Ira Mayer

Early Intensive Resuscitation of Patients With Upper Gastrointestinal Bleeding Decreases Mortality

OBJECTIVE:Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study.METHODS:A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention.RESULTS:Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21–94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p = 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p = 0.04).CONCLUSION:Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.

Percutaneous endoscopic sigmoidopexy using T-fasteners for management of sigmoid volvulus

BackgroundSigmoid volvulus (SV) is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. SV has traditionally been managed via endoscopic detorsion and decompression followed by non-emergent surgical resection owing to the high risk of recurrence. Most cases of SV occur in elderly debilitated patients with multiple comorbidities and may not be candidates for surgical resection. Endoscopic sigmoidopexy has been described as an alternative to surgical resection. Here, we describe our experience with endoscopic sigmoidopexy using T-fasteners.MethodsThree patients with recurrent SV that were identified as poor surgical candidates by our colorectal surgery team underwent endoscopic sigmoidopexy. The patients received preoperative bowel preparation. A colonoscope was inserted and the site of the volvulus was visualized and assessed for adequate decompression. Subsequently, four points of fixation were identified and T-fasteners were deployed.ResultsTwo patients underwent successful sigmoidopexy without any complications or recurrence on follow-up. One patient developed post procedure pneumoperitoneum that was successfully treated conservatively; however, he passed away from their underlying comorbidities.ConclusionOverall, preliminary results for sigmoidopexy using T-fasteners have been promising, offering a potential option to prevent recurrence in high risk patients unsuitable for surgical intervention.

Safety of Percutaneous Endoscopic Gastrostomy Tubes in Centenarian Patients

Background/Aims Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, no study has evaluated the safety of PEG tube placement in patients over the age of 100 years. Methods We conducted a retrospective review of patient records for patients who underwent PEG tube placement. Thirty patients aged 100 years and older were identified and a random sample of 275 patients was selected for comparison. Results The mean age of the patients was 80.6±16.2 years. No procedure-related deaths or major complications were identified; the overall inpatient mortality rate was 7.6%. Minor complications were noted in 4% (n=12) of the patients. Centenarian patients were predominantly female (80% [n=24] vs. 54% [n=147], p=0.006), with a mean age of 100.5±0.9 years. There was no significant difference in procedural success rates (93.3% vs. 97.4%, p=0.222) or inpatient mortality (6.7% [n=2] vs. 7.7% [n=21], p=1.000) between the two groups. However, a higher minor complication rate was noted in the older patients (13.3% [n=4] vs. 2.9% [n=8], p=0.022). Conclusions Success rates, major complications and inpatient mortality associated with PEG tubes in patients aged over 100 years are comparable to those observed in relatively younger patients at our center; however minor complication rates are relatively higher. These findings lead us to believe that PEG tubes may be safely attempted in carefully selected patients in this subset of the population.

Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe?

Background/Aims Literature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients. Methods A total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events. Conclusions Age ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.

Endoscopic ultrasound-fine needle aspiration: A novel way to diagnose a solitary extramedullary plasmacytoma of the liver.

Plasmacytoma is a neoplastic production of a single line of plasma cells, usually forming monoclonal immunoglobulin. It most often occurs in the bone marrow; however, in 3% of the cases, solitary extramedullary plasmacytoma arises, which is a proliferation in the soft tissue, outside the bone marrow. In only 10% of the cases is the gastrointestinal tract involved. A 77-year-old female presented with lethargy, abdominal fullness, bilious vomiting, and clay-colored stools. The patient was anemic with initial laboratory results showing increased total and direct bilirubin with elevated transaminases. Despite conservative management, liver function tests (LFTs) continued to increase. On endoscopic ultrasound (EUS), there was mild diffuse mucosal thickening consistent with possible infiltrative disease of the gastric body without any obvious focal lesions. There was a 1.7 cm Χ 1.8 cm hypoechoic heterogeneous lesion noted in the porta hepatis and fine needle aspiration (FNA) was performed. Cytology showed infiltrative plasma cells. The patient was then taken for computed tomography (CT)-guided biopsy of the liver. Pathology showed liver involvement by atypical plasma cells in a nodular and sinusoidal pattern. Immunohistochemical staining appropriately identified the solitary extramedullary plasmacytoma. Plasma cell neoplasm is essentially a clonal disease of differentiated B-cells that can encompass a broad spectrum and present as asymptomatic monoclonal gammopathy of undetermined significance to plasma cell neoplasms or multiple myeloma. Five percent of patients with multiple myelomas are diagnosed with extramedullary plasmacytomas, and even less than that are diagnosed as a primary lesion. When the liver is affected, either as a direct diffuse neoplastic plasma cell infiltration, or as a single or multiple space occupying lesion as plasmacytomas, symptomatic features include extrahepatic biliary obstruction, jaundice, or ascites. In our case, the patient was diagnosed via EUS-guided FNA (EUS-FNA) bringing to light an alternative method to its diagnosis.

A Self-Expanding Metal Colonic Stent Causing a Contained Splenic Perforation

A 69-year-old woman with a past medical history of colon cancer with metastatic disease to the liver presented to our hospital with nausea, vomiting, and jaundice. At an outside hospital, the patient had had a self-expanding colonic metal stent (SEMS) placed in the colon. Computed tomography of the abdomen revealed an existing colonic stent with a contained perforation extending into the spleen (images: left, coronal; right, sagittal). There was no evidence of peritonitis on exam. The patient was managed conservatively and discharged to hospice.

Severe Hypercholesterolemia: A Unique Presentation of Non-Hodgkin's Lymphoma in a Patient with Neurofibromatosis Type 1.

We report a case of non-Hodgkins lymphoma (NHL) with an unusual initial manifestation as severe hypercholesterolemia and obstructive jaundice in a patient with neurofibromatosis type 1 (NF 1). NHL should be considered in the evaluation of obstructive jaundice alone or in combination with severe hypercholesterolemia. Relief of biliary obstruction led to the resolution of hypercholesterolemia in our 59-year-old male patient, followed by doxorubicin-based chemotherapy for the underlying lymphoma. NF 1 is a genetic condition that results from a defect in a tumor-suppressor gene and it is likely that this led to the development of NHL in our patient. It is important that clinicians are familiar with the gastrointestinal manifestations of NF 1, especially its association with intra-abdominal malignancies, when treating patients with a personal or family history. To the best of our knowledge, this is the first case of NHL presenting initially as severe hypercholesterolemia and it is also one of the few instances where NHL has been reported in association with NF 1.

Sa1159 Venous Blood Gas Calculated Hematocrit is an Accurate Predictor of Hematocrit in Patients With Acute Upper Gastrointestinal Hemorrhage

Background: Proton pump inhibitors (PPI) are a commonly used medication in the medical intensive care unit (MICU). Overuse of PPIs can lead to increased healthcare costs as well as a possible risk of Clostridium difficile infection and aspiration pneumonia. The aim of our study is to analyze the prescribing patterns of PPIs in the MICU in order to identify opportunities for improvement. Materials and Methods: 507 MICU admissions were retrospectively reviewed for data concerning PPI use. PPI prescriptions and their indications were analyzed. Results: Of 507 MICU admissions reviewed, 342 (67.5 %) received a PPI. Of the 342 who received a PPI, 40 patients (11.7%) had no documented indication. In addition, 78 admissions out of the 342 (22.8%) received PPI solely for stress ulcer prophylaxis, where an H-2 blocker would have sufficed. Discussion: Our study revealed that PPIs were frequently prescribed in our MICU, but that up to one third (34.5%) of the prescriptions were inappropriate, and represent opportunities for cost savings and possibly reduced clinical complications. Our next step is to improve the rate of appropriate PPI prescription in our ICU through a combination of educational modules and direct interventions to the availability of the drug in current pharmacy order sets.

333 The Effect of Obesity on Bowel Preparation for Colonoscopy: Results From a Large Prospective Study at an Urban Health Care Center

Background/Purpose: Childhood obesity is a growing epidemic in the United States. However, healthcare providers, including medical students and residents, do not feel prepared to diagnose obesity, perform counseling, or treat obesity and its complications. The purpose of this study is to design a web-based module to adequately deliver educational content pertinent to medical students on the topic of pediatric obesity. The effectiveness of the module was evaluated in terms of content mastery and overall satisfaction using a pre-test, post-test, and post-test survey. We hypothesize that there will be a significant increase in knowledge on key content areas related to the topic of pediatric obesity after viewing the web-based module. Methods: An IRB approved, prospective study of 217 third year U.S. medical students was performed. Students were given a pre-test followed by educational content delivered in the form of a web-based module, then a post-test. Test questions centered on areas of the assessment, evaluation, counseling, treatment, and complications of pediatric obesity. Participants served as their own controls to compare pretest and posttest scores. Overall satisfaction with both the content and method of delivery of the web-based module was assessed using a post-test survey. Results: Completing the web-based module resulted in improved scores when comparing post-test to pre-test scores. Average scores increased from 77.4% correct on the pre-test to 93.6% on the post-test, an overall 16.2% increase in content mastery (95% CI 13.9-18.5, p<0.00001). In addition, students were overall highly satisfied with both the content and delivery method of the module as reported on the post-test satisfaction survey. Conclusions: The web-based method of instruction shows potential for increasing knowledge in the important areas of assessment, counseling, consequences, and treatment plans surrounding the topic of pediatric obesity. Students reported overall satisfaction with this web-basedmethod of instruction. In an era of increasing demands on student time, this web-based module served the purpose of delivering education with objective documentation of improved student knowledge. We plan to expose other health-care learners to the pediatric obesity module.

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases morbidity and mortality

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases morbidity and mortality