Galia Abuksis

Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients

OBJECTIVE:Percutaneous endoscopic gastrostomy (PEG) is a widely used method for insertion of a gastrostomy tube in patients who are unable to eat but have a normally functioning gut. Complications have been described, especially in fragile, debilitated patients, and 30-day mortality rates of 4.1–26% have been reported. We assessed the outcome of PEG tube placement for inpatients and outpatients, based on morbidity, mortality, and long-term survival.METHODS:We reviewed the medical records of all patients who underwent PEG at our institution between January 1, 1995 and December 31, 1996. Four groups of patients were compared: Group 1, patients from nursing homes; Group 2, hospitalized patients; Group 3, hospitalized patients matched to Group 2 for diseases, except mental disorder, and not treated with PEG; and Group 4, the general hospital population matched for age.RESULTS:A total of 114 PEG tubes were inserted in 114 patients, 47 from Group 1, 67 from Group 2. Eighty-seven percent of patients in Group 1 underwent PEG because of dementia, versus 46% of Group 2 (p < 0.001). The mortality rate was five times higher in Group 2 than in Group 3 (p < 0.001). The 30-day mortality was seven times higher in Group 2 than in Group 1, twice that in Group 3, and five times higher than in Group 4 (p = 0.002 and p < 0.001, respectively). When intention-to-treat analyses were applied to the data, 19/48 patients died (39.5%) in Group 1, and 60/83 (72.0%) died in Group 2, (p < 0.001).CONCLUSIONS:Patients hospitalized with acute illness are at high risk for serious adverse events after PEG insertion and this procedure should be avoided.

A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department

OBJECTIVE:The growing use and complexity of endoscopy procedures in GI units has increased the need for good patient preparation. Earlier studies in this area have focused on the psychological benefits of patient education programs. The present study was directed at determining cost-effectiveness of a patient education program.METHODS:A prospective, randomized, controlled design was used. The patient population consisted of 142 patients aged 18–90 yr referred for an endoscopy procedure. Ninety-one (64%) participated in a targeted educational session conducted by a dedicated departmental nurse (group 1), 38 (27%) did not (group 2), and 13 (9%) received telephonic instruction (group 3). Before the endoscopy, all patients completed a questionnaire covering background data, endoscopy-related variables, anxiety level, and satisfaction. Patient cooperation and success/failure of the procedure were documented by the attending nurse.RESULTS:Male gender, previous endoscopy, and explanation from the referring physician were associated with a low level of anxiety (p < 0.05). There was a significant association between attendance in the education program and success of the endoscopy (p = 0.0009). Cancellations of procedures because of poor preparation occurred in 4.39% of group 1 in comparison with 26.31% and 15.38% of groups 2 and 3, respectively (p = 0.005). The overall cost of the procedure was reduced by 8.6%, 8.9%, and 5.5% for gastroscopy, colonoscopy, and sigmoidoscopy, respectively. All participants expressed satisfaction with the brochure.CONCLUSION:A pre-endoscopy patient education program apparently increase patient compliance, thereby decreasing both the need for repeated examinations and their attendant costs.

Endoscopy in Asymptomatic Minidose Aspirin Consumers

Aspirin is widely used for its antiplatelet activity, but it harbors a risk of severe adverse gastrointestinal effects, such as bleeding and perforation, especially in elderly people. Our aim to assess the prevalence of upper gastrointestinal lesions and the effect of aspirin on the gastrointestinal mucosa in asymptomatic subjects taking minidose aspirin (100 to 325 mg per day) for more than 3 months. A prospective, open design was used. Patients attending the ophthalmology and cardiology outpatient clinics who had a medical history of more than 3 months of regular aspirin consumption were referred for esophagogastroduodenoscopy (EGD). Of the 90 patients referred for EGD, 44 were symptomatic (epigastric pain or dyspepsia) and were excluded from the study. The 46 asymptomatic patients included 22 men and 24 women of mean age 70 ± 10 years (range, 36 to 87 years); 32% were current or former smokers. Mean daily aspirin dose was 129.34 ± 76.61 mg. Only 24% were taking a gastroprotective agent. EGD revealed ulcer or erosions in 47.83% of the patients: erosive gastroduodenitis in 13 patients, gastric ulcer in 14, duodenal ulcer in 2, and gastric and duodenal ulcers in 2. Urease test for Helicobacter pylori infection was positive in 26%. Univariate and multivariate analysis revealed no factor other than aspirin predictive of a positive endoscopy. Minidose aspirin treatment is associated with a high prevalence of ulcerations of the stomach and duodenum.

Epidemiology of Crohn's disease in Israel: a survey of Israeli kibbutz settlements.

Objective:The prevalence of Crohns disease ranges from 10 to 70 cases per 100,000 population, and is 3–8 times more common among Jews. However, this excess risk is not evident in the Jewish population of Israel. Recently we have described a significant increase in the prevalence and incidence of Crohns disease in the south of Israel. The aim of this study was to confirm this trend in a stable population found in communal (kibbutz) settlements.Methods:We repeated a community-based survey in 124,400 kibbutz residents, 10 yr after our first study. This population represents 5% of the Jewish population of Israel. All Crohns disease patients were located by contacting the kibbutz clinics of the 269 kibbutz settlements (100% compliance). Data was updated to December 31st, 1997, which was designated the point prevalence date, and included information on gender, age, origin, education, profession, extent of the inflammatory process, clinical spectrum of the disease, therapy, complications of the disease, and treatment. The average annual incidence for the 10 yr was calculated from the prevalence data. Only cases with a definite diagnosis of Crohns disease made in a recognized gastroenterology unit were accepted into the study.Results:There were 81 confirmed cases of Crohns disease and the prevalence rate rose from 25.5/100,000 in 1987 to 65.1/100,000 in 1997 (p < 0.001). The mean annual incidence rate for this period (1987–1997) is 5.0/100,000/yr. Prevalence rates were higher in women than men, and in those born in Israel or Europe/America than in Asia/Africa. The mean age at presentation of the disease was lower in 1997 than in 1987, 37.4 ± 17.0 and 45.0 ± 17.0 yr, respectively (p= 0.041). Prevalence was highest in men with >16 yr of education, and in women with 11–12 yr education, 119.7 and 100.3/100,000, respectively.Conclusion:During the decade 1987–1997, the prevalence of Crohns disease has increased in Israel and is approaching the rates in Europe and America.

Epidemiology of ulcerative colitis in Israel : A survey of Israeli Kibbutz settlements

OBJECTIVE:The incidence of ulcerative colitis ranges from 3 to 15 cases per 100,000 persons per year with a prevalence of 50–80 cases per 100,000, and the disease is 3–5 times more common among Jews. In Israel, Ashkenazi Jews have a higher incidence than Sephardi Jews, but a lower incidence than Ashkenazi Jews in the United States or Northern Europe. The aim of this study was to examine the prevalence, mean annual incidence, and clinical patterns of ulcerative colitis in a stable population of communal settlements (kibbutz).METHODS:We repeated a community-based survey in 124,400 kibbutz residents, 10 yr after our first study. This population represents 2.5% of the Jewish population of Israel. All ulcerative colitis patients were located by contacting the kibbutz clinics of the 269 kibbutz settlements (100% compliance). Data were updated to December 31st, 1997, which was designated the point prevalence date, and included information on gender, age, origin, education, profession, extent of the inflammatory process, clinical spectrum of the disease, therapy, complications of the disease, and treatment. The mean annual incidence for the 10 yr was calculated from the prevalence data. Only cases with a definite diagnosis of ulcerative colitis made in a recognized gastroenterology unit were accepted into the study.RESULTS:There were 208 confirmed cases of ulcerative colitis disease, 113 women and 95 men (female:male ratio = 1.19). The prevalence rate rose from 121.0/100,000 in 1987 to 167.2/100,000 in 1997 (p < 0.001). The prevalence rates were higher in women than men. Prevalence was highest in Israeli-born members in 1987 but in European/American-born members in 1997. The average annual incidence rate for the 10-yr period was 5.04/100,000/yr. In 1987, 146 cases of ulcerative colitis were collected. During 10 yr of surveillance 17 patients left the kibbutz, 12 died, and 62 new cases were added. The mean age at presentation of the disease was lower in 1987 than in 1997, 46.14 ± 11.10 and 51.43 ± 16.67 yr, respectively. Prevalence was highest in men with >16 yr and in women with 9–10 yr of education, 259.3 and 242.9/100,000, respectively.CONCLUSIONS:The prevalence of ulcerative colitis in this Israeli population increased and has reached the upper range for European and American populations. The mean annual incidence rate of ulcerative colitis is in the lower range of that reported for the Western countries.

Indications for Percutaneous Endoscopic Gastrostomy Insertion: Ethical Aspects

Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient’s illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a ‘cooling off’ period of 30–60 days should be scheduled from the time of the PEG request to actual insertion.

13C-urea breath test, referral patterns, and results in children.

Background The family is the core unit for Helicobacter pylori (Hp) infection. In most instances, Hp colonization occurs in early childhood, and correlates with socioeconomic parameters. Helicobacter pylori infection is highly prevalent in many countries, and may cause chronic gastritis and peptic ulcer in adults and in children. Gastritis induced by Hp may be associated with recurrent abdominal pain in children, and eradication of the bacterium may improve the clinical symptoms. Aim The primary aim of this study is to characterize the group of pediatric patients according to the referral patterns and results of 13C-urea breath test (13C -UBT) in our laboratory. The secondary aim is to investigate the result of different treatment combinations for Hp eradication. Methods The 13C-UBT was performed with 75 mg urea labeled with 13C in 200 mL orange juice. Breath samples were collected at 0 and 30 minutes, and the results expressed as the change in the 13C/12C ratio at T30´ minus T0´ The cutoff for Hp eradication was 3.5. The physicians who ordered the test completed a questionnaire covering demographic data (age, gender, and origin), indication for the test was use of a proton pump inhibitor (PPI), and type of combination eradication therapy. Results The study sample consisted of 1655 children, aged 1 to 18 years, 992 (59.9%) boys and 663 (40.1%) girls, from all parts of the country. The 13C-UBT was positive in 763 (46.1%). The prevalence of positive results was directly correlated with age. History of peptic disease was the main indication for the test, in 1346 (81.4%) cases. Details on eradication therapy were available for 435 children of whom 42.5% had a positive 13C-UBT, indicating a successful eradication rate of 57.5%. Compared with Israeli and American–European origin, children of Asian–African origin had a higher rate of referrals for reason of validation of successful Hp eradication, greater long-term PPI use, and a higher rate of 13C-UBT positivity. No significant difference was demonstrated between the triple therapy regimens used. Conclusion 13C-UBT may be performed in children of all age groups. The main indication is a history of peptic ulcer disease. The prevalence of Hp infection increased with age and the only factor associated with increased Hp infection was Asian–African origin. The most frequent eradication therapy used in childdren is a combination of omeprazole, amoxicillin, and clarithromycin.

Survey of the opinions, knowledge and practices of surgeons and internists regarding Helicobacter pylori test-and-treat policy

Background Helicobacter pylori infection is highly prevalent and may cause disease in 10% to 15% of infected individuals: duodenal and gastric ulcer, gastric cancer and gastric lymphoma. Guidelines for a test-and-treat policy have been published by the European H. pylori working group in Maastricht. Goals To assess the current approach to H. pylori–related diseases, indications for testing and eradication therapy, among internists and surgeons of a University affiliated medical center. Study A 15-items questionnaire was formulated according to the Maastricht II test-and-treat recommendation and distributed among the physicians of 6 internal medicine departments and the department of surgery. The questionnaires were completed anonymously at the departments staff meeting, under the supervision of the head of the department. All questions required a yes/no answer; the maximum possible score was 15. The relative ratio (RR) of correct answers was calculated for every question and by subgroups as follows: all participants, internists, surgeons, experts and residents in internal medicine and surgery. Results The response rate was 68% (55 out of 80 physicians). Total score for all participants was 10.9 (RR = 0.73), significantly lower than the maximum score of 15 (RR = 1.00). The internists had significantly higher average score than the surgeons for 2 questions: causative agent in gastric cancer (p = 0.003) or gastric lymphoma (p = 0.003), 1 question about triple therapy, PPI, penicillin and azythromycin being not recommended (p = 0.022), and for 1 question of test-and-treat policy: should this strategy apply to family members of gastric cancer patients (p = 0.045). Only 56% of the internists and 21% of surgeons knew what MALToma is, and the correlation with H. pylori infection. Conclusion Knowledge of Surgeons and Internists regarding H. pylori infection and correlation with diseases or test and treat policy should be improved.

Re: Sanders et al. —high mortality rate after percutaneous endoscopic gastrostomy in patients with dementia

TO THE EDITOR: Sanderset al. (1) described a high mortality rate after percutaneous endoscopic gastrostomy (PEG) in patients with dementia. They compared the group of dementive patients to three other groups (oropharyngeal malignancy, acute stroke, and miscellaneous) and found a 1-month mortality rate of 54% in the dementia group in comparison with a 28% overall mortality rate for the entire cohort. The authors described nine cases of deaths due to direct procedural complication (peritonitis and hemorrhage). These cases should be omitted from the calculation: as they were not related to any particular patient group, the reader may assume they all belong to the dementia group. Thus, when omitted, there may be no statistically significant difference in the 1-month mortality rate between the groups. We believe that the issue of inserting PEG in dementive patients has many ethical problems, but the strong recommendation of the authors against PEG in dementia is not justified. The authors failed to separate their dementia patients into hospitalized (probably with acute, severe, disease) and ambulatory subgroups (most of them could be healthy, dementive patients). When we did that (2), only a 4% 1-month mortality rate in the subgroup of ambulatory patients was found, despite the fact that most of them (87.2%) had dementia, in comparison with a significant higher 1-month mortality rate (29%) in the subgroup of inpatients, of whom fewer patients suffered from dementia (46.2%). Our results are supported by at least two papers (3, 4) that did not include dementia in the factors of worse prognosis after PEG.

Re: Gerson and triadafilopoulos—colorectal screening before herniorrhaphy

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