[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.

Diabetes Mellitus and lower genital tract tears after vaginal birth: A cohort study.

INTRODUCTION: Diabetes Mellitus in pregnancy is increasing. No existing studies have examined Diabetes Mellitus as the primary exposure for lower genital tract tears after vaginal birth. The objective was to study the association between Diabetes Mellitus (all types combined), Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus and lower genital tract tears after vaginal birth. MATERIAL AND METHODS: A register-based cohort study of women with singleton pregnancy and without a previous cesarean section at near-term (≥ 35 + 0 weeks) and term (≥ 37 + 0 weeks) gestational age, n = 31,297 at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012. The associations between Diabetes Mellitus and lower genital tract tears were analysed using a fixed multiple logistic regression analyses. RESULTS: Approximately 32,000 women were eligible for the study; 796 women had diabetes (2.5%) and 1318 experienced anal sphincter injury (4.3%). The overall risk of lower genital tract tears was similar among women with a diagnosis of diabetes (Type1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and Gestational Diabetes Mellitus) compared to women without diabetes, except for nulliparous women with Type1 Diabetes Mellitus who experienced a higher risk of episiotomies, crude and adjusted odds ratios (OR 2.13, 95% CI 1.14-3.97) and (OR 2.48, 95% CI 1.21-5.10), respectively. CONCLUSIONS: Women with Diabetes Mellitus without a previous cesarean section who gave birth vaginally to a single child at term or near term did not experienced an increased risk of lower genital tract tears. However, nulliparous women with Type 1 Diabetes Mellitus experienced a higher risk of episiotomy. These results may be used to individualised counselling of women with Diabetes Mellitus regarding mode of birth and may reduce worries about genital tract tears in women with Diabetes Mellitus considering vaginal birth.

Shared Risk Factors for Constipation, Fecal Incontinence, and Combined Symptoms in Older U.S. Adults.

OBJECTIVES: To estimate the prevalence of constipation, fecal incontinence (FI), and combined symptoms and to identify shared factors associated with bowel symptoms in older U.S. men and women DESIGN: Population-based cross-sectional study. SETTING: National Health and Nutrition Examination Survey (2005-2010). PARTICIPANTS: Women and men aged 50 and older. MEASUREMENTS: Constipation was defined as hard stool consistency on the validated Bristol Stool Form Scale or stool frequency of fewer than three bowel movements per week. FI was defined as at least monthly loss of solid, liquid, or mucus stool. Combined symptoms was defined as constipation and FI. Multinomial multivarible models adjusted for age, race, socioeconomic status, education, self-rated health, depression, impairments in activities of daily living, and number of comorbidities. RESULTS: Women (n = 3,078) reported higher prevalence of bowel symptoms than men (constipation 11.8% vs 4.7%%, FI 11.2% vs 8.6%, combined symptoms 1.4% vs 0.4%). In adjusted models, women had greater odds of having constipation (odds ratio (OR) = 3.0, 95% confidence interval (CI) = 2.3-3.8), FI (OR = 1.4, 95% CI = 1.1-1.8), and combined symptoms (OR = 4.6, 95% CI = 2.0-10.2) than men. Shared risk factors included poor self-rated health and depression symptoms (constipation: OR = 1.8, 95% CI = 1.4-2.4 and OR = 1.8, 95% CI = 1.0-3.2; FI: OR = 1.6, 95% CI = 1.2-2.2 and OR = 2.3 95% CI = 1.4-3.6; combined symptoms: OR = 2.6 95% CI = 1.5-4.8 and OR = 4.6, 95% CI = 1.3-16.4). CONCLUSION: When defining constipation and FI using validated instruments, women had a much higher prevalence of constipation than men, whereas men had a higher prevalence of FI than constipation. Shared risk factors reflect the negative effect that bowel symptoms have on quality of life.

Prophylaxis Versus Treatment Use of Laxative for Paralysis of Lower Gastrointestinal Tract in Critically Ill Patients.

GOALS: To evaluate the prevalence of lower gastrointestinal tract paralysis and to compare the success to achieve defecation between treatment and prophylaxis strategies. BACKGROUND: Laxatives use is commonly the first-level measure to achieve defecation in critically ill patients with lower gastrointestinal tract paralysis. Studies comparing prophylaxis versus treatment of lower gastrointestinal tract paralysis have not been performed yet. STUDY: We designed 3 sequential phases of 4 months each: observational phase, treatment phase, and prophylaxis phase. First-level measure was intermittent polyethylene glycol (PEG) 4000 by nasogastric tube. Second-level measures were enema, neostigmine, and continuous PEG. Primary endpoints were the prevalence of constipation for the observational phase and the number of patients that failed to achieve defecation with first-level measures for the treatment and prophylaxis phases. RESULTS: Paralysis of lower gastrointestinal tract in the observational phase was found in 57 of 63 patients (90.5%). Failure to achieve defecation with the first-level measure occurred in 16 of 64 patients (25%) in the treatment phase and in 6 of 70 patients (8.6%) in the prophylaxis phase (P=0.01). Eighteen measures of second level were applied in the treatment phase and 6 in the prophylaxis phase. CONCLUSIONS: Paralysis of the lower gastrointestinal tract in mechanically ventilated ICU patients is common. PEG given as prophylaxis on the first day after mechanical ventilation is associated with faster resolution of paralysis of gastrointestinal tract than PEG given as a treatment on day 4.

Correlation between lower gastrointestinal tract symptoms and quality of life in patients with stable chronic obstructive pulmonary disease.

OBJECTIVE: To explore correlations between the symptoms of constipation and abdominal distention and severity of chronic obstructive pulmonary disease (COPD) in patients with stable disease. METHODS: We studied 191 patients with stable COPD (according to defined criteria) in this cross-sectional study from four three-level class A Chinese medicine hospitals in China. We built an Epidata 3.0 database and performed statistical analysis with SPSS, version 17.0. We analyzed correlations between the frequency of lower gastrointestinal tract symptoms (constipation and abdominal distention) and scores for major pulmonary symptoms (cough, sputum and wheezing) based on the St. George's Respiratory Questionnaire (SGRQ), 6-minute walking distance (6MWD) and frequency of acute exacerbations of COPD (AECOPD). RESULTS: In addition to their pulmonary symptoms, 39.79% and 40.31% of study patients with stable COPD reported constipation and abdominal distention, respectively. Scores for major pulmonary symptoms (cough, sputum and wheezing), AECOPD and SGRQ values in patients with constipation and abdominal distention were significantly greater, and the 6MWD markedly shorter, than in those without them. According to Pearson's correlation analysis, there were strong correlations between these lower gastrointestinal tract symptoms and scores for pulmonary symptoms, SGRQ, 6MWD and AECOPD. CONCLUSION: Lower gastrointestinal tract symptoms such as constipation and abdominal distention can adversely affect pulmonary symptoms, frequency of acute exacerbations and quality of life in patients with stable COPD.

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.

Lower gastrointestinal distress in endurance athletes.

Training regimens and race days place significant demands upon both the competitive endurance athlete and the frequent-recreational runner. Lower gastrointestinal derangements, especially those involving diarrhea and rectal bleeding, are common and can impact adversely both the performance and the health of the athlete. While most cases are relatively benign, more significant and severe symptoms may not only impair sports performance, but also signify more serious disease. The sports medicine clinician should be familiar with the management of these problems in order to optimize treatment, facilitate return to play, and maximize the athlete's potential.

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