Colonic stool burden on computed tomography does not correlate with bowel habit: a cross-sectional study.

PURPOSE: Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function. METHODS: Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians. RESULTS: The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice. CONCLUSIONS: Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation.

Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release. PURPOSE: To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI. METHODS: For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? FINDINGS: The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist. CONCLUSIONS: In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 1 Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence). 2 Colonic self-expandable metal stent (SEMS) placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction (strong recommendation, high quality evidence). 3 For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, I. e. American Society of Anesthesiologists (ASA) Physical Status ≥ III and/or age > 70 years (weak recommendation, low quality evidence). 4 SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction (strong recommendation, high quality evidence), except in patients treated or considered for treatment with antiangiogenic drugs (e. g. bevacizumab) (strong recommendation, low quality evidence).(AU)

Outcome of repeat ERCP after initial failed use of a needle knife for biliary access.

INTRODUCTION: A needle knife is often used to gain bile duct access when standard techniques have failed. If unsuccessful, the next step may involve either radiological- or endoscopic ultrasound-guided biliary access. However, repeat endoscopic retrograde cholangiopancreatography (ERCP) may be an option if the patient's clinical condition permits. AIM: To determine the success of repeat ERCP after failed use of a needle knife to gain biliary access. METHODS: Retrospective analysis of all patients who underwent initial unsuccessful biliary cannulation after use of a needle knife between 2007 and 2010. RESULTS: Seventy five patients were identified. Of these, 51 (68%) underwent repeat ERCP, and biliary cannulation was successful in 38 (75%). The median time to repeat ERCP was 7.7 days (range 1-28 days). Complications developed in two (4%) patients. These included one case each of wire-guided perforation and mild pancreatitis, both of which were resolved by conservative management. CONCLUSIONS: Repeat ERCP within a few days after failed use of a needle knife for biliary access is associated with acceptable success and acceptable incidence of complications, and therefore obviates the need for alternative approaches for biliary access for most patients.

Prevention of Post-ERCP Pancreatitis.

Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.

Colonic stenting in 2011.

Self expanding metal stents (SEMS) are an established treatment in the management of malignant obstructing lesions throughout the gastrointestinal tract. SEMS have been utilized both as palliation in and as a bridge to surgical resection for malignant colonic obstruction. Many studies have demonstrated that placement of SEMS for malignant colonic obstruction is both efficacious, with high technical and clinical success rates, and safe with a low complication rate. In contrast, there is a paucity of data on the role of SEMS in the management of benign colonic obstruction, an indication which remains controversial. This review outlines the most recent developments in colonic stenting, their current indications, and the evidence to support their use in these indications.

Fluticasone propionate for treatment of esophageal lichen planus. A case series.

Esophageal lichen planus is a rare condition, and although the majority of cases occur in conjunction with lichen planus at other sites, the endoscopic features are often misinterpreted resulting in a delay in diagnosis. We report a series of five patients presenting to our unit between 2005 and 2009. All five patients were female and presented with dysphagia. Endoscopy demonstrated proximal esophageal stricturing in four patients. Characteristic histological findings were found in four patients. Lichen planus was diagnosed at other sites, and preceded gastrointestinal symptoms, in all patients; five had oral involvement, two had genital involvement, and one had dermal involvement. All patients received proton pump inhibitor therapy without demonstrable benefit. Administration of oral fluticasone proprionate resulted in symptomatic improvement in three patients.

Reducing unnecessary outpatient attendances.

PURPOSE: The purpose of this paper is to explore unnecessary outpatient department attendances and to improve efficiency by actively pre-assessing patient charts and pre-specifying management plans before scheduled outpatient visits. DESIGN/METHODOLOGY/APPROACH: All charts were reviewed by a senior clinician two weeks before the clinic and a brief, written management plan made. FINDINGS: A significant reduction in clinic sizes by about 40 per cent can be expected. There was a non-significant increase in the ratio of new to review patients and no significant reduction in waiting lists. RESEARCH LIMITATIONS/IMPLICATIONS: Pre-assessing patient charts leads to cancelling unnecessary outpatient reviews, which can increase outpatient department effectiveness. ORIGINALITY/VALUE: Clinical efficiency is becoming increasingly important. This work describes a simple strategy to improve outpatient department productivity.

Approach to biliary imaging amongst consultant and specialist registrars in gastroenterology in a national setting.

BACKGROUND: Radiological investigation plays an important role in the management of conditions affecting the hepatobiliary system. However, multiple imaging modalities exist and inappropriate requesting can lead to delays in diagnosis and subsequent treatment. AIMS: To assess the approach to biliary imaging amongst Irish gastroenterologists across a number of scenarios, and examine and seek to explain any variations. METHODS: A survey to determine "best practice" radiological investigation of real-life clinical scenarios was designed and distributed to fully trained and trainee gastroenterologists nationally. RESULTS: The responses to scenarios ranged from near unanimity, with up to 97% agreement, to notable lack of consensus amongst both registrars and consultants. CONCLUSION: An algorithm for the management of hepatobiliary disease was formulated.

Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system.

BACKGROUND: Suprapapillary needleknife fistulotomy is performed when standard biliary cannulation methods have failed. However, its role is controversial, with conflicting reports on its use. This study aimed to determine the efficacy and safety of needleknife fistulotomy after failure of conventional cannulation techniques. METHODS: All patients who underwent needleknife fistulotomy were identified from a single tertiary referral center database prospectively maintained from 1997 to 2007. RESULTS: A total of 2,603 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) over the 10-year period. Fistulotomy was performed for 352 patients (13.5%), with 317 of these patients (90.1%) experiencing successful biliary cannulation. With the use of fistulotomy, the total cannulation success rate increased from 79.0 to 91.2% (P < 0.0001). Endoscopic management of choledocholithiasis and hepatobiliary malignancy increased from 48.9 to 55.1% (P < 0.001), and from 12.0 to 16.0% (P < 0.001) for all cases. The complication rate was significantly higher for the patients who underwent fistulotomy than for those who did not (4.8% vs. 2.1%; P < 0.001), which can be explained by a higher rate of mild bleeding in the fistulotomy group. However, no significant difference in pancreatitis or perforation between the two groups was observed. In addition, no fatalities occurred after fistulotomy. CONCLUSION: Suprapapillary needleknife fistulotomy is an effective method for accessing the biliary system after failed standard cannulation. Despite a higher rate of mild bleeding, fistulotomy was not associated with an increased risk of serious complications.

Accelerated infliximab infusions are safe and well tolerated in patients with inflammatory bowel disease.

INTRODUCTION: Infliximab is used widely for patients with inflammatory bowel disease (IBD). Drug manufacturers advise a 2-h infusion, with subsequent monitoring for a further 2-h period. Accelerated infusions, however, have been used in rheumatological patients with no significant increase in adverse events reported. OBJECTIVES: The primary endpoint was to assess the incidence of infusion reactions in IBD patients receiving infliximab via an accelerated infusion protocol. Secondary endpoints were to identify factors that may increase risk of an infusion reaction. METHODS: This was a prospective study examining patients with IBD receiving infliximab with the accelerated infusion protocol (first four infusions over 2 h, with 2 h of monitoring, the next five infusions over 1 h, and subsequent infusions over 30 min). RESULTS: Over 40 months, 1146 infusions were administered to 144 patients, 139 patients with Crohn's disease, two with ulcerative colitis, two with pouchitis and one with indeterminate colitis. Fourteen reactions during the 2-h infusion, with four delayed hypersensitivity reactions were observed, 13 during 1-h infusions with one delayed hypersensitivity reaction and 10 during a 30-min infusion. Thirty-two reactions were mild, allowing completion of the infusion, but five were severe, resulting in cessation of infliximab. Sex, age, disease type (fistulising vs. inflammatory), administration (episodic vs. maintenance infusions), type of immunomodulator or number of infusions were not predictors of an infusion reaction. CONCLUSION: Rapid infusion of infliximab is safe and well tolerated, with no increase in infusion-related reactions. Where reactions do occur, they are usually mild, allowing completion of therapy.