical humanities should teach. It argues that the field has been dominated (to its detriment) by two misguided movements, postmodernism and narrative medicine, and that it should be redirected from utilitarian aims towards the goal of exposing medical students to a climate of thought and reflection.

Petr Skrabanek: the abominable no-man.

Petr Skrabanek (1940-94) was a Czech-born doctor, polemicist and literary scholar. He qualified in medicine in Ireland, and spent most of his career at the Medical School of Trinity College Dublin. He was an outspoken critic of modern medicine, particularly of what he called 'coercive healthism'. Skrabanek's sceptical and iconoclastic ideas are more relevant today than ever. This essay aims to rekindle interest in his life and work.

Endoscopy in pregnancy.

Endoscopy is rarely required during pregnancy. The potential risks of endoscopy during pregnancy include foetal hypoxia due to sedative drugs and exposure to radiation. There is no evidence that endoscopy precipitates premature labour, and studies in this area have concluded that endoscopy during pregnancy is generally safe. There should be a strong indication for the procedure, which should be deferred whenever possible to the second trimester. Procedures should be performed without any sedation, or with the lowest dose of sedative medication. Radiation exposure should be kept to a minimum. Support should be obtained from specialists in obstetrics and anaesthesia. Indications for endoscopy during pregnancy are as follows: (1) gastroscopy: upper gastrointestinal bleeding, dysphagia, uncontrolled nausea/vomiting; (2) sigmoidoscopy/colonoscopy: rectal bleeding, diarrhoea; and (3) ERCP: choledocholithiasis, biliary pancreatitis. Sedative drugs, such as midazolam appear to be safe if used carefully. Radiation exposure during ERCP can be kept well below the danger level for teratogenicity.

Intestinal tuberculosis mimicking Crohn's disease: lessons relearned in a new era.

Over 400 000 cases of tuberculosis existed in Europe in 2002, 1% of which were intestinal tuberculosis. With population migrations on the increase, physicians may have to face an increase in intestinal tuberculosis. One of the attributes of intestinal tuberculosis is its ability to present in nonspecific ways and to mimic other disorders, in particular inflammatory bowel disease. We present a case series of intestinal tuberculosis presenting as inflammatory bowel disease and referred for management to a specialized clinic in inflammatory bowel disease, followed by a discussion of the difficulties encountered with this condition. We highlight the consequences that misdiagnosis can have, in an era where population demographics are changing in Europe and where immunomodulators and biological agents have the potential to do more harm than good.

Comparison of three stool antigen assays with the 13C- urea breath test for the primary diagnosis of Helicobacter pylori infection and monitoring treatment outcome.

BACKGROUND: The urea breath test (UBT) is the gold-standard non-invasive test for the detection of Helicobacter pylori infection, however, the lack of availability of the UBT due to the high cost of the test, and in particular the need for expensive analytical instrumentation, limits the usefulness of this method. Stool antigen assays may offer an alternative non-invasive method for the diagnosis of infection. OBJECTIVE: To compare the accuracy of three stool antigen assays (HpSA, IDEIA HpStAR, and ImmunoCard STAT) against the UBT for the primary diagnosis of H. pylori infection and for monitoring treatment outcome. METHODS: A total of 102 patients attending two gastroenterology day-case clinics for the investigation of dyspepsia were included. Each patient provided breath and stool samples for analysis. Patients who tested positive for H. pylori by the validated UBT were prescribed triple therapy and invited to return for repeat breath and stool sample analysis 6 weeks post-treatment. RESULTS: Of the 102 patients tested, 48 were diagnosed with H. pylori infection by the UBT. The HpSA assay interpreted 38 of these as positive (79% sensitive). Of the 54 UBT-negative patients the HpSA assay interpreted all 54 as negative (100% specific). The IDEIA HpStAR assay correctly identified 44 patients as positive (92% sensitive) and 50 as negative (92.5% specific). The ImmunoCard STAT assay interpreted 38 patients as positive (79% sensitive) and 52 as negative (96.3% specific). CONCLUSION: The findings indicate that the IDEIA HpStAR stool antigen kit is the most accurate assay of the three assays evaluated, and possibly represents a viable alternative to the UBT for the primary diagnosis of H. pylori infection and for monitoring treatment outcome.

Advanced hepatocellular carcinoma associated with cystic fibrosis.

Advances in the treatment of the respiratory complications of cystic fibrosis, including the availability of lung transplantation have led to a greater awareness of the manifestations of liver disease in up to 40% of patients with Cystic Fibrosis (CF). We report the case of an 18 year old female with CF who presented with advanced hepatocellular carcinoma and no prior clinical evidence of chronic liver disease. Hepatocellular carcinoma is usually the most severe manifestation of advanced cirrhosis although its development in non-cirrhotic cases of chronic liver disease has been reported. With the increasing life expectancy of CF patients it is likely that more unusual hepatic complications of this disease may be identified. Greater awareness may perhaps lead to earlier diagnosis in those at risk.