National trends and inpatient outcomes of inflammatory bowel disease patients with concomitant chronic liver disease

BACKGROUND

There is little information on the frequency of chronic liver disease among hospitalized patients with inflammatory bowel disease (IBD). In this study, we seek to define the common etiologies contributing to chronic liver disease among IBD patients and to identify potential risk factors predictive of increased mortality in this population.

METHODS

We analyzed the Nationwide Inpatient Sample from 1988 to 2006 to determine the frequency of chronic liver disease among patients with IBD and to determine their in-hospital outcomes.

RESULTS

From 1988 to 2006, the age-adjusted rate of chronic liver disease among hospitalized patients with IBD has increased from 4.35 per 100,000 persons in 1988-2001 to 7.45 per 100,000 persons in 2004-2006. The most common etiologies contributing to chronic liver disease among IBD patients were: primary sclerosing cholangitis, unspecified chronic hepatitis, chronic hepatitis C, and nonalcoholic fatty liver disease. Compared to IBD patients without liver disease, there was more than a twofold higher rate of inpatient morality among IBD patients with concomitant liver disease (2.7% vs. 1.3%, p < 0.01). The multivariate analysis showed that factors predictive of inpatient mortality include age >50, spontaneous bacterial peritonitis, ascites, hepatic encephalopathy, presence of cirrhosis, malnutrition, Clostridium difficile colitis, and hospital-acquired pneumonia.

CONCLUSION

There is a higher rate of inpatient mortality among patients with concomitant IBD and chronic liver disease compared to IBD alone. Early recognition and management of complications related to portal hypertension among patients with IBD and chronic liver disease is particularly important in order to reduce inpatient mortality and morbidity.

Weekday vs weekend endoscopy: Is there a true difference in patient outcomes? A meta-analysis

AIM: To evaluate the “weekend effect” on outcomes in patient admitted on the weekend for upper gastrointestinal bleeding (UGIB).

METHODS: A comprehensive search was performed (March 2014). Studies comparing weekend and weekday endoscopy in patients with UGIB were included. All studies had at least 2 of 3 primary outcomes which included: mortality, need for surgery, time to endoscopy, endoscopy on admission day, and length of hospital stay. Three authors individually extracted data. Meta-analysis was performed using pooled estimates with odds ratio or mean difference by fixed and random effects models.

RESULTS: Eleven studies met the inclusion criteria. Patients admitted with UGIB on the weekend exhibited a statistically significant increase in mortality (OR = 1.13; 95%CI: 1.06-1.20; P < 0.01), need for surgery (OR = 2.46; 95%CI: 1.51-3.99; P < 0.01), and time to endoscopy (MD 2.68; 95%CI: 0.17-5.20; P = 0.04) as compared to patients admitted with UGIB on a weekday. Furthermore, patients with UGIB admitted on weekend experienced statistically significant less endoscopy on day of admission (OR = 0.72; 95%CI: 0.62-0.85; P < 0.01). No difference was noted between the two groups for length of hospital stay (MD -1.29; 95%CI: -3.03-0.45; P = 0.15).

CONCLUSION: A weekend effect seems to be apparent in patients with UGIB with significantly poorer outcomes.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy.

METHODS: MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency.

RESULTS: Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%.

CONCLUSION: Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

National Trends and In-Hospital Outcomes of Adult Patients With Inflammatory Bowel Disease Receiving Parenteral Nutrition Support

BACKGROUND

Patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are susceptible to protein-calorie malnutrition secondary to decreased oral intake, malabsorption, and increased metabolic expenditure. In this study, we seek to assess the national frequencies of parenteral nutrition (PN) use among hospitalized patients with IBD and to determine their in-hospital outcomes.

METHODS

We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the frequency of PN usage among patients with UC or CD and to determine their in-hospital outcomes. A multivariate analysis was performed to identify factors predictive of increased inpatient mortality in this population.

RESULTS

From 1988-2006, the annual incidence of PN use among hospitalized patients with CD was 4.29 per 100,000 and among those with UC was 3.80 per 100,000, with trends being relatively stable through the indexed period. The mean length of hospitalization among patients with UC receiving PN was longer compared with patients with CD. Factors predictive of an increased risk for mortality include the following: age >50 years, acute kidney injury, hospital-acquired pneumonia, Clostridium difficile colitis, prolonged postoperative ileus requiring PN use, pulmonary embolism, malnutrition, and patients with UC relative to CD.

CONCLUSION

Traditionally, patients with CD are at a higher risk for developing malnutrition than patients with UC; however, there is a 2-fold higher risk for inpatient mortality and a longer length of hospitalization among patients with UC compared with those with CD. This pattern suggests that the use of PN, particularly among patients with UC, serves as a surrogate marker of higher disease acuity and severity.

Improving Maintenance Medication Adherence in Adult Inflammatory Bowel Disease Patients: A Pilot Study

Medication nonadherence in inflammatory bowel disease (IBD) may lead to suboptimal control of the disease, decreased quality of life, and poor outcomes. This pilot study evaluated the feasibility, intervention mechanism, and potential effectiveness of a three-month continuous self-improvement (CSI) intervention to enhance medication adherence (MA) in adult nonadherent IBD patients. Adult IBD patients taking a daily or twice-daily dosed maintenance medication were screened electronically for two months to determine baseline MA levels. Nonadherent IBD participants were randomized to the CSI or the attention control (AC) intervention and monitored for three months. The CSI intervention consisted of a data evaluation and system refinement process in which system changes were identified and implemented. The AC group was given educational information regarding IBD disease process, extra-intestinal manifestations of IBD, and medical therapy. Demographic statistics, change scores for within and between-group differences, and effect size estimates were calculated. Nine nonadherent participants (medication adherence score <0.85) were eligible for randomization. The intervention was found feasible and acceptable. Although no statistically significant improvement in MA was found (P=0.14), adherence improved in 3 of 4 of the CSI group and 1 of 2 in the attention control group. The effect size calculation of 1.9 will determine the sample size for future study. The results of this pilot study showed the intervention was feasible and had a positive effect on MA change score and adherence levels. A larger fully powered study is needed to test of the effectiveness of this innovative intervention.

Bilateral and unilateral stenting for malignant hilar obstruction: a systematic review and meta-analysis

BACKGROUND

Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction.

STUDY SELECTION CRITERIA

Studies using stents for palliation in patients with malignant hilar obstruction were selected.

DATA COLLECTION AND EXTRACTION

Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement.

STATISTICAL METHODS

Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables 1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.

Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: a systematic review and meta analysis

AIM

To detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs.

METHODS

Only EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model).

RESULTS

Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION

EUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.

Ascorbic acid and low-volume polyethylene glycol for bowel preparation prior to colonoscopy: A meta-analysis

AIM: To evaluate the benefits of low-volume polyethylene glycol (PEG) with ascorbic acid compared to full-dose PEG for colonoscopy preparation.

METHODS: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, CINAHL, PubMed, and recent abstracts from major conferences were searched (January 2012). Only randomized-controlled trials on adult subjects comparing low-volume PEG (2 L) with ascorbic acid vs full-dose PEG (3 or 4 L) were included. Meta-analysis for the efficacy of low-volume PEG with ascorbic acid and full-dose PEG were analyzed by calculating pooled estimates of number of satisfactory bowel preparations as well as adverse patient events (abdominal pain, nausea, vomiting). Separate analyses were performed for each main outcome by using OR with fixed and random effects models. Heterogeneity was assessed by calculating the I² measure of inconsistency. RevMan 5.1 was utilized for statistical analysis.

RESULTS: The initial search identified 242 articles and trials. Nine studies (n = 2911) met the inclusion criteria and were analyzed for this meta-analysis with mean age range from 53.0 to 59.6 years. All studies were randomized controlled trials on adult patients comparing large-volume PEG solutions (3 or 4 L) with low-volume PEG solutions and ascorbic acid. No statistically significant difference was noted between low-volume PEG with ascorbic acid and full-dose PEG for number of satisfactory bowel preparations (OR 1.07, 95%CI: 0.86-1.33, P = 0.56). No statistically significant difference was noted between low-volume PEG with ascorbic acid and full-dose PEG for abdominal pain (OR 1.09, 95%CI: 0.81-1.48, P = 0.56), nausea (OR 0.70, 95%CI: 0.49-1.00, P = 0.05), or vomiting (OR 0.99, 95%CI: 0.78-1.26, P = 0.95). No publication bias was noted.

CONCLUSION: Low-volume PEG with the addition of ascorbic acid demonstrates no statistically significant difference to full-dose PEG for satisfactory bowel preparation and side-effects.

Bowel preparation prior to colonoscopy: a continual search for excellence

Bowel preparation prior to colonoscopy is essential to maximize the benefits of colonoscopy. Numerous bowel preparations have been studied, ranging from 4 L polyethylene glycol (PEG) to split-dose regimens to 2 L PEG with an adjunct laxative (senna, bisacodyl, ascorbic acid). Due to the large volume of PEG required for adequate bowel preparation, many studies have focused on reducing this large volume to only 2 L PEG with the addition of an adjunct. Recently, a randomized controlled trial by Tajika et al showed that the addition of mosapride to only 1.5 L PEG was non-inferior to mosapride and 2 L PEG for bowel cleansing but did provide improvements in patient tolerance. This study offers yet another potential bowel preparation for patients undergoing colonoscopy and may trigger further studies with 1.5 L PEG with an adjunct. In this letter, we discuss the current state of bowel preparation prior to colonoscopy and offer information to guide clinicians on choosing the appropriate bowel preparation for their patients.

Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials

BACKGROUND/AIM

Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB.

METHODS

Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration).

RESULTS

Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD - 0.41; 95% CI: -0.82 to -0.01, P = 0.04), and the duration of hospital stay (WMD - 1.51; 95% CI: -2.45 to -0.56, P < 0.01).

CONCLUSIONS

Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Low-volume polyethylene glycol and bisacodyl for bowel preparation prior to colonoscopy: a meta-analysis

BACKGROUND

Quality of bowel preparation prior to colonoscopy is essential. Studies have shown a reduced volume of polyethylene glycol (PEG) with bisacodyl may improve visualization and tolerability, but results have varied. Therefore, a meta-analysis was performed to analyze the efficacy of a low-volume PEG bowel preparation with bisacodyl for bowel preparation prior to colonoscopy.

METHODS

Multiple databases were searched (June 2012). Only randomized controlled trials in peer-reviewed journals on adult subjects comparing low-volume PEG (2 L) with bisacodyl versus 4 L PEG were included. Meta-analysis for the efficacy of low-volume PEG with bisacodyl and 4 L PEG were analyzed by calculating pooled estimates of number of satisfactory, excellent, and poor bowel preparations as well as adverse patient events (abdominal pain, nausea, vomiting, bloating).

RESULTS

Six studies (N=1,540) met the inclusion criteria. No statistically significant differences were noted between low-volume PEG (2 L) with bisacodyl and 4 liters PEG for number of satisfactory (OR 0.86; 95% CI: 0.45-1.63, P=0.64), excellent (OR 1.08; 95% CI: 0.78-1.50, P=0.63), or poor bowel preparations (OR 0.68; 95% CI: 0.35-1.34, P=0.27). A statistically significant decrease in nausea (OR 0.57; 95% CI: 0.36-0.89, P=0.01), vomiting (OR 0.57; 95% CI: 0.40-0.81, P<0.01), and bloating (OR 0.65; 95% CI: 0.49-0.87, P<0.01) was noted for the low-volume PEG with bisacodyl as compared to 4 L PEG. No statistically significant differences were noted between the two groups for abdominal pain (P=0.62).

CONCLUSION

Low-volume PEG (2 L) with bisacodyl demonstrates less nausea, vomiting, and bloating without adversely affecting the bowel preparation.

Osseous Metaplasia in an Inflammatory Polyp of the Rectum: A Case Report and Review of the Literature

Osseous metaplasia is a rare finding in colonic neoplasms. We report a case osseous metaplasia in a 74 year-old male who underwent surveillance colonoscopy and found to have a 7 mm rectal polyp. Histopathologic examination revealed an inflammatory polyp with osseous metaplasia.

A Rare Cause of Massive Upper Gastrointestinal Hemorrhage in Immunocompromised Host

Mucormycosis is an invasive and aggressive opportunistic fungal infection that usually presents with rhinocerebral or pulmonary involvement and rarely involves the gastrointestinal tract. The disease is acute with mortality rate up to 100%. A 68-year-old male was undergoing treatment at a local hospital for COPD exacerbation with IV steroids and antibiotics. Two weeks into his treatment he suddenly developed massive upper GI bleeding and hemodynamic instability that necessitated transfer to our tertiary care hospital for further treatment and management. An urgent upper endoscopy revealed multiple large and deep gastric and duodenal bulb ulcers with stigmata of recent bleeding. The ulcers were treated endoscopically. Biopsies showed fibrinopurulent debris with fungal organisms. Stains highlighted slightly irregular hyphae with rare septa and yeast suspicious for Candida. The patient was subsequently placed on fluconazole. Unfortunately, the patient’s general condition continued to worsen and he developed multiorgan failure and died. Autopsy revealed disseminated systemic mucormycosis. Most of the cases of gastrointestinal mucormycosis were reported from the tropics and few were reported in the United States. The disease occurs most frequently in immunocompromised individuals. The rare incidence of GI involvement, acute nature, severity and the problematic identification of the organisms on biopsies make antemortem diagnosis challenging. Treatment includes parenteral antifungals and debridement of the infected tissues. Gastroenterologists should be aware of this rare cause of gastrointestinal bleeding and understand the importance of communication with the reviewing pathologist so that appropriate, and often lifesaving, therapies can be administered in a timely manner.

Effect of Helicobacter pylori treatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials

OBJECTIVE

Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD.

MATERIAL AND METHODS

Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency.

RESULTS

Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56-1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72-1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35-0.87, p = 0.01). Funnel plot revealed no publication bias.

CONCLUSIONS

Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Warfarin Use During Fecal Occult Blood Testing: A Meta-Analysis

Background

Fecal occult blood testing (FOBT) is a widely used screening test for colorectal cancer (CRC). Given the limited data about the effects of warfarin on FOBT are inconclusive, current screening guidelines for CRC do not address whether warfarin should be discontinued before FOBT. Therefore, we conducted a meta-analysis to evaluate the influence of warfarin on the yield of FOBT.

Methods

Multiple medical databases were searched (April 2011). Studies examining the use of warfarin versus no warfarin for FOBT were included. Meta-analysis for the effect of warfarin or no warfarin for FOBT was performed by calculating pooled estimates of colonoscopy findings and detection of neoplasia, any adenoma, advanced adenoma, or colon cancer by odds ratio (OR) with fixed and random effects model. RevMan 5.1 was utilized for statistical analysis.

Results

Five studies (N = 11,244) met the inclusion criteria. No statistically significant difference was noted between FOBT with or without warfarin for colonoscopy findings (OR 0.88; 95% CI: 0.48 - 1.62, P = 0.67) or detection of neoplasia (OR 0.88; 95% CI: 0.58 - 1.35, P = 0.57), any adenoma (OR 1.08; 95% CI: 0.73 - 1.58, P = 0.71), advanced adenoma (OR 1.07; 95% CI: 0.69 - 1.65, P = 0.78), and colon cancer (OR 0.69; 95% CI: 0.38 - 1.23, P = 0.21).

Conclusions

Among patients with positive FOBT, the yield of colonoscopy appears not to be altered by warfarin use.

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB.

MATERIALS AND METHODS

Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD).

RESULTS

Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85-8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24-0.74, p < 0.01), and a trend for less units of blood transfused (WMD -0.48; 95% CI -0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin.

CONCLUSIONS

Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.

Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND

Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting.

OBJECTIVE

We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy.

DESIGN

Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models.

SETTING

Literature search.

PATIENTS

Per RCTs.

MAIN OUTCOME MEASUREMENTS

Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects.

RESULTS

Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P < .01) and willingness to repeat the same preparation (OR 1.76; 95% CI, 1.06-2.91; P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P < .01) compared with full-dose PEG.

LIMITATIONS

Limited number of studies.

CONCLUSIONS

The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

BACKGROUND

Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results.

OBJECTIVE

We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis.

DESIGN

MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency.

SETTING

Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis.

PATIENTS

Adult patients undergoing ERCP.

INTERVENTIONS

Pancreatic stent placement for the prevention of post-ERCP pancreatitis.

MAIN OUTCOME MEASUREMENTS

Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement.

RESULTS

Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies.

LIMITATIONS

Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement.

CONCLUSIONS

Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Small Bowel Obstruction Caused by Carcinoid Tumor and Incidental Capsule Retention

Capsule endoscopy (CE) is a sensitive modality for examining the small bowel and is commonly employed to identify a variety of small bowel pathologies. We report a case of capsule retention leading to diagnosis of a chronic condition. A 60-year-old female presented with abdominal pain, nausea, and weight loss for 3 years. Physical exam revealed a mildly tender abdomen with hypoactive bowel sounds. Laboratory was normal. Abdominal radiographs showed a partial small bowel obstruction with retained capsule. Abdominal computed tomography (CT) demonstrated a retained capsule in the mid-portion of the jejunum, dilated small bowel, and terminal ileal mass. She underwent exploratory laparotomy showing an ileal mass with hepatic metastasis. A right hemicolectomy, reanastomosis, and removal of the retained capsule were performed. Pathology showed well-differentiated carcinoid tumor. She was discharged home for further treatment with oncology. Carcinoid tumors of the small bowel usually present with abdominal pain or small bowel obstruction. Our patient had intermittent small bowel obstruction due to a carcinoid tumor and retained capsule causing her symptoms. CE is a valuable tool but requires extensive consideration and possible patency capsule prior to use in patients presenting with symptoms consistent with Crohn's disease or small bowel tumor.

Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review

BACKGROUND

Rectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied.

AIM

To evaluate the accuracy of EUS in T0 staging of rectal cancers. METHOD (STUDY SELECTION CRITERIA): Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa. DATA COLLECTION AND EXTRACTION: Articles were searched in Medline, PubMed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both the fixed-effects model and random-effects model.

RESULTS

An initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (N = 1,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7-99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3-97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3-29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04-0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10.

CONCLUSIONS

EUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47-85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51-64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.