Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes.

BACKGROUND: Percutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities. AIM: To assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications. METHODS: We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression. RESULTS: 154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications. CONCLUSION: Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

Primary jejunal amelanotic melanoma: case report and review of literature.

Intussusception more commonly occurs in pediatrics but is a rare cause of bowel obstruction and gastrointestinal bleeding in adults. It typically occurs in adults due to a malignancy, which serves as a pathologic lead point. We present a case of a 64-year-old female with nausea, vomiting, and melena who was found to have intussusception associated with a primary jejunal amelanotic melanoma. Both intussusception and primary small bowel melanomas are rare causes of obstruction and bleeding. Intussusception occurring as a result of a primary small bowel amelanotic melanoma is exceedingly rare with very few reported cases. We provide a case report and review of the literature.

Sequence of same-day upper and lower gastrointestinal endoscopy does not affect total procedure' time or medication use: A randomized trial.

BACKGROUND AND AIM: Same-day double upper and lower gastrointestinal endoscopy is frequently performed due to overlapping indications. However, it is unclear whether an upper-lower (U-L) or lower-upper (L-U) sequence is optimal. We analyzed the effect of sequence on total procedure time and sedation use. METHODS: A total of 100 patients scheduled for same-day double endoscopy were randomized to the U-L or L-U sequence arm. Primary outcomes, mean total procedure time, and sedative dosages were compared using a t-test. We also explored associations of the primary outcomes with patient-related and procedure-related factors. RESULTS: Comparing U-L and L-U sequences, mean total procedure time was 41.9 (16.2) versus 43.0 (14.5) min (P = 0.73), diphenhydramine dose 5.5 (15.4) versus 4.5 (14.0) mg (P = 0.74), fentanyl dose 71.5 (119.3) versus 77.6 (164.02) µg (P = 0.83), midazolam dose 1.6 (2.5) versus 1.4 (2.7) mg (P = 0.69), and propofol dose 437.4 (351.4) versus 444.5 (256.0) mg (P = 0.91), respectively. Total procedure and upper endoscopy times were significantly longer with trainee presence (P = 0.0002) and shorter with conscious sedation (P = 0.003). Upper endoscopy time was longer with higher body mass index (P = 0.001), and lower endoscopy time was longer in patients with cirrhosis or chronic kidney disease (P = 0.002 and 0.009, respectively). Time between procedures was significantly longer in the L-U sequence (7.4 [2.9] vs 5.3 [1.1] min, [P < 0.001]). The study had 80% power to detect an 8 min difference in total procedure time. CONCLUSIONS: The sequence of same-day double gastrointestinal endoscopy does not affect total procedure time or medication use. Longer total procedure and upper endoscopy times were associated with trainee presence and use of conscious sedation.

Formation of Pancreatoduodenal Fistula in Intraductal Papillary Mucinous Neoplasm of the Pancreas Decreased the Frequency of Recurrent Pancreatitis.

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are characterized by proliferation of mucin-secreting cells in the main pancreatic duct (PD) or its branches. The secreted thick mucin usually leads to PD obstruction and dilation. A common complication of IPMN is recurrent acute pancreatitis secondary to poor pancreatic fluid drainage, and rarely, pancreatobiliary and pancreatointestinal fistulae. We describe a unique case of IPMN in a 57-year-old male who was referred to our institution for evaluation of recurrent acute pancreatitis. After extensive evaluation, he was diagnosed with main duct IPMN. Intraductal PD biopsy revealed intestinal type IPMN with intermediate grade dysplasia. Patient was managed clinically by large caliber (10 French) PD stenting which eliminated his recurrent acute pancreatitis. The patient was initially referred for pancreatic resection; however, surgery was aborted and evaluated to be high risk with high morbidity secondary to the extensive adhesions between the pancreas and surrounding structures. Patient remained clinically stable for a few years except for an episode of acute pancreatitis that happened after a trial of stent removal. Subsequently, the patient did well after the PD stent was replaced. Recently, repeat abdominal imaging revealed a large pancreatoduodenal fistula which was confirmed on repeat endoscopic retrograde cholangiopancreatography. We were able to perform pancreatoscopy by advancing a regular upper scope through the fistula and into the PD. Interestingly, the fistula relieved the symptoms of obstruction and subsequently decreased the frequency of recurrent pancreatitis episodes with no further episodes at 6 months follow-up. This case highlights the importance of providing adequate PD drainage to reduce the frequency of recurrent acute pancreatitis in the setting of main duct IPMN, especially if the patient is not a surgical candidate. Also, physicians need to monitor for complications such as fistula formation between the pancreas and surrounding structures in the setting of chronic inflammation due to recurrent episodes of pancreatitis. Early identification of a fistula is important for surgical planning. Furthermore, since recent studies suggested a higher incidence of additional primary malignancies in patients with IPMN of the pancreas compared to the general population, patients may be considered for screening for other primary malignancies.

Peptic Ulcer Disease and Helicobacter pylori infection.

Peptic ulcer disease (PUD) is a common condition that both primary care providers and gastroenterologists encounter. Symptoms of peptic ulcer disease are variable and may include abdominal pain, nausea, vomiting, weight loss and bleeding or perforation with complicated disease. Identifying the risk factors and mechanisms that lead to the development of PUD helps to understand the approach behind diagnostic and treatment strategies.

Risk of Gastric Cancer Among Patients With Intestinal Metaplasia of the Stomach in a US Integrated Health Care System.

BACKGROUND & AIMS: Gastric intestinal metaplasia (GIM) is a common finding from routine endoscopies. Although GIM is an early step in gastric carcinogenesis, there is controversy regarding routine surveillance of patients with GIM in regions with a low prevalence of gastric cancer. We aimed to determine the incidence of gastric cancer among patients with GIM and risk factors for gastric cancer. METHODS: We performed a retrospective cohort study of patients from the Kaiser Permanente Southern California region diagnosed with GIM from 2000 through 2011. GIM was identified by a keyword search of pathology reports; gastric cancer cases were identified by cross-reference with an internal cancer registry. The incidence of gastric cancer in patients with GIM (n = 923; median age at diagnosis, 68 y) was compared with that of an age- and sex-matched reference population (controls). Risk factors such as ethnicity, smoking status, history of Helicobacter pylori infection, and family history of gastric cancer were evaluated by individual Cox proportional hazards regression. We then performed a second case-cohort study to evaluate the risk of gastric cancer based on the location and extent of GIM. The median duration of follow-up evaluation was 4.6 years (interquartile range, 3.0-6.7 y). RESULTS: We identified 25 patients with GIM who developed gastric cancers. Seventeen cases of cancer were diagnosed at the same time as the diagnosis of GIM. Eight cases of cancer were identified within a median time period of 4.6 years after a diagnosis of GIM (interquartile range, 2-5.7 y). The overall incidence rate for the cohort was 1.72 (95% confidence interval, 0.74-3.39). Among the risk factors evaluated, only family history (hazard ratio, 3.8; 95% confidence interval, 1.5-9.7; P = .012) and extent of GIM (odds ratio, 9.4; 95% confidence interval, 1.8-50.4) increased the risk for gastric cancer. The incidence rate for gastric cancer in patients with a positive family history was 8.12 (95% confidence interval, 1.67-23.73). CONCLUSIONS: In an analysis of patients with GIM listed in the Kaiser Permanente Southern California database, 2.7% were diagnosed with gastric cancer; almost 70% of cases of gastric cancer were detected at the time of GIM diagnosis. Family history and extensive metaplasia were associated with an increased risk of subsequent gastric cancer. Targeted surveillance of patients with these criteria could increase early detection of gastric cancer.