Category Archives: Gastroenterology

What and When for ERCP with Gallstone Pancreatitis

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A recent case vignette highlights several key points regarding use and timing of ERCP (endoscopic retrograde cholangiopancreatography) for gallstone pancreatitis (NEJM 2014; 370: 150-7). Figure 1 provides a nice illustration of ERCP.

Indications:  Suspected bile-duct stones as the cause of pancreatitis AND one of the following:

  • cholangitis (fever, jaundice, sepsis)
  • persistent biliary obstruction (conjugated bilirubine level >5 mg/dL)
  • clinical deterioration (worsening pain, increasing white cell count, worsening vital signs)
  • stone evident in the common bile duct on imaging

AGA position paper (2007):

  • Urgent ERCP (within 24 hours of admission) was recommended in those with cholangitis
  • Early ERCP (within 72 hours of admission) was recommended if suspicion of persistent bile-duct stones remained high

Patient information/animated videos for pancreatic diseases from the National Pancreas Foundation: http://ow.ly/sF9vb 

Related post:

Indomethacin to prevent post-ERCP pancreatitis | gutsandgrowth

Variation in Practice -The Influence of Money

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A recent study highlights the problem of bundling and shows how financial incentives distort care in some gastroenterology practices (Clin Gastroenterol Hepatol 2014; 12: 58-63).

Background: When needed, patients can undergo both colonoscopy and esophagogastroduodenoscopy (EGD) at the same time; when combined, the procedures are considered bundled.  It is more convenient for patients and less costly to do the two procedures during the same sedation.  However, Medicare reimbursement to physicians for bundled procedures is less than the sum of the two procedures when charged separately. This creates an incentive for physicians to unbundle these procedures.

Study design: The authors examined Medicare claims from 2007-2009 in a national, random sample (patients ≥66 years) –part of the Surveillance Epidemiology and End Results Program.

Results:

  • 12,982 had colonoscopy and EGD within 180 days.  ~35% of these were not bundled.  This included 2359 (18%) unbundled procedures which were performed within 30 days of each other.
  • Geographic differences were noted: bundling occurred less often in the Northeast (55%) and most often in the West (68%)

What does this study indicate about bundling (& human nature)?  This study indicates that physicians respond to underlying financial incentives to separate these procedures.  In our pediatric practice, we do not unbundle procedures.  The additional facility costs, use of anesthesia, costs to families from missing work, and convenience are compelling reasons to combine procedures if feasible.  However, this data indicates that unless physicians are paid the same value for each EGD and colonoscopy, there will continue to be many patients who have their procedures scheduled on separate dates.

Bottomline: Medicare and other insurance companies will save money by not paying less for combined procedures.

Another example of financial incentive influencing care with regard to ambulance and EMS care:  How Perverse Incentives Drive Up Health Care Costs / ideastream …

Moving to All Oral Therapy for Hepatitis C

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Two more studies show the promise of all oral treatment for Hepatitis C virus:

  • NEJM 2014; 370: 211-21.
  • NEJM 2014; 370: 222-32.

A summary of these articles is available at the following link: http://t.co/Z8jMPKoLGz.

Here is an excerpt:

Hepatitis C treatment isn’t pretty, but the dark days of weekly injections, rough side effects and no guarantee of full recovery from the liver-damaging disease may soon be over, researchers report.

Two studies, both published in the Jan. 16 issue of the New England Journal of Medicine, involved giving various combinations of antiviral pill cocktails to patients with hepatitis C. Some had failed to respond to standard treatments, and some had not received treatment yet. Yet, the cocktails cleared the virus in both studies for between 93 percent and 98 percent of the patients…

The first study, conducted by Johns Hopkins researchers, included 211 men and women with hepatitis C who took two pill-form antiviral medications, daclatasvir and sofosbuvir. The patients were treated at 18 medical centers in the United States and Puerto Rico. They took 60 milligrams of daclatasvir and 400 milligrams of sofosbuvir for either 12 or 24 weeks, with or without a third drug, ribavirin….

98 percent of the 126 previously untreated patients and 98 percent of 41 patients whose infections had not cleared despite treatment with standard hepatitis C therapy, were considered cured. “There was no detectable virus in their blood three months after the treatment stopped,” he noted.

The second study, headed up by researchers at Virginia Mason Medical Center in Seattle, involved more than eight medical centers in the United States and internationally. It included 571 patients with hepatitis C, some of whom had not received treatment previously and others who had previously received standard treatments with interferon injections and ribavirin — an antiviral drug that when given reduces relapses — but had not responded to them.

The participants were randomly assigned to take any of three combinations of antiviral pills — medications called ABT-450, ABT-267, and ABT-333 — for eight, 12 or 24 weeks…

Almost all of the patients (more than 93 percent in both groups) saw the virus cleared from their systems within 24 weeks.

Bottomline: Once daily treatment with a combination of medicines will be an effective and safe cure for more than 90% of individuals with HCV. Whether these agents will be affordable remains in doubt.

Related blog posts:

 

AGA Guidelines for the Use of Thiopurines and Anti-TNF Agents for Crohn’s

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The link (from KT Park’s twitter feed): gastrojournal.org/article/S0016-5085(13)01521-7/fulltext …

Some of the key points/recommendations for adults with Crohn’s disease:

  • In clinical practice, CD of moderate severity is defined as disease requiring systemic corticosteroids for symptom control.

For Induction of Remission:

  • We Suggest Against Using Thiopurine Monotherapy to Induce Remission in Patients With Moderately Severe CD (Weak Recommendation, Moderate-Quality Evidence)
  • We Suggest Against Using Methotrexate to Induce Remission in Patients With Moderately Severe CD (Weak Recommendation, Low-Quality Evidence)
  • We Recommend Using Anti–TNF-α Drugs to Induce Remission in Patients With Moderately Severe CD (Strong Recommendation, Moderate-Quality Evidence)
  • We Suggest Using Anti–TNF-α Drugs in Combination With Thiopurines Over Anti–TNF-α Drug Monotherapy to Induce Remission in Patients Who Have Moderately Severe CD (Weak Recommendation, Moderate-Quality Evidence)

Maintenance of Remission:

  • We Recommend Using Thiopurines Over No Immunomodulator Therapy to Maintain a Corticosteroid-Induced Remission in Patients With CD (Strong Recommendation, Moderate-Quality Evidence)
  • We Suggest Using Methotrexate Over No Immunomodulator Therapy to Maintain Corticosteroid-Induced Remission in Patients With CD (Weak Recommendation, Low-Quality Evidence)
  • We Recommend Using Anti–TNF-α Drugs Over No Anti–TNF-α Drugs to Maintain Corticosteroid- or Anti–TNF-α—Induced Remission in Patients With CD (Strong Recommendation, High-Quality Evidence)
  • We Make No Recommendation for or Against the Combination of an Anti–TNF-α Drug and a Thiopurine Versus an Anti–TNF-α Drug Alone to Maintain Remission Induced by a Combination of These Drugs in Patients With CD (No Recommendation, Low-Quality Evidence)

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Predicting Severe Clostridium Difficile

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According to a recent publication (Clin Gastroenterol Hepatol 2013; 11: 1466-71), the most important risk factors for severe Clostridium difficile infection (CDI) are the following:

  • Peripheral leukocytosis (WBC >15,000)
  • Elevated serum creatinine >1.5 times baseline
  • Narcotic use
  • Acid-blocking medications
  • Older age

This study reviewed the records of inpatient cases at the Mayo clinic between 2007-2010. In total, 487 of 1446 patients had severe CDI, defined as ICU admssion (26.7%), colectomy (2.7%) or death (8.9%) within 30 days of diagnosis.

Patients with these risk factors may need to be treated more aggressively.

Also, noted: Am J Gastroenterol 2013; 108: 1794-1801. (Thanks to Ben Gold). Using electronic medical records, the authors identified 894  adult inpatients with a first-time CDI (2009-2012).  Receipt of PPIs concurrent with CDI treatment was not associated with CDI recurrence.

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Intermittent Abdominal Pain and Intestinal Swelling –a Mystery?

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A recent “Think Like a Doctor”  -full link to the solved case: nyti.ms/1aJtxFK 

First an except from the challenge:

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again a CT scan showed an abnormality in the small intestines. This time the doctors were so worried they took her straight into the operating room.

“They thought my guts were tangled up in knots,” she told the doctor. But when she woke up, the surgeon told her that he was amazed to see that her insides were pristine. There was swelling and a lot of fluid in her belly, but no twisting, and no infection. And nothing to take out.

At that hospital she had an endoscopy so doctors could look at her stomach and upper G.I. tract and a colonoscopy to look at the other end. Those exams were normal.

And now the answer (an excerpt):

The correct diagnosis is…

Intestinal angioedema, triggered by lisinopril, the ACE inhibitor the patient took for her high blood pressure.

The Diagnosis:

Angioedema is a localized type of swelling usually involving the mouth, tongue or upper airways. It can be part of a typical allergic reaction, with hives and itching, or it can be isolated, with swelling as the only notable finding. While there is an inherited form of this disease, most cases are acquired. And medications are the most common cause of this form of the syndrome…

his patient had a rare form of the problem that arose not in the face but in the intestine. When swelling occurs in the gut, it can block off the intestinal lumen and bring digestion to a screeching halt, causing the terrible pain and vomiting this patient experienced.

Remarkably, no matter where in the body the swelling occurs, or how severe it gets, it always resolves quickly – often within hours – even if the patient continues to take the medication.

When the angioedema happens in the G.I. tract, the diagnosis can be delayed for months or years because so many doctors don’t know that this kind of reaction is even possible. When the medication is stopped, the episodic reaction also finally stops…

the resident on call that day at the University of Chicago Medical Center, and told her that he thought this was a reaction to the patient’s blood pressure medication.

He also recommended that the patient be tested for the inherited version of the disease.

Related blog post: 

Overlooking Important Detail$ in Hereditary Angioedema Treatment …

PEG Decisions

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In pediatric gastroenterology, percutaneous endoscopic gastrostomy (PEG) tube placement is not typically a palliative measure and there is a very low mortality rate.  In adult medicine, PEG tube placements are often part of palliative care and used to allow easier management in nursing homes.

A few studies this past month highlight the mortality and potential ethical dilemmas focused around PEG tube placement.

Clin Gastroenterol Hepatol 2013; 11: 1437-44.  “In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006.”

Clin Gastroenterol Hepatol 2013; 11: 1445-50.  Between 2004-2010, among 1327 patients with prospectively collected data from 2 UK hospitals, 344 (23%) did not undergo gastrostomy placement after multidisciplinary team discussion. This group had 35.5% mortality at 30 days compared with 11.2% of the 1027 who proceeded with PEG.  Age >60 and low albumin were predictors of 30-day mortality.

Clin Gastroenterol Hepatol 2013; 11: 1451-52.  The editorial on these two studies tries to redirect the focus from futility to quality of life in terms of PEG decision-making.  “An objective scoring system to predict survival, minimize futility, and promote justice in the allocation of resources toward PEG placement is not the direction endoscopists should be taking.” If, for example, PEG tube provides palliative decompression for outlet obstruction or allows transfer to nursing home, this may align with the principle of patient autonomy.  The editorial argues that if the potential goals of PEG placement can be met, this is the key factor.

Bottomline: Information on outcomes and potential futility should be discussed as part of the informed consent process.  But, I bet this will not make those decisions any easier.

Related blog entries:

PPIs -another reference for EoE

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“The outcome of patients with oesophageal eosinophilic infiltration after an eight-week trial of a proton pump inhibitor”

  1. G. Vazquez-Elizondo1,
  2. S. Ngamruengphong1,
  3. M. Khrisna2,
  4. K. R. DeVault1,
  5. N. J. Talley1,
  6. S. R. Achem1,*

Article first published online: 5 OCT 2013

DOI: 10.1111/apt.12513

Link to article: bit.ly/18bA3SS (from John Pohl’s twitter feed)

Methods: Sixty consecutive symptomatic patients with documented oesophageal eosinophilia received open-label omeprazole 20 mg orally twice daily before meals for 8 weeks.  Mean age 48.7 years (18-79).

Results: Clinical improvement occurred in 43 (71.6%), endoscopic signs were reduced in 34 (61.8%) and normalised in 12 (21.8%), and histologically, 34 (56.6%) improved, while 15 (25%) obtained complete resolution. Overall, 22 patients (36.7%) obtained both complete clinical and histological remission

Additional related blog entries:

Top Cited 100

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In a recent commentary, the authors provide a list of the most commonly cited digestive disease articles from 1967-2007.  (Gastroenterol 2013; 144: 673-76)

The top three:

  1. Manns, M, et al. Lancet 2001; 358: 958-65. This study compared peginterferon alfa-2b with ribavirin against interferon with ribavirin for hepatitis C
  2. Fried M, et al. NEJM 2002; 347: 975-82. This study examined the use of peginterferon alfa-2a with ribavirin for hepatitis C
  3. Marshall B, Warren J. Lancet 1984; 1: 1311-15.  This study identified a bacteria (now called Helicobacter pylori) as a cause of ulcers and gastritis.

http://dx.doi.org/10.1053/j.gastro.2013.02.013