Alastair W. McKinlay

A review of the instruments used to assess the quality of life of adult patients with chronic intestinal failure receiving parenteral nutrition at home

Home parenteral nutrition is an established method of supporting patients with intestinal failure, but this treatment may be life long and imposes severe restrictions on daily life. Impact on quality of life is an important outcome when considering the management of home parenteral nutrition patients. This paper reviews studies in which the quality of life of patients receiving home parenteral nutrition has been assessed. A systematic search of electronic databases and relevant publications was undertaken to identify generic or treatment-specific questionnaires used with home parenteral nutrition patients. Many of the thirty-four reports discovered were small studies. Nineteen used non-specific generic instruments, eight used non-validated questionnaires, four used a combination of both, and three did not use any formal tool. Few systematic patterns emerged. There are few available data on the quality of life of home parenteral nutrition patients, and there is a need for standardised, scientifically validated, treatment-specific instruments to measure quality of life in this population.

Refeeding syndrome in a patient with anorexia nervosa.

A 22 year old woman with a one year history of anorexia nervosa was admitted as an emergency after she collapsed. She was hypoglycaemic, with a blood glucose concentration of 1.5 mmol/l. Her hypoglycaemia was corrected, and, after discussion with her and her eating disorder specialist, she was transferred to the gastroenterology unit to start nasogastric refeeding. Her body mass index was 12.9. During the next 10 days her liver function tests became deranged—alanine transaminase was 546 U/l, and γ glutamyltransferase was 47 U/l. She was subsequently transferred to a specialist eating disorder unit as an inpatient for psychiatric and psychotherapeutic management alongside the continued refeeding programme. ### 1 What classic biochemical and physical complications may occur in refeeding syndrome? #### Short answer Hypophosphataemia, hypomagnesaemia, gastric dilation, congestive cardiac failure, severe oedema, confusion, coma, and death. #### Long answer Refeeding syndrome is chiefly defined as the …

Outcomes after through-the-PEG tube placement of jejunal extensions: a case series from a single center.

1 PEG was first described by Gauderer et al and is used for providing long-term feeding. Enteral feeding is indicated in patients with functional GI tracts unable to meet nutritional requirements orally. PEG tube placement has several indications, with the strongest evidence in patients with acute dysphagic stroke and oropharyngeal malignancy. PEG feeding is not suitable for alldfor example, in those with gastroparesis in whom post-gastric or jejunal feeding is required to maintain adequate nutrition. Recurrent aspiration has been reported in up to 30% of PEG-fed individuals, with some evidence that jejunal feeding decreases the aspiration risk. However, this is a contentious issue because other studies show no advantage to this approach. Establishing stable access to the small bowel can be difficult, and placement of a percutaneous endoscopic jejunostomy (PEJ) tube challenging. A PEG with jejunal extension (PEG-J) is an alternative technique for patients who do not tolerate gastric feeding. Many methods of PEG-J tube placement have been reported, but no consensus on the most effective technique exists. Conventional techniques are time consuming, technically demanding, and generally require sedation, oral intubation, and fluoroscopic guidance. Most methods involve passing a guidewire or jejunal tube through the PEG tube and catching this in the stomach with a standard endoscope and forceps. The

Care on the General Medical Ward

When should we consider admission to a medical ward? How do we assess physical risk in a patient with severe malnutrition? What is the role of the medical unit in the management of the severely ill patient? How can we safely manage the potentially fatal complication of refeeding syndrome? When is nasogastric feeding required and how can it be conducted safely? How can the patient’s anorexic behaviour be contained, to prevent or heal any splitting and low morale among staff? What are the risks and problems of transition to further care?

How Do Medical Conditions Interact with Eating Disorders and How Are They Managed in This Context

How do the following medical conditions interact with eating disorders and how are they managed?

PWE-105 Is there a correlation between severity of bile acid malabsorption (BAM) and response to treatment?

Introduction NICE guidelines in 2012 have recommended SeHCAT to be used in research in order to collect more information in its usefulness in the diagnosis and treatment of BAM. A previous study has identified a lack of consistent cut-off threshold values for abnormal SeHCAT results. The aim of this study is to determine whether there is any relationship between the severity of BAM and treatment response. Methods Medical records of 492 patients who had a SeHCAT scan at Aberdeen Royal Infirmary between 23/7/2013 to 9/6/2017 were retrospectively reviewed. Mild, moderate and severe BAM were defined as 10.1%–15%, 5.1%–10% and <5% retention of SeHCAT after one week respectively. Data including the severity and types of BAM were recorded. Treatment responses to bile acid binders were also recorded when patients were followed up in the clinic after the scans. Results 492 scans were performed and 51% (252/492) of patients had abnormal SeHCAT results (<15%) over the study period. The mean age was 51.6 with a female predominance of 69% (174/252). 20% (50/252) of these patients had a prior diagnosis of IBS and 27% (67/252) patients had previous cholecystectomy. 17% (44/252) had type 1 BAM, 53% (134/252) had type 2 BAM and 29% (74/252) had type 3 BAM. The mean SeHCAT retention percentage was 2.59% for type 1 BAM, 7.45% for type 2 BAM and 5.63% for type 3 BAM. The difference was statistically significant (p<0.001). 52% (132/252) of patients had treatment response documented following their scans and 13% (17/132) of these patients stopped treatment due to side effects. For the remaining 115 patients, 71% (12/17) of patients with mild BAM had good response to bile acid binder compared to 77% (23/30) with moderate BAM and 78% (55/68) with severe BAM. The difference was not statistically significant (p<0.635). 15 out of 90 patients who responded to colesevelam previously found cholestyramine ineffective or intolerance of it. Conclusions In our study, the mean SeHCAT retention level was significantly lower for BAM type 1 compared to BAM types 2 and 3. There was an overall good therapeutic response to bile acid binders in patients with a positive SeHCAT scan. However, there was no statistically significant difference between severity of BAM and theurapeutic response. Further prospective study using larger sample size is required to assess the accuracy and cut-offs of the SeHCAT test in diagnosing BAM as determined by theurapeutic response to BAS treatment.

OC-024 Predicting 30-day Mortality Following Peg Insertion: External Validation Of A Previous Scoring System And Analysis For Additional Predictive Factors

Introduction Percutaneous endoscopic gastrostomy (PEG) insertion is a well-established technique for providing long-term enteral nutrition. However concerns have been raised regarding the high 30-day mortality associated with PEG, and the related ethical implications of patient selection. Accordingly, a previous predictive tool was developed using age and serum albumin level but was created on a relatively small cohort. External validation of the score was performed in the same region but has not been outside of this area. This study aimed to externally validate this previous scoring system and also try to identify any further predictors of 30-day mortality in a larger cohort. Methods Retrospective review of all gastroscopy reports documenting PEG insertions between January 2001 and January 2012 in our centre was undertaken. Hospital electronic systems were used to determine patient demographics, laboratory results and outcome at 30 days. In patients with newly inserted PEG tubes, the scoring system was applied and assessed using receiver operating curve analysis to determine the discriminative capacity. Furthermore, univariate and multivariate binary logistic regression analyses were performed using the current database to identify additional predictors of 30-day mortality. Results The PEG database included 1373 patients, of which 808 were new PEG insertions and suitable for analysis. For each increasing gradation of the scoring system, mortality rose with 4% of those scoring zero dying compared to 50% scoring three. An area under the ROC curve of 0.686 (95% confidence interval 0.635–0.737) indicated reasonable discriminative capacity. Multivariate analysis demonstrated that age ≥60 years (OR = 2.097 [p = 0.016]), serum albumin levels of 25–34 g/l (OR = 2.447 [p = 0.001]) or < 25 g/l (OR = 6.769 [p < 0.001]), C-Reactive Protein ≥10 mg/l (OR = 2.713 [p = 0.009]) and lymphocyte count of <1.5 × 109/l (OR = 2.016 [p = 0.004]) increased the odds of 30-day mortality, whilst inpatient PEG placement decreased the risk of death (OR = 0.529 [p = 0.005]). Conclusion The previous scoring system demonstrated reasonable predictive proficiency but the area under the ROC curves were not >0.8. The recognition of further predictors of 30-day mortality allows for remodelling of the score which may improve the accuracy. However, future prospective, multicentre studies with defined outcomes are necessary to improve data collection. Additionaly, more information is needed about cause of 30-day mortality and importantly quality of life following PEG insertion. Disclosure of Interest None Declared.

PWE-191 Is Gastropexy an Alternative to Radiological Gastrostomy? a Single Centre Experience

Introduction Standard inside-out PEG insertion is not always technically possible or safe especially when there is narrowing of the oesophagus or pharynx with head-and-neck or oesophageal cancers. There is also concern about tumour seeding with inside-out technique. Similarly, in some patients it is not possible to pass the standard gastroscope through to upper GI tract. Gastropexy is an alternative technique which allows insertion of a gastrostomy tube with outside-in technique and can be performed using slimmer scopes. Gastropexy has been routinely performed in our unit for some time and therefore we aimed to review the experience of Gastropexy insertion in our unit. Methods Gastropexy placement in our unit is based upon a previously described technique using Kimberly Clark MIC introducer kit. A standard endoscopy is performed by the oral or nasal route, a site identified and the stomach secured against the anterior abdominal wall with 3 pre-loaded T-toggles which can be fastened with a locking disc. A tract is formed using a single serial dilator passed over a guidewire and a 14F balloon gastrostomy inserted through the dilator and secured. The outer sheath of the dilator will then be peeled out. All patients receive pre-procedural prophylactic antibiotics. A retrospective review of all gastropexy procedures between June 2009 and November 2012 was carried out. Patient demographics, indication, sedation requirements and complication rates were recorded. Results 45 procedures were carried out on 42 patients (28 males, median age 63 years range 56 – 84) with a technical success rate of 95.7% for placement. Indication for placement was head-and-neck cancer (n = 34), oesophageal stricture/cancer (n = 9) and neurological (n = 2). 17% of procedures were performed under general anaesthesia as part of another surgical procedure with the remainder having conscious sedation (mean doses midazolam 3.8mg and pethidine 17.8mg). 58% of procedures were performed using a nasal/neonatal endoscope. Of these, 62% cases had head-and-neck cancer, 31% had oesophageal cancer/stricture. One patient had a minor gastric fluid leak and one patient developed a pneumoperitoneum both of which were managed conservatively. At 7 days, 1/45 (2.2%) had a site infection and 1/45 (2.2%) had died whereas at 28 days, 5/45 (11.1%) had a site infection and 4/45 (8.8%) had died. Mortality at 1 year was 48%, with median survival of 5 months. The primary pathology in all the patients who died was head and neck or oesophageal cancer. None of the deaths were procedure related. Conclusion Gastropexy is a suitable alternative in patients with difficult access and can be inserted with high success rate and low complication rates. Ideally, a randomised trial comparing gastropexy and radiological gastrostomy insertion should be undertaken. Disclosure of Interest None Declared.

PMO-082 Outcomes after “through the peg” placement of jejunal extensions

Introduction Percutaneous endoscopic gastrojejunostomy (PEG-J) placement by conventional techniques is technically demanding, time consuming and its use is often limited by jejunal tube dysfunction. We aim to describe our outcomes using a “through the PEG” technique of jejunal extension placement. Methods PEG-J placement in our unit is based upon the technique described by Berger et al in 1996. Briefly, a 28Fr PEG tube is inserted and an ultrathin endoscope (4.5 mm) is passed through the PEG tube into the stomach and deep into the small bowel. A guidewire is passed down the endoscope and the endoscope withdrawn leaving the guidewire in place. A 12Fr jejunal extension is passed over the guidewire and inserted fully until seated in the PEG tube. A retrospective review of all PEG-J procedures covering the period 2006–2010 was carried out. Patient demographics, procedure type and indication, sedation requirements and complication rates were recorded. Average tube patency was calculated for each patient (in days) and reason for tube replacement was recorded. Results Over the study period, 121 procedures were carried out in 17 patients (mean age 59.6 years; 70.6% (n=12) males). Initial placement was successful in 120/121 (99.2%) procedures with a procedure related complication rate of 1/121 (0.8%> bleeding). Indications for PEG-J placement were recurrent aspiration (n=6), stroke (n=2), neurodegenerative disorder (n=2), gastroparesis (n=2), post-operative (n=1), oesophageal tear (n=1), drainage (n=1) and not documented (n=2). 102/121 (84.3%) procedures were for replacement of the jejunal extension tube alone. 73/102 (71.2%) had no indication for tube replacement recorded. The most common causes of jejunal tube dysfunction were kinking (n=12), occlusion (n=8) tube breakage (n=3), tube leakage (n=3) and other (n=3). The mean number of procedures per patient was 7.1 and the mean tube patency was 123.6 days. 90/121 (74.4%) of procedures were performed without conscious sedation. 13/102 (12.7%) jejunal replacements were performed under sedation vs 18/19 (94.7%) gastrostomy plus jejunal extension placements (p<0.001). Conclusion “Through the PEG” placement of the jejunal extension is a safe and well tolerated procedure in what is often a difficult group of patients. Our technique confers high success rates of initial placement and low complication rates, with acceptable tube patency. Sedation is only occasionally required for those undergoing replacement of the jejunal extension. Competing interests None declared.

Implementing Nutritional Standards: The Scottish Experience

In the United Kingdom, 5% of the population are underweight or have features of malnutrition. The prevalence of malnutrition rises with age and is more common in the north of England than in the south, but comparable data are not available for Scotland. In 2003, the National Health Service Quality Improvement Scotland (NHS QIS) developed a standard for food, fluid and nutritional care in hospitals (FFNCH). In 2006, a peer review of Scottish health boards was published. The reviewers reported that all Scottish health boards had started to implement the standards, but not across all clinical areas. Every health board had set up a nutritional care group to oversee and advise on the implementation of the standards, but none had produced a financial framework to support the work of the groups. Most health boards had not fully developed a policy or strategic plan to improve nutritional care as required, and there was a shortage of specialist nutrition nurses and clinical and nutrition support teams to supervise the treatment of patients with complex nutritional needs. The Scottish experience emphasizes the size of the task that health services face to bring about change.