Ariwan Rakvit

Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts.

We carried out the first meta-analysis comparing the technical success and clinical outcomes of endoscopic ultrasound-guided drainage (EUD) and conventional transmural drainage (CTD) for pancreatic pseudocysts. We searched PubMed, Embase, Scopus, and the Cochrane library to identify relevant prospective trials. The technical success rate, short-term (4–6 weeks) success, and long-term (at 6 months) success in symptoms and the radiologic resolution of pseudocysts, complication rates, and death rates were compared. Two eligible randomized-controlled trials and two prospective studies including 229 patients were retrieved. The technical success rate was significantly higher for EUD than for CTD [risk ratio (RR)=12.38, 95% confidence interval (CI): 1.39–110.22]. When CTD failed because of the nonbulging nature of pseudocysts, a crossover was carried out to EUD (n=18), which was successfully performed in all these cases. All patients with portal hypertension and bleeding tendency were subjected to EUD to avoid severe complications. EUD was not superior to CTD in terms of short-term success (RR=1.03, 95% CI: 0.95–1.11) or long-term success (RR=0.98, 95% CI: 0.76–1.25). The overall complications were similar in both groups (RR=0.98, 95% CI: 0.52–1.86). The most common complications were bleeding and infection. There were two deaths from bleeding after CTD. The short-term and long-term treatment success of both methods is comparable only if proper drainage modality is selected in specific clinical situations. For bulging pseudocysts, either EUD or CTD can be selected whereas EUD is the treatment of choice for nonbulging pseudocysts, portal hypertension, or coagulopathy.

Predictor of 90-Day Readmission Rate for Hepatic Encephalopathy.

Objectives The purpose of our study was to identify clinical parameters associated with readmissions within 90 days in patients with hepatic encephalopathy (HE). Methods We reviewed electronic medical records of patients admitted between January 1, 2010 and September 30, 2013 at University Medical Center, Lubbock, Texas. Inclusion criteria were admission to the hospital with diagnosis of HE in patients older than 18 years. We compared the patients with readmission within 90 days with patients with no readmission using routine clinical data. Results A total of 140 admissions met inclusion criteria; 35% were white, 59.3% were Hispanic, and their mean age was 55.6 ± 10.5 years. The median admission Model for End-Stage Liver Disease score was 15.5 (4–38). Univariate analysis demonstrated that a history of diabetes mellitus, a history of hypertension, prior transjugular intrahepatic portosystemic shunt placement, a history of prior HE, and the use of lactulose posthospitalization were associated with increased readmission rates and the presence of gastrointestinal bleeding was associated with decreased readmission rates (P < 0.05 for each factor). Multivariate logistic regression demonstrated that history of hypertension (P = 0.02) predicted an increased readmission rate. Conclusions Our study demonstrates that hypertension increased the risk of readmission in patients with HE. More intensive interventions in these patients may decrease readmission rates and improve outcomes.

Diverticulitis in the young.

Background: Colonic diverticulitis is relatively uncommon in young patients, especially those younger than 40 years. We compared demographic data, clinical presentation, management, and clinical course of diverticulitis in patients ≤40 years old compared with patients >40 years old. Methods: This study included all patients who presented to the emergency department with a diagnosis of diverticulitis between October 1, 2009 and September 30, 2010. Patients were divided into 2 groups: group 1 (≤40 years old) and group 2 (>40 years old). Demographic characteristics, clinical presentation and management, and short-term outcomes were compared. Results: Ninety-four patients were included in the study (37 patients in group 1 and 57 patients in group 2). A higher percentage of obese and Hispanic men was found in group 1 (P > .05). The rate of discharge from the emergency department was significantly higher in group 1 (56.8% in group 1 vs 7.0% in group 2, P < .01). Group 2 patients had a shorter median length of stay than group 1 patients (3.1 vs 5.7 days, P = .16). There were no differences in vital signs, laboratory data (including complete blood count and basic metabolic panel), and in-hospital mortality rates between the 2 groups. Conclusions: This study demonstrates that young Hispanic men develop diverticulitis and that this diagnosis needs to be considered when they present to emergency rooms with abdominal symptoms. A longitudinal study is needed to determine the long-term outcomes in these patients and to investigate the pathogenesis.

When Should a Patient with a Nonvariceal Upper Gastrointestinal Bleed Be Fed

Abstract Nonvariceal upper gastrointestinal hemorrhage is a common cause for admission to the intensive care unit. Most patients are prohibited from oral or enteral feeding for 72 hours despite different risks for rebleeding. Fasting is believed to improve the ability to control intragastric pH, stabilize clots, and reduce the risk of rebleeding; however, studies have shown no difference in intragastric pH and complications in patients who received early feeding. Approximately 50% of patients are classified as low risk for rebleeding and can be safely fed immediately and discharged early, even on the same day as endoscopy. Only the patients with a high risk of rebleeding should be kept nil per os and be hospitalized for at least 72 hours after endoscopic treatment. Most high-risk lesions become low-risk lesions within 72 hours, and most rebleeding occurs within this time. Randomized controlled trials have demonstrated that early feeding does not have adverse consequences, however. More studies on the timing and type of nutrition in patients with high-risk stigmata are needed.