RESUMO
BACKGROUND AND STUDY AIMS: Sphincter of Oddi manometry is considered to be the gold standard for diagnosing sphincter of Oddi dysfunction (SOD). Elevated basal sphincter pressures are found in about half of the patients with findings consistent with biliary type II SOD, and most of these patients will symptomatically improve after endoscopic sphincterotomy. Since manometric sphincter evaluation is not widely available, a decision analysis was used to compare the overall costs and outcomes of manometry-directed therapy with "empirical" sphincterotomy in patients with suspected biliary type II SOD. PATIENTS AND METHODS: A decision analysis model was constructed using a software program. In a hypothetical cohort of 100 patients with suspected type II SOD, the following strategies were evaluated: a). endoscopic retrograde cholangiopancreatography (ERCP) with manometry followed by biliary sphincterotomy only if an elevated sphincter of Oddi basal pressure was found; and b). "empirical" biliary sphincterotomy without manometry. Data on the probability of an elevated sphincter of Oddi basal pressure at the time of ERCP in patients with suspected biliary SOD type II, the proportion of patients who improved after biliary sphincterotomy (with and without elevated basal pressures), the proportion of patients who improved without biliary sphincterotomy, complications, and death were obtained from the literature and from our center. The procedural and hospitalization costs represented the average Medicare reimbursement at our institution. The expected overall costs and numbers of patients improving with each strategy were compared.[nl] RESULTS: The strategy of ERCP with manometry resulted in total costs of US dollars 2790 per patient, whereas a strategy of "empirical" biliary sphincterotomy resulted in total costs of US dollars 2244. In a cohort of 100 patients with suspected SOD, 55 % of patients would be expected to improve if manometry were performed, compared to 60 % of patients improving with "empirical" biliary sphincterotomy. Univariate sensitivity analyses demonstrated that "empirical" biliary sphincterotomy continued to be a cost-saving strategy in comparison with ERCP with manometry as long as the probability of spontaneous improvement in patients with "normal" manometry was less than 41 %, the probability of complications associated with manometry was greater than 6 %, and the probability of complications due to biliary sphincterotomy was less than 19 %. CONCLUSIONS: For patients with suspected biliary SOD type II, empirical biliary sphincterotomy performed by experienced endoscopists appears to be cost-saving in comparison with a strategy based on the results of manometry.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/cirurgia , Árvores de Decisões , Manometria/economia , Esfíncter da Ampola Hepatopancreática/cirurgia , Esfinterotomia Endoscópica/economia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Análise Custo-Benefício , Tomada de Decisões Assistida por Computador , Custos de Cuidados de Saúde , Humanos , Esfíncter da Ampola Hepatopancreática/fisiopatologiaRESUMO
GERD and peptic ulcer disease are important diseases in the elderly. GERD presents similarly in the elderly and the young, although elderly patients may have less severe symptoms yet more severe mucosal disease and a higher prevalence of BE. Although the prevalence of H. pylori is falling, the elderly remain at risk for peptic ulcer because of the widespread use of NSAIDS. The presentation of peptic ulcer disease in the elderly can be subtle and atypical when compared with younger patients, leading to a delay in diagnosis. Because of comorbidity in the aged, peptic ulcer disease and its complications result in increased morbidity and mortality rates.
Assuntos
Refluxo Gastroesofágico , Úlcera Péptica , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/terapia , Humanos , Úlcera Péptica/diagnóstico , Úlcera Péptica/epidemiologia , Úlcera Péptica/terapia , Fatores de Risco , Estados Unidos/epidemiologiaAssuntos
Bacteriemia/diagnóstico , Colite/diagnóstico , Infecções Estreptocócicas/diagnóstico , Streptococcus bovis/isolamento & purificação , Strongyloides stercoralis/isolamento & purificação , Estrongiloidíase/diagnóstico , Animais , Antibacterianos/administração & dosagem , Bacteriemia/complicações , Bacteriemia/tratamento farmacológico , Biópsia por Agulha , Colite/tratamento farmacológico , Colite/etiologia , Colonoscopia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Infecções Estreptocócicas/complicações , Infecções Estreptocócicas/tratamento farmacológico , Estrongiloidíase/complicações , Estrongiloidíase/tratamento farmacológico , Resultado do TratamentoRESUMO
Cocaine use can result in various gastrointestinal complications, including gastric ulcerations, retroperitoneal fibrosis, visceral infarction, intestinal ischemia, and gastrointestinal tract perforation. We report cocaine-associated colonic ischemia in three patients and review the literature. Including ours, 28 cases have been reported, with a mean patient age of 32.6 years (range, 23 to 47 years); 53.5% were men and 46.5% were women. The interval between drug ingestion and onset of symptoms varied from 1 hour to 2 days. Cocaine is a potentially life-threatening cause of ischemic colitis and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and bloody diarrhea, especially in the absence of estrogen use or systemic disorders that can cause thromboembolic events, such as atrial fibrillation.
Assuntos
Transtornos Relacionados ao Uso de Cocaína/complicações , Colite Isquêmica/induzido quimicamente , Cocaína Crack/efeitos adversos , Dor Abdominal/induzido quimicamente , Adulto , Diagnóstico Diferencial , Diarreia/induzido quimicamente , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Sigmoidoscopia , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
Gastrointestinal side effects from nonsteroidal anti-inflammatory drugs (NSAIDs) result mainly from inhibition of the enzyme cyclooxygenase (COX)-1; it is responsible for the synthesis of prostaglandin E2, which leads to increased mucosal blood flow, increased bicarbonate secretion, and mucus production, thus protecting the gastrointestinal mucosa. In inflammation, COX-2 is induced, causing synthesis of the prostaglandins in conditions such as osteoarthritis and rheumatoid arthritis. Two NSAIDs (celecoxib and rofecoxib) with very high specificity for COX-2 and virtually no activity against COX-1 at therapeutic doses have been approved for clinical use. In trials of celecoxib and rofecoxib, only 0.02% of patients had clinically significant gastrointestinal bleeding, compared to a 1% to 2% yearly incidence of severe gastrointestinal side effects with NSAIDs. Our patient had arthritis of the hips and chronic atrial fibrillation and was on warfarin therapy for stroke prevention; less than a week after starting celecoxib therapy, gastrointestinal bleeding and hypoprothrombinemia occurred.