Brian J. Hanson

Endoscopic and medical therapy for chronic radiation proctopathy: a systematic review.

BACKGROUND: Chronic radiation proctopathy is associated with significant morbidity. The effectiveness of endoscopic and medical therapies has not been evaluated. OBJECTIVES: The aim of this study was to conduct a systematic review of the effectiveness of endoscopic and comparative medical therapies for chronic radiation proctopathy. DATA SOURCES: A comprehensive search Medline and PubMed was performed. STUDY SELECTION: A comprehensive literature search was performed for studies of endoscopic and medical therapy for clinical and endoscopic improvement in chronic radiation proctopathy from January 1990 until December 2010. The quality of the overall evidence was rated according to the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. SETTING: Patients in both inpatient and outpatient settings were assessed. PATIENTS: Patients experiencing chronic radiation proctopathy were included. INTERVENTIONS: Patients had undergone medical or endoscopic treatments for chronic radiation proctopathy. MAIN OUTCOME MEASUREMENTS: The primary outcomes measured were the resolution or improvement in symptoms. RESULTS: A total of 39 studies were found, of which 27 evaluated endoscopic therapy and 12 evaluated medical therapy chronic radiation proctopathy. Overall, there is low-level evidence for the effectiveness of endoscopic therapy with argon plasma coagulation in reducing short-term (⩽6 weeks) symptoms of chronic radiation proctopathy and insufficient evidence for long-term improvement. There is moderate-level evidence for the use of sucralfate enemas and low-level evidence for use of short-chain fatty acid enemas and hyperbaric oxygen. There is insufficient evidence for other agents: topical formalin, 5-aminosalicylic acid compounds, sulfasalazine, vitamin A, and pentoxifylline. LIMITATIONS: Individual authors were not contacted, and the search was limited to English language journals only. CONCLUSION: Endoscopic treatment with argon plasma coagulation appears effective in the short-term outcome of chronic radiation proctopathy. There is a moderate level of evidence for the use of sucralfate enemas. Large, randomized, placebo-controlled studies evaluating endoscopic and medical therapies for chronic radiation proctopathy are needed.

Safety and Outcomes of Capsule Endoscopy in Patients with Left Ventricular Assist Device: a Single-Center Retrospective Case Series.

Obscure gastrointestinal bleeding (GIB) in patients with continuous-flow left ventricular assist devices (CF-LVAD) is common. Capsule endoscopy (CE) can be used in the diagnosis of obscure GIB. Safety and outcomes of CE in patients with CF-LVAD are unknown. The aim is to define the safety and outcomes of CE in this population. Paitents with CF-LVAD undergoing CE at a single center between 2007 and 2014 were retrospectively reviewed. Thirty-four CE studies were performed. Positive CE occurred in 19 studies. No clinically significant cardiac events occurred. Medical intervention was the most common management strategy. Rebleeding after CE occurred in 10 patients. Patients with active bleeding or lesions such as arteriovenous malformations (AVM) incurred a higher risk of rebleeding, transfusion, and repeated endoscopy. CE is safe in patients with CF-LVAD. The risk of rebleeding was more common in patients with active bleeding or AVM lesions although this result did not reach statistical significance.

American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation

Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, Case Western Reserve University and Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio; and Division of Gastroenterology, University of Minnesota and Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota

American Gastroenterological Association Institute Technical Review on the Medical Management of Opioid-Induced Constipation

Abbreviations used in this paper: AE, adverse event; AGA, American Gastroenterological Association; BFI, Bowel Function Index; BM, bowel movement; BSFS, Bristol Stool Form Scale; CI, confidence interval; FDA, Food and Drug Administration; GI, gastrointestinal; GRADE, Grading of Recommendations Assessment, Development and Evaluation; MD, mean difference; OIC, opioid-induced constipation; PAC-QOL, Patient Assessment of Constipation-Quality of Life; PAMORA, peripherally acting m-opioid receptor antagonist; PEG, polyethylene glycol; PICO, population, intervention, comparator, and outcomes; PROM, patient-reported outcome measure; QOL, quality of life; RCT, randomized controlled trial; RFBM, rescue-free bowel movement; RR, relative risk; SBM, spontaneous bowel movement.

Not Too Hot, Not Too Cold, but “Just Right”

Abstract: When ordering diagnostic tests, physicians are faced with a problem of not too many tests, not too few, but ‘just right’. However, in medical diagnostics ‘just right’ may be very difficult to identify. Such is the conundrum presented in study by Rubenstein and colleagues regarding appropriate use of repeat esophagogastroduodenoscopy (EGD) in Veterans Health Administration (VHA) medical facilities. The important message of this paper is that out of 235,855 patients with an index EGD, 36% underwent repeat EGD over 5 years, of which only 9% (range 3–18%a cross VHA facilities) were classified as probable overuse.

Haematological, neurological and electrocardiographic findings in secondary hypothermia

The association between secondary hypothermia and pancytopaenia is uncommon. A young woman presented with chronic hypothermia (28.8–34.6°C) secondary to surgical hypothalamic injury postcraniopharyingioma resection as a child. Associated findings included pancytopaenia (haemoglobin 8.1 g/dl, leucocytes 3500/mm3, platelets 63 000/mm3), ataxia, upper motor neuron signs, decreased level of consciousness and new ECG changes. An extensive evaluation failed to reveal any cause of pancytopaenia other than chronic hypothermia. The haematological and neurological changes improved after active rewarming.