A dynamic flow model mimicking duodenoscope reprocessing after bacterial contamination for translational research.

Objective: Duodenoscopy-associated infections and outbreaks are reported globally despite strict adherence to duodenoscope reprocessing protocols. Therefore, new developments in the reprocessing procedure are needed. Design: We evaluated a novel dynamic flow model for an additional cleaning step between precleaning and manual cleaning in the reprocessing procedure. Methods: A parallel plate flow chamber with a fluorinated ethylene propylene bottom plate was used to mimic the duodenoscope channels. The flow chamber was inoculated with a suspension containing Klebsiella pneumoniae to simulate bacterial contamination during a duodenoscopic procedure. After inoculation the flow chamber was flushed with a detergent mimicking precleaning. Subsequently the flow chamber was subjected to different interventions: flow with phosphate-buffered saline (PBS), flow with 2 commercial detergents, flow with sodium dodecyl sulfate with 3 different concentrations, and flow with microbubbles. Adhering bacteria were counted using phase-contrast microscopy throughout the experiment, and finally, bacterial viability was assessed. Results: During precleaning both PBS and 1% (v/v) Neodisher Mediclean Forte were able to desorb bacteria, but neither proved superior. After precleaning only sodium dodecyl sulfate could desorb bacteria. Conclusions: Flushing during precleaning is an essential step for reducing adhering luminal bacteria, and sodium dodecyl sulfate is a promising detergent for bacterial desorption from duodenoscope channels after precleaning.

Symptoms and PCR testing interval for bacterial pathogens in patients with diarrhoea.

Introduction . Acute diarrhoea can be caused by Salmonella species, Shigella species, Yersinia enterocolitica, Campylobacter species and Plesiomonas shigelloides (SSYCP). In clinical practice, however, polymerase chain reaction (PCR) for SSYCP is frequently performed as part of the diagnostic work-up for patients with chronic diarrhoea and gastrointestinal complaints.Hypothesis. This study postulates that PCR for SSYCP is of limited clinical use in patients with chronic diarrhoea and gastrointestinal complaints.Aim. The primary aim of this study is to evaluate whether testing for SSYCP remains sensible in patients with chronic diarrhoea and gastrointestinal symptoms and if earlier testing leads to more positive PCR results.Methodology. Between January 2017 and December 2018, data on PCR results, culture results, symptoms, symptom to testing interval (STI) and immune status were retrospectively collected from the medical records of patients with gastrointestinal symptoms for whom PCR results for SSYCP were available. The STIs of PCR-positive patients and PCR-negative patients were compared.Results. In total, 146 PCR-positive and 149 PCR-negative patients were included. STIs of <7 days occurred in 55 % of all PCR-positive patients compared to 38 % in PCR-negative patients. PCR-positive patients were more often tested within 7 days after onset of gastrointestinal symptoms or diarrhoea. A third of PCR-positive patients had an STI of >7 days. Immunocompromised patients had a shorter STI. Admitted patients had a shorter STI. Eighty-six PCR-positive patients had a positive culture (58 %). Antibiotic use 3 months prior to PCR testing was correlated with negative PCR results.Conclusions . This study shows that early testing correlates with more positive PCR results and underlines that PCR for SSYCP is of lesser importance in the diagnostic workup of chronic diarrhoea and/or gastrointestinal symptoms. The shorter STI found in immunocompromised patients is possibly due to a lower threshold for testing in this population. It is also important to take recent antibiotic use into consideration when interpreting PCR results, given the correlation between negative PCR results and antibiotic use. Careful and precise documentation of symptoms in medical records is essential for clinical practice and research.

A narrative review on current duodenoscope reprocessing techniques and novel developments.

Duodenoscopy-associated infections occur worldwide despite strict adherence to reprocessing standards. The exact scope of the problem remains unknown because a standardized sampling protocol and uniform sampling techniques are lacking. The currently available multi-society protocol for microbial culturing by the Centers for Disease Control and Prevention, the United States Food and Drug Administration (FDA) and the American Society for Microbiology, published in 2018 is too laborious for broad clinical implementation. A more practical sampling protocol would result in increased accessibility and widespread implementation. This will aid to reduce the prevalence of duodenoscope contamination. To reduce the risk of duodenoscopy-associated pathogen transmission the FDA advised four supplemental reprocessing measures. These measures include double high-level disinfection, microbiological culturing and quarantine, ethylene oxide gas sterilization and liquid chemical sterilization. When the supplemental measures were advised in 2015 data evaluating their efficacy were sparse. Over the past five years data regarding the supplemental measures have become available that place the efficacy of the supplemental measures into context. As expected the advised supplemental measures have resulted in increased costs and reprocessing time. Unfortunately, it has also become clear that the efficacy of the supplemental measures falls short and that duodenoscope contamination remains a problem. There is a lot of research into new reprocessing methods and technical applications trying to solve the problem of duodenoscope contamination. Several promising developments such as single-use duodenoscopes, electrolyzed acidic water, and vaporized hydrogen peroxide plasma are already applied in a clinical setting.

Yersinia pseudotuberculosis infection with severe localised inflammation and ulceration of the ileum in a heart transplant patient.

In this case, we present an uncommon gastrointestinal infection in an immunocompromised patient that was solely diagnosed because of close collaboration between treating physicians and microbiologists. The patient is a 42-year-old male who underwent heart transplantation 5 years earlier. He presented with fever, weight loss, diarrhoea and tiredness. Initial investigations could not elucidate the aetiology of his symptoms. The patient was referred to the department of infectious diseases for further evaluation. Serology for Yersinia species was ordered and the result was suggestive for the possibility of a Yersinia species infection. Close collaboration between treating physicians and microbiologists followed and led to additional investigations, which revealed the diagnosis of a Yersinia pseudotuberculosis infection with extensive lesions in the gastrointestinal tract. Treatment with ciprofloxacin resulted in complete resolution of symptoms and healing of the gastrointestinal lesions. In conclusion, this case underlines the need for a multidisciplinary approach to complex patients of which symptoms have yet to be understood.

[Radiologically inserted gastrostomy]. / Radiologische plaatsing van percutane voedingssondes.

Radiologically inserted gastrostomy (RIG) is an alternative to percutaneous endoscopic gastrostomy (PEG) for patients with eating difficulties who need long-term enteral nutrition. This articles provides an overview of the technique of RIG as well as an analysis of the results of RIG at our institute over the last five years and a discussion of the literature. The number of centres in the Netherlands offering RIG is growing and therefore we want to raise awareness amongst colleagues who are not familiar with this alternative to PEG.

Independent root-cause analysis of contributing factors, including dismantling of 2 duodenoscopes, to investigate an outbreak of multidrug-resistant Klebsiella pneumoniae.

BACKGROUND AND AIMS: Worldwide, an increasing number of duodenoscope-associated outbreaks are reported. The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP at risk of exogenous transmission of microorganisms. The contributing factors of the duodenoscope design to contamination are not well understood. This article reports on the investigation after the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes. METHODS: We conducted a contact patient screening and microbiologic laboratory database search. Reprocessing procedures were audited, and both duodenoscopes were fully dismantled to evaluate all potential contamination factors. Outcomes were reviewed by an experienced independent expert. RESULTS: In total, 102 patients who had undergone an ERCP procedure from January to August 2015 were invited for screening. Cultures were available of 81 patients, yielding 27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active infection. The 2 duodenoscopes had attack rates (the number of infected or colonized cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical MRKP isolates were cultured from channel flushes of both duodenoscopes. The review revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities, including the forceps elevator, elevator lever, and instrumentation port sealing. CONCLUSIONS: Outbreaks are associated with a combination of factors, including duodenoscope design issues, repair issues, improper cleaning, and systemic monitoring of contamination. To eliminate future duodenoscope-associated infections, a multipronged approach is required, including clear communication by all parties involved, a reliable servicing market, stringent surveillance measures, and eventually new duodenoscope designs and reprocessing procedures with a larger margin of safety.

A clinical guideline on Dientamoeba fragilis infections.

Dientamoeba fragilis (D. fragilis) is an intestinal parasite frequently detected in humans with abdominal pain and diarrhoea, but it is also commonly found in asymptomatic subjects. Hence its clinical relevance is often disputed. The introduction of polymerase chain reaction (PCR) is a versatile and sensitive diagnostic technique for the detection of intestinal parasites, and in some Western world countries PCR has almost completely replaced microscopic diagnostics. PCR has however resulted in an increase in the number of D. fragilis-positive patients. The disputed pathogenic nature of this intestinal parasite and an apparent increase in the incidence of patients with positive PCR results have renewed the discussions between clinicians and microbiologists on how to deal with an infected patient. Moreover, treatment guidelines differ throughout the world which makes it difficult for clinicians to choose an optimal therapeutic regimen.AimTo summarize and discuss the current knowledge on the pathogenicity, best diagnostic approach, treatment and follow-up of children and adults infected with D. fragilis.

Electromagnetic-guided placement of nasoduodenal feeding tubes versus endoscopic placement: a randomized, multicenter trial.

BACKGROUND AND AIMS: Electromagnetic-guided placement (EMP) of a nasoduodenal feeding tube by trained nurses is an attractive alternative to EGD-guided placement (EGDP). We aimed to compare EMP and EGDP in outpatients, ward patients, and critically ill patients with normal upper GI anatomy. METHODS: In 3 centers with no prior experience in EMP, patients were randomized to placement of a single-lumen nasoduodenal feeding tube either with EGDP or EMP. The primary endpoint was post-pyloric position of the tube on abdominal radiography. Patients were followed for 10 days to assess patency and adverse events. The analyses were performed according to the intention-to-treat principle. RESULTS: In total, 160 patients were randomized to EGDP (N = 76) or EMP (N = 84). Three patients withdrew informed consent, and no abdominal radiography was performed in 2 patients. Thus, 155 patients (59 intensive care unit, 38%) were included in the analyses. Rates of post-pyloric tube position between EGDP and EMP were comparable (79% vs 82%, odds ratio 1.16; 90% confidence interval, 0.58-2.38; P = .72). Adverse events were observed in 4 patients after EMP (hypoxia, GI blood loss, atrial fibrillation, abdominal pain) and in 4 after EGDP (epistaxis N = 2, GI blood loss, hypoxia). Costs of tube placements were lower for EMP compared with EGDP: $519.09 versus $622.49, respectively (P = .04). CONCLUSIONS: Success rates and safety of EMP and EGDP in patients with normal upper GI anatomy were comparable. Lower costs and potential logistic advantages may drive centers to adopt EMP as their new standard of care. (Clinical trial registration number: NTR4286.).

Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial.

OBJECTIVES: Electromagnetic (EM)-guided bedside placement of nasoenteral feeding tubes by nurses may improve efficiency and reduce patient discomfort and costs compared with endoscopic placement by gastroenterologists. However, evidence supporting this task shift from gastroenterologists to nurses is limited. We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement. METHODS: We performed a multicenter randomized controlled non-inferiority trial in 154 adult patients who required nasoenteral feeding and were admitted to gastrointestinal surgical wards in five Dutch hospitals. Patients were randomly assigned (1:1) to undergo EM-guided or endoscopic nasoenteral feeding tube placement. The primary end point was the need for reinsertion of the feeding tube (e.g., after failed initial placement or owing to tube-related complications) with a prespecified non-inferiority margin of 10%. RESULTS: Reinsertion was required in 29 (36%) of the 80 patients in the EM-guided group and 31 (42%) of the 74 patients in the endoscopy group (absolute risk difference -6%, upper limit of one-sided 95% confidence interval 7%; P for non-inferiority=0.022). No differences were noted in success and complication rates. In the EM-guided group, there was a reduced time to start of feeding (424 vs. 535 min, P=0.001). Although the level of discomfort was higher in the EM-guided group (Visual Analog Scale (VAS) 3.9 vs. 2.0, P=0.009), EM-guided placement received higher recommendation scores (VAS 8.2 vs. 5.5, P=0.008). CONCLUSIONS: EM-guided bedside placement of nasoenteral feeding tubes by nurses was non-inferior to endoscopic placement by gastroenterologists in surgical patients and may be considered the preferred technique for nasoenteral feeding tube placement.

Clinical consequences of polymerase chain reaction-based diagnosis of intestinal parasitic infections.

The implementation of polymerase chain reaction (PCR)-based diagnostics of intestinal protozoa has led to higher sensitivity and (subtype) specificity, more convenient sampling, and the possibility for high-throughput screening. PCR for routine detection of human intestinal protozoa in fecal samples is used by an increasing number of clinical laboratories. This paper discusses the recent developments in the diagnosis of intestinal protozoa, with an emphasis on PCR-based diagnostics. Although many reviews have described the technical aspects of PCR-based diagnostics, this review focuses on the clinical consequences that result from the shift from microscopic toward PCR-based diagnostics. Despite its undisputed superiority, the use of PCR comes with challenges that clinicians should be aware of.

Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial.

BACKGROUND: Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs. METHODS/DESIGN: The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications. DISCUSSION: The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes. TRIAL REGISTRATION: Dutch Trial Register: NTR4420 , date registered 5-feb-2014.

Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score.

BACKGROUND: Adequate bowel preparation is important for optimal colonoscopy. It is important to identify patients at risk for inadequate bowel preparation because this allows taking precautions in this specific group. OBJECTIVE: To develop a prediction score to identify patients at risk for inadequate bowel preparation who may benefit from an intensified bowel cleansing regimen. DESIGN: Patient and colonoscopy data were prospectively collected, whereas clinical data were retrospectively collected for a total of 1996 colonoscopies in participants who received split-dose bowel preparation. Multivariate logistic regression analyses were conducted in a random two-thirds of the cohort to develop a prediction model. Validation and evaluation of the discriminative power of the prediction model were performed within the remaining one-third of the cohort. SETTING: Four centers, including one academic and three medium-to-large size nonacademic centers. PATIENTS: Consecutive colonoscopies in November and December 2012. Mean age was 57.3 ± 15.9 years, 45.8% were male and indications for colonoscopy were screening and/or surveillance (27%), abdominal symptoms and/or blood loss and/or anemia (60%), inflammatory bowel disease (9%), and others (4%). INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Inadequate bowel preparation defined as Boston Bowel Preparation Scale score <6. RESULTS: A total of 1331 colonoscopies were included in the development cohort, of which 172 (12.9%) had an inadequate bowel preparation. Independent factors included in the prediction model were American Society of Anesthesiologists Physical Status Classification System score ≥3, use of tricyclic antidepressants, use of opioids, diabetes, chronic constipation, history of abdominal and/or pelvic surgery, history of inadequate bowel preparation, and current hospitalization. The discriminative ability of the scale was good, with an area under the curve of 0.77 in the validation cohort. LIMITATIONS: Study design partially retrospective, no data on patient compliance. CONCLUSION: We developed a validated, easy-to-use prediction scale that can be used to identify subjects with an increased risk of inadequate bowel preparation with good accuracy.

Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial.

OBJECTIVES: To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy. METHODS: Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE). RESULTS: Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21). CONCLUSIONS: Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

Acute gastrointestinal bleeding from a submucosal gastric mass.

We report a case of a 44-year-old male patient who presented with melena and hemodynamic instability. The endoscopic investigation of the upper and lower gastrointestinal tract was initially negative, but a repeat gastroduodenoscopy revealed a submucosal mass in the lesser curvature of the stomach with central erosion, primarily perceived as ectopic pancreas, but it was later discovered that it pertained to a gastrointestinal stromal tumor.

Esophageal pH-impedance monitoring in patients with therapy-resistant reflux symptoms: 'on' or 'off' proton pump inhibitor?

BACKGROUND: In patients with proton pump inhibitor (PPI)-resistant symptoms, ambulatory 24-h pH-impedance monitoring can be used to assess whether a relationship exists between symptoms and reflux episodes. Until now, it is unclear whether combined pH-impedance monitoring in these patients should be performed on or off PPI. METHODS: Thirty patients with symptoms of heartburn, chest pain, and/or regurgitation despite PPI twice daily underwent ambulatory 24-h pH-impedance monitoring twice, once on PPI and once after cessation of the PPI for 7 days. The order of the measurements was randomized. Reflux episodes were identified and classified as acid, weakly acidic, or weakly alkaline reflux. In addition, the symptom association probability (SAP) was calculated for each measurement. RESULTS: The total number of reflux episodes and proximal extent were not affected by PPI therapy. On PPI, there were fewer acid reflux episodes (49 +/- 34 off PPI vs 20 +/- 25 on PPI) while more weakly acidic reflux episodes were identified (24 +/- 17 off PPI vs 48 +/- 31 on PPI). Symptom association analysis identified 15 and 11 patients with a positive SAP in the measurement off and on PPI, respectively, the difference in yield of the SAP not being statistically significant. Eight of the 19 patients who had no symptoms or a negative SAP during measurement on PPI had a positive SAP off PPI therapy. In contrast, only 4 patients with a positive SAP on PPI were missed in the measurement off PPI therapy. CONCLUSIONS: In order to demonstrate or exclude GERD in patients with PPI-resistant symptoms, ambulatory 24-h pH-impedance monitoring should preferably be performed after cessation of PPI therapy because this approach seems to offer the best chance to assess a relationship between symptoms and reflux episodes.

Probiotics in primary sclerosing cholangitis: a randomized placebo-controlled crossover pilot study.

BACKGROUND: Beneficial effects of probiotics have been reported in liver disease. Inflammatory bowel disease concurs in 90% of primary sclerosing cholangitis (PSC) patients, suggesting that substances originating from the inflamed gut may damage the biliary tree. OBJECTIVE: To assess potential beneficial effects of probiotics on serum liver tests, pruritus and fatigue in PSC. METHODS: Fourteen patients (13 male/one female, mean age 45 years), with concurrent inflammatory bowel disease were randomized to treatment with probiotics (Ecologic 641, containing four Lactobacillus and two Bifidobacillus strains; Winclove Bio Industries, Amsterdam, The Netherlands) or placebo during 3 months in a double-blind fashion. After a 1-month washout period, crossover was made. RESULTS: No changes in pruritus, fatigue and stool frequency were noted during placebo or probiotics. No significant differences were observed between treatment with probiotics and placebo in bilirubin (at end of probiotic vs. placebo period: -13 vs. -15% change from baseline; P=0.89), alkaline phosphatase (-9 vs. -9%; P=0.99), gamma glutamyl transpeptidase (-11 vs. -5%; P=0.60), aspartate aminotransferase (-16 vs. -15%; P=0.99), alanine aminotransferase (-27 vs. -26%; P=0.97), prothrombin, albumin or bile salts. CONCLUSION: Our data do not support beneficial effects of probiotics on symptoms, liver biochemistry or liver function in PSC.