Modern Challenges to Gastrointestinal Nutrition Physicians and the Nutrition Support Team: Cautionary Tales and Call to Action.

The current climate of healthcare economics in the United States has imposed unprecedented market stressors on health institutions traditionally providing tertiary care to those with the most challenging healthcare needs. In such a stressed financial atmosphere, administrators look to streamline costs and cut margins as tightly as possible. This often results in restructuring, consolidating, or closing service lines that are perceived as unprofitable or unsupportable. Nutrition support often falls into this category because of few sources of direct revenue-generating activities and poor reimbursement from third-party payers. This article discusses the challenges to modern nutrition support teams, particularly those with gastroenterologists as physician leaders, and delineates market forces that need shifting to continue to make this a viable part of the healthcare system.

Seronegative Adult Autoimmune Enteropathy in a Patient With Rheumatoid Arthritis.

Autoimmune enteropathy is a rare disorder of the immune system. We present a 75-year-old woman with rheumatoid arthritis who presented with 4 months of intractable vomiting, diarrhea, and unexplained weight loss. Initial workup was negative for infection and celiac disease, but her symptoms progressed. Repeat esophagogastroduodenoscopy showed duodenal scalloping and friability. Biopsies of the duodenum and terminal ileum showed glandular destruction, epithelial apoptosis, and goblet cell depletion. Colonoscopic examination was normal, and random colon biopsies did not show evidence of microscopic colitis. She was diagnosed with autoimmune enteropathy, and treatment consisted of an extended corticosteroid taper, with the resolution of symptoms.

Nutrition in Cirrhosis.

PURPOSE OF REVIEW: This review discusses the prevalence of malnutrition in cirrhosis, metabolic functions of the liver and alterations in cirrhosis, malnutrition screening tools, and common macronutrient and micronutrient deficiencies encountered in individuals with chronic liver disease and their impact on morbidity and mortality. RECENT FINDINGS: Several meta-analyses and international society guidelines recommend malnutrition screening and nutrition interventions to improve outcomes in all patients with chronic liver disease given their high risk of malnutrition which is often under recognized. Malnutrition is common in individuals with chronic liver disease and has a significant impact on patient outcomes. Thus, it is critical that validated malnutrition screening tools are used routinely in this patient population in order to identify high-risk patients and implement nutrition and exercise interventions early.

Nutritional Strategies in the Management of Adult Patients with Inflammatory Bowel Disease: Dietary Considerations from Active Disease to Disease Remission.

Inflammatory bowel disease (IBD) is a group of chronic, lifelong, and relapsing illnesses, such as ulcerative colitis and Crohn's disease, which involve the gastrointestinal tract. There is no cure for these diseases, but combined pharmacological and nutritional therapy can induce remission and maintain clinical remission. Malnutrition and nutritional deficiencies among IBD patients result in poor clinical outcomes such as growth failure, reduced response to pharmacotherapy, increased risk for sepsis, and mortality. The aim of this review is to highlight the consequences of malnutrition in the management of IBD and describe nutritional interventions to facilitate induction of remission as well as maintenance; we will also discuss alternative delivery methods to improve nutritional status preoperatively.

Long-Term Nutrition: A Clinician's Guide to Successful Long-Term Enteral Access in Adults [Formula: see text].

Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.

Enteral tube feeding for individuals with cystic fibrosis: Cystic Fibrosis Foundation evidence-informed guidelines.

Nutrition is integral to the care of individuals with cystic fibrosis (CF). Better nutritional status is associated with improved pulmonary function. In some individuals with CF, enteral tube feeding can be useful in achieving optimal nutritional status. Current nutrition guidelines do not include detailed recommendations for enteral tube feeding. The Cystic Fibrosis Foundation convened an expert panel to develop enteral tube feeding recommendations based on a systematic review of the evidence and expert opinion. These guidelines address when to consider enteral tube feeding, assessment of confounding causes of poor nutrition in CF, preparation of the patient for placement of the enteral feeding tube, management of the tube after placement and education about enteral feeding. These recommendations are intended to guide the CF care team, individuals with CF, and their families through the enteral tube feeding process.

Long-Term Nutrition: A Clinician's Guide to Successful Long-Term Enteral Access in Adults.

Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.

Specialized enteral nutrition therapy in Crohn's disease patients on maintenance infliximab therapy: a meta-analysis.

OBJECTIVES: Many patients with Crohn's disease on infliximab maintenance therapy have recurrent symptoms despite an initial clinical response. Therefore, concomitant therapies have been studied. We conducted a meta-analysis to assess the effect of specialized enteral nutrition therapy with infliximab versus infliximab monotherapy in patients with Crohn's disease. METHODS: A comprehensive search of multiple databases was performed. All studies of adult patients with Crohn's disease comparing specialized enteral nutrition therapy (elemental or polymeric diet with low-fat or regular diet) with infliximab versus infliximab monotherapy without dietary restrictions were included. Meta-analysis was performed using the Mantel-Haenszel (fixed effect) model with odds ratio (OR) to assess for clinical remission. RESULTS: Four studies (n = 342) met inclusion criteria. Specialized enteral nutrition therapy with infliximab resulted in 109 of 157 (69.4%) patients reaching clinical remission compared with 84 of 185 (45.4%) with infliximab monotherapy [OR 2.73; 95% confidence interval (CI): 1.73-4.31, p < 0.01]. Similarly, 79 of 106 (74.5%) patients receiving enteral nutrition therapy and infliximab remained in clinical remission after one year compared with 62 of 126 (49.2%) patients receiving infliximab monotherapy (OR 2.93; 95% CI: 1.66-5.17, p < 0.01). No publication bias or heterogeneity was noted for either outcome. CONCLUSIONS: The use of specialized enteral nutrition therapy in combination with infliximab appears to be more effective at inducing and maintaining clinical remission among patients with Crohn's disease than infliximab monotherapy.

Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success.

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872-5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569-80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the "tips and tricks" that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

The pharmacologic treatment of short bowel syndrome: new tricks and novel agents.

Short bowel syndrome (SBS) is a manifestation of massive resection of the intestines resulting in severe fluid, electrolyte, and vitamin/mineral deficiencies. Diet and parenteral nutrition play a large role in the management of SBS; however, pharmacologic options are becoming more readily available. These pharmacologic agents focus on reducing secretions and stimulating intestinal adaptation. The choice of medication is highly dependent on the patient's symptoms, remaining anatomy, and risk versus benefit profile for each agent. This article focuses on common and novel pharmacologic medications used in SBS, including expert advice on their indications and use.

Nasal bridles for securing nasoenteric tubes: a meta-analysis.

BACKGROUND: Nasoenteric feeding tubes may easily become dislodged due to patient mental status, transfers, or positional changes. Nasal bridles were introduced to provide a better, more reliable system to secure these tubes. This meta-analysis was performed to evaluate the effectiveness of nasal bridles compared with the traditional method of adhesive tape alone in securing enteral feeding tubes. MATERIALS AND METHODS: Multiple databases were searched (October 2013). All studies that evaluated the use of nasal bridles in adult patients were included in the analysis. Meta-analysis for the outcomes from use of a nasal bridle vs the more traditional method of adhesive tape alone for securing nasoenteric tubes was analyzed by calculating pooled estimates of dislodgement, skin complications, and sinusitis. Statistical analysis was performed using RevMan 5.1. RESULTS: Six studies (n = 594) met the inclusion criteria. Use of a nasal bridle for securing enteral tubes resulted in a statistically significant reduction in tube dislodgement compared with traditional adhesive tape alone (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.10­0.27; P < .01). The use of nasal bridles was associated with a higher rate of skin complications compared with traditional adhesive tape (OR, 4.27; 95% CI, 1.79­10.23; P < .01). Incidence of sinusitis was no different between the 2 groups (OR, 0.26; 95% CI, 0.03­2.28; P = .22). CONCLUSION: Nasal bridles appear to be more effective at securing nasoenteric tubes and preventing dislodgement than traditional use of tape alone.

Surveillance for hepatocellular carcinoma in a Medicaid cirrhotic population.

GOALS: To estimate the hepatocellular carcinoma surveillance in the Medicaid cirrhotic population. BACKGROUND: Most studies predate 2005 American Association for the Study of Liver Diseases surveillance recommendations and do not examine the primary target population, cirrhotics. STUDY: From 2006 to 2007, we identified adults with at least 1 cirrhosis International Classification of Disease code and 15 months of continuous enrollment in North Carolina Medicaid, recording claims for abdominal ultrasound, computed tomography, magnetic resonance imaging, and α-fetoprotein testing. We used multivariable logistic regression to identify factors independently associated with imaging. RESULTS: A total of 5061 subjects were identified: mean age 54 years, 54% male patients, 35% African American, 56% white. Cirrhosis risk factors were alcohol (59%), hepatitis C (30%), hepatitis B (4%), others (18%), and unknown (24%). Only 26% underwent at least 1 imaging test. Just 12% of those not hospitalized or seen in an emergency department underwent any imaging test. Care in an academic facility, younger age, female sex, viral hepatitis, and Medicare coinsurance were positively associated with imaging. Twenty-one percent saw a gastroenterologist, which increased the odds of undergoing imaging (odds ratio, 2.81; 95% confidence interval, 2.32-3.41), whereas primary care visits did not (odds ratio, 0.94; 95% confidence interval, 0.76-1.16). CONCLUSIONS: Only a quarter of North Carolina Medicaid cirrhotics underwent abdominal imaging over a 15-month period, and many tests may have been conducted without surveillance intent. Gastroenterology visits nearly tripled the odds of imaging, but primary-care visits had no effect. Efforts to improve surveillance rates in cirrhotic patients should target primary care and increased access to subspecialty care.

Quality of colonoscopy reporting in community practice.

BACKGROUND: Quality endoscopy reporting is essential when community endoscopists perform colonoscopies for veterans who cannot be scheduled at a Veterans Administration (VA) facility. OBJECTIVE: To examine the quality of colonoscopy reports received from community practices and to determine factors associated with more complete reporting, by using national documentation guidelines. DESIGN: Cross-sectional analysis. SETTING: Reports submitted to the Durham VA Medical Center, Durham, North Carolina, from 2007 to 2008. PATIENTS: Subjects who underwent fee-basis colonoscopy. MAIN OUTCOME MEASUREMENTS: Scores created by comparing community reports with published documentation guidelines. Three scores were created, one for each category of information: Universal Elements (found on all endoscopy reports), Indication Elements (specific to the procedure indication), and Finding Elements (specific to examination findings). RESULTS: For the 135 included reports, the summary scores were Universal Elements, 57.6% (95% confidence interval [CI], 55%-60%); Indication Elements, 73.7% (95% CI, 69%-78%); and Finding Elements, 75.8% (95% CI, 73%-79%). Examples of poor reporting included patient history (20.7%), last colonoscopy date (18.0%), average versus high risk screening (32.0%), withdrawal time (5.9%), and cecal landmark photographs (45.2%). Only the use of automated reporting software was associated with more thorough reporting. LIMITATIONS: Modest sample size, mostly male participants, frequent pathologic findings, limited geography, and lack of complete reporting by a minority of providers. CONCLUSIONS: The overall completeness of colonoscopy reports was low, possibly reflecting a lack of knowledge of reporting guidelines or a lack of agreement regarding important colonoscopy reporting elements. Automated endoscopy software may improve reporting compliance but may not completely standardize reporting quality.

Quality of care in inflammatory bowel disease: a review and discussion.

The Institute of Medicine's publications To Err Is Human and Crossing the Quality Chasm publicized the widespread deficits in U.S. health care quality. Emerging studies continue to reveal deficits in the quality of adult and pediatric care, including subspecialty care. The inflammatory bowel diseases (IBD) Crohn's disease and ulcerative colitis require diligent, long-term management and attention to their impact on intestinal and extraintestinal organ systems. Although the quality of IBD care has not been prospectively or comprehensively evaluated in the United States, several small studies have demonstrated significant variation in care. As variation may indicate underuse, overuse, or misuse of medical services, such variation suggests a clear need for translating evidence-based practices into the actual practice and follow-up provided for patients. This article reviews the history, rationale, and methods of quality measurement and improvement and identifies the unique challenges in adapting these general strategies to the care of the inflammatory bowel diseases.

Risk of radiation and choice of imaging.

Radiological imaging plays an important role in the diagnosis and management of patients with inflammatory bowel diseases (IBD). The barium or contrast techniques enteroclysis (SBE) and small bowel follow through (SBFT) are still the mainstays in small bowel imaging. However, abdominal CT and MRI, including enteroclysis, have comparable sensitivity and specificity in detecting intestinal pathologies and have gained in popularity over conventional techniques. The cancer risk associated with diagnostic procedures employing radiation has been receiving increasing attention over the last few years. The cumulative exposure to ionizing radiation may be a specific concern in young patients with IBD, who are more susceptible than adults to the risks of ionizing radiation. Substantial exposure to radiation seems to be mainly caused by CT examinations of the abdomen. For that reason, imaging methods such as MRI or ultrasound should be considered first when debating between alternative imaging strategies, particularly in young IBD patients. The major drawbacks of MRI are its limited availability and greater costs compared to CT. Moreover, the diagnostic accuracy of abdominal ultrasound is clearly operator dependent, which limits the range of its applications. In light of these concerns, diagnostic imaging studies using radiation will continue to play an important role in the evaluation of patients with IBD. Therefore, we need to develop low-radiation imaging protocols or improve access to MRI imaging procedures. We also need to identify subsets of IBD patients who are at greater risk of a significant lifetime exposure to radiation and develop methods to monitor their radiation exposure rate.

Diagnostic ionizing radiation exposure in a population-based sample of children with inflammatory bowel diseases.

OBJECTIVES: The degree of diagnostic radiation exposure in children with inflammatory bowel diseases (IBD) is largely unknown. In this study, we describe this exposure in a population-based sample of children with IBD and determine the characteristics associated with moderate radiation exposure. METHODS: We ascertained radiological study use, demographic characteristics, IBD medication use, and the requirement for hospitalization, emergency department (ED) encounter, or inpatient gastrointestinal surgery among children with IBD within a large insurance claims database. Characteristics associated with moderate radiation exposure (at least one computed tomography (CT) or three fluoroscopies over 2 years) were determined using logistic regression models. RESULTS: We identified 965 children with Crohn's disease (CD) and 628 with ulcerative colitis (UC). Over 24 months, 34% of CD subjects and 23% of UC subjects were exposed to moderate diagnostic radiation (odds ratio (OR) 1.71, 95% confidence interval (CI), 1.36 - 2.14). CT accounted for 28% and 25% of all studies in CD and UC subjects, respectively. For CD subjects, moderate radiation exposure was associated with hospitalization (OR 4.89, 95% CI 3.37 - 7.09), surgery (OR 2.93, 95% CI 1.59 - 5.39), ED encounter (OR 2.65, 95% CI 1.93 - 3.64), oral steroids (OR 2.25, 95% CI 1.50 - 3.38), and budesonide (OR 1.80, 95% CI 1.10 - 3.06); an inverse association was seen with immunomodulator use (OR 0.67, 95% CI 0.47 - 0.97). Except for oral steroids and immunomodulators, similar relationships were seen in UC. CONCLUSIONS: A substantial proportion of children with IBD are exposed to moderate amounts of radiation as a result of diagnostic testing. This high utilization may impart long-term risk, given the chronic nature of the disease.

Quality of health care in the United States: implications for pediatric inflammatory bowel disease.

The Institute of Medicine's publications To Error is Human and Crossing the Quality Chasm publicized the widespread deficits in US health care quality. Emerging studies continue to reveal deficits in the quality of adult and pediatric care, including subspecialty care. In recent years, key stakeholders in the health care system including providers, purchasers, and the public have been applying various quality improvement methods to address these concerns. Lessons learned from these efforts in other pediatric conditions, including asthma, cystic fibrosis, neonatal intensive care, and liver transplantation may be applicable to the care of children with inflammatory bowel disease (IBD).This review is intended to be a primer on the quality of care movement in the United States, with a focus on pediatric IBD. In this article, we review the history, rationale, and methods of quality measurement and improvement, and we discuss the unique challenges in adapting these general strategies to pediatric IBD care.

Improving screening practices for Barrett's esophagus.

This article reviews the epidemiology of Barrett's esophagus (BE) and current evidence for or against screening for BE to provide insight into the screening process. Data demonstrate that multiple criteria of a successful screening program remain unfulfilled or unproven in endoscopic screening for BE. The operating characteristics of the test are poorly described, and inadequate risk stratification limits the effectiveness and cost-effectiveness of the approach. We suggest modifications to BE screening practices that may have the potential to improve outcomes for patients with BE.