Diagnosis and Management of Celiac Disease.

This JAMA Clinical Guidelines Synopsis summarizes the American College of Gastroenterology's 2023 guideline update on diagnosis and management of celiac disease.

Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics.

Enteral nutrition, generally preferred to parenteral nutrition, is indicated when patients cannot meet their energy and metabolic demands. Gastrostomy tubes are placed directly into the stomach (either endoscopically, surgically, or radiologically) through the abdominal wall. Routine gastrostomy tube care is important to maintain well-functioning tubes. Postpyloric feeding tubes are preferable to gastric feeding tubes if patients have a history of aspiration, gastroesophageal reflux, severe gastroparesis, and/or recurrent nausea and vomiting. Feeding jejunostomy tubes are placed surgically and are indicated if gastric feeding is unsafe or impossible. Dual-lumen gastrojejunostomy tubes are used when both gastric decompression and feeding are desired. The general risks of enteral tube feeding include diarrhea, metabolic derangements, and aspiration. Additional complications for gastrostomy tubes, which can arise at any time, include tube dysfunction (clogging or deterioration), infection, bleeding, peristomal leakage, ulceration, gastric outlet obstruction, and accidental removal. After percutaneous endoscopic gastrostomy placement, there are also early or late complications that may occur. Multiple factors should be considered in the decision-making process for feeding tube placement. It is important to be realistic about the patient's prognosis and goals and to discuss the risks and benefits ahead of time. Consultation with palliative care or clinical ethics specialists should be considered in certain clinical scenarios.

Controversy in Nutrition Recommendations for Short Bowel Syndrome: How Type of SBS Impacts Response.

PURPOSE OF REVIEW: This review examines the current recommendations for dietary management of patients living with short bowel syndrome (SBS) and outlines the need for future research to provide optimal care for this unique group of patients. RECENT FINDINGS: Providers caring for patients with SBS lack sufficient data to help guide recommendations regarding diet. The majority of studies are conducted at a single medical institution on a small number of anatomically diverse patients. Multi-center studies would allow for inclusion of a larger number of patients and may lead to more individualized dietary recommendations. Patients with short bowel syndrome should be evaluated on an individual basis by a multidisciplinary team including physicians, dieticians, pharmacists, and nurses specializing in the care of these complex patients. Tailoring both medical and nutritional therapy will help realize the overarching goal for these patients of maintaining adequate nutrition with diet and medications, and achieving independence from parenteral support.

Ketogenic Diet: from the Historical Records to Use in Elite Athletes.

PURPOSE OF REVIEW: To review the available literature/evidence on low carbohydrate/high fat (LCHF) and low carbohydrate ketogenic (LCKD) diets' effects on human athletic performance and to provide a brief review of the physiology and history of energy systems of exercise. RECENT FINDINGS: Multiple studies have been conducted in an attempt to answer this question, many within the last 3-5 years. Studies are heterogenous in design, intervention, and outcome measures. Current available data show that LCHF and LCKD do not significantly enhance or impair performance in endurance or strength activities. However, there is a trend towards improved body composition (greater percent lean body mass) across multiple studies. While this may not translate to enhanced performance in the primarily laboratory conditions in the reviewed studies, there could be a benefit in sports in which an athlete's strength-to-weight ratio is a significant determinant of outcome.

Premixed vs Compounded Parenteral Nutrition: Effects of Total Parenteral Nutrition Shortage on Clinical Practice.

PURPOSE OF REVIEW: Drug shortages continue to impact our patients with intestinal failure and their ability to receive nutrition. ASPEN guidelines address the management of certain shortages in compounded total parenteral nutrition (TPN); however, some institutions have utilized premixed total parenteral nutrition (pTPN) in place of TPN. RECENT FINDINGS: Premixed TPN appears to be as safe, if not safer, as compounded TPN when comparing the risk of bloodstream infection. However, there is an increased use of supplemental electrolytes to meet patient needs. Cost-effectiveness depends on multiple factors and should be evaluated by each institution when considering the use of TPN. In light of the published information on the use of pTPN compared to TPN, institutions and nutrition clinicians should consider their current practice and opportunities to consider when pTPN may be beneficial for their patients, not only from a safety perspective, but also considering cost savings. However, close monitoring and individual patient needs should be considered as these formulas may not meet all patient nutritional and electrolyte needs.

Musculoskeletal Injuries Are Commonly Reported Among Gastroenterology Trainees: Results of a National Survey.

BACKGROUND: Endoscopy-related musculoskeletal injuries are increasingly recognized among gastroenterologists. While injury rates and risk factors have been studied among practicing gastroenterologists, little is known about rates among trainees during fellowship. AIMS: This study analyzes the prevalence of endoscopy-related overuse injuries and risk factors for injuries among a national sample of gastroenterology (GI) fellows. We also surveyed GI fellowship program directors and fellows about perceptions of overuse injuries during GI training. METHODS: We distributed a 29-item electronic survey to GI fellows at accredited programs in the USA in April 2016. Survey items included demographic information, questions pertaining to injuries, and level of agreement on the importance of ergonomics training in GI fellowship. Additionally, we distributed a 7-item electronic survey to fellowship program directors evaluating perception of overuse injuries and prevention during fellowship training. Fisher's exact test determined factors associated with sustaining an injury. RESULTS: An estimated 1509 fellows received the survey. Eleven percent (n = 165) of gastroenterology fellows completed the survey. Twenty percent reported having a musculoskeletal injury. Female gender was the only factor associated with a higher rate of reported injury (p < 0.01). The most common injuries reported were thumb and other hand-related pain (n = 28 [64%]). CONCLUSIONS: Musculoskeletal injuries may affect up to 20% of GI fellows. Female fellows more frequently report injuries and may be at particularly high risk which has not been found in previously reported surveys of practicing gastroenterologists. Standardized curricula on ergonomic considerations and injury prevention are needed to enhance GI fellowship training and reduce injury rates.

Hyperemesis Gravidarum.

Nausea and vomiting of pregnancy affect the majority of pregnancies, while the most severe version, hyperemesis gravidarum (HG), affects a much smaller subset of women. Despite the prevalence of nausea and vomiting of pregnancy and the severe consequences of HG, the pathophysiology of these conditions is not fully understood. Currently, it is thought that a combination of hormonal factors accounts for their development. Multiple treatments have been described for nausea and vomiting of pregnancy and HG with varying levels of success. In this paper we describe the epidemiology of nausea and vomiting of pregnancy and HG, the recommended workup, their proposed etiologic factors, treatments, and their potential impact on mother and baby.

Influence of previous night call and sleep deprivation on screening colonoscopy quality.

OBJECTIVES: There are few studies evaluating the influence of sleep deprivation on endoscopic outcomes. To evaluate the effect of a previous night call on the quality of screening colonoscopies performed the following day. METHODS: Average-risk patients undergoing screening colonoscopies were included. Quality metrics were retrospectively compared between two groups of post-call colonoscopies and colonoscopies performed by the same individuals not on call the night before: those performed by gastroenterologists who were only on call the night prior and those performed by gastroenterologists who performed emergent on-call procedures the night prior. RESULTS: Between 1 July 2010 and 31 March 2012, 447 colonoscopies were performed by gastroenterologists who were on call only the night prior, 126 colonoscopies were performed by gastroenterologists who had completed on-call emergent procedures the night prior, and 8,734 control colonoscopies were completed. There was a lower percent of patients who were screened with adenomas detected in procedures performed by endoscopists who had performed emergent on-call procedures the night prior compared with the controls (30 vs. 39%, respectively; P=0.043). The mean withdrawal time for these colonoscopies was significantly longer than that for the control procedures (15.5 vs. 14.0 min; P=0.025). For the colonoscopies performed by endoscopists who were on call only the night prior, there was no significant difference in the percent of patients screened with adenomas detected compared with controls (42 vs. 39%, respectively; P=0.136). CONCLUSIONS: (1) Despite longer withdrawal times, being on call the night prior and performing an emergent procedure lead to a significant 24% decrease in the adenoma detection rates. (2) It is imperative for screening physicians to be aware of the influence of sleep deprivation on procedural outcomes and to consider altering their practice accordingly.