Svetang V. Desai

Nutrition in the ICU: An Evidence-Based Approach

Providing artificial nutrition is an important part of caring for critically ill patients. However, because of a paucity of robust data, the practice has been highly variable and often based more on dogma than evidence. A number of studies have been published investigating many different aspects of critical care nutrition. Although the influx of data has better informed the practice, the results have often been conflicting or counter to prevailing thought, resulting in discordant opinions and different interpretations by experts in the field. In this article, we review and summarize the data from a number of the published studies, including studies investigating enteral vs parenteral nutrition, supplementing enteral with parenteral nutrition, and use of immunonutrition. In addition, published studies informing the practice of how best to provide enteral nutrition will be reviewed, including the use of trophic feedings, gastric residual volumes, and gastric vs postpyloric tube placement.

Postgraduate Education CornerNutrition in the ICU: An Evidence-Based Approach

Providing artificial nutrition is an important part of caring for critically ill patients. However, because of a paucity of robust data, the practice has been highly variable and often based more on dogma than evidence. A number of studies have been published investigating many different aspects of critical care nutrition. Although the influx of data has better informed the practice, the results have often been conflicting or counter to prevailing thought, resulting in discordant opinions and different interpretations by experts in the field. In this article, we review and summarize the data from a number of the published studies, including studies investigating enteral vs parenteral nutrition, supplementing enteral with parenteral nutrition, and use of immunonutrition. In addition, published studies informing the practice of how best to provide enteral nutrition will be reviewed, including the use of trophic feedings, gastric residual volumes, and gastric vs postpyloric tube placement.

Early Outcomes of Empiric Embolization of Tumor-related Gastrointestinal Hemorrhage in Patients with Advanced Malignancy☆☆☆

PURPOSE To report short-term results of empiric transcatheter embolization for patients with advanced malignancy and gastrointestinal (GI) hemorrhage directly from a tumor invading the GI tract wall. MATERIALS AND METHODS Between 2005 and 2011, 37 mesenteric angiograms were obtained in 26 patients with advanced malignancy (20 men, six women; mean age, 56.2 y) with endoscopically confirmed symptomatic GI hemorrhage from a tumor invading the GI tract wall. Angiographic findings and clinical outcomes were retrospectively evaluated. Clinical success was defined as absence of signs and symptoms of hemorrhage for at least 30 day following embolization. RESULTS Active extravasation was demonstrated in three cases. Angiographic abnormalities related to a GI tract tumor were identified on 35 of 37 angiograms, including tumor neovascularity (n = 21), tumor enhancement (n = 24), and luminal irregularity (n = 5). In the absence of active extravasation, empiric embolization with particles and/or coils was performed in 25 procedures. Cessation of hemorrhage (ie, clinical success) occurred more frequently when empiric embolization was performed (17 of 25 procedures; 68%) than when embolization was not performed (two of nine; 22%; P = .03). Empiric embolization resulted in clinical success in 10 of 11 patients with acute GI bleeding (91%), compared with seven of 14 patients (50%) with chronic GI bleeding (P = .04). No ischemic complications were encountered. CONCLUSIONS In patients with advanced malignancy, in the absence of active extravasation, empiric transcatheter arterial embolization for treatment of GI hemorrhage from a direct tumor source demonstrated a 68% short-term success rate, without any ischemic complications.

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy patients. METHODS Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy (39 with gastric bypass Roux-en-Y, 2 with Billroth II gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42 (30.9%), biliary obstruction suggested on imaging: 20 of 42 (47.6%), suspected sphincter of Oddi dysfunction: 4 of 42 (9.5%), abnormal liver enzymes: 1 of 42 (2.4%), ascending cholangitis: 2 of 42 (4.8%), and bile leak: 2 of 42 (4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS Successful visualization of the major ampulla was accomplished in 32 of 42 procedures (76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla (81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bile duct was cannulated (92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients (23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients (7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d. CONCLUSION It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.

Sa1378 Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients With Suspected Pancreatic Neoplasm

G A A b st ra ct s mass prompting biopsy, were excluded. MRI scans performed in patients without a diagnosis of pancreatic cancer served as controls. We used a ratio of 1 control patient for every 3 cancer patients.MRI scans were reviewed in a blinded fashion by two experienced radiologists. A descriptive analysis was performed of MRI findings at 2-24 months prior to the diagnosis of cancer. Agreement between reviewers was assessed via McNemars test and a kappa statistic. Differences between cancer and control group were assessed using chi square tests or fisher exact tests. Results: 550 patients were diagnosed with adenocarcinoma of the pancreas during the study period. 58.3% of patients were men. The average age was 69.9 years (+10.3). Of the cancer patients, 306 had MRI scans. 63 scans were performed in the 2 months to 2 years prior to diagnosis of cancer. 91.3% of scans were unenhanced. MRI Findings are noted in Table 1 and interobserver agreement in Table 2. Comparing MRI of cancer patients to control patients, a solid mass was identified in 41.3% v. 11.8%, p = 0.024. A cystic lesion was identified in 29% v. 17.6%, p = 0.347. Cysts with mural nodules or septations were noted in 11.1% v. 5.9%, p= 0.46. Pancreatic duct (PD) dilation was noted in 54% v. 17.6%, p=0.007. A PD stricture was identified in 47.6% v. 11.8%, p = 0.007. A duct cut-off sign was noted in 42.9% v. 5.9%, p =0.046. Interobserver agreement (kappa) was >0.7 for PD abnormalities. Conclusions: Abnormal findings including solid masses, cystic masses and PD abnormalities were described in nearly 76% of patients undergoing MRI scanning of the abdomen in the 2 years preceding a diagnosis of cancer. Inter-observer agreement was low for the detection of solid or cystic masses. More agreement was noted for the findings of PD abnormalities. Based on high level of association and interobserver agreement, we suggest PD dilation, PD stricture, and PD cut-off sign as the earliest signs for an underlying pancreatic cancer. Table 1: Frequency of MRI Findings in Pancreatic Cancer Patients and Controls

Metabolic and Anatomic Complications Following Bariatric Surgery

There has been a virtual explosion in the number of bariatric procedures done in the USA and globally in the past 5 years. It is anticipated that more than 200,000 bariatric procedures will be done in the USA in 2012. Bariatric procedures carried out today are generally safe, in most cases effective, and commonly cost-effective in the total health care cost of this population [1]. This chapter reviews the short- and long-term complications of bariatric procedure.

Extramedullary plasmacytoma of the gallbladder diagnosed by endoscopic ultrasound fine needle aspiration (EUS-FNA).

Extramedullary plasmacytoma (EMP) is a rare entity that can exist independently or in conjunction with underlying plasma cell myeloma (PCM). When there is underlying multiple myeloma, the presence of EMP portends a poor prognosis. The most common locations for an EMP include the gastrointestinal tract, pleura, testis, skin, peritoneum, liver, endocrine glands and lymph nodes; involvement of the gallbladder is exceedingly rare with only five other cases reported and only one of which was associated with PCM. EMP of the gallbladder can manifest as acute cholecystitis, biliary obstruction, or may be asymptomatic. Treatment is traditionally surgical resection plus adjuvant chemotherapy or autologous stem cell transplant. We present a case of a 53-year-old man with PCM who was found to have a gallbladder mass on imaging and underwent endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of the mass, which was diagnostic of a plasma cell neoplasm.

Hepatobiliary Fascioliasis: An Uncommon Cause of Biliary Obstruction in the United States.

Video demonstrating removal of Fasciola hepatica from the common bile duct after retrieval balloon sweep during ERCP.