Aminda De Silva

Chronic radiation enteritis and malnutrition

Radiation enteritis is defined as the loss of absorptive capacity of the intestine following irradiation, which is most commonly seen after radiotherapy for pelvic and abdominal malignancies. It is divided into acute and chronic forms and usually presents with diarrhea and malabsorption. Malnutrition is a common complication of chronic radiation enteritis (CRE). We reviewed the etiology, prevalence, symptoms, diagnosis and management of CRE and CRE with malnutrition in this article. Functional short bowel syndrome as a cause of malnutrition in CRE is also considered. The diagnostic work‐up includes serum markers, endoscopy, cross‐sectional imaging and the exclusion of alternative diagnoses such as recurrent malignancy. Management options of CRE include dietary manipulation, anti‐motility agents, electrolyte correction, probiotics, parenteral nutrition, surgical resection and small bowel transplantation. Treatment may also be required for coexisting conditions including vitamin B12 deficiency, bile acid malabsorption and depression.

Effi cacy of nasal bridles in avoiding percutaneous endoscopic gastrostomy placement

Objective The aim of the study was to report the use of nasogastric tube bridles to avoid dislodging of percutaneous endoscopic gastrostomy tubes. Specifically it was intended to see if they reduced feeding time, medical input and costs. Design and setting This was a cohort study in a district hospital setting. Patients 164 patients admitted with conditions causing acutely impaired swallowing. Interventions 140 of 164 patients referred received a NGT bridle. Results Of these, 49 (35%) died by 28 days and 68 (48.6%) at 1 year; 73 (52.1%) had regained adequate oral intake at 28 days and 27 (19.2%) had proceeded to PEG. Of those not bridled, nine (37.5%) died by 28 days and 10 (41.7%) at 1 year with the remainder eating. There was no significant difference in mortality between groups. There were no complications attributed to bridles. Conclusion We conclude that nasogastric bridles are safe and represent an appropriate method to maintain nutrition while seeing if the underlying disease process will stabilise in these critically ill patients. They have the benefits of avoiding unnecessary PEG and the associated complications and cost.

S1350 Efficacy of Nasal Bridles in Preventing Nasogastric Tube Displacement. the Royal Berkshire Experience

Introduction Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. Methods Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. Conclusion Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

Pyoderma gangrenosum as a first presentation of inflammatory bowel disease

Up to 40% of patients with inflammatory bowel disease (IBD) develop an extraintestinal manifestation of the disease with the skin being the most commonly involved organ. Pyoderma gangrenosum (PG), an autoinflammatory non-infectious neutrophilic dermatosis, occurs in 1–2% of patients with IBD. PG can follow a course independent to that of the bowel disease, however, most reported cases describe PG occurring in patients with an established diagnosis of IBD. We present a case of a young patient who presented with axillary skin ulceration, which was subsequently diagnosed as PG. On further investigation for a possible underlying cause, she was found to have Crohns disease. She had not developed any preceding change in her bowels and did not have abdominal pain; the IBD was diagnosed on endoscopic findings. This case is also unusual for the distribution of the PG lesions that typically occur in the lower limbs.

Management of psoriasis in patients treated with anti-TNF-α therapy for inflammatory bowel disease

We read with interest the article by Saad-Hossne et al.1 summarising 222 cases of anti-TNF for IBD giving rise to psoriasis. We note that the anti-TNF therapy was continued effectively in the majority of cases, similar to a recent series2 in which the anti-TNF agent was maintained and psoriasis treated with topical agents. This seems …

The importance of full-thickness jejunal biopsy in diagnosing inflammatory neuromuscular gastrointestinal disorders.

The Importance of Full-Thickness Jejunal Biopsy in Diagnosing Inflammatory Neuromuscular Gastrointestinal Disorders

Metabolic acidosis in short bowel syndrome: think D-lactic acid acidosis

Short bowel syndrome (SBS) is a condition when a person’s gastrointestinal function is insufficient to supply the body with essential nutrients and hydration. Patients with SBS suffer from diarrhoea and symptoms of malabsorption such as weight loss, electrolyte disturbances and vitamin deficiencies. Long-term management of this condition can be complicated by the underlying disease, the abnormal bowel function and issues related to treatment like administration of parenteral nutrition and the use of a central venous catheter. Here, we describe a case of D-lactic acid acidosis, a rarer complication of SBS, presenting with generalised weakness and severe metabolic acidosis.

Mesenteric vein thrombosis; not going with the flow.

A 71-year-old woman presented with a 2-week history of epigastric pain, nausea and vomiting; on examination she demonstrated signs of peritonism. CT imaging was performed and this demonstrated extensive thrombosis of the superior mesenteric, omental and portal veins with infarction of the distal small bowel. A non-operative approach was initiated and anticoagulation rapidly started. Within 48 h the patient demonstrated significant clinical improvement and she subsequently made a full recovery.

MARSIPAN and the deadly triad: management of malnourished patients

A 44-year-old gentleman was admitted with a deliberate overdose of olanzapine, paracetamol and bisoprolol. On admission, he was hypothermic, bradycardic and hypotensive and his body mass index was 12 kg/m2. Problems identified on admission included polypharmacy overdose, risk of refeeding syndrome and sepsis. Despite careful reintroduction of feeding and generous electrolyte replacement, he developed persistent hypophosphataemia, hypokalaemia and a marked transaminitis. Several days later, he was noted to be hypothermic and hypoglycaemic. No increase in white cell count or C reactive protein was noted and his clinical appearance was otherwise unremarkable. Nevertheless, given these signs he was started on broad spectrum antibiotics for possible sepsis, which was subsequently confirmed on chest radiograph in addition to a further finding of likely aspergilloma on a later chest CT. His metabolic function stabilised after 3 weeks of carefully titrated nutrition and the sepsis responded to antibiotics and antifungal therapy.