All Bleeding Stops (part 2)

Posted on July 21, 2016 by gutsandgrowth

Several years ago, this blog provided a summary of the guidelines for stopping upper gastrointestinal bleeding (All bleeding stops | gutsandgrowth). Most of the recommendations are unchanged. A nice review of this topic (L Laine. NEJM 2016; 374: 2367-76), specifically focused on peptic ulcers, provides a few new pointers.

Two areas with more data:

Transfusion. “A randomized trial showed lower rates of death (the primary outcome), rebleeding, and adverse events with a transfusion threshold of 7 g per deciliter than with a transfusion threshold of 9 g per deciliter.”
Proton pump inhibitors. “A recent meta-analysis showed that intermittent oral or intravenous proton-pump inhibitor therapy results in outcomes that were non inferior to those after continuous infusion.” (JAMA Intern Med 2014; 174: 1755-62) For adults, the suggested dosing was 80 mg followed by 40 to 80 mg twice daily for 72 hours.

As before, the author recommends preoperative (30 min prior) erythromycin (250 mg) and states that a nasogastric tube in not needed. The author also recommends that in patients with idiopathic ulcers (not due to NSAIDs or H pylori) that ongoing (indefinite) use of once-daily maintenance therapy with a proton-pump inhibitor is recommended to prevent rebleeding.

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An Overlooked Finding in a Recent Acute Severe Ulcerative Colitis Study

Posted on July 20, 2016 by gutsandgrowth

A recent study (S Choshen et al. JPGN 2016; 63: 58-64) examined 283 children who were treated with IV steroids for acute severe ulcerative colitis. This study focused on steroid dosing. Their conclusion: “there does not seem to be a consistent superiority of high dose (>2 mg/kg/day) versus standard (1.25 mg/kg/day) or low-dose (1 mg/kg/day) methylprednisolone in pediatric acute severe colitis.”

Before looking into the details a little closer, one finding that was not even discussed in the abstract or discussion was the colectomy rate of 31%. Previous pediatric studies of patients with ulcerative colitis had found rates generally half that rate but notably included patients with milder presentations of ulcerative colitis. Thus, this rate of 31% (by 1 year after discharge) is useful information to reference when considering pediatric patients with acute severe colitis (ACS).

This study used datasets from the prospective Outcome of Steroid therapy in Colitis Individuals (OSCI) (n=128) and from the retrospective OSCI study (n=99).

Other results:

By day 5 of steroids, 45% had at most mild disease (ie PUCAI <35)
31% had failed IV steroids and required salvage therapy (biologic or calcineurin inhibitor)
20% had colectomy by discharge
When examining steroid dosage and outcomes, the authors could not discern any differences in need for salvage therapy, PUCAI <35 at day 5, or need for salvage therapy within 1 year. There was a mild difference in length of stay with 9 days in the low-dose group and 10-days in the high dose group.

My take: This large cohort provides some reassurance that current steroid dosing recommendations are probably right, in that there was no discernible improvement with higher doses. This is in agreement with previous studies in adults which have not shown advantages of methylprednisolone >60 mg/day. The high colectomy rate of 31% is worth keeping in mind in this population.

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Do You Know When Hepatitis C Virus Transmission Peaked?

Posted on July 19, 2016 by gutsandgrowth

According to a recent study (AC Spaulding, LS Miller. Lancet Infect Dis. 2016 Mar 30. doi: 10.1016/S1473-3099[16 …), peak transmission of hepatitis C virus (HCV) peaked about 1950, likely due to reuse of metal and glass syringes.

This study counters the idea that HCV transmission was “primarily due to injection drug use, unsafe tattooing, high-risk sex, and travel to high endemic areas during youth,” according to the researchers. Here’s the link: Apportioning blame in the North American Hepatitis C virus epidemic

My take: Will this take away some of the stigma of HCV infection? Probably not. But, hopefully as the costs for treatment reduce, more individuals can be infection-free and avoid complications related to infections.

Expanding VEO Variants

Posted on July 18, 2016 by gutsandgrowth

A recent study (Q Li, CH Lee, LA Peters, et al. Gastroenterol 2016; 150: 1196-1207) provides a description of a new genetic variant causing very early onset inflammatory bowel disease (VEOIBD), which designates cases of IBD which presents <6 years of age.

Using whole exome sequencing, the authors identified TRIM22 mutations in 3 infants with fistulizing perianal disease and granulomatous colitis. The authors further characterized the defect using functional studies that showed TRIM22 is important in the regulation of nucleotide binding oligomerization domain containing 2 (NOD2)–dependednt activation of interferon-beta signaling and nuclear factor (NF)-κB.

“NOD2 has long been recognized as a critical player in Crohn’s disease pathogenesis, where it is proposed to regulate innate immunity through NF-κB induced proinflammatory responses triggered by peptidoglycan…Simarlarly, mutations in XIAP..are associate with loss of NOD-2-dependent mediated NF-κB signaling” and has a similar phenotype.

My take: Identification of the numerous mutations that lead to VEOIBD is likely to help understand the pathogenesis and ultimately to better therapies.

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How Much Lower Would The Braves Be Without the Marlins?

Addicts and Anti-Diarrhea Drugs

Posted on July 17, 2016 by gutsandgrowth

According to NY Times:

Addicts Who Can’t Find Painkillers Turn to Anti-Diarrhea Drugs

Here’s an excerpt:

The active ingredient, loperamide, offers a cheap high if it is consumed in extraordinary amounts. But in addition to being uncomfortably constipating, it can be toxic, even deadly, to the heart.

A report published online in Annals of Emergency Medicine recently described two deaths in New York after loperamide abuse. And overdoses have been linked to deaths or life-threatening irregular heartbeats in at least a dozen other cases in five states in the last 18 months.

Most physicians just recently realized loperamide could be abused, and few look for it. There is little if any national data on the problem, but many toxicologists and emergency department doctors suspect that it is more widespread than scattered reports suggest.

Meerkat, Atlanta Zoo 2016

Latest Obesity Data Discouraging

Posted on July 16, 2016 by gutsandgrowth

From LA Times (reporting on CDC study): In U.S., 38% of adults and 17% of kids are now obese

“How do government agencies, private foundations, industry groups and professional societies squander hundreds of millions of dollars? By trying to fight America’s obesity epidemic.

Two new studies show that the best efforts of all these players – as well as schools, churches and individual healthcare providers – have largely failed to keep most Americans from getting fatter.”

Outcome with POTS –Better than Expected?

Posted on July 15, 2016 by gutsandgrowth

Adolescents with postural orthostatic tachycardia syndrome (POTS) are often seen in pediatric GI offices due to the associated GI symptoms. A recent report (R Bhatia et al. J Pediatr 2016; 173: 149-53) offers up some encouraging data.

172 patients (of 502) responded to the authors’ survey. The mean duration since the time of diagnosis was 5.4 years. Key findings:

19% (n=33) reported complete resolution of their symptoms
51% reported improvement, but persistent, symptoms
28% reported intermittent symptoms
Thus, 86% reported that their POTS resolved, improved or was intermittent.

The authors note that some symptoms like dizziness and fatigue are common in patients without POTS and that “persistence of some symptoms can be part of a normal healthy life.”

My take: This study indicates that most adolescents with POTS are likely to have a good functional outcome.

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Bryce Nat’l Park

Vedolizumab for Primary Sclerosing Cholangitis (with IBD)?

Posted on July 14, 2016 by gutsandgrowth

“The monoclonal antibody vedolizumab may reduce biliary inflammation in patients with primary sclerosing cholangitis and comorbid inflammatory bowel disease, according to early, open-label study findings reported at the meeting sponsored by the European Association for the Study of the Liver” –according to GIHepNews: Biliary inflammation reduced by IBD drug

“Vedolizumab given to 27 patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) resulted in a 50% reduction or normalization of serum alkaline phosphatase levels in 17 cases (63%).”

This was an open-label, proof-of-concept study involving 27 patients aged 25-30 years with PSC and comorbid IBD.

My take: This is interesting but needs a lot more study.

Atlanta Zoo 2016

Slipping Rib Syndrome

Posted on July 13, 2016 by gutsandgrowth

The entity, of “Slipping Rib Syndrome,” which could be mistaken for a gastronomical error at The Boathouse, is also called Cyriax syndrome. A recent brief report (L Calvete et al. J Pediatric 2016; 172: 216) describes a typical case. This teenager had a 1-year history of “brief, episodic, sharp upper left abdominal pain, accompanied by a [subtle] chest wall deformity, which started after physical activity.”

Key points:

This disorder is most common in middle-aged females but can occur at any age
It can result from hyper mobility of the false ribs, allowing “the affected rib to sublet or ‘slip’ under the adjacent rib,..and cause pain
The disorder can be elicited with the ‘hooking’ maneuver. “In this test, the patient lies in the supine position, while the clinician hooks his or her fingers beneath the costal margins of the affected side, displacing them upward and anteriorly pulling gently. A positive test reproduces pain.”
Treatment: avoidance of displacement and mild analgesics

My take: I’ve only seen this condition once but think it is important to consider in patients presenting with intermittent abdominal pain.

Atlanta Zoo 2016

Solitary Hepatic Nodule and Alagille Syndrome

Posted on July 12, 2016 by gutsandgrowth

A retrospective study (A Alhammad et al. JPGN 2016; 62: 226-32) of 55 children from 1999-2014 examined the frequency of a solitary hepatic nodule adjacent to the right portal vein as a potential diagnostic finding for Alagille syndrome. Only 39 had appropriate imaging to examine.

Key findings:

In 12 (of 39) focal hepatic lesions were evident (11 were solitary).
The median diameter was 8.1 cm.
In those with pathology review, the cases were suggestive of a regenerative nodule.
In all but one case, the alpha-fetoprotein levels were normal.
10 of these lesions were adjacent to the right portal vein.

One other point from the discussion:

~21% of patients with Alagille require liver transplantation, primarily for unremitting cholestasis and pruritus

My take: Recognition of this entity will help avoid mistaking this lesion for hepatocellular carcinoma.

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