Management of dyspepsia-The role of the ED Observation unit to optimize patient outcomes.

BACKGROUND: Dyspepsia is a common complaint that can confer significant burden on one's quality of life and may also be associated with serious underlying conditions. The objective of this study was to determine if patients admitted to the emergency department observation unit (EDOU) for severe or persistent dyspepsia would have cost effective management in terms of investigations performed, length and cost of hospital stay. The secondary objective was to determine if any patient characteristics could predict a need for admission to the inpatient unit. METHODS: Retrospective chart reviews of patients admitted to the EDOU under the Dyspepsia protocol between January 2008 and August 2014 were conducted. Baseline demographics, investigations performed, outcomes related to EDOU stay, admission and 30-day re-presentation outcomes were recorded. RESULTS: A total of 1304 patients were included. Median length of stay was 1day. Cumulative bed-saved days were 38 per month. Two hundred eighteen (16.7%) patients required admission to the inpatient service for further management, while 533 (40.9%) and 313 (24.0%) patients underwent esophagogastroduodenoscopy and hepatobiliary ultrasonography, respectively. No major adverse events were attributed to the EDOU admissions or delays in treatment. No significant clinically relevant factors were associated with a need for admission from the EDOU to the inpatient unit. Median cost of the EDOU admission was approximately one-third that of a similar admission to the inpatient unit. CONCLUSION: The EDOU is an appropriate setting to facilitate investigations and treatment of patients with dyspepsia with considerable bed-saved days.

Preoperative diagnosis of a paraesophageal bronchogenic cyst using endosonography.

Preoperative diagnosis of paraesophageal bronchogenic cysts is difficult, and its management remains controversial. We describe the case of an incidental paraesophageal bronchogenic cyst, suspected preoperatively with endoscopic ultrasound and established intraoperatively by thoracoscopic inspection. Surgical treatment was achieved by cyst excision using a needlescopic technique. Endoscopic ultrasound seems to be the preoperative diagnostic test of choice for paraesophageal bronchogenic cysts.

Effect of biopsies on sensitivity and specificity of ultra-rapid urease test for detection of Helicobacter pylori infection: a prospective evaluation.

AIM: To prospectively assess the sensitivity, specificity and time to positivity of theUltra-rapid urease test (URUT) for Helicobacter pylori (H pylori), and compare the results of one with those of two biopsies. METHODS: Five antral biopsies were taken in consecutive patients undergoing upper endoscopy: one and two biopsies for URUT, and one each for H pylori culture and histology. URUT was read at 1, 5, 10, 20 and 30 min, 1, 2, 3 and 24 h after biopsy insertion into the reagent. A positive histology and/or culture was used as positive reference "gold standards". RESULTS: URUT was more sensitive for detecting H pylori with two biopsies rather than one, at all time points up to 120 min. The sensitivity improved from 3.6% to 82.1% for one biopsy and 10.7% to 85.7% for two biopsies from 1 to 120 min. The sensitivity reached 96.4% at 24 h for both, but the specificity reduced from 100% to 96% and 92% for one and two biopsies, respectively. CONCLUSION: Development of a positive URUT result is hastened by doubling the number of gastric biopsies. We recommend taking two instead of one biopsy to achieve an earlier positive URUT result so that H pylori eradication therapy can be initiated before patient is discharged from the endoscopy suite.

Diagnosis and treatment of Helicobacter pylori for peptic ulcer bleeding in clinical practice - factors associated with non-diagnosis and non-treatment, and diagnostic yield in various settings.

BACKGROUND/AIMS: To study the practice of clinicians in the diagnosis and treatment of H. pylori for peptic ulcer bleeding, and the diagnostic yield of H. pylori tests in various situations. MATERIALS AND METHODS: All consecutive patients aged ≥18 years who underwent esophagogastroduodenoscopy for the indications of coffee-grounds vomitus, hematemesis or melena with endoscopically diagnosed peptic ulcers were included. RESULTS: 374 patients were included. H. pylori testing was performed during acute bleeding for 296 patients. 80% of patients who tested negative for H. pylori during the acute episode were planned for repeat H. pylori testing. 11/88 patients who tested negative for H. pylori during the acute episode were positive for H. pylori during repeat testing (diagnostic yield 12.5%). Prior proton-pump inhibitor and antibiotic ingestion within 4 weeks of presentation was associated with lower diagnostic yield for H. pylori. On multivariate analysis, patient's age, systolic blood pressure, heart rate, activated partial thromboplastin time, and need for endoscopic treatment were associated with failure to take biopsies for H. pylori testing during acute episode. 100/106 patients tested positive for H. pylori during the acute episode of gastrointestinal bleeding had H. pylori treatment. CONCLUSION: Repeat H. pylori testing after index negative H. pylori testing during acute episodes gave a diagnostic yield of 12.5%, reinforcing the importance of repeat testing.

High output enterocutaneous fistula: a literature review and a case study.

An enterocutaneous (EC) fistula is referred to as a channel between the gut and the skin. Effluent of an EC fistula of more than 500 ml per day is considered as high output. Patients with high output EC fistulae have a high morbidity and mortality rate. No evidence-based guidelines are available for this condition and more research is required to evaluate the effectiveness of treatment. Nevertheless, patients with fistulae should be managed based on the available evidence, detailed clinical and nutrition assessment, and close monitoring. Management of high output EC fistula is complex and challenging. It involves nutrition, medical, skin care and psychological treatment, which is best managed by a multidisciplinary team. It requires an individualized nutrition and clinical treatment plan to maximize patient outcomes. Up to 70% of patients with fistulae have malnutrition and it is a significant prognostic factor of spontaneous fistula closure. Nutrition therapies including macronutrient and micronutrient delivery, enteral nutrition and parenteral nutrition are discussed in this review. A case study of a patient with multiple EC fistulae is presented to illustrate the management of high output EC fistulae.