Andrew Ukleja

Dumping Syndrome: Pathophysiology and Treatment

Anatomic and physiologic changes introduced by gastric surgery result in clinically significant dumping syndrome in approximately 10% of patients. Dumping is the effect of alteration in the motor functions of the stomach, including disturbances in the gastric reservoir and transporting function. Gastrointestinal hormones play an important role in dumping by mediating responses to surgical resection. Treatment options of dumping syndrome include diet, medications, and surgical revision. Poor nutrition status can be anticipated in patients who fail conservative therapy. Management of refractory dumping syndrome can be a challenge. This review highlights current knowledge about the mechanisms of dumping syndrome and available therapy.

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

ObjectiveStricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation.MethodsThis is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure.ResultsSixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19–68 years); mean preoperative BMI was 45 kg/m2 (range: 42–61 kg/m2). Mean time from surgery to symptoms onset was 2 months (range: 1–6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation.ConclusionThis is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.

Esophageal motility disorders in the morbidly obese population.

BackgroundMost studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery.MethodsA total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis.ResultsThe study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain.ConclusionsDespite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion.

Altered GI motility in critically ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach.

Gastrointestinal (GI) motility disturbances are common in critically ill patients. GI tract dysmotility has been linked to increased permeability of intestinal mucosa and bacterial translocation, contributing to systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction syndrome. A key issue in providing nutrition to critically ill patients is intolerance of enteral feeding as a result of impaired GI motility. Remarkable progress has been made in the understanding of the regulation of GI motility in critical illness. Predominant motility abnormalities seen in ICU patients include antral hypomotility, delayed gastric emptying, and reduced migrating motor complexes. The diagnosis of motility disturbances can be challenging to establish in critically ill patients. The available tests used for detection of abnormal motility have major limitations in the ICU setting. Recognition of the type and site of intestinal motility disorder is important to guide the therapy and improve the outcome.

Standards for Nutrition Support Adult Hospitalized Patients

The American Society for Parenteral and Enteral Nutrition defines standards as benchmarks representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care in most circumstances. Standards are documents that define the structure needed to provide competent care. These Standards for Nutrition Support for Adult Hospitalized Patients are an update of the 2010 Standards. These practice-based standards are intended for use by healthcare professionals charged with the care of adult hospitalized patients receiving nutrition support therapy in any hospital with or without a formal nutrition support service or team. These Standards address professional responsibilities as they relate to patient assessment, diagnosis, education, care plan development, implementation, clinical monitoring, evaluation, and professional issues around nutrition support.

Endoscopic botox injections in therapy of refractory gastroparesis

Gastroparesis (GP) is a common disease seen in gastroenterology practice particularly in western countries, and it may be underdiagnosed. The available drug therapies for this condition are quite disappointing. Botulinum toxin type A (BT) has been found to be effective therapy in various spastic disorders of smooth muscle of gastrointestinal tract. However, the benefits of BT injections in GP have been unclear. Several retrospective and open label studies have shown clinical advantages of intrapyloric Botulinum toxin type A injections, while two small randomized trials did not show positive results. Therefore, the available published studies yielded conflicting results leading to fading out of botox therapy for GP. We recognize possible clinical benefit of BT injections without any disadvantages of this treatment. We are calling for revisiting the endoscopy guided botox therapy in refractory GP. In this review we discuss important features of these studies pointing out differences in results among them. Differences in patient selection, doses and method of administration of botox toxin in the prior studies may be the cause of conflicting results. The mechanism of action, indications, efficacy and side-effects of BT are reviewed. Finally, we recognize limited evidence to recommend BT in GP and calling attention for future research in this field since no advances in drug management had been made in the last two decades.

Esophageal dilations in eosinophilic esophagitis: A single center experience

AIM To diagnose the clinical and histologic features that may be associated with or predictive of the need for dilation and dilation related complications; examine the safety of dilation in patients with eosinophilic esophagitis (EoE). METHODS The medical records of all patients diagnosed with EoE between January 2002 and July 2010 were retrospectively reviewed. Esophageal biopsies were reexamined by an experienced pathologist to confirm the diagnosis (≥ 15 eos/hpf per current guidelines). Patients were divided into 2 groups: patients who did not receive dilation therapy and those who did. Demographics, clinical history, the use of pharmacologic therapy, endoscopic and pathology findings, and the number of biopsies and dilations carried out, if any, and their locations were recorded for each patient. The dilation group was further examined based on the interval between diagnosis and dilation, and whether or not a complication occurred. RESULTS Sixty-one patients were identified with EoE and 22 (36%) of them underwent esophageal dilations for stricture/narrowing. The peak eos/hpf was significantly higher in patients who received a dilation (P = 0.04). Four (18% of pts.) minor complications occurred: deep mucosal tear 1, and small mucosal tears 3. There were no cases of esophageal perforations. Higher peak eos/hpf counts were not associated with increased risk of complications. CONCLUSION Esophageal dilation appears to be a safe procedure in EoE patients, carrying a low complication rate. No correlation was found between the peak of eosinophil count and complication rate. Complications can occur independently of the histologic features. The long-term outcome of EoE treatment, with or without dilation, needs to be determined.

Clinical, Ergonomic, and Economic Outcomes With Multichamber Bags Compared With (Hospital) Pharmacy Compounded Bags and Multibottle Systems A Systematic Literature Review

Background: Multichamber bags (MCBs) may offer potential clinical, ergonomic, and economic advantages compared with (hospital) pharmacy compounded bags (COBs) and multibottle systems (MBSs). Methods: A systematic literature review was performed to identify and assess the available evidence regarding advantages of MCBs compared with COBs and MBSs. Medline, Embase, the Cochrane Databases, and EconLit were searched for articles reporting clinical, ergonomic, and economic outcomes for MCBs compared with COBs or MBSs. The search was limited to studies conducted in hospitalized patients >2 years of age that were published in English between January 1990 and November 2014. The Population Intervention Comparison Outcomes Study Design (PICOS) framework was used for the analysis. Results: From 1307 unique citations, 74 potentially relevant publications were identified; review of references identified 2 additional publications. Among the 76 publications, 18 published studies met the inclusion criteria. Most were retrospective in design. Ten studies reported clinical outcomes, including 1 prospective randomized trial and multiple retrospective analyses that reported a lower risk of bloodstream infection for MCBs compared with other delivery systems. Sixteen studies reported ergonomic and/or economic outcomes; most reported a potential cost benefit for MCBs, with consistent reports of reduced time and labor compared with other systems. The largest cost benefit was observed in studies evaluating total hospitalization costs. Conclusions: The systematic literature review identified evidence of potential clinical, ergonomic, and economic benefits for MCBs compared with COBs and MBSs; however, methodological factors limited evidence quality. More prospective studies are required to corroborate existing evidence.

Splenic rupture after screening colonoscopy: case report and literature review.

Splenic rupture is a rare complication after colonoscopy, and to date there are only 46 reported cases in the English-language literature. Presented is a case report of splenic rupture after screening colonoscopy that resulted in laparotomy and splenectomy within 24 hours of the original procedure. The article covers the hypothesized mechanisms of injury, various precautions to take during colonoscopy, suggested diagnostic algorithm, determining factors in treatment, and vaccine regimen. The article concludes by stating that as the number of colonoscopies increase, so will the prevalence of associated complications, and that physicians are encouraged to understand this paradigm shift.

Management of gastroparesis-associated malnutrition.

Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re‐evaluation and enteral and parental nutrition should be considered in complex GP patients.