Kashyap V Panganamamula | PubMed Health

PubMed2005

Chronic Intestinal Pseudo-Obstruction.

Chronic intestinal pseudo-obstruction (CIP) is a gastrointestinal motility disorder characterized by chronic symptoms and signs of bowel obstruction in the absence of a fixed, lumen-occluding lesion. Radiographic findings consist of dilated bowel with air-fluid levels. Pseudo-obstruction is an uncommon condition and can result from primary or secondary causes. The management is primarily focused on symptom control and nutritional support to prevent weight loss and malnutrition. The principles of management of patients with CIP involve 1) establishing a correct clinical diagnosis and excluding mechanical obstruction; 2) differentiating between idiopathic and secondary forms; 3) performing a symptomatic and physiologic assessment of the parts of the gastrointestinal (GI) tract involved by manometric and whole gut transit scintigraphic studies; 4) careful assessment of nutritional status of the patient; and 5) developing a therapeutic plan addressing the patient's symptoms and nutritional status. Treatment of CIP includes frequent small meals with a low-fat, low-fiber diet, liquid nutritional supplements may be needed; prokinetic agents such as metoclopramide may help to reduce upper GI symptoms. Trials of drugs such as erythromycin, domperidone, cisapride, and tegaserod may be considered if there is no response. Subcutaneous octreotide may be helpful to improve small bowel dysmotility especially in patients with scleroderma. In patients with symptoms suggestive of bacterial overgrowth, courses of antibiotics such as metronidazole, ciprofloxacin, and doxycycline may be needed. Nutritional assessment and support is an important aspect of management. Enteral nutrition is usually preferred. In carefully selected patients, feeding jejunostomy with or without decompression gastrostomy may be tried. Long term parenteral nutrition should be reserved for patients who can not tolerate enteral nutrition. Complications associated with total parenteral nutrition include infections, sepsis, and cholestatic hepatic dysfunction.

Journal Article↗

PubMed2003

Risk of esophageal variceal bleeding based on endoscopic ultrasound evaluation of the sum of esophageal variceal cross-sectional surface area.

OBJECTIVE: The aim of this study was to evaluate the risk of future variceal bleeding, based on the endoscopic ultrasound measurement of the sum of the cross-sectional surface area (CSA) of all of the esophageal varices in the distal esophagus. METHODS: Twenty-eight patients with portal hypertension and esophageal varices, but no prior history of variceal bleeding, were evaluated using endoscopic ultrasound (20-MHz ultrasound probe, Microvasive, Boston, MA; Olympus, Tokyo, Japan). The entire esophagus was imaged, and an image was selected at a point where the varices appeared the largest. This image was digitized, and the sum of the CSA of all of the varices was measured (Image Pro Plus, Silver Springs, MD) by an investigator blinded to the patients' clinical status. The follow-up time for each patient was calculated (time to first bleed, time to liver transplantation, time to death, or time to the end of study). The Cox Proportional Hazards Model was used to determine if there was a significant difference between the sums of the CSA in the patients who bled compared with those who did not bleed. An OR was calculated to determine the risk of future variceal bleeding based on the sum of the CSA as measured in cm(2)/month. Positive and negative predictive values were calculated for future variceal bleeding. RESULTS: Six of 28 patients (21%) experienced esophageal variceal bleeding on follow-up. The mean CSA +/- SEM of the sum of the esophageal varices in these patients was 0.77 cm(2) +/- 0.31 cm(2) (range 0.07-2.09 cm(2)). The mean time to bleeding was 15.5 months +/- 4.95 months (range 1-29 months). Twenty-two of 28 patients (79%) did not experience variceal bleeding. The mean CSA +/- SEM of the sum of the varices in these patients was 0.36 cm(2) +/- 0.08 cm(2) (range 0.02-1.19 cm(2)). The mean time to follow-up was 35.7 months +/- 6.69 months (range 1.2-103.2 months). The sum of the CSA between the patients who bleed and those who did not bleed was significantly different at the p < 0.018 level. The OR for the risk of variceal bleeding for each one cm(2) difference in the sum of the CSA per month was 6.34. Using a cutoff of 0.45 cm(2), the sensitivity and specificity for future variceal bleeding was 83% and 75%, respectively. CONCLUSIONS: There is a significant difference (p < 0.018) in the sum of the esophageal variceal CSA between those patients who will experience future variceal bleeding and those who will not. There is a 76-fold increase per year in the risk of future variceal bleeding for each one cm(2) increase in variceal CSA. Using a cutoff value for the CSA of 0.45 cm(2), the sensitivity and specificity for future variceal bleeding above and below this point is 83% and 75%, respectively.

Adult↗