[Endoscopic diagnosis, treatment, and follow-up of polyps of the lower gastrointestinal tract]. / Endoskopische Diagnostik, Therapie und Nachsorge von Polypen des unteren Gastrointestinaltrakts.

BACKGROUND: The endoscopic management of polyps of the lower gastrointestinal tract (l-GIT) has emerged in recent years as a result of numerous technological innovations. However, proven expertise and experience are essential. OBJECTIVES: Presentation of novel and standard techniques and best-practice recommendations for the characterization and resection of l­GIT polyps. METHODS: Recent specialist literature and current guidelines. RESULTS: High-definition endoscopy should be the standard when performing colonoscopy. The (virtual) chromoendoscopy can improve detection and characterization of polyps, but always requires special expertise and experience of the endoscopist in advanced endoscopic imaging. In this regard, computer-aided-diagnosis (CAD) systems have the potential to support endoscopists in the future. Pedunculated polyps should be removed with a hot snare. Small flat polyps can be resected by cold snare or large forceps. Large, non-pedunculated polyps should be treated in an interdisciplinary approach at a referral center with long-standing experience depending on its malignancy potential. After complete resection of small adenoma without high grade dysplasia, surveillance endoscopy is recommended after 5-10 years. Patients with large adenoma or high grade dysplasia should undergo endoscopy after 3 years and patients with multiple adenoma earlier than 3 years. After incomplete or piecemeal resection or insufficient bowel preparation, near-term endoscopy is recommended. CONCLUSIONS: Adequate characterization and treatment are essential for the appropriate management of l­GIT polyps.

Alvimopan Is Associated With a Reduction in Length of Stay and Hospital Costs for Patients Undergoing Radical Cystectomy.

OBJECTIVE: To evaluate the impact of alvimopan in patient undergoing radical cystectomy (RC) for bladder cancer. We hypothesize that alvimopan can decrease cost for RC by reducing length of stay (LOS). METHODS: We identified patients who underwent elective RC for bladder cancer from 2009 to 2015 in the Premier Healthcare Database, a nationwide, all-payer hospital-based database, and compared patients who received and did not receive alvimopan in the perioperative period. Hospitals that had no record of administering alvimopan for patients undergoing RC were excluded. The primary outcomes were LOS and the direct hospital costs. The secondary outcomes were 90-day readmission for ileus and major complications. RESULTS: After applying the inclusion criteria, the study cohort consisted of 1087 patients with 511 patients receiving perioperative alvimopan. Alvimopan was associated with a reduction in hospital costs by -$2709 (95% confidence interval: -$4507 to -$912, P = .003), decreased median LOS (7 vs 8 days, P < .001), and lower likelihood of readmission for ileus (adjusted odds ratio: 0.63, P = .041). While alvimopan use led to higher pharmacy costs, this was outweighed by lower room and board costs due to the reduced LOS. There was no significant difference between 2 groups regarding major complications. These results were robust across multiple adjusted regression models. CONCLUSION: Our data show that alvimopan is associated with a substantial cost-saving in patients undergoing RC, and suggest that routine use of alvimopan may be a potential cost-effective strategy to reduce the overall financial burden of bladder cancer.

How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy.

OBJECTIVE: To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). METHODS: This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. RESULTS: Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes. CONCLUSION: We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Upper versus lower gastrointestinal bleeding: a direct comparison of clinical presentation, outcomes, and resource utilization.

PURPOSE: To compare prevalence, clinical outcomes, and resource utilization between subjects with lower gastrointestinal bleeding (LGIB) and upper gastrointestinal bleeding (UGIB). METHODS: Using administrative data, patient surveys, and chart abstraction, comparisons between subjects admitted with LGIB and UGIB were made by employing bivariate and multivariate statistics. RESULTS: A total of 367 subjects were identified, LGIB = 187 and UGIB = 180. Subjects with UGIB compared to LGIB had greater admission hemodynamic instability including tachycardia and orthostasis but clinical outcomes were similar. In multivariate analyses, no significant differences were observed for in-hospital mortality transfer to the intensive care unit (ICU) or 30-day readmission rate. Resource utilization was similar in UGIB and LGIB, including mean costs, length of stay, and number of endoscopic procedures. CONCLUSIONS: Unlike prior studies, this direct comparison of LGIB to UGIB identified more similarities than differences with similar prevalence rates, clinical outcomes, and resource utilization, suggesting that the epidemiology of gastrointestinal bleeding may be changing.

Palliative care and pain: new strategies for managing opioid bowel dysfunction.

Opioid analgesics are a cornerstone of pain therapy in the hospice and palliative care population. However, opioid-induced bowel dysfunction (OBD) is a commonly associated condition that frequently compromises the usefulness of these agents. Although its most common and debilitating symptom is constipation, the impact of OBD extends beyond constipation to encompass a myriad of gastrointestinal (GI) signs and symptoms, ranging from decreased gastric emptying and reflux to abdominal pain, cramping, bloating, nausea, and vomiting. Even after aggressive therapies to improve bowel function have been implemented, many patients continue to experience symptoms of OBD. To avoid these unwanted effects, some even choose to decrease or discontinue therapy with opioid analgesics, and experience inadequate pain control. The net result of OBD is a seriously negative impact on quality of life (QOL). For these reasons, it is important that palliative care practitioners have an adequate understanding of normal GI function and the underlying mechanisms responsible for OBD, the burden of OBD in the context of appropriate and effective pain management, and the benefits provided by effective pharmacotherapy. Several real-world cases are discussed to illustrate the application of optimal symptom management and the use of strategies that minimize the effects of OBD and improve patient QOL.

Doenças do trato gastrintestinal / Gastrointestinal diseases

O trato gastrintestinal é um tubo que está em continuidade com o meio ambiente externo em ambas as extremidades. Essa via mede de 7 a 8 metros de comprimento. Ela se estende desde a boca passando através do esôfago, do estômago e dos intestinos, vai até o ânus. Com o processo de envelhecimento, começam a ocorrer alterações que vão influenciar o processo digestivo