Understanding Idiopathic Nausea

Posted on by

A recent article describes a retrospective chart review of 45 children with chronic nausea and compares them to 49 children with chronic abdominal pain (J Pediatr 2014; 164: 1104-09).

Key findings:

  • While onset of symptoms was similar, the chronic nausea cohort presented at a median age of 15 years compared with 12 years for the pain cohort.
  • Comorbid conditions like anxiety, dizziness and fatigue were common in chronic nausea cohort.
  • Family history of migraines was note in 71% of nausea cohort compared with 22% in pain cohort
  • Extensive laboratory and imaging was much more frequent in nausea cohort.  With nausea cohort, 78% had abdominal ultrasound, 60% an upper GI, 58% brain imaging with either a CT scan or MRI, 38% gastric emptying, 31% abdominal CT or MRI, and 24% had HIDA.
  • Almost all endoscopies were normal (98% of chronic nausea group and 100% of pain cohort)
  • For nausea cohort treatment, tricyclic antidepressants showed a good response (=at least 50% symptom improvement) in 44% with a mean maximal dose of 50 mg. In contrast, with proton pump inhibitors, only 22% had some improvement (=at least 25% symptom improvement).  Similarly, ondansetron showed some improvement in 50% –though none had a “good response.”
  • Twelve patients (27%) of the nausea cohort met diagnostic criteria for cyclic vomiting syndrome (CVS) (with interepisode nausea) and another nine (20%) developed chronic nausea after ‘outgrowing’ CVS.
  • Postural (orthostatic) tachycardia syndrome (POTS) was noted in 16 of 45 in the nausea cohort based on an orthostatic screen (heart rate ≥30 beats/min during positional changes from 10 minutes in supine position to standing.

As the authors note, their study, conducted between 2006-2012, had numerous limitations, particularly the relative small size and retrospective nature.  In addition, the physician expertise in nausea/vomiting at Children’s Hospital of Wisconsin predisposes to a selection bias.

Take-home message: Nausea can be a severe symptom but is often difficult to manage. Extensive workup has a low yield in absence of other complaints or physical exam findings.

An AGA technical review on nausea and vomiting was published in 2001: GASTROENTEROLOGY 2001;120:263–286 

Related blog posts:

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.

 

Why I’m Not a Fan of the “1-Step” PEG

Posted on by

A recent article describes a single-center retrospective review of the 1-Step Low-Profile percutaneous gastrostomy (PEG) tube (“EndoVive” from Boston Scientific) (JPGN 2014; 58: 616-20).  The potential rationale for the 1-Step PEG tubes:

  • 1-time procedure for a low-profile device

My personal experience with these devices is quite limited.  However, I did have one patient who resumed walking after placement of a 1-step dome device gastrostomy tube. He had stopped walking several months before, mainly due to some mild neurological problems.  After receiving this PEG tube, he said he was in so much pain when he was sitting down that he started walking again.  He was able to continue walking after switching to a different gastrostomy tube.  This particular ‘miracle’ explains one of the pitfalls of this device.  This patient had an embedded bolster.

In the current series, the authors’ conclusion was that the 1-step PEG “has complication rates and outcomes comparable with standard PEGs.”  However, their reported results suggest a higher rate of complications: embedded bolster occurred in 5%, cellulitis in 23% (6.6% needing IV antibiotics), and perforation occurred in 0.8%.

Given the relatively small number of patients (n=121 who met inclusion) and retrospective nature of the study, whether these complication rates are significantly higher is a matter of debate.  It should be noted that there may have been some selection bias given that there were only 31 patients less than one year in the study.

With regard to embedded PEG tubes, the authors note that this complication rate typically is 2.3% with a traditional PEG.  The authors minimize the discrepancy of their higher rate, noting the “importance of choosing the right size of the 1-step PEG.”  For those who perform this procedure, this admonition sounds easy but in practice can be problematic.  In addition, the main advantage of this procedure is the “1-step” procedure.  Yet  in Figure 2, the authors note that 67 (more than 50%) underwent a change to a balloon device.

Bottomline: The authors state that the 1-step PEG, “in our opinion, is a preferable PEG technique for children who need long-term enteral feeds.”  My opinion: I’m not a fan and think the 1-step, for initial placement, is less safe overall.

Related blog entries:

The Future is Now (for Hepatitis C)

Posted on by

Three more impressive hepatitis C (HCV) studies have been published (in print):

  1. NEJM 2014; 370: 1973-82
  2. NEJM 2014; 370: 1983-92
  3. NEJM 2014; 370: 1993-2001

In the commentary on these three studies (pages 2043-47), the authors note that only a year ago, they had “speculated that highly effective interferon-free regimens would be available and should revolutionize the treatment of HCV infection…Now, we would have to say that the future is here.”

In the first study, “TURQUOISE-II,” 380 patients with Child-Pugh class A cirrhosis received either 12 weeks or 24 weeks of ritonavir (ABT-450/r), ombitasvir (ABT-267), dasabuvir (ABT-333) and ribavirin.  In the 12 week group, the sustained virologic response (SVR) was 91.8% whereas the 24 week group had an SVR of 95.9%.

In the second study, “PEARL-III and PEARL-IV,” 419 patients with genotype Ib and 305 patients with genotype 1a received 12 weeks of ritonavir, ombitasvir, dasavuvir, and ribavirin (or placebo) for 12 weeks.  For genotype 1b, SVR were 99.5% with ribavirin and 99% without ribavirin.  For genotype 1a, SVR were 97% and 90.2% respectively.

In the third study, “VALENCE,” among 419 patients with genotype 2 or 3 (21% with cirrhosis, and 58% previous interferon-based treatment), patients were treated with sofusbuvir-ribavirin or placebo for 12 weeks; the genotype 3 patients treatment was extended to 24 weeks (unblinded) after data emerged indicating a need for longer treatment course.  For the genotype 2 patients, SVR was met in 93%.  For genotype 3 patients, 85% who received a 24 week course had an SVR.

Key Points (from editorial):

  • In the first two studies, SVR was approximately 96% in untreated and treated patients without cirrhosis.
  • Patients with cirrhosis had a response rate of approximately 90%.
  • Ethnicity, IL28B, and baseline HCV RNA were not important factors in predicting response.
  • “In the era of potent DAA (direct-acting antivirals), …response-guided therapy is no longer necessary” because by week 4 of treatment, 99% of patients had non-quantifiable HCV RNA.
  • Drug resistance against these DAAs is common in preclinical studies; therefore, combination regimens are important.  “In the case of sofosbuvir and ledipasvir, a two-drug combination is sufficient…Sofosbuvir seems to have a high genetic barrier to resistance.”
  • “Perhaps the more important achievement of these interferon-free regimens is the lower rate and severity of side effects.”

Related (recent) blog posts:

Copy Forward: What Could Go Wrong?

Posted on by

From GI & Hepatology News: “Copy and paste at your own risk”

Here’s an excerpt:

In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue…

When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her “accompanied by spouse” at every visit.

Facts and Fiction with Lyme Disease and Picture of the Deadliest Animal

Posted on by

Since summer is around the corner, a recent article on Lyme disease may be of interest.  This clinical practice article on Lyme disease opens w/ case, reviews tx strategies & guidelines, ends w/ recommendations. Here’s a link to the article: 

Lyme disease is caused mainly by the spirochete Borrelia burgdorferi (and other related species outside of U.S.).  Pediatric gastroenterologists sometimes are asked to evaluate children with persistent symptoms attributed to Lyme disease.  This expert review makes a few key points:

  • Erythema migrans lesions often do not have central clearing; the majority are uniformly erythematous or have enhanced central erythema (pictures noted in Figure 1).  A useful differential diagnosis is noted in Table 2.
  • Antibody testing is not indicated routinely in patients with erythema migraines due to poor sensitivity in early infections.
  • Treatments are highly effective –mainly doxycycline, amoxicillin or cefuroxime
  • Prophylactic treatment with doxycycline can reduce risk of infection after tick bite, but usually not given.  “Even in areas where Lyme disease is highly endemic, the risk of disease transmission from a recognized bite is low (1 to 3%).”
  • “There is no evidence that patients treated for Lyme disease who have persistent, nonspecific symptoms (eg. arthralgia and fatigue) have persistent infection; the risks of prolonged treatment with antimicrobial agents far outweigh the benefit, if any.”
  • There is “extensive publicity as well as misinformation on the Internet about ‘chronic’ Lyme disease, a condition for which there is no clear definition or scientific evidence of its existence.”

My two cents: ‘an ounce of prevention is worth a pound of cure.’  If spending a lot of time outdoors, consider applying topical insecticides like DEET and/or wearing long sleeves/pants.

More important globally than Lyme disease is the deadliest animal in the world (from Bill Gates), http://b-gat.es/1kjGmpL :

Which animal kills the most people? Hint: It’s not sharks, lions, or even humans. Introducing Mosquito Week.

Buckyball Recall –It’s Official

Posted on by

From NASPGHAN twitter feed, 5/13/14: consumerfed.org/news/785

Consumer advocates and pediatric gastroenterologists applaud the Consumer Product Safety Commission’s announcement today that a settlement has been reached with Craig Zucker, the former CEO and President of the company that manufactured Buckyballs and Buckycubes, Maxfield and Oberton, which was dissolved in 2012.

High powered magnets, such as Buckyballs or Buckycubes, are bb-shaped smooth balls or cubes that connect to one another with a strong magnetic bond.  The magnets are individual balls or cubes that are sold in packages of many individual balls.  These products were originally sold as toys to children over 13 years of age, but after a recall in 2010, these products are sold to teens and adults age14 and older.  The new warning label that has appeared on the package of Buckyballs since the recall has not resulted in a decrease in serious injuries to children.  In November of 2011, CPSC issued a safety warning to consumers about this product but the injuries continue to occur.  In July of 2012, CPSC filed a law suit against the manufacturer of Buckyballs to issue a recall of these products. The settlement announced today is a resolution of that complaint…

Consumers will have six months to participate in the recall by requesting a refund.  The recall trust will be funded by Craig Zucker and will be overseen by the CPSC.

Related blog posts:

Diarrhea -a Universal Experience

Posted on by

To be clear, by the term “universal” I am in no way referring to a theme park.  A recent review in the NEJM (N Engl J Med 2014; 370:1532-1540) discusses acute diarrhea, http://nej.md/1l2bAIn .

“In the United States, there are approximately 179 million cases of acute diarrhea per year. This update on the diagnosis and management of acute diarrhea in immunocompetent adults gives particular attention to the roles of noroviruses and Clostridium difficile.”

This post is mainly to provide an up-to-date useful reference.

The Bigger Picture -Mammography as an Example

Posted on by

This week, a commentary makes a strong case for eliminating mammography (N Engl J Med 2014; 370:1965-1967):  “Abolishing Mammography Screening Programs? A View from the Swiss Medical Board”

Here’s a link from the NEJM: nej.md/1hV8q0L

What is fascinating is how ingrained mammography has become in our medical culture and how most individuals believe that mammography is so beneficial.  Take a look at the figure in the link to get a better perspective.  While women think that mammography may save 80 lives out of a thousand screened, according to the commentary, the data suggest that 1 woman may be saved.  The main problem: “for every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.”

If a well-established screening measure like mammography is not so beneficial, what else could be on the chopping block?  As noted in a previous blog post (Do you know about the “Choosing Wisely … – gutsandgrowth), even the annual physical exam has been deemed a low-value service.

Another related blog post:

“There is More to Life Than Death” | gutsandgrowth

 

The Latest on EoE and PPI-REE

Posted on by

A recent study shows similar clinical, endoscopic and histologic findings between eosinophilic esophagitis (EoE) and proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE) (Aliment Pharmacol There 2014; 39: 603-08 -thanks to Seth Marcus for this reference).

The authors used two databases: one from Walter Reed and one from the Swiss EoE database.  All of these patients were >/=18 years.  Response to PPI was defined as achieving less than 15 eos/hpf and a 50% decrease from baseline following at least 6-weeks of PPI treatment.

Demographics: 63 EoE patients, 40 PPI-REE, mean age 40 years (75% male, 89% Caucasian).

Findings:

  • Similar dysphagia 97% vs. 100% (in EoE and  of PPI-REE cohorts)
  • Similar food impaction 43% vs. 35% (in EoE and  of PPI-REE cohorts)
  • Similar heartburn 33% vs. 32% (in EoE and  of PPI-REE cohorts)
  • Similar duration of symptoms: 6.0 years vs 5.8 years (in EoE and  of PPI-REE cohorts)
  • Similar endoscopic findings too: rings 68% in both groups, furrows 70% in both groups, strictures 49% vs 30% (in EoE and  of PPI-REE cohorts)
  • Similar histology: proximal esophagus 39 vs 38 eos/hpf and distal esophagus 50 vs 43 eos/hpf

Take-home message: EoE and PPI-REE are very similar in presentation and indistinguishable without a PPI trial.

Related blog posts:

 

 

SEED Journal Club: FPIES

Posted on by

The main topic at this month’s SEED (SouthEast Eosinophilic Disease) Center Journal club was Food Protein-Induced Enterocolitis Syndrome (FPIES) with two featured articles:

  • J Allergy Clin Immunol In Practice 2013; 1: 317-22. Review
  • J Allergy Clin Immunol In Practice 2013; 1: 343-9. Original Study

The review covers the key issues including presentation, diagnosis, differential diagnosis, outcome and management. Some of the key points:

  • FPIES is characterized by repetitive emesis (often to the point of dehydration and lethargy) and sometimes diarrhea.  It typically starts within the first 3-6 months of life.
  • Trigger foods are most commonly milk, then soy, then grains (rice cereal). FPIES in exclusively breastfed babies is extremely rare.
  • FPIES is a non-IgE mediated reaction; thus testing with skin prick tests or serum for food-specific IgE has poor utility.
  • Differential diagnosis (Table E4): gastroenteritis/food poisoning, sepsis, anaphylaxis, inborn errors of metabolism, intussception, Hirschsprung’s, necrotizing enterocolitis, and proctocolitis
  • Variable time to resolution  (Table E6): Cow’s milk resolution up to 60% resolution by 10 months, though some studies report 60% resolution at 3 years.  Soy resolution as much as 90% by 10 months of age (less in other studies).  Solids -resolution in 67% by 3 years.
  • Management: Avoid trigger foods. If supplementing breastmilk, consider hydrolyzed (or amino acid based) formula.  Conduct food challenges in supervised medical setting (often inpatient).  Acute management: Consider intravenous fluids and methylprednisolone (1 gm/kg) during bouts

2nd Article: Retrospective chart review of 462 patients with FPIES from CHOP (Philadelphia).  Inclusion criteria: “classic reaction of prolonged vomiting and diarrhea that occurred 2-6 hours after ingestion of the food.”

Key findings:

  • Diarrhea occurred in about 50%.
  • Mean age of onset was 7 months for milk or soy compared with 12 months for grains
  • 43% of patients with milk-triggered FPIES react to soy as well
  • 42% of patients with a grain trigger react to two or more grains
  • More than 85% outgrew FPIES by 5 years of age.  35% outgrew their FPIES by age 2, 70% by age 3, and 80% by age 4.

Journal club discussion:

  • It was noted in the group discussion that FPIES in adults is most often triggered by shellfish/fish and eggs.
  • FPIES does not “run” in families. Though, atopic patients have increased risk. (As an aside: If you have diarrhea, it might be genetic –it might run in your jeans.)
  • The nomenclature of FPIES is problematic.  How come only ~50% have diarrhea if this is an “Enterocolitis” disorder?
  • Typically, trigger foods would not be reintroduced for a minimum of 12-18 months after last exposure/reaction.

Take home message: FPIES is a clinical diagnosis.  Be careful with oral challenges.

Related blog posts: