Shoba Theivanayagam

Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials.

Background/Aim: Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. Methods: Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). Results: Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01). Conclusions: Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding.

Background Multiple studies have demonstrated that feeding ⩽4 hours after placement of a percutaneous endoscopic gastrostomy (PEG) tube is a reasonable option. Many physicians, however, continue to delay feedings until the next day or 24 hours; therefore, we evaluated the safety and effect of early feeding (⩽4 hours) after PEG placement in our tertiary care center. Methods A retrospective study of 444 patients who underwent PEG between June 2006 and December 2011 was performed. Early feeding was defined as feeding ⩽4 hours and delayed feeding was defined as feeding >4 hours. Statistical analysis was performed using the Fisher exact test and the Student t test. Results A total of 444 patients underwent PEG between June 2006 and December 2011. A majority of PEGs were performed on inpatients by gastroenterologists. The mean time of feeding after PEG was 3.2 ± 0.9 hours for the early group (n = 197) and 17.0 ± 10.0 hours for the delayed group (n = 247). No statistically significant differences were noted between the early (⩽4 hours) feedings versus the delayed (>4 hours) feedings for overall morality within 30 days (P = 0.72) and overall complications (P = 1.00). Furthermore, no statistically significant differences were noted between early versus delayed feeding for 24-hour mortality (P = 1.00), 24- to 72-hour mortality (P = 0.20), and 3–30 days mortality (P = 0.86). For each complication, there were no statistically significant differences noted between the two groups for wound infection (P = 0.52), melena (P = 0.26), vomiting (P = 0.42), leakage (P = 0.41), stomatitis (P = 0.13), aspiration pneumonia (P =1.00), and other complications (P = 0.47). Conclusions Feeding ⩽4 hours after PEG appears to be as safe as delayed feeding. Based on this study and the literature, strong consideration for the majority of patients should be undertaken to begin feeding within 4 hours after PEG.

Asa Classification Pre-endoscopic Procedures: A Retrospective Analysis on the Accuracy of Gastroenterologists.

Objectives Before an endoscopic procedure, an evaluation to assess the risk of sedation is performed by the gastroenterologist. To risk stratify based on medical problems, the American Society of Anesthesiologists (ASA) classification scores are used routinely in the preprocedure evaluation. The objective of our study was to evaluate among physicians the ASA score accuracy pre-endoscopic procedures. Methods At a single tertiary-care center an institutional review board–approved retrospective study was performed. Upper endoscopies performed from May 2012 through August 2013 were reviewed; data were collected and recorded. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement (⩽0.20 is poor agreement, 0.21–0.40 is fair, 0.41–0.60 is moderate, 0.61–0.80 is good, and 0.81–1.00 is very good). Results The mean ASA scores by the gastroenterologist compared with the anesthesiologist were 2.28 ± 0.56 and 2.78 ± 0.60, respectively, with only fair agreement (weighted kappa index 0.223, 95% confidence interval [CI] 0.113–0.333; 48% agreement). The mean ASA scores for gastroenterologists compared with other gastroenterologists were 2.26 ± 0.5 and 2.26 ± 0.44, respectively, with poor agreement (weighted kappa index 0.200, 95% CI 0.108–0.389; 68% agreement). Agreement on ASA scores was only moderate between the gastroenterologist and himself or herself (weighted kappa index 0.464, 95% CI 0.183–0.745; 75% agreement). Conclusions Gastroenterologists performing preprocedure assessments of ASA scores have fair agreement with anesthesiologists, poor agreement with other gastroenterologists, and only moderate agreement with themselves. Given this level of inaccuracy, it appears that the ASA score pre-endoscopy is of limited significance.

Airway assessment of patients undergoing endoscopic procedures.

Objectives In advance of endoscopic procedures, an evaluation to assess the risk of sedation is performed by the gastroenterologist. Based on regulations, gastroenterologists are required to perform an airway assessment. At this time, data supporting this regulation are limited; therefore, we evaluated airway assessment accuracy by gastroenterologists before endoscopic procedures. Methods A retrospective, single tertiary care center study was performed from May 2012 through August 2013. Patients who underwent an endoscopy or colonoscopy performed at the University of Missouri–Columbia with documented Mallampati scores were included in the analysis. Three primary cohorts of patients were included in our study: gastroenterologist versus anesthesiologist, gastroenterologist versus other gastroenterologists, and gastroenterologists versus themselves. Data were collected and recorded for patient age, body mass index, and Mallampati score. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement. Results For gastroenterologists versus anesthesiologists and versus other gastroenterologists, the agreement on Mallampati scores was poor (weighted kappa index 0.103, 95% confidence interval [CI] −0.0126 to 0.219; percentage of agreement 42% and 0.120, 95% CI −0.0211 to 0.260; percentage of agreement 46%, respectively). For gastroenterologists versus themselves for the same patient, the agreement on Mallampati scores was only moderate (weighted kappa index 0.420, 95% CI 0.119–0.722; percentage of agreement 65%). Conclusions Gastroenterologists performing a preprocedure assessment using Mallampati scores have poor agreement with anesthesiologists and colleagues and only moderate agreement with themselves.

Endoscopy after acute myocardial infarction: an evaluation of safety.

Objectives Upper gastrointestinal bleeding in the setting of acute myocardial infarction (MI) has substantial morbidity and mortality. Several studies have been performed on the safety of esophagogastroduodenoscopy (EGD) after MI; however, these studies vary in definitions and results. We evaluated the safety and effect of EGD in patients with acute MI in a tertiary center. Methods A retrospective, single tertiary-care center study was undertaken of 87 patients who underwent EGD within 30 days of an acute MI between January 2001 and March 2012. Type of MI (ST segment elevation MI [STEMI] and non–ST segment elevation MI [NSTEMI]), peak troponin I, time from MI to EGD, Acute Physiology and Chronic Health Evaluation (APACHE) II score at EGD, cardiac catheterization before EGD, and medical complications within 24 hours of EGD were noted. Medical complications were defined as major complications (death, life-threatening arrhythmias) and minor complications (chest pain, abnormal vital signs, or minor arrhythmias). Results Eighty-seven patients underwent EGD within 30 days of having an MI. No major complications were observed. Minor complications occurred in 27 of 87 patients (31.0%), including mild hypotension, mild bradycardia, or increased chest pain. Patients with STEMI demonstrated statistically significant quicker endoscopy (P = 0.01) and were more likely to undergo cardiac catheterization in advance of EGD (P < 0.01) than those with NSTEMI. No statistically significant differences were noted for peak troponin I (P = 0.21), APACHE II score at EGD (P = 0.55), or minor complications (P = 0.08) among patients with STEMI versus NSTEMI. Cardiac catheterization before EGD did not seem to affect results. Patients with APACHE II scores >16 experienced more minor complications (P = 0.02). Conclusions EGD appears relatively safe for the diagnosis and management of upper gastrointestinal bleeding in patients with acute MI.