Irritable bowel syndrome: a review and update.

The understanding of irritable bowel syndrome (IBS) has undergone a rapid evolution with scientific advancement. IBS is a common functional bowel disorder that generates a significant health care burden and is the most commonly diagnosed gastrointestinal condition. There are well-established diagnostic criteria and algorithms for the initial evaluation of patients presenting with the symptoms of IBS. The symptoms can be targeted for therapy with a variety of pharmaceutical and nonpharmaceutical agents. Therapy should be individualized for the patient, and the cornerstone for any effective treatment strategy should be the solid patient-physician relationship.

Endoscopist-directed administration of propofol: a worldwide safety experience.

BACKGROUND & AIMS: Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS: We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS: A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million. CONCLUSIONS: EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Ehlers-Danlos syndrome: complications and solutions concerning anesthetic management.

Ehlers-Danlos syndrome is an inherited disorder that results in dysfunctional collagen bundles. These dysfunctional collagen bundles are most noticeable in tissues rich with collagen fibers--skin, vessels, GI, and ligaments. Until gene therapy advancements can correct the underlying gene mutations causing faulty collagen, the mainstay of treatment is prevention of traumatic injury. The success of anesthetic management in patients with EDS requires and understanding of the role of collagen in the various tissues of the body. Collagen-rich tissue fragility, skin hyperextensibility, joint hypermobility, hematoma formation and cardiovascular disease are just some of the complications that need to be accounted for before every anesthetic procedure involving EDS patients. Anesthesiologists should be keenly that any physical manipulation of EDS patients incurs risks of trauma.

Does integrated practice guideline testing in gastroenterology fellowship training improve fellows' education?

BACKGROUND: Multiple professional societies have issued practice guidelines that provide up-to-date evidence-based recommendations and expert opinions on patient care in the field of gastroenterology (GI). While most physicians are aware that formal guidelines exist, these GI guidelines have not been integrated into academic training curricula in most of the top-ranked GI fellowship programs. METHODS: Two fellows in the Ochsner GI fellowship program (the control group) reviewed 14 current American Society of Gastrointestinal Endoscopy guidelines deemed essential for GI fellowship training and wrote 200 questions based on these guidelines. Four additional fellows (the experimental group) had no knowledge of which articles would be tested. A 14-week curriculum focused on reviewing the guidelines. All 6 fellows took a pretest before the guideline review and then took a postreview test. All of the participating GI fellows completed a survey evaluating the perceived effectiveness of the formal guideline testing. RESULTS: The experimental group had a 33% improvement in test scores between the pre- and posttest, while the control group had a 7% improvement. The survey showed that 100% of the fellows felt more secure in their knowledge of the guidelines and would recommend that this learning format be implemented into the annual academic curriculum. All also agreed that this format provided evidence-based knowledge to improve patient safety and provide optimal patient care. CONCLUSION: We plan to continue formal practice guideline reviews in our fellowship and believe this format would benefit other medical training programs as well.

How to choose the best preparation for colonoscopy.

The success and accuracy of colonoscopy is largely dependent on appropriate cleansing of the colon. The ideal bowel preparation should be safe, well-tolerated and effective. Although colonoscopy preparations are vastly better than the earliest barium enemas used in X-ray regimens, none of the currently available formulations sufficiently fulfills the above criteria. Currently used techniques of colon cleansing include dietary and cathartic methods, gut lavage and the administration of phosphates. All of these methods are efficacious, particularly when administered in a split dose (one the evening before and one just before the planned colonoscopy). Gut lavage methods are the safest method; however, dietary and cathartic methods are also reasonably safe. Low-dose phosphate preparations are well tolerated, but safety concerns have led to the withdrawal of some phosphate products from the US market. A new oral sulfate product that achieves a desirable balance of safety, tolerability in patients and efficacy will shortly be introduced. Physicians should be aware of the range of colonoscopy preparations available and their limitations, so that the best preparation can be chosen for an individual patient.