Linda M. Herrick

Home Parenteral Nutrition—A 3-Year Analysis of Clinical and Laboratory Monitoring

We report a 3-year analysis (1986 to 1989) of the management of 63 home parenteral nutrition patients, 40 with short-bowel syndrome and 23 with chronic intestinal obstruction with or without intestinal resection. Intravenous fluid requirements varied from 0.9 to 6 L/day, and the content of glucose varied between 46 and 531 g/day, protein varied from .0 to 85 g/day, fat from .0 to 100 g/day, sodium from 37 to 695 mEq/day, potassium from 30 to 220 mEq/day, chloride from 60 to 760 mEq/day, and acetate from 0 to 200 mEq/day. Body weight was normalized and well maintained in the majority of patients, but using the strict definition of deficiency as the presence of one abnormal value during 3 years, more than half had abnormal plasma chloride, glucose, alkaline phosphatase, serum glutamic oxaloacetic transaminase, total protein, albumin, selenium, and iron concentrations, and more than a third had low calcium, magnesium, vitamin D, and vitamin C levels. Normochromic anemia was seen in 73% and high blood creatinine associated with low urine volumes in 42%. Most (78%) returned to relatively normal lifestyles, but employability was occasionally impaired by loss of third-party insurance coverage resulting from a therapy that may cost

Effect of Amitriptyline and Escitalopram on Functional Dyspepsia: A Multicenter, Randomized Controlled Study.

100,000 per year. Overall mortality was low (5% per year), but 73% needed readmission to hospital, mainly for suspected catheter sepsis. The results indicate that home parenteral nutrition has allowed many patients to survive gut failure and return to work but problems with chronic fluid, electrolyte and micronutrient deficiencies, catheter sepsis, and insurance coverage often restrict optimal rehabilitation.

Clinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture

BACKGROUND & AIMS Antidepressants are frequently prescribed to treat functional dyspepsia (FD), a common disorder characterized by upper abdominal symptoms, including discomfort or postprandial fullness. However, there is little evidence of the efficacy of these drugs in patients with FD. We performed a randomized, double-blind, placebo-controlled trial to evaluate the effects of antidepressant therapy on symptoms, gastric emptying (GE), and meal-induced satiety in patients with FD. METHODS We performed a study at 8 North American sites of patients who met the Rome II criteria for FD and did not have depression or use antidepressants. Patients (n = 292; 44 ± 15 years old, 75% were female, 70% with dysmotility-like FD, and 30% with ulcer-like FD) were randomly assigned to groups given placebo, 50 mg amitriptyline, or 10 mg escitalopram for 10 weeks. The primary end point was adequate relief of FD symptoms for ≥5 weeks of the last 10 weeks (of 12). Secondary end points included GE time, maximum tolerated volume in Nutrient Drink Test, and FD-related quality of life. RESULTS An adequate relief response was reported by 39 subjects given placebo (40%), 51 given amitriptyline (53%), and 37 given escitalopram (38%) (P = .05, after treatment, adjusted for baseline balancing factors including all subjects). Subjects with ulcer-like FD given amitriptyline were >3-fold more likely to report adequate relief than those given placebo (odds ratio = 3.1; 95% confidence interval: 1.1-9.0). Neither amitriptyline nor escitalopram appeared to affect GE or meal-induced satiety after the 10-week period in any group. Subjects with delayed GE were less likely to report adequate relief than subjects with normal GE (odds ratio = 0.4; 95% confidence interval: 0.2-0.8). Both antidepressants improved overall quality of life. CONCLUSIONS Amitriptyline, but not escitalopram, appears to benefit some patients with FD, particularly those with ulcer-like (painful) FD. Patients with delayed GE do not respond to these drugs. ClinicalTrials.gov ID: NCT00248651.

Point prevalence of alcoholism in hospitalized patients: Continuing challenges of detection, assessment, and diagnosis

Aliment Pharmacol Ther 2011; 33: 1059–1067

Sleep disturbances are linked to both upper and lower gastrointestinal symptoms in the general population

OBJECTIVE To measure a 1-day point prevalence of alcohol dependence among hospitalized patients and to assess practices of detection, evaluation, and diagnosis of alcohol problems. PATIENTS AND METHODS On April 27, 1994, a total of 795 adult inpatients at 2 midwestern teaching hospitals were asked to complete a survey that included the Self-administered Alcoholism Screening Test (SAAST). The records of SAAST-positive patients were reviewed to determine the numbers of patients receiving laboratory screening for alcoholism, addiction consultative services, and a discharge diagnosis of alcoholism. RESULTS The survey response rate was 84% (667/795). Of the 569 patients who provided SAAST information, 42 (7.4%) had a positive SAAST score and thus were identified as alcohol dependent. Thirteen (31%) of the 42 alcoholic patients received addiction or psychiatric consultative services during their hospitalization. Serum gamma-glutamyltransferase was measured in 4 (11%) of the 38 actively drinking alcoholic patients. Three (7%) of 42 alcoholic patients received a discharge diagnosis of alcohol abuse or dependence. CONCLUSIONS The alcoholism prevalence rate was lower than those observed in several other US hospitals. Laboratory testing may be underutilized in identifying hospitalized patients who may be addicted to alcohol. Physician use of consultative services and diagnosis of alcohol dependence had not improved from similar observations more than 20 years earlier. These findings may indicate persistent problems in physician detection, assessment, and diagnosis of alcoholism.

Associations among binge eating behavior patterns and gastrointestinal symptoms: a population-based study

Abstract  In tertiary referral patients, there is association between altered sleep patterns, functional bowel disorders and altered gut motor function. Body mass index (BMI) is also associated with gastrointestinal (GI) symptoms including diarrhoea, and with sleep disturbances. Our hypothesis is that sleep disturbances are associated with GI symptoms, and this is not explained by BMI. A 48‐item‐validated questionnaire was mailed to 6939 community participants in Olmsted County, MN. The survey included GI symptoms, sleep disturbance, daily lifestyle and quality of life (QOL). Independent contributions of sleep disturbance to individual symptoms were assessed using logistic regression adjusting for age, gender, lifestyle and mental health status. The association of an overall sleep score with an overall symptom score was examined and the ability of both scores to predict SF‐12 physical and mental functioning scores assessed in multiple linear regression models. Among 3228 respondents, 874 (27%) reported trouble staying asleep. There was a significant correlation of overall sleep scores with overall GI symptom scores (partial r = 0.28, P < 0.001). Waking up once nightly at least four times a month was significantly associated with pain, nausea, dysphagia, diarrhoea, loose stools, urgency and a feeling of anal blockage. Trouble falling asleep was significantly associated with rectal urgency. Associations were independent of gender, age, lifestyle factors and BMI. Overall, sleep scores and GI symptom scores were both significant independent predictors of impaired QOL. In the community, reporting poor sleep is associated with upper and lower GI symptoms, but this is independent of BMI.

Antidepressants in functional dyspepsia.

Background:The psychological symptoms associated with binge eating disorder (BED) have been well documented. However, the physical symptoms associated with BED have not been explored. Gastrointestinal (GI) symptoms such as heartburn and diarrhea are more prevalent in obese adults, but the associations remain unexplained. Patients with bulimia have increased gastric capacity. The objective of the study was to examine if the severity of binge eating episodes would be associated with upper and lower GI symptoms.Methods:Population-based survey of community residents through a mailed questionnaire measuring GI symptoms, frequency of binge eating episodes and physical activity level. The association of GI symptoms with frequency of binge eating episodes was assessed using logistic regression models adjusting for age, gender, body mass index (BMI) and physical activity level.Results:In 4096 subjects, BED was present in 6.1%. After adjusting for BMI, age, gender, race, diabetes mellitus, socioeconomic status and physical activity level, BED was independently associated with the following upper GI symptoms: acid regurgitation (P<0.001), heartburn (P<0.001), dysphagia (P<0.001), bloating (P<0.001) and upper abdominal pain (P<0.001). BED was also associated with the following lower GI symptoms: diarrhea (P<0.001), urgency (P<0.001), constipation (P<0.01) and feeling of anal blockage (P=0.001).Conclusion:BED appears to be associated with the experience of both upper and lower GI symptoms in the general population, independent of the level of obesity. The relationship between increased GI symptoms and physiological responses to increased volume and calorie loads, nutritional selections and rapidity of food ingestion in individuals with BED deserves further study.

Irritable Bowel Syndrome and Chronic Pelvic Pain: A Population-Based Study

Functional dyspepsia refers to a clinical syndrome characterized by unexplained postprandial fullness, early satiety (inability to finish a normal-size meal) and epigastric pain or burning [1]. The condition often remains very frustrating for patients and physicians, with no satisfactory or approved treatment and heterogeneous outcomes. Standard pharmaco logical treatment includes antisecretory agents and prokinetics, but these are often unsatisfactory leading to the use of largely unproven alternatives, including antidepressants [1]. A randomized clinical trial funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is currently underway to examine the effectiveness and mechanisms of the tricyclic antidepressant amitriptyline and the selective serotonin-reuptake inhibitor (SSRI) escitalopram in functional dyspepsia. The extent of functional dyspepsia in the USA is significant, with up to one in four people having symptoms suggestive of functional dyspepsia; many are probably mislabeled as having gastroesophageal reflux disease [1–3]. Approximately a quarter of these people seek medical assistance [2,3]; functional dyspepsia and related functional bowel diseases account for over half of all gastrointestinal consultations in the USA, and remain the most frequent gastrointestinal problems in primary care [2,3]. In addition to substantially impairing quality of life [2,3], healthcare costs for functional dyspepsia have been calculated to be enormous, conservatively exceeding several billion dollars annually in the USA, including billions of dollars for dyspepsia drugs [2,4,5]. Functional dyspepsia is currently considered to be a biopsychosocial disorder with disturbances of gastroduodenal motor function, heightened visceral sensitivity and possibly a CNS disturbance [6,7]. Psychosocial factors can alter motility and/or enhance sensation and inf luence the timing of patients’ presentation to physicians [6,7]. Standard treatment includes dietary advice of no established value and peripherally active pharmacological treatment, including antisecretory agents (H 2 blockers and proton pump inhibitors) and prokinetics. In systematic reviews of the available therapies, it has been concluded that the only drugs established to be better than placebo in functional dyspepsia are antisecretory and prokinetic agents [8–10]. However, a Cochrane meta-ana lysis also suggested that the positive cisapride data might simply reflect publication bias, based on a funnel plot [8]. Of the pro kinetics, only metoclopramide is available in the USA since the withdrawal of cisapride, and side effects limit its use; tegaserod, a serotonin type 4 receptor agonist, was of limited efficacy in a Phase II functional dyspepsia trial, and the drug has been withdrawn [11]. Many patients with dyspepsia turn to alternative therapies of totally unproven value [12]. Nonpharmacological treatments have also been tested, but only in a very limited fashion; hypnotherapy was superior to Nicholas J Talley, MD, PhD, FRACP, FRCP, FACP

Overdiagnosis of gastro-esophageal reflux disease and underdiagnosis of functional dyspepsia in a USA community

Background Women with irritable bowel syndrome (IBS) frequently report chronic pelvic pain, however, it is still unanswered whether these are truly separate entities. IBS negatively impacts on quality of life, but the impact of IBS on sexual function is not clear. Goals We aimed to (1) describe the impact of IBS on sexual function, and (2) evaluate the association between pelvic pain and IBS, and in particular identify if there are unique characteristics of the overlap group. Study The Talley Bowel Disease Questionnaire was mailed to an age- and gender-stratified random sample of 1031 Olmsted County, Minnesota residents aged 30 to 64 years. Manning (at least 2 of 6 positive) and Rome criteria (Rome I and modified Rome III) were used to identify IBS. Pelvic pain was assessed by a single item. Somatization was assessed by the valid somatic symptom checklist. Results Overall 648 (69%) of 935 eligible participants responded (mean age 52 years, 52% female). Self-reported sexual dysfunction was rare (0.9%; 95% CI 0.3-2.0%). Among women, 20% (95% CI 16-24%) reported pain in the pelvic region; 40% of those with pelvic pain met IBS by Manning, or Rome criteria. IBS and pelvic pain occurred together more commonly than expected by chance (P<0.01). The overall somatization score (and specifically the depression and dizziness item scores) predicted IBS-pelvic pain overlap versus either IBS alone or pelvic pain alone. Conclusion In a subset with pelvic pain, there is likely to be a common underlying psychologic process (somatization) that explains the link to IBS.

Effect of current tobacco use and history of an alcohol problem on health status in hospitalized patients

There is symptom overlap between gastro‐esophageal reflux disease (GERD) and functional dyspepsia (FD). We aimed to test the hypothesis that FD cases are now more likely mislabeled as GERD.