Trends in endoscopic retrograde cholangiopancreatography in children within the United States, 2000-2009.

We investigated the volume of endoscopic retrograde cholangiopancreatographies (ERCPs) performed in hospitalized children in the United States using a nationwide healthcare administrative database for the years 2000 to 2009. A total of 22,153 cases of ERCP were identified: 6372 diagnostic and 17,314 therapeutic (1533 cases were recorded as undergoing both types during a single hospitalization). The number of ERCPs increased from 5337 to 6733 per year; diagnostic ERCPs decreased 43% and therapeutic increased 69% (significant decreasing trends for diagnostic and increasing for therapeutic ERCPs, P<0.001 for each analysis). Our results define a recent increase in the use of therapeutic ERCPs in hospitalized children.

Cor triatriatum sinistrum presenting as cardioembolic stroke: an unusual cause of adolescent hemiparesis.

Cor triatriatum sinistrum is a rare congenital cardiac malformation, in which the left atrium (LA) is divided into two distinct chambers by a fibromuscular membrane. Classically, the proximal (upper or superior) chamber of the LA receives pulmonary venous connections, whereas the distal (lower or inferior) chamber contains LA appendage and true atrial septum containing fossa ovalis. The distal chamber is in continuity with the atrioventricular valve, while the two chambers communicate through a defect in the membrane. The hemodynamics of cor triatriatum sinistrum are similar to that of mitral stenosis due to obstructive property of membrane. The majority of reported cases of cor triatriatum occur in infants with symptoms of pulmonary venous obstruction, with adult cases being rare. Herein, we describe an unusual case of cor triatriatum in a 17-year-old boy who presented for the first time with embolic cerebral infarction with left hemiparesis.

A double-masked, randomized, placebo-controlled trial of temporary endoscopic mucosal gastric electrical stimulation for gastroparesis.

BACKGROUND: Endoscopically placed, temporary gastric electrical stimulation (tGES) may relieve symptoms of gastroparesis (Gp) and predict permanent gastric electrical stimulation (GES) outcomes. OBJECTIVE: To measure effects of 72 hours of temporary GES on Gp symptoms. DESIGN, SETTING, AND PATIENTS: From 2005 to 2006, we conducted a hospital-based, randomized, placebo-controlled, crossover trial of two consecutive, 4-day sessions (session 1 and session 2), enrolling 58 patients (11 males, 47 females; mean age 46 years) with GP symptom histories of three etiologies (idiopathic, 38; diabetes mellitus, 13; postsurgical, 7). INTERVENTION: 72 continuous hours temporary GES was provided for group A during session 1, and for group B during session 2. MAIN OUTCOME MEASUREMENTS: Symptoms measured daily; gastric emptying, electrogastrography, and quality of life measured at baseline and session close. RESULTS: In session 1, vomiting decreased in both groups, but was greater with stimulation, resulting in a day 3 difference of -1.02 (95% CI, -1.62 to -0.42; P < .001). Scores did not return to baseline during washout; on day 4, the difference persisted at -1.08 (95% CI, -1.81 to -0.35; P = .005). In session 2, vomiting slightly decreased with stimulation and slightly increased without it; at day 8, the nonactivated group had nonsignificantly greater vomiting, 0.12 (-0.68 to 0.92; P = .762). An overall treatment effect of a slight, nonsignificant daily decrease in average vomiting scores, -0.12 (-0.26 to 0.03; P = .116), was observed by pooling stimulation effects across sessions. LIMITATIONS: Missing data; potential physiological imbalances between groups. CONCLUSIONS: Although overall treatment effects were not significant, differences in favor of stimulation were suggested. Barriers to observing treatment effects included a decrease in vomiting for both groups during session 1, insufficient washout, and the absence of baseline vomiting for some patients. Future studies should better define inclusion criteria, use longer washout periods, randomize by etiology and baseline physiological findings, and pursue alternative designs. ( CLINICAL TRIAL REGISTRATION NUMBER: 00432835.).

Nursing practice of checking gastric residual volumes based on old dogmas: opportunity to improve patient care while decreasing health care costs.

It is a common practice to check gastric residual volumes (GRV) in tube-fed patients in order to reduce the risk of aspiration pneumonia. However, there is a paucity of scientific evidence to support this practice which consumes significant amounts of health care resources. We conducted a survey of the nursing practice of GRV checks in our hospital as part of a systems improvement project using a standardized questionnaire in a single hospital setting. The questionnaire included questions about the practice of checking GRV including what constituted "high" GRV and adherence to physician orders. We observed a wide variation in the responses of the practice of management of GRV. All the nurses in our hospital checked GRV, whether or not there were physician orders. Nurses' responses to "high GRV" varied from 100 mL to 200 mL at which point they would withold feedings. Some, but not all nurses, would report the "high GRV" and witholding of feedings to the physicians. The wide variation of gastric residual checks, including unnecessary checks and withholding feedings, observed above not only increased health care costs but also has the potential to impact patient outcomes. This calls for a standardized evidence based tube-feeding protocol to check GRV and should be an integral part of hospital policy. For the benefit of the readers, we present the GRV check protocol instituted in our hospital which, based on anecdotal reports, is resulting in decreased interruptions of feedings to our patients and reducing the nursing time consumed, thus potentially decreasing health care costs.

Racial differences in general health, suicidal thoughts, physical and sexual abuse in African-Americans and Caucasians with irritable bowel syndrome.

OBJECTIVES: Knowledge of the contribution of race to irritable bowel syndrome (IBS)-associated morbidity helps not only with health care policy decisions but also may provide important clues to the pathophysiologic interactions involved. METHODS: We conducted a survey at 9 different sites in our metro area. Subjects filled a questionnaire which included Rome II criteria for IBS. Subjects were asked about demographic and clinical characteristics. Subjects with a prior history of chronic inflammatory bowel disease and gastrointestinal cancer were excluded. RESULTS: Nine hundred and ninety subjects (670 African-Americans and 320 Caucasians) were included in the final analysis. IBS patients had more food allergies and were more likely perceived to have poor health as well as physical limitations. A reduced logistic regression model demonstrated that travel abroad, upper respiratory infections, tonsillectomy, and loss of appetite were independently associated with race in the IBS patients. There were no racial differences in physical or sexual abuse, loss of interest in life, or suicidal thoughts. CONCLUSIONS: Substantial similarities as well as differences in IBS patients of the two races support the concept that, while there is an important role for a biological component to the pathogenesis of IBS, it by itself may not be an exclusive determinant.

Probiotics for preventive health.

Gut flora and probiotics have potential to affect health and disease far beyond the gut. There is increasing evidence that probiotics have beneficial effects in preventing a wide range of conditions and improving health. Randomized, double-blind studies have provided evidence of the effectiveness of probiotics for preventing various diarrheal illnesses as well as allergic disorders. Evidence for their efficacy for use in the prevention and treatment of bacterial vaginosis and urinary tract infections is also mounting. In addition, probiotics may be useful for preventing respiratory infections, dental caries, necrotizing enterocolitis, and certain aspects of inflammatory bowel disease. Data also suggest that probiotics may promote good health in day care and work settings, and may enhance growth in healthy as well as ill and malnourished children. Results from meta-analyses and systematic reviews that combine results of studies from different types of probiotics to examine the effects in any disease state should be interpreted with caution. Specific strains are effective in specific disease states. No 2 probiotics are exactly alike; we should not expect reproducible results from studies that employ different species or strains, variable formulations, and diverse dosing schedules.

Prevalence of abdominal and pelvic surgeries in patients with irritable bowel syndrome: comparison between Caucasian and African Americans.

BACKGROUND: Although controversial, studies suggest that irritable bowel syndrome (IBS) is associated with an increased risk of abdominal and pelvic surgeries. However, the role of race in this interaction has not been defined. We studied the prevalence of appendectomy, cholecystectomy, and hysterectomy among African American patients with IBS among the population at large and compared it with the Caucasians residing in same area. METHODS: A total of 990 adults from 9 different sites in the Jackson, Mississippi, metropolitan area (670 African Americans and 320 Caucasians), completed self-administered questionnaires providing sociodemographic information and details regarding bowel habits and associated symptoms for diagnosing the IBS, based on ROME II criteria. We recorded the patient's name, age, sex, race, history of smoking, and history of surgeries. Subjects with a history of IBD and gastrointestinal cancer were excluded. The prevalence of appendectomy and hysterectomy was compared between IBS patients and non-IBS control subjects. RESULTS: One thousand ninety-nine, or 84%, of those distributed were returned. On checking the exclusion and inclusion criteria, we eliminated 109 subjects. The reasons for elimination of 109 subjects included incomplete questionnaires and incorrect marking of questionnaires that resulted in invalid data. Overall, there was significantly higher prevalence of appendectomy (15.3% vs 5.1%) and cholecystectomy (6.6% vs 3.4%) but not hysterectomy (21.1% vs 17.6%; P = NS) among Caucasian Americans as compared with African Americans. The prevalence of appendectomy among IBS patients (n = 95) versus non-IBS subjects (n = 895) was not statistically significant (10.5% vs 8.2%; OR, 1.3; 95% CI, 0.7 to 2.7; P = 0.43). The prevalence of cholecystectomy in the 2 groups was also similar (5.3% vs 4.4%). Likewise, there was no statistically significant difference for the prevalence of hysterectomy among females IBS patients versus non-IBS females (23.3% vs 18.2%; OR, 1.4; 95% CI, 0.8 to 2.4; P = 0.29). Comparing the prevalence of these surgeries in with IBS patients (African Americans versus Caucasian Americans), we found significant difference in the prevalence of appendectomy to be 1.9% vs 21.4% (P < 0.01). In contrast, there was no difference in the prevalence of cholecystectomy or hysterectomy. Logistical regression suggested that race but not IBS was a significant factor in the prevalence of various surgeries. CONCLUSIONS: Based on responses to ROME II criteria questionnaire administered to community at large, IBS is not associated with greater prevalence of abdominal and pelvic surgeries. Caucasians are more likely to have these surgeries irrespective of whether they have IBS or not. Our study does not exclude the possibility that there may indeed be association between IBS and surgeries if only the IBS patients seeking health care are considered.

Malignant seeding of percutaneous endoscopic gastrostomy tract in patient with head and neck cancer.

Malignant seeding of the percutaneous endoscopic gastrostomy (PEG) stoma is a rare and unusual complication of PEG performed in patients with head and neck cancer. Direct seeding of PEG stoma is believed to be the culprit. We present one such case of metastasis that lends support to an alternate hypothesis of vascular spread. First responders in such cases are usually not gastroenterologists and may include dieticians, primary care physicians, and radiologists. As such, we also provide pictures that would help the health care providers recognize this rare entity and manage appropriately and promptly.

Gastric electrical stimulation is safe and effective: a long-term study in patients with drug-refractory gastroparesis in three regional centers.

BACKGROUND: Drug-refractory gastroparesis has previously been without acceptable alternative therapies. Although gastric electrical stimulation has been used for over a decade, no long-term multicenter data exist. METHODS: We studied 214 consecutive drug-refractory patients with the symptoms of gastroparesis (146 idiopathic, 45 diabetic, 23 after surgery) who consented to participate in a variety of clinical research and clinical protocols at three centers from January 1992 through January 2005, resulting in 156 patients implanted with a gastric electrical stimulation device and the other 58 patients serving as controls. The patients were stratified into three groups: (1) consented but never permanently implanted; (2) implanted with permanent device, and (3) consented while awaiting a permanent device. The patients were followed over time for gastrointestinal symptoms, solid gastric emptying, health-related quality of life, survival, device retention, and complications. Demographics, descriptive statistics, and t tests were used for comparison between baseline and latest follow-up. RESULTS: At latest follow-up, median 4 years for 5,568 patient months, most patients implanted (135 of 156) were alive with intact devices, significantly reduced gastrointestinal symptoms, and improved health-related quality of life, with evidence of improved gastric emptying, and 90% of the patients had a response in at least 1 of 3 main symptoms. Most patients explanted, usually for pocket infections, were later reimplanted successfully. There were no deaths directly related to the device. CONCLUSION: Based on this sample of patients, implanted with gastric electrical stimulation devices at three centers and followed for up toward a decade, gastric electrical stimulation for drug-refractory gastroparesis is both safe and effective.

Prokinetic therapy reduces aspiration pneumonia in tube-fed patients with severe developmental disabilities.

To evaluate the clinical benefit of prokinetic therapy in aspiration pneumonia in patients with developmental disabilities, we conducted a retrospective study; records of 22 tube-fed patients were reviewed from December 1990 to October 1998 for a mean of 22.7 months before and 38.9 months during Cisapride therapy. Numbers of hospital admissions per patient-year before and during Cisapride administration were reduced from 2.75 to .61, with a relative risk reduction of 4.5. Days of hospitalization were reduced from 32.3 to 6.4. There were no adverse events noted from the therapy. Appropriately monitored prokinetic therapy may prove to be beneficial in preventing aspiration pneumonia in selected patients with developmental disabilities.

Gastrointestinal complications of bariatric surgery: diagnosis and therapy.

Severe or morbid obesity, with body mass indexes exceeding 35 to 40, are often refractory to all therapies other than surgery. The increasing number of patients undergoing bariatric surgery will result in increasing numbers of patients with gastrointestinal complications. The types of complications vary with type of surgery, whether restrictive, malabsorptive, or both, depending on what anatomical and physiologic changes occur postoperatively. One complication of bariatric surgery (gallstones) is due to weight loss after surgery, not the surgery itself. Based on previous meta-analyses, most of the top 10 complications from bariatric surgery are gastrointestinal: dumping, vitamin/mineral deficiencies, vomiting (and nausea), staple line failure, infection, stenosis (and bowel obstruction), ulceration, bleeding, splenic injury, and perioperative death. Two other gastrointestinal complications of bariatric surgery are indirect consequences of the surgery: bacterial overgrowth and diarrhea. Awareness of the types and frequency of gastrointestinal complications of bariatric surgery allows for timely diagnosis and appropriate therapy. As new surgical, and even endoscopic, procedures to treat obesity are developed, new gastrointestinal complications will need to be recognized.

Looking to the future: electrical stimulation for obesity.

Among all classes of therapies for morbid obesity-behavioral, drugs, devices, and surgery-devices for electrical stimulation are a relatively new approach. This article reviews the history of electrical therapies for the gastrointestinal tract with an emphasis on the development of stimulation for obesity. Based on similar animal work, electrical stimulation of the gastrointestinal tract has been applied to treat morbid obesity much in the way it has been used to treat nausea and vomiting. The current status of gastrointestinal electrical stimulation for the treatment of morbid obesity is reviewed, with an emphasis on human studies. The physics of electrical stimulation and the possible mechanism of stimulation in the gastrointestinal tract, including for the treatment of morbid obesity, are also discussed. Future work on stimulation for obesity offers the opportunity for better understanding of possible mechanisms of action.

Nutrition aspects of gastroparesis and therapies for drug-refractory patients.

Gastroparesis, broadly defined as disordered gastric emptying, is a commonly encountered clinical problem. Nutrition problems frequently occur in gastroparesis, primarily due to inadequate oral intake but also due to losses from vomiting or diarrhea. Treatment of gastroparesis may include dietary modification with or without medication. Some patients require supplementation with either enteral or parenteral nutrition for survival. However, many patients with gastroparesis are drug-refractory and invariably do not do well with enteral or parenteral access. Historically, these patients have been without effective therapeutic options. The development of gastrointestinal electrical stimulation has allowed many with drug-refractory gastroparesis to be treated successfully. Enteric electrical stimulation for gastroparesis often corrects many of the nutrition abnormalities, along with improving symptoms and quality of life and reducing costs; for some categories of patients, it may improve survival rates.

Assessing thrombosis risk in patients with idiopathic, diabetic, and postsurgical gastroparesis.

Patients with severe gastrointestinal motility disorders are often found to have intravenous access clots or deep venous thrombosis. It has previously been reported that many patients who have intravenous access thrombosis have concomitant thrombotic risk factors. In this study, the goal was to determine the underlying prevalence of hypercoagulable risk in a series of patients with documented gastroparesis. Investigators studied 62 consecutive patients (52 female; mean age, 42 y) who had symptoms of gastroparesis. All patients were evaluated for placement of a gastric neural stimulation device, or they had had one placed previously. Patients underwent a hematologic interview and standardized coagulation measures of thrombotic risk. Laboratory studies measured acquired elevations of Factor VII, Factor VIII, fibrinogen, lupus anticoagulant panel, antiphospholipid antibody panel, homocysteine (in the setting of kidney disease), and activated protein resistance. Investigators also measured congenital factors: Factor VIII (with C-reactive protein levels), antithrombin III, protein C, protein S (total and free), Factor II mutation, Factor V Leiden, methylenetetrahydrofolate reductase, and homocysteine. Fifty-five patients (89%) were found to have detectable hypercoagulable risk factors. Twenty-five of the 62 patients (40%) had a documented history of abnormal clotting, including deep venous thrombosis, intravenous access thrombosis, and pulmonary embolism. All patients with a previous history of thrombosis had detectable clotting abnormalities. Of 56 patients, 40 (71%) had hypercoagulability and did not have diabetes (P=.036), and 20 (36%) had hypercoagulability and no known history of infection. However, this value was not statistically significant when infection and hypercoagulability were compared (P=.408). A high prevalence of acquired and congenital hypercoagulable defects has been observed in patients with gastroparesis, which may predispose them to arterial and venous clots. This unique finding warrants consideration of coagulation evaluation in patients with severe gastroparesis, especially when these patients are placed in high-risk thrombophilic situations, such as hospitalization, prolonged intravenous access, and surgery.

Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy: a case report.

Colonoscopic diagnosis of asymptomatic early acute appendicitis is exceedingly rare. Although obstruction of the lumen due to various causes is believed to be the most common physiologic mechanism of acute appendicitis, all of the previously documented cases in the literature have only shown a patent appendiceal lumen with pus flowing into the cecum. We present the case of a patient undergoing colonoscopy for colorectal cancer evaluation with no abdominal symptoms. An obstructed, swollen appendix was seen. The process was probably initiated during the colonoscopy, documenting perhaps the earliest stage of acute appendicitis for the first time. Endoscopic, CT and microscopic documentation of the case is also presented.

Gastroparesis and the gastric pacemaker: a revolutionary treatment for an old disease.

Gastroparesis--or delayed gastric emptying--can apply to either solids or liquids but the term (gastroparesis) usually refers to delayed solid emptying, in an appropriate clinical setting. Impaired gastric emptying can occur acutely in a variety of conditions from neurologic to metabolic. Intractable nausea and vomiting, and the inability to tolerate oral intake, occurs frequently in patients with severe gastroparesis. The patients' nutritional status is adversely affected by gastroparesis as are the socioeconomic aspects of patient's lives. The previous treatments of gastroparesis, such as medications and surgery, were often not successful. Our recent understanding of the normal gastric electro-mechanical function and its abnormalities/dysrythmias has led to the development of a gastric electrical stimulator, analagous to other devices used to stimulate dysfunctional organs. Gastric electrical stimulation is associated with improvements in symptomatic relief, nutritional status, health resource utilization and costs and is now approved by the FDA as a humanitarian use device. It offers a new and hopeful therapy for patients with refractory gastroparesis where none have existed before.