Melvyn G. Korman

Percutaneous endoscopic gastrostomy: A review of indications, complications and outcome

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective method of feeding via the stomach in situations where oral intake is not possible. Its simplicity has led to its potential use in areas of dubious clinical benefit. Our unit has faced a major increase in referrals for PEG insertion over the last 2 years. For this reason we decided to audit our PEG insertion procedures with regard to indications, complications, outcome and follow up. We studied 168 patients who had an initial PEG insertion during the period 1 February 1996–31 January 1998. The medical records of these patients were reviewed with regard to the procedure, antibiotic use and complications. All patients (or carers or next of kin) were contacted by telephone to provide details regarding late complications and follow up. There were 87 females and 81 males (aged 16–98 years, median age 70 years). At 2 years, 67% were alive. The most frequent indication for PEG insertion was a neurological condition, the commonest being stroke. Most patients received either ticarcillin/clavulanic acid or cephazolin antibiotic prophylaxis before and after the procedure. In six patients (3.6%) infection at the PEG site required intravenous antibiotics. Four of these six patients did not have antibiotic prophylaxis. Only two deaths could be directly related to the procedure. Three died within 7 days of the procedure due to unrelated medical complications. Sixteen patients died within 1 month, the majority of these patients did not leave hospital. One‐fifth of the patients (35/168) had their PEG removed due to the reestablishment of oral feeding, with median time of use, 4.3 months. It is a safe, effective feeding method in the elderly, but experience with case selection, the procedure and careful follow up remain essential. The use of prophylactic antibiotics resulted in few significant infections of the PEG site. Up to one‐fifth of patients will require their PEG only for a short term.

Early detection of protein depletion in alcoholic cirrhosis : role of body composition analysis

BACKGROUND Malnutrition is common in alcoholic cirrhosis. Bedside nutritional assessment techniques may be unreliable in patients with chronic liver disease. The aim of this study was to quantify changes in body composition and compare methods for measuring body composition in alcoholic cirrhosis. METHODS Thirty-eight men with alcoholic cirrhosis were compared with 16 age-matched healthy men. Body composition was assessed using anthropometry and bioelectrical impedance to determine fat-free mass and body fat, deuterium oxide dilution to measure total body water, in vivo neutron activation analysis to measure total body protein, and dual energy x-ray absorptiometry to measure bone mineral content and total body fat mass. RESULTS With increasing severity of cirrhosis, total body water increased, whereas total body protein decreased with a significant decrease in serum albumin levels. Total body protein levels, expressed as an index, were a more sensitive indicator of protein depletion than serum albumin levels. When patients were assessed by anthropometry and bioelectrical impedance for fat-free mass, there was no reduction compared with controls. CONCLUSIONS Anthropometry and bioelectrical impedance do not accurately reflect changes in body composition associated with chronic liver disease. Quantification of body composition changes in alcoholic cirrhosis requires the use of direct methods such as in vivo neutron activation analysis, dual energy x-ray absorptiometry, or deuterium oxide dilution.

Helicobacter pylori prevalence in endoscopy and medical staff

Abstract The epidemiology and mode of transmission of Helicobacter pylori is currently unclear; it is postulated that the human stomach is the natural reservoir and that spread occurs by faecal‐oral or oral‐oral transmission. The aim of this study was to assess the prevalence of H. pylori in gastroenterologists and gastroenterology nurses compared with internists, general nurses and the normal population. An enzyme‐linked immunosorbent assay technique (sensitivity 96%, specificity 88%) was used to detect circulating H. pylori immunoglobulin G antibodies in 39 gastroenterologists, 107 gastroenterology nurses, 25 internists and 42 general nurses. These subjects were compared to an age‐ and sex‐matched Caucasian population obtained by random sampling of an urban population area. The overall prevalence of H. pylori in gastroenterologists was 69% compared to 40% of internists (P < 0.01), 17% of gastroenterology nurses (P < 0.001), 19% of general nurses (P < 0.01) and 32% of controls (P < 0.01). There was no significant difference in H. pylori prevalence between the gastroenterology nurses and controls, general nurses and controls. The prevalence in gastroenterologists increased with years of practice to levels greater than age‐matched controls. The prevalence in gastroenterology nurses increased with age and years of working and was similar to age‐matched control subjects. These findings of an increased prevalence of H. pylori infection in gastroenterologists performing endoscopy support human‐to‐human transmission possibly from patients to medical staff.

Acceptance of flexible sigmoidoscopy and colonoscopy for screening and surveillance in colorectal cancer prevention.

Objectives: To study an individuals experience of either flexible sigmoidoscopy (FS) or colonoscopy in a colorectal cancer prevention programme. Methods: Consecutive individuals in a Bowel Cancer Prevention Programme, who had either an unsedated FS or a colonoscopy with sedation, participated in a prospective cross-sectional questionnaire-based study. Results: A total of 447 responses were obtained for 256 colonoscopies and 191 FSs (200 men [45%] and 247 women [55%]). The overall experience of colonoscopy was more comfortable than FS (75% versus 18%; P<0.001). Embarrassment was low for both procedures (8%). There was no pain associated with colonoscopy and most individuals had a pain score of less than 3 (11-point scale) for FS: 72% of men, 55% of women (P<0.001). Most individuals did not have a gender preference for the endoscopist. For colonoscopy, the worst part of the procedure was the preparation (78%) and for FS the preparation and the procedure ranked equally worst (30%). Conclusions: We have shown that colonoscopy with sedation is a very comfortable procedure. FS is more uncomfortable than colonoscopy; however, for the majority it is a tolerable experience. Women found FS only slightly more painful than men. The worst part of either procedure was the preparation. Embarrassment with either procedure was minimal. Both procedures are well tolerated and suitable for colorectal cancer screening.

Gastrointestinal bleeding after cold biopsy

Cold biopsy of the gastric mucosa is useful in many gastroduodenal disorders. Antral biopsies are done with increasing frequency to confirm Helicobacter pylori infection and to determine the type and content of gastritis. Gastrointestinal bleeding after gastric cold biopsy is rare. We report two patients who developed melena after cold biopsy of the gastric antrum. Repeat gastroscopies excluded lesions other than the biopsied sites as the source of bleeding. Colonoscopies in both cases did not reveal any evidence of lower GI bleed. Relevant medications include amlodipine, in case 1, and brufen, which was used in case 2 but discontinued before biopsy. Literature review has shown the rarity of clinically significant hemorrhage resulting from gastric cold biopsy. Nevertheless, all patients undergoing gastroscopy should be informed of this potential complication.

Sucralfate : the Bangkok review

Abstract Sucralfate is a site‐protective ulcer healing drug with a remarkable range of mechanisms of action. Recent studies highlight the capacity of sucralfate to bind basic fibroblast growth factor (bFGF) and deliver it in high concentration to the ulcer. Basic fibroblast growth factor stimulates the production of granulation tissue, angiogenesis and re‐epithelization, thus improving the quality of ulcer healing. The effect of sucralfate in reducing parietal cell sensitivity may be another factor important in the lower relapse rate demonstrated after duodenal ulcer healing. Sucralfate has been demonstrated to be efficacious in healing both duodenal and gastric ulcers together with mild oesophagitis, and it is safe for both short‐term use and maintenance. In stress ulcer prophylaxis it is as effective as acid suppression or neutralization and has the advantage of lesser rates of nosocomial pneumonia than are demonstrated with antacids or H2 antagonists. The potential advantages of sucralfate lie in the better quality of ulcer healing associated with longer duration of remission.

Sucralfate as an alternative to bismuth in quadruple therapy for Helicobacter pylori eradication.

There are persuasive arguments for treating all patients with Helicobacter pylori– associated peptic ulcer disease. However, the choice of therapeutic regimen remains problematical. Bismuth triple therapy produces greater than 80% cure of H. pylori infection, whereas omeprazole and bismuth quadruple therapy has produced cure rates in excess of 90%. Colloidal bismuth is not available in many countries, hence limiting the use of bismuth‐based therapeutic regimens. We substituted widely available sucralfate for bismuth in a quadruple‐therapy regimen.

Lansoprazole Quadruple Therapy Is Effective in Curing Helicobacter pylori Infection

Quadruple therapy using omeprazole combined with classic bismuth triple therapy has been advocated as optimal therapy for the cure of Helicobacter pylori (H. pylori) infection. We investigated the efficacy of substituting lansoprazole for omeprazole in proton pump quadruple therapy.

Quality of healing in peptic ulcer disease--are H2 receptor antagonists all we need?

SummaryThe rapid relief of symptoms and ulcer healing can now be achieved in most patients with peptic ulcer. Histamine2 (H2) receptor antagonists, proton pump inhibitors, prostaglandin analogues, colloidal bismuth and sucralfate have all proved safe and effective for the initial treatment of peptic ulcer. However, most ulcers will recur when treatment is stopped. Meta-analyses suggest a higher relapse rate after H2 antagonist therapy than that following sucralfate or bismuth. This difference has not been explained although improved morphology and/or functional status of the gastroduodenal mucosa (“quality of healing”) has been claimed. Eradication of Helicobacter pylori leads to marked reduction in relapse rate but more effective and safer eradication regimens are needed. Since most ulcers do recur, maintenance therapy with H2 antagonists remains a commonly used option. Continuous maintenance results in low symptomatic relapse, complications occur rarely, and such treatment is safe. An alternative is Symptomatic Self Care (on-demand therapy) which provides an economic option for patients with no concomitant disease or previous complications. Future research should decide the exact role of Helicobacter eradication; bur for now, we can still rely on maintenance therapy with the widely-used and proven H2 receptor antagonists.