James A. DiSario

North American Summit on Aspiration in the Critically Ill Patient: Consensus Statement

Aspiration is the leading cause of pneumonia in the intensive care unit and the most serious complication of enteral tube feeding (ETF). Although aspiration is common, the clinical consequences are variable because of differences in nature of the aspirated material and individual host responses. A number of defense mechanisms normally present in the upper aerodigestive system that protect against aspiration become compromised by clinical events that occur frequently in the critical care setting, subjecting the patient to increased risk. The true incidence of aspiration has been difficult to determine in the past because of vague definitions, poor assessment monitors, and varying levels of clinical recognition. Standardization of terminology is an important step in helping to define the problem, design appropriate research studies, and develop strategies to reduce risk. Traditional clinical monitors of glucose oxidase strips and blue food coloring (BFC) should no longer be used. A modified approach to use of gastric residual volumes and identification of clinical factors that predispose to aspiration allow for risk stratification and an algorhythm approach to the management of the critically ill patient on ETF. Although the patient with confirmed aspiration should be monitored for clinical consequences and receive supportive pulmonary care, ETF may be continued when accompanied by appropriate steps to reduce risk of further aspiration. Management strategies for treating aspiration pneumonia are based on degree of diagnostic certainty, time of onset, and host factors.

Alcohol and Smoking as Risk Factors in an Epidemiology Study of Patients With Chronic Pancreatitis

BACKGROUND & AIMS Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers. METHODS We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified). RESULTS The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP. CONCLUSIONS The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.

Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study

BACKGROUND Urgent endoscopy in patients with acute upper-GI bleeding identifies many patients who may be safely treated without hospitalization. The aim of this multicenter trial was to determine whether urgent endoscopy effectively decreases health care resource utilization in a real-life setting where primary care providers determine the course of care. METHODS Ninety-three outpatients with acute upper-GI bleeding were randomized to either urgent endoscopy (before hospitalization) or elective endoscopy after admission. The results of urgent endoscopy and a recommendation regarding patient disposition were provided to the attending physician. Medical outcomes and resource utilization were measured. RESULTS The timing of endoscopy did not affect resource utilization or patient outcomes. Length of stay was similar (urgent endoscopy, OR 3.98 days: 95% CI[2.84, 5.11] vs. elective endoscopy, OR 3.26 days: 95% CI[2.32, 4.21], p=0.45). The mean number of days in an intensive care unit was the same (1.2 days). The urgent endoscopy group had more high-risk endoscopic lesions (15 vs. 9; p=0.031). Outpatient care was recommended for 19 patients (40%). Only 4 patients were discharged. CONCLUSIONS Urgent endoscopy did not reduce hospitalization or resource utilization because the results of early endoscopy did not impact the decision by attending physicians regarding admission. For early (triage) endoscopy to impact resource utilization, the results of endoscopy must change subsequent patient care.

Type of pain, pain-associated complications, quality of life, disability and resource utilisation in chronic pancreatitis: a prospective cohort study

Objective To compare patients with chronic pancreatitis (CP) with constant pain patterns to patients with CP with intermittent pain patterns. Methods This was a prospective cohort study conducted at 20 tertiary medical centers in the USA comprising 540 subjects with CP. Patients with CP were asked to identify their pain from five pain patterns (A–E) defined by the temporal nature (intermittent or constant) and the severity of the pain (mild, moderate or severe). Pain pattern types were compared with respect to a variety of demographic, quality of life (QOL) and clinical parameters. Rates of disability were the primary outcome. Secondary outcomes included: use of pain medications, days lost from school or work, hospitalisations (preceding year and lifetime) and QOL as measured using the Short Form-12 (SF-12) questionnaire. Results Of the 540 CP patients, 414 patients (77%) self-identified with a particular pain pattern and were analysed. Patients with constant pain, regardless of severity, had higher rates of disability, hospitalisation and pain medication use than patients with intermittent pain. Patients with constant pain had lower QOL (by SF-12) compared with patients who had intermittent pain. Additionally, patients with constant pain were more likely to have alcohol as the aetiology for their pancreatitis. There was no association between the duration of the disease and the quality or severity of the pain. Conclusions This is the largest study ever conducted of pain in CP. These findings suggest that the temporal nature of pain is a more important determinant of health-related QOL and healthcare utilisation than pain severity. In contrast to previous studies, the pain associated with CP was not found to change in quality over time. These results have important implications for improving our understanding of the mechanisms underlying pain in CP and for the goals of future treatments and interventions.

Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study.

Background There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. Methods Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. Results Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. Conclusions Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.

Phenotypic characteristics and risk of cancer development in hyperplastic polyposis: case series and literature review.

OBJECTIVES:Hyperplastic polyposis (HP) is a poorly understood condition. The aim of this study is to describe the phenotype and the risk of cancer in HP.METHODS:Patients with HP, as defined by the WHO International Classification, were identified through the University of Utah and the Huntsman Cancer Institute databases. Family history was retrieved when possible.RESULTS:Fifteen patients were identified (10 M, 5 F) with a mean age at diagnosis of 52.6 ± 16.4 yr (18–71). Sixty-five colonoscopies were performed (2–11 per person). A median of 90 polyps (16–210) per person and 15 polyps (range, 0–100) per procedure were reported. The median follow-up was 33 months (3–133); no cancer occurred during this period. Polyps were more frequent in the distal than the proximal colon (74% vs 26%; p < 0.001). The median polyp size was 4 mm (1–40 mm). Fifty-one hyperplastic polyps >10 mm were identified in 10 patients (38 proximal, 13 distal; P = 0.089). Forty-eight adenomas were found in 11 patients and were uniformly distributed. Serrated adenomas (n = 3) were found in one patient. A unique patient had 20 large hyperplastic polyps, 24 adenomas, 3 serrated adenomas, and 118 hyperplastic polyps. None of the patients had a first-degree relative with colon cancer.CONCLUSIONS:In HP, hyperplastic polyps are more frequently distal colonic, and vary greatly in size and number. Most patients also develop adenomas that are distributed throughout the colon. No cancers developed within 3 yr of follow-up. Colonoscopic surveillance at intervals of 1–3 yr, depending upon the number and size of both adenomatous and hyperplastic polyps, appears prudent.

Argon laser therapy for hemorrhagic radiation proctitis: long-term results

In chronic radiation proctitis bleeding occurs from mucosal friability and neovascular telangiectasias. Fourteen patients with bleeding from chronic radiation proctitis underwent endoscopic argon laser therapy at 4 to 8 W. The goal of treatment was obliteration of all telangiectasias. The average follow-up was 35 months. Of the 51 procedures, 48 (94%) were performed on outpatients with enema preparation and little or no sedation. A median of three procedures was performed per patient, with two sessions required for initial control of bleeding. Ten patients (71%) required maintenance therapy for recurrent bleeding from telangiectasias that developed after initial therapy. The mean interval between maintenance sessions was 7 months. No immediate or late complications occurred.

Combined Bicarbonate Conductance-Impairing Variants in CFTR and SPINK1 Variants Are Associated With Chronic Pancreatitis in Patients Without Cystic Fibrosis

BACKGROUND & AIMS Idiopathic chronic pancreatitis (ICP) is a complex inflammatory disorder associated with multiple genetic and environmental factors. In individuals without cystic fibrosis (CF), variants of CFTR that inhibit bicarbonate conductance but maintain chloride conductance might selectively impair secretion of pancreatic juice, leading to trypsin activation and pancreatitis. We investigated whether sequence variants in the gene encoding the pancreatic secretory trypsin inhibitor SPINK1 further increase the risk of pancreatitis in these patients. METHODS We screened patients and controls for variants in SPINK1 associated with risk of chronic pancreatitis and in all 27 exons of CFTR. The final study group included 53 patients with sporadic ICP, 27 probands with familial ICP, 150 unrelated controls, 375 additional controls for limited genotyping. CFTR wild-type and p.R75Q were cloned and expressed in HEK293 cells, and relative conductances of HCO(3)(-) and Cl(-) were measured. RESULTS SPINK1 variants were identified in 36% of subjects and 3% of controls (odds ratio [OR], 18.1). One variant of CFTR not associated with CF, p.R75Q, was found in 16% of subjects and 5.3% of controls (OR, 3.4). Coinheritance of CFTR p.R75Q and SPINK1 variants occurred in 8.75% of patients and 0.38% of controls (OR, 25.1). Patch-clamp recordings of cells that expressed CFTR p.R75Q showed normal chloride currents but significantly reduced bicarbonate currents (P = .0001). CONCLUSIONS The CFTR variant p.R75Q causes a selective defect in bicarbonate conductance and increases risk of pancreatitis. Coinheritance of p.R75Q or CF causing CFTR variants with SPINK1 variants significantly increases the risk of ICP.

Sigmoidoscopy training for nurses and resident physicians

Five gastrointestinal nurses (three licensed practical nurses and two registered nurses) and five resident physicians were enrolled in a sigmoidoscopy training protocol. Patients referred for a screening sigmoidoscopy were randomized to have the procedure performed by a nurse or a resident. Objective criteria for proficiency were depth of endoscope insertion, procedure time, and identification of anatomic landmarks and pathologic lesions; subjective criteria included thoroughness and the need for assistance. Four nurses and all of the residents were deemed proficient at a mean of 20 procedures in both groups. One registered nurse did not achieve proficiency after 35 procedures; this determination was based on subjective criteria. Insertion depth and identification of normal anatomy improved with experience. Trainees missed 1.4% of pathologic lesions, and no complications were observed. Nurses can be trained to perform a screening sigmoidoscopy in a safe and effective manner, with results similar to those for doctors.

Colorectal cancers of rare histologic types compared with adenocarcinomas.

PURPOSE: To examine clinical characteristics of colorectal cancers of rare histologic types compared with adenocarcinomas. METHODS: Review of a population-based registry with complete ascertainment. RESULTS: There were 7,422 colorectal cancers, 4,900 (66 percent) colonic and 2,522 (34 percent) rectal. Two hundred fifty-five cancers (3 percent) were of nonadenocarcinoma varieties including 75 (33 percent) squamous, 74 (33 percent) malignant carcinoids, 37 (16 percent) transitional cell-like, 25 (11 percent) lymphomas, 9 (4 percent) sarcomas, and 2 (0.9 percent) melanomas. Sixty (1.2 percent) of the colon cancers occurred in the appendix, and proportionately more carcinoids accounted for these tumors. Compared with adeno-carcinomas, colonic and rectal carcinoids and colonic lymphomas accounted for a larger proportion of cancers in the younger age groups. The elderly had proportionately fewer colonic carcinoids. Colonic carcinoids, rectal squamous-cell cancers, and rectal transitional cell-like cancers were more common in women. Colonic lymphomas had a worse prognosis than adenocarcinomas. Survival was better with colonic and rectal carcinoids and rectal transitional cell-like cancers than with adenocarcinomas. CONCLUSIONS: Colorectal cancers of histologic varieties other than adenocarcinoma have distinctive epidemiologic and clinical traits.