Detergent Pod Ingestions -Is an Endoscopy Needed?

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A recent study (A Singh et al. JPGN 2019; 68: 824-8) provides a descriptive retrospective review of a single center experience with detergent pods (a.k.a. laundry pods or dishwater pods). There is very little published in this area and no clear consensus on management.

For me, the most interesting finding in the study is the discrepancy between the ENT service which only did a direct laryngoscopy-bronchoscopy (DLB) in 6 of 23 (26%) ingestions compared with 21 of 23 (91%) EGD rate among patients who presented to the GI service.

Key findings:

  • Of those undergoing an EGD, 76% were normal; abnormal findings (edema, erythema or ulceration) were present in 24% (though figure 4 suggests erythema in 28%). Ulceration was noted in 14%.
  • In the DLB cohort (n=6), 33% were normal and 67% were abnormal.

Unfortunately, this report has a lot of limitations:

  • It did not provide any information regarding long-term effects (if any were present)
  • It did not provide much guidance in determining whether an EGD is worthwhile. The authors did note that patients with oral injuries were more likely to have an abnormal EGD. 80% of patients with positive oropharyngeal findings had an abnormal EGD compared with 20% with a normal oropharyngeal exam.
  • In the discussion, the authors reference a study which reported esophageal injury in only 0.1% of cases (Davis et al.  2016 May;137(5). pii: e20154529. doi: 10.1542/peds.2015-4529. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014). There were two deaths in this study.

My take: This would have been a good report to have an associated commentary/expert opinion.  Even if an EGD is abnormal, this does not mean that the EGD was needed.  The bigger question is how often an EGD would improve management.  Given the lack of specific treatments, it is likely that an EGD should be reserved for severe cases –which could include the following:

  • intentional ingestions
  • significant oropharyngeal burns
  • food refusal
  • drooling/difficulty managing secretions
  • stridor

Related blog post: New caustic danger from detergent pods

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Detergent Pods -Still an Issue -This Tweet is from June 5, 2019

It Can’t Hurt Right? Complimentary and Alternative Medicine and Gluten-Related Disorders

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A recent study (G Boyer et al. Am J Gastroenterol 2019; 114: 786-91) examined the promotion of testing and treatment of gluten-related disorders among complementary and alternative medicine (CAM) practitioners. Thanks to Ben Gold for this reference.

Background: CAM expenditures in 2016 by Americans was $30.2 billion in 2016. “Studies have found that it is not uncommon for CAM clinics to make wide-reaching claims as to their abilities to diagnose a plethora of conditions.”  In the present study, the authors reviewed the advertising content of 500 CAM clinic websites with regard to gluten-related disorders..

Key points:

  • The authors further identified 232 claims from 114 clinic websites; 138 (59.5%) were judged as unproven or false.
  • “Some clinics advertised treatments that pose potential harm;” this includes the sale of digestive enzymes promoted to digest gluten and which purport to allow the person with celiac or nonceliac gluten sensitivity (NCGS) to ingest gluten safely.  “This is a baseless claim that could lead to serious harm.”
  • “Other clinics falsely claimed that everyone should be on a gluten-free diet regardless of a diagnosis of celiac disease or NCGS.”

My take: Given the popularity of CAM along with the frequency of misleading claims, this suggests the need for increased regulation.  These websites are likely to increase confusion about the diagnosis and management of gluten-related disorders (which can  be confusing without any help!)

Related blog posts:

Comparing Gastric Bypass Outcomes in Adolescents and Adults

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Studies have shown that adults with obesity who were obese as adolescents have worse medical outcomes than persons who became obese in adulthood (Nat Rev Endocrinol 2018; 14: 183-8; NEJM 2011; 365; 1876-85). Thus, the question is whether earlier intervention would improve outcomes.

A recent study (TH Inge et al. NEJM 2019; 380: 2136-45, editorial TD Adams, pgs 2175-7) compares the 5-year outcomes of adolescents (n=161) and adults (n=396) who underwent Roux-en-Y gastric bypass (RYGB). The two prospectively enrolled cohorts were participants in two related but independent studies.

Key findings:

  • There was similar weight loss in both groups at the 5-year mark: -26% in adolescents and -29% in adults
  • Adolescents had greater remission in both type 2 diabetes (86% vs 53%) and in hypertension (68% and 41%).
  • Three adolescents (1.9%) and seven adults (1.8%) died in the 5-years after surgery.  Two of the adolescents deaths were consistent with overdose.
  • Reoperations were significantly higher in adolescents than adults (19 vs 10 reoperations per 500 person years). The authors comment that the reason for this finding is unclear, possibly related to recall bias or closer monitoring of the adolescents.
  • Nutrient deficiencies were common in adolescents at followup. After 2 years, 48% of adolescents had low ferritin compared with 29% of adults (98% of participants had normal ferritin prior to RYGB. The authors note that  this is likely related to adherence to vitamin/mineral supplementation (which is needed lifelong).

Limitations: observational study design

The associated commentary::

  • “Almost 6% of adolescents in the U.S. are severely obese and  bariatric surgery is now the only successful long-term management…Negative health outcomes of bariatric surgery reported in adolescents mirror those reported in adults — including, for example, potential for self-harm (including suicide) and increased risk of alcohol or drug abuse.”
  • “Adolescent patients may not have fully developed the capacity for decision making, especially about a procedure that will have lifetime consequences.”

My take: This study and commentary point out some clear health benefits for adolescents who undergo RYGB. Given the lifelong need for monitoring and adherence with medical treatment as well as some of the negative health outcomes, it is also clear how challenging it is to proceed with RYGB in teenage years.

Related blog posts:

Square in Toledo, Spain

 

William Meyers

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Yesterday I attended the Inaugural William Meyers Lecture and intended for this post to be a summary of that.  Sadly, he passed away last night.

Billy, a partner in our GI group, had been fighting brain cancer for the past year. This lecture was established to honor him. Jose Garza gave a lecture which highlighted the important work of the neurogastroenterology service, established in large measure by Billy.

Also, Billy served on numerous hospital committees.  Much of his efforts were ‘behind the scenes’ and usually the type of work that many of us seek to avoid.  In addition to working on these hospital committees, Billy remained a busy clinician.  In the past year, I’ve had the opportunity to interact with many of his patients and families.  Uniformly I have heard how compassionate and patient he was, even with the most complex situations.  In the 22 years that I had the opportunity to work with Billy, I cannot seem to recall him ever being flustered.  He was a truly wonderful person, physician, and mentor..   I will miss his kindness and friendship.

 

 

 

Briefly noted: Can We Afford (Multi) Million Dollar New Therapies?

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New Gene Therapy: NPR: Zolgensma From Novartis -Most Expensive Medication Ever Approved

An excerpt:

The federal Food and Drug Administration has approved a gene therapy for a rare childhood disorder that is now the most expensive drug on the market. It costs $2.125 million per patient….

Zolgensma’s price tag, he says, is just the most extreme example of how drug prices are draining resources from society. The first gene therapy for an inherited disease was approved in 2017 for a genetic form of blindness. It is also very expensive — $425,000 for each eye.

 

What’s Going On in Patients with Reflux Who Fail Proton Pump Inhibitors

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A recent prospective study (J Abdallah et al. Clin Gastroenterol Hepatol 2019; 17: 1073-80) examined adults patients with documented reflux at baseline.  Patients who reported heartburn and/or regurgitation at least twice a week for 3 months (n=16) despite proton pump inhibitor (PPI) therapy were considered PPI failures. Those (n=13) who responded to standard dose PPI for at least 4 weeks were in the “PPI success” group.

Standard PPI dosing in this study:

  • Omeprazole 20 mg per day
  • Esomeprazole 40 mg per day
  • Pantoprazole 40 mg per day

Methods: Both groups (PPI Failure group, PPI Success group) underwent EGD and pH-MII studies. Abnormal acid exposure was considered if pH <4 was present for >4.2%.

Key findings:

  • 12 patients (75%) in the PPI failure group had either functional heartburn or reflux hypersensitivity
  • 4 patients in both groups had abnormal pH test result.
  • There was no statistically significant differences in the number of reflux events, acid exposure or nonacid reflux parameters between patients who failed or those who were successfully treated with PPIs.
  • In the PPI failure group: 25% had persistent GERD, 12.% had overlap with reflux hypersensitivity, and 62.5% had overlap with functional heartburn

My take: The difference between PPI failure and PPI success largely is due to the overlapping presence of functional esophageal disorders.

Related blog posts:

Royal Palace, Madrid

NAFLD Outcomes After Bariatric Surgery

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A recent systematic review and meta-analysis (Y Lee, et al. Clin Gastroenterol Hepatol 2019; 17: 1040-60) included 32 cohort studies with 3093 liver biopsy specimens from patients with nonalcoholic fatty liver disease (NAFLD).

Key findings:

  • Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66%, inflammation in 50%, ballooning degeneration in 76%, and fibrosis in 40%.
  • Bariatric surgery resulted in worsening features of NAFLD in 12%.
  • The authors note that Roux-en-Y Gastric Bypass (RYGB) “showed greater reduction of liver side effects and higher: resolution of NAFLD.”
  • Jejejnoileal bypass (JIB) and biliopancreatic diversion (BPD) “both have been associated with higher liver function morbidity.”
  • The overall GRADE quality of evidence was considered very low.

My take: Though better studies are needed, the majority of patients’ livers appear to benefit from bariatric surgery.

Related blog posts:

Liver Briefs -June 2019 part 2

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E Cowell et al. JPGN 2019; 68: 695-99. This study reviewed 61 cases of pediatric hepatocellular carcinoma to determine predisposing conditions  (in Houston TX).  The majority did NOT have recognizable predisposing conditions.  25 of 61 (41%) had a predisposing condition including cryptogenic cirrhosis/steatosis (9), genetic (7), biliary pathology (4), viral hepatitis (1), and other (4).  Those without a recognizable predisposing condition were diagnosed later and with more advanced disease/decreased survival.

VA McLin et al. JPGN 2019; 68: 615-22. Useful review on congenital portosystemic shunts.

DE Kaplan et al. Gastroenterol 2019; 156: 1693-1706. This large study form the VA with more than 70,000 patients examined the relationship between statin exposure and survival in patients with cirrhosis.  “Each cumulative year of statin exposure was associated with an independent 8-8.7% decrease of mortality of patients with cirrhosis of Child-Turcotte-Pugh classes A and B.”

AG Singal et al. Gastroenterol 2019; 156: 1683-1692. Direct-acting antiviral therapy was not associated with recurrent hepatocellular carcinoma (HCC) in a multicenter cohort study with 793 patients with HCV-associated HCC. Thus, DAAs appear safe in patients who have achieved a complete response to HCC Rx

Liver Briefs -June 2019

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YH Yeo et al. Hepatology 2019; 69: 1385-97.  The prevalence of high risk individuals in the U.S. who are susceptible (not immune) to hepatitis B has decreased from 83% to 69% from 2003 to 2014.  That still leaves 64 million who would benefit from HBV vaccination.

M Sharma et al. Hepatology 2019; 69: 1657-75. This meta-analysis compared therapies for primary prevention of esophageal varices and concluded that nonselective beta-blocker (NSBB) monotherapy may decrease all-cause mortality and carried a lower risk of serious complications than variceal band ligation (VBL). However, the commentary (1382-84 by L Laine) reaches a different conclusion. “Current recommendations for primary prevention with VBL or NSBB or carvediolo still appear to be acceptable…using a shared decision-making approach” to weigh issue such as daily medication or periodic endoscopy.

J Nguyen et al. J Pediatr 2019; 207: 90-6. This study modeled the cost-effectiveness of early treatment with direct-acting antiviral therapy in adolescents with hepatitis C infection.  With pangenotypic agenst, the cost would be $10000 to $21000 per QALY gained.

S Trinh et al. Clin Gastroenterol Hepatol 2019; 17: 948-56. This retrospective hepatitis B study examined the changes in renal function between 239 tenofovir disoproxil fumarte (TDF) treated patients and 171 entecavir treated patients.  Key finding: TDF was not associated with higher risk of worsening renal function in this cohort with a mean followup of 43-46 months in patients with baseline normal renal function.  In patients with renal impairment, deterioration of renal function was noted in TDF-treated patients.  Thus, TDF should be avoided in patients with impaired renal function.

 

Rhododendrom in Sandy Springs

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