Rethink analgo-sedation in digestive endoscopy: the role of scientific societies in tracing training path.

OBJECTIVE: The Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care Medicine (SIAARTI) and the Italian Society of Digestive Endoscopy (SIED) worked together to produce a joint Good Clinical Practice (GCP) on analgo-sedation in digestive endoscopy and launched a survey to support the document. The aim was to identify and describe the actual clinical practice of sedation in Italian digestive endoscopy units and offer material for a wider and more widespread discussion among anesthetists and endoscopists. SUBJECTS AND METHODS: A national survey was planned, in order to support the statements of the GCP. Twelve thousand and five hundred questionnaires were sent to the members of SIAARTI and SIED in June 2020. RESULTS: A total of 662 forms (5.3%) returned completed. Highly complex procedures are performed according to 70% of respondents; daily anesthesiologist's assistance is guaranteed in 26%, for scheduled sessions in 14.5% and as needed in 8%. 69% of respondents declared not to have a dedicated team of anesthesiologists, while just 5% reported an anesthesiologist in charge. A complete monitoring system was assured by 70% of respondents. Dedicated pathways for COVID-19-positive patients were confirmed in <40% of the answers. With regard to moderate/deep sedation, 90% of respondents stated that an anesthetist decides timing and doses. Propofol was exclusively administered by anesthetists according to 94% of answers, and for 6% of respondents the endoscopist is allowed to administer propofol in presence of a dedicated nurse, but with a readily available anesthetist. Only 32.8% of respondents reported institutional training courses on procedural analgo-sedation. CONCLUSIONS: The need to provide patients scheduled for endoscopy procedures with an adequate analgo-sedation is becoming an increasing concern, well-known in almost all countries, but many factors compromise the quality of patient care. Results of a national survey would give strength to the need for a shared GCP in gastrointestinal endoscopy. Training and certification of non-anesthetist professionals should be one of the main ways to center the objective.

Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients.

BACKGROUND: The influence of aging on video capsule endoscopy (VCE) in obscure gastrointestinal bleeding (OGIB) has never been prospectively assessed. AIMS: To demonstrate if age is a risk factor for incomplete VCE examination in a setting of ongoing hospitalization for OGIB and if it affects the yield of VCE. METHODS: Forty-eight consecutive patients referred to our unit for obscure-overt GI bleeding from March 2007 to September 2009 were prospectively evaluated. Patients were divided into two groups according to their age: ≤65 years (group A) and >65 years (group B). The VCE completion rate and clinically significant findings were studied. RESULTS: The cecum was reached in 73% of patients. There was no difference between the two groups of patients in the VCE completion rate (78% vs. 68%, P=0.4). The overall diagnostic yield was 61%. A significant difference in the diagnostic yield between group A and group B (45% vs. 75%, P=0.04) was shown. Angiodysplasia was diagnosed in 13 out of 24 (54%) patients of group B, whereas mucosal breaks, such as erosions or ulcers, accounted for over a quarter of the group A findings. CONCLUSIONS: Old age is not a risk factor for incomplete VCE examination and it is associated with increased VCE yield.

Long-acting octreotide as rescue therapy in chronic bleeding from gastrointestinal angiodysplasia.

BACKGROUND: Octreotide has shown to be effective against rebleeding from gastrointestinal angiodysplasias, but a long-term daily parenteral administration is recommended. Long-acting octreotide (LAR-OCT) could overcome such a limitation, but it has not been studied extensively. AIM: To investigate the usefulness of long-acting octreotide in the control of chronic bleeding from gastrointestinal angiodysplasias. METHODS: Thirteen patients with chronic gastrointestinal bleeding because of angiodysplasias were enrolled. Diagnosis was made by endoscopy and wireless video capsule. Long-acting octreotide was administered intramuscularly at a dosage of 10 mg/monthly for 1 year. Patients were followed up for a minimum period of 1 year, and haemoglobin levels, blood transfusions, iron supplementation and hospitalizations were recorded 1 year before and after starting long-acting octreotide therapy. RESULTS: Follow-up ranged from 12 to 60 months. Nine of 13 patients (69%) did not need blood transfusions and iron supplementation any longer; a partial improvement was observed in one patient; no effect was found in the others. No side effect was recorded in any patient. CONCLUSIONS: Long-acting octreotide for 1 year may be beneficial as a rescue therapy for controlling chronic bleeding from gastrointestinal angiodysplasias in patients not eligible for surgery. Its monthly administration represents an advantage, which makes such a formulation the choice when a long-term treatment is mandatory.

Management and outcomes of hepatic cirrhosis: Findings from the RING study.

BACKGROUND/AIM: Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology. MATERIAL/METHODS: More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU. RESULTS: Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8). CONCLUSIONS: Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Seasonal patterns of hospital treatment for inflammatory bowel disease in Italy.

AIM: It is still debated whether clinical flare-ups of chronic inflammatory bowel disease follow a seasonal pattern, and the various reports are based on general practitioners' records or hospital discharge charts. There are, however, no specific figures for treatment in hospital gastroenterology units, which serve as a reference point for these disorders. This study was therefore designed to investigate whether there is a seasonal pattern in admissions for inflammatory intestinal disease in Italy, differing from what is generally known about gastrointestinal pathologies, since there are no nation-wide figures on the subject. METHODS: The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 22 centers in Italy. RESULTS: From winter 2000 to autumn 2003, the 22 gastroenterology units participating in the RING project discharged 32,357 patients following ordinary hospital admissions. Of these, 2,856 (8.8%) had a main diagnosis of inflammatory bowel disease: 1,541 Crohn's disease, and 1,315 ulcerative colitis. No seasonal patterns were detected for either category, or when the analysis was done by age, sex and site of disease. CONCLUSIONS: The most serious flare-ups of inflammatory bowel disease, i.e. those requiring routine hospital treatment, do not appear to follow any seasonal pattern, regardless of the site of the disease or the patient's age or sex.

The prolongation of triple therapy for Helicobacter pylori does not allow reaching therapeutic outcome of sequential scheme: a prospective, randomised study.

BACKGROUND AND AIM: One-week triple therapy for Helicobacter pylori revealed, during these last few years, a decrease in the eradication rate, so that the prolongation of its duration has been proposed. A sequential scheme recently showed very satisfactory results. We performed a prospective randomised study with the aim of either evaluating whether the triple therapy prolongation may improve its effectiveness and comparing its outcome with that of sequential regimen. PATIENTS AND METHODS: Three hundred and forty-two H. pylori positive patients completed the study. They were randomised to receive one of the following treatments: (i) a 7-day triple therapy comprising of rabeprazole (20 mg, b.i.d.) plus clarithromycin (500 mg, b.i.d.) and amoxycillin (1 g, b.i.d.); (ii) a 10-day triple therapy comprising the same scheme; (iii) a 10-day sequential regimen comprising of rabeprazole (20 mg, b.i.d.) plus amoxycillin (1 g, b.i.d.) for 5 days followed by rabeprazole (20 mg, b.i.d.) plus clarithromycin (500 mg, b.i.d.) and tinidazole (500 mg, b.i.d.) for the next 5 days. Therapeutic results were expressed using both intention-to-treat and per protocol analyses with 95% confidence intervals. A model of multivariate logistic regression analysis was performed using therapeutic outcome as a dependent variable and including endoscopic finding, smoking habit, age and sex as candidates for the model. RESULTS: Sequential regimen showed a significant gain in the eradication rate as compared to the 7-day (P < 0.0001) and the 10-day (P < 0.01) triple therapies, respectively. Overall eradication was lower in smokers than in non-smokers, but the difference remained significant only in the 7-day triple therapy (P < 0.01). Additionally, the overall eradication was higher in peptic ulcer than dyspepsia (P < 0.01), even if this difference was significant only for both triple therapies. CONCLUSIONS: Seven-day triple therapy achieves disappointing eradication rates in dyspeptics and smokers. Prolonging triple therapy to 10 days does not significantly improve the eradication rate. The novel 10-day sequential regimen is more effective and equally tolerated than the 10-day triple therapy.

The RXc graph in evaluating and monitoring fluid balance in patients with liver cirrhosis.

A recent study, using height-standardized resistance (R/H) and reactance (Xc/H) and assuming a bivariate distribution, has proposed the "RXc graph". We applied this new approach for patients with chronic liver disease in differentiating various degrees of fluid unbalance. Our data showed that a 95% confidence ellipse of patients with chronic hepatitis (CH) overlapped that of healthy control subjects (CONTR), while those of patients with liver cirrhosis (CIR), patients with cirrhosis and ascites (ACIR), and patients with cirrhosis, edemas, and ascites (AECIR) were clearly different for both genders. A progressively shorter mean impedance vector proportional to the stage of liver disease and to the degree of fluid unbalance was found. The lower half of the 50% tolerance ellipse for the healthy population proved to be a threshold for cirrhotics, while almost all the subjects with clinically detectable edema fell outside this limit. The RXc graph was shown to be useful in monitoring the treatment of fluid unbalance and for the immediate selection of patients in whom BIA can precisely assess body composition.