DOCSLIB.ORG

The British Society of Gastroenterology

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The British Society of Gastroenterology Gut: first published as 10.1136/gut.21.5.A443 on 1 May 1980. Downloaded from Gut, 1980, 21, A443-A468 The British Society of Gastroenterology A joint meeting of the Association of Surgeons, the British Society ot Gastroenterology, and the British Society for Digestive Endoscopy took place in Bournemouth on Wednesday, 26 to Saturday, 29 March. The very full and varied scientific programme was preceded and followed by Symposia, teaching days, and satellite sessions and supported by a varied social programme. Abstracts of scientific communications read before the Societies follow. usual with CDCA but rare with UDCA. risk' for the spread of HBV, independent CLINICAL I We concluded that outcome of dis- of the crowding and social level. Probably solution therapy may be predicted from a as a result of their depressed immuno- six month cholecystogram; UDCA is no responsiveness, the aged, when infected more efficacious than CDCA. with HBV at a late age, tend to have mild, often subclinical, hepatitis and to remain Can a six-month cholecystogram predict HBsAg+ve. eventual response to gallstone dissolution therapy? Hepatitis B virus infection in the elderly: an underestimated problem? M C BATESON, D B TRASH, AND A D 0 http://gut.bmj.com/ BOUCHIER (University Department of M CHIARMONATE, A FLOREANI, AND R NAC- The immune response to bacterial gastro- Medicine, Ninewells Hospital and Medical CARATO (Cattedra di Gastroenterologia, enteritis School, Dundee, and Walsall Manor Clinica Medica 10, Universita di Padova, Hospital, Walsall) Results of treatment Italy) Four hundred and five elderly J LABROOY, D J C SHEARMAN, AND D with chenodeoxycholic acid (CDCA) and subjects (aged 66-98 years) without overt ROWLEY (Department of Medicine and ursodeoxycholic acid (UDCA) for radio- liver disease were tested for HBsAg, Microbiology and Immunology, University lucent gallbladder stones were analysed to antiHBs, antiHBc (radioimmunoassay, of Adelaide, South Australia) The anti- assess whether it was possible to predict Abbott Lab): 214 subjects lived at home, body response in serum and intestinal on September 25, 2021 by guest. Protected copyright. individual response, avoiding prolonged 191 in three homes for the aged (one of secretions after Salmonella and Shigella ineffective therapy. In 46 courses of treat- high and two of poor socioeconomic gastroenteritis has been measured using ment where no response occurred at six level). sensitive radioimmunoassay in 15 adults months, continuation on unchanged dose The three HBV markers' cumulative and 12 controls. Intestinal antibody, for at least another six months showed prevalence is significantly higher in mainly of the IgA class, was consistently subsequent complete dissolution in only (1) the total group of aged compared with detected in paired samples taken one to two patients. Twenty-three patients 1055 randomly selected adults (55.3% vs 10 weeks after infection, whereas antibody achieved complete stone dissolution, 14 21.6 %); (2) the institutionalised people was undetectable in intestinal secretions of at six months, five at one year and four at (without differences between the three most controls. While serum antibody, two years. Seven out of the nine with institutions) compared with the non- mainly of the IgG class, was similarly in- delayed total dissolution had evidence of institutionalised group (72-2 % vs 40.1 %). creased in the patients as a group, there partial response at six months. Of the 24 HBsAg+ve institutionalised was marked dissociation of serum and Using response at six months as a guide subjects, two (8.3 %) had evidence of intestinal antibody responses in indivi- to successful outcome, analysis of treat- chronic liver disease; 18 (75%) were duals. Although serum and salivary IgA ment in 35 patients with CDCA starting asymptomatic carriers; four (16.6%) antibody responses are easier to measure at 1000 mg daily showed eight complete belonged to the group of 15 who had re- than intestinal antibody responses they and 11 partial responses. Sixteen patients covered from acute hepatitis in the last did not correlate with intestinal antibody reviewed similarly after UDCA 1000 mg three years. The HBsAg+ve prevalence responses. Eight patients were studied daily had one complete and five partial increases with age and length of in- again after one to two years and intestinal responses. Nine patients treated with stitutionalisation. antibody was still detectable in the UDCA 500 mg daily had two complete In conclusion, aged people are highly majority. Patients were found to be and one partial response; two had non- exposed to HBV infection and institu- carrying the pathogen responsible for functioning gallbladders. Diarrhoea was tionalisation in itself represents a 'high their infections months after sympto- A443 Gut: first published as 10.1136/gut.21.5.A443 on 1 May 1980. Downloaded from A444 The British Society of Gastroentterology matic recovery and in spite of a marked is unlikely to affect PG synthesis by multiple gastric apudomas, and was also local antibody response. homogenates, we have examined its effect found to have an asymptomatic para- The feasibility of measuring intestinal on PG synthesis in tissue culture. thyroid adenoma. One female, aged 53 antibody over a prolonged period of time Rectal biopsies from 28 patients with years, had an early mucosal cancer in the and its dissociation from the immune ulcerative colitis or irritable colon syn- antrum, and underwent total gastrectomy. response at other sites emphasise the im- drome were bisected and put into tissue Thirteen of the patients were also portance of its measurement in the study culture, with or without prednisolone, studied by barium meal examination, of intestinal infection. This is particularly concentration 8.33 x 10-7 M. The super- which revealed abnormalities in only one relevant to programmes aimed at develop- natant was sampled at 16, 26 and 40 of five patients with endoscopically ing effective vaccines against bacterial hours, subjected to extraction and thin visible lesions. disease of the gut. layer chromatography, and assayed bio- The study is continuing, and patients logically for PG E2 using laminar flow with moderate and severe dysplasia are superfusion. Two biopsies not showing a being followed up. Controlled trial of alternate day pred- significantly linear rate of production of nisolone as a maintenance treatment for PG E2 were excluded. ulcerative colitis in remission Mean synthesis of PG E2 over 40 hours Low lgA plasma cell counts in the jejunal by biopsy halves not exposed to predniso- mucosa of atopic children J POWELL-TUCK, R L BOWN, T J CHAMBERS, lone was 2665 pmol/mg wet weight AND J E LENNARD-JONE,S (St Mark 's Hospit- (0-537 pmol,!~g protein). Biopsy halves K SLOPER, D SMITH, C G D BROOK, AND S al, London) Prednisone, 15 mg daily in exposed to prednisolone synthesised 10-26 HERMAN (Department of Paediatrics, divided doses, did not prevent relapse in pm/mg wet weight (0.217 pmol,',ug pro- Central Middlesex Hospital, London, and patients with ulcerative colitis in remission tein), representing significant inhibition D KINGSTON, J R PEARSON, AND M SHINER and some patients experienced trouble- (61-5%, P<0-001, and 59.6%, P<<0001, (Intestinal Stuidies Group, Division of some side-effects. In other diseases, respectively). Clinical Sciences, Clinical Research Centre, higher doses of corticosteroids have Biopsies from inflamed mucosae syn- Harrow, Middlesex) IgA deficiency has proved beneficial without increasing side- thesised more PG E2 than from unin- been postulated as a cause of gastro- effects when given in single doses on flamed mucosae (mean 33-87 pmol tmg intestinal allergy and diarrhoea in atopic alternate days. An alternative to sul- vs 9-70 pmol/!mg, wet weight P< 0.05, and infants. We studied, by immunofluo- phasalazine is needed to prevent frequent 0-674 pmol/,ug vs. 0-195 pmol '~tg pro- rescence, the plasma cells of the jejunal relapses of ulcerative colitis in a small tein, P< 0 05). mucosa obtained by peroral biopsy of all group of patients intolerant to the drug This is the first demonstration that children referred for symptoms of diar- http://gut.bmj.com/ or for whom it is ineffective. A randomised therapeutic concentrations of predniso- rhoea and,'or failure to thrive, who had double-blind crossover trial has therefore lone can inhibit PG synthesis by rectal eczema (n 15) or atopy in first degree been performed among such patients of mucosa, an action which may underly its relatives (n=four). Patients' ages were: prednisolone, 40 mg given orally in one clinical effectiveness in ulcerative colitis. 0-5 months: four; 6-11 months: four; dose on alternate mornings, against 12-23 months: six; 24 months onwards: control tablets. Results were assessed on five. The histology of the jejunal mucosa the basis of symptoms, sigmoidoscopic was normal in four (only two were under Gastroscopy survey in pernicious anaemia and rectal biopsy appearances. The study 23 months) and showed a partial villous on September 25, 2021 by guest. Protected copyright. was conducted over two periods of three atrophy (PVA) in 15 (12 under 23 months). months with a two-week crossover R W STOCKHRUGGER, G G MENON, R R Compared with the IgA and IgM plasma period. Of 24 patients who completed MASON, J 0 W BEILBY, R BOURNE, AND cell counts of non-eczematous children both periods, 11 relapsed while taking PB COTTON (Gastrointestinal Unit and under 23 months with PVA (n= 12) a control tablets but did not while taking Department of Radiology, The Middlesex significantly lower IgA cell count prednisolone, and one relapsed while Hospital, London, Bland Sutton Institute of (P< 0001) was found in eczematous (or taking prednisolone but did not while Pathology, The Middlesex Hospital atopic family history) children of the same taking control tablets (P< 0-01). One Medical Sc.hool) We have performed age group.
Load more

Recommended publications
  • Laparoscopy As a Diagnostic Tool in Ascites of Unknown Origin: a Retrospective Study Conducted at Kasturba Hospital, Manipal
    Research Article Open Access J Surg Volume 8 Issue 3 - March 2018 Copyright © All rights are reserved by Chetan R Kulkarni DOI: 10.19080/OAJS.2018.08.555740 Laparoscopy as a Diagnostic Tool in Ascites of Unknown Origin: A Retrospective Study Conducted at Kasturba Hospital, Manipal Chetan R Kulkarni1*, Badareesh Laxminarayan2 and Annappa Kudva3 1Assistant Professor, Department of Surgery, Kasturba Hospital, Manipal 2Associate Professor, Department of Surgery, Kasturba Hospital, Manipal 3Professor, Department of Surgery, Kasturba Hospital, Manipal Received: February 16, 2018; Published: March 01, 2018 *Corresponding author: Chetan R Kulkarni, Assistant Professor, Department of Surgery, Kasturba Hospital, Manipal, India. Tel: 9535974395;Email: Abstract Background: Laparoscopy as a minimally invasive technique has long played an important role in the evaluation of ascites. Methods: A retrospective analysis was carried out on the record of 80patients who underwent laparoscopy after appropriate investigations had failed to reveal the cause of ascites. Results: Tuberculous peritonitis was reported in 46(57%), malignancies in 18(25%), cirrhosis in 4(5%) and peritonitis of unknown etiology in 8(10%)Conclusion: of patients. Two (2.5%) patients had complications, an Ileal perforation and in other Incisional hernia. Keywords: Ascites;Laparoscopy Diagnostic was Laparoscopy able to diagnose the pathology in 72 (90%) patients with ascites of unknown origin. Introduction Laparoscopy, as a minimally invasive technique has developed rapidly in recent years. Endoscopic examination of conventional laboratory examinations (including ascitic fluid cell count, albumin level, total protein level, Gram stain, culture who termed it as “Celioscopy” [1,2]. The term ‘ascites’ refers to and cytology ) as well as after imaging investigations (including peritoneal cavity was first attempted in 1901 by George Kelling Materialultrasound andand CT Methods scan).
    [Show full text]
  • Recurrent Pneumothorax Following Abdominal Paracentesis
    Postgrad Med J (1990) 66, 319 - 320 © The Fellowship of Postgraduate Medicine, 1990 Postgrad Med J: first published as 10.1136/pgmj.66.774.319 on 1 April 1990. Downloaded from Recurrent pneumothorax following abdominal paracentesis P.J. Stafford Department ofMedicine, Newham General Hospital, Glen Road, Plaistow, London E13, UK. Summary: A 62 year old man presented with abdominal ascites, without pleural effusion, due to peritoneal mesothelioma. He had chronic obstructive airways disease and a past history of right upper lobectomy for tuberculosis. On two occasions abdominal paracentesis was followed within 72 hours by pneumothorax. This previously unreported complication of abdominal paracentesis may be due to increased diaphragmatic excursion following the procedure and should be considered in patients with preexisting lung disease. Introduction Abdominal paracentesis is a widely used palliative right iliac fossa. Approximately 4 litres of turbid therapy for malignant ascites and is generally fluid was drained over 72 hours. The protein accepted as a procedure with few adverse effects: concentration was 46 g/l and microbiology and pneumothorax is not a recognized complication. I cytology were not diagnostic. Laparoscopy re- report a patient with recurrent pneumothorax vealed matted loops of bowel with widespread apparently precipitated by abdominal paracen- peritoneal seedlings. Histological examination of copyright. tesis. these lesions showed malignant mesothelioma of the epithelioid type. The patient suffered a left pneumothorax within Case report 48 hours ofparacentesis (before laparoscopy). This was treated with intercostal underwater drainage A 62 year old civil servant presented with a 6-week but recurred on two attempts to remove the drain, history ofworsening abdominal distension.
    [Show full text]
  • Intestinal and Multiple Organ Transplantation 1679
    1678 TRANSPLANT ATION euglycemia and survive longer than 200 islets in allogeneic and xenogeneic diabetic hosts. Transplant Proc 1993; 25:953-954. 67. Gotoh M, Maki T, Satomi S, et al: Immunological characteristics of purified islet grafts. Transplantation 1986; 42j387. 68. Klima G, Konigsrainer A, Schmid T, et al: Is the pancreas reo jected independently of the kidney after combined pancreatic­ renal transplantation? Transplant Proc 1988; 20:665. 69. Prowse 5J, Bellgrau D, Lafferty KJ: Islet allografts are destroyed by disease recurrence in the spontaneously diabetic BB rat. Di­ abetes 1986; 35:110. 70. Markmann JF, Posselt AM, Bassiri H, et al: Major-histocompat­ ibility-complex restricted and nonrestricted autoil1'\mune effec­ tor mechanisms in BB rats. Transplantation 1991; 52:662-667. 71. Navarro X, Kennedy WR, Loewenson RB, et al: Influence of pancreas transplantation on cardiorespiratory reflexes, nerve conduction, and mortality in diabetes mellitus. Diabetes 1990; 39:802. 72. Weber q, Silva FG, Hardy MA, et al: Effect of islet transplan­ tation on renal function and morphology of short- and long­ term diabetic rats. Transplant Proc 1979; 11:549. 73. Gotzche 0, Gunderson HJ, Osterby R: Irreversibility of glomer­ ular basement membrane accumulation despite reversibility of renal hypertrophy with islet transplantation in early diabetes. Diabetes 1981; 30:481. 74. Fung H, Alessini M, Abu-Elmagd K, et al: Adverse effects asso­ ciated with the use ofFK 506. Transplant Proc 1991; 23:3105. 75. Tzakis AG: Personal communication, 1991. I CHAPTER 185 Figure 185-1. Cluster allograft (shaded portion), including the liver, pancreas, and duodenal segment of small intestine. (From Starzl TE, Todo S.
    [Show full text]
  • Guidelines on the Management of Ascites in Cirrhosis
    Downloaded from gut.bmjjournals.com on 25 September 2006 Guidelines on the management of ascites in cirrhosis K P Moore and G P Aithal Gut 2006;55;1-12 doi:10.1136/gut.2006.099580 Updated information and services can be found at: http://gut.bmjjournals.com/cgi/content/full/55/suppl_6/vi1 These include: References This article cites 148 articles, 21 of which can be accessed free at: http://gut.bmjjournals.com/cgi/content/full/55/suppl_6/vi1#BIBL Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article Topic collections Articles on similar topics can be found in the following collections Liver, including hepatitis (945 articles) Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to Gut go to: http://www.bmjjournals.com/subscriptions/ Downloaded from gut.bmjjournals.com on 25 September 2006 vi1 GUIDELINES Guidelines on the management of ascites in cirrhosis K P Moore, G P Aithal ............................................................................................................................... Gut 2006;55(Suppl VI):vi1–vi12. doi: 10.1136/gut.2006.099580 1.0 INTRODUCTION N Grade 1 (mild). Ascites is only detectable by ultrasound examination. Ascites is a major complication of cirrhosis,1 occurring in 50% of patients over 10 years of N Grade 2 (moderate). Ascites causing moderate follow up.2 The development of ascites is an symmetrical distension of the abdomen. important landmark in the natural history of N Grade 3 (large). Ascites causing marked cirrhosis as it is associated with a 50% mortality abdominal distension.
    [Show full text]
  • Procedure Coding in ICD-9-CM and ICD- 10-PCS
    Procedure Coding in ICD-9-CM and ICD- 10-PCS ICD-9-CM Volume 3 Procedures are classified in volume 3 of ICD-9-CM, and this section includes both an Alphabetic Index and a Tabular List. This volume follows the same format, organization and conventions as the classification of diseases in volumes 1 and 2. ICD-10-PCS ICD-10-PCS will replace volume 3 of ICD-9-CM. Unlike ICD-10-CM for diagnoses, which is similar in structure and format as the ICD-9-CM volumes 1 and 2, ICD-10-PCS is a completely different system. ICD-10-PCS has a multiaxial seven-character alphanumeric code structure providing unique codes for procedures. The table below gives a brief side-by-side comparison of ICD-9-CM and ICD-10-PCS. ICD-9-CM Volume3 ICD-10-PCS Follows ICD structure (designed for diagnosis Designed and developed to meet healthcare coding) needs for a procedure code system Codes available as a fixed or finite set in list form Codes constructed from flexible code components (values) using tables Codes are numeric Codes are alphanumeric Codes are 3-4 digits long All codes are seven characters long ICD-9-CM and ICD-10-PCS are used to code only hospital inpatient procedures. Hospital outpatient departments, other ambulatory facilities, and physician practices are required to use CPT and HCPCS to report procedures. ICD-9-CM Conventions in Volume 3 Code Also In volume 3, the phrase “code also” is a reminder to code additional procedures only when they have actually been performed.
    [Show full text]
  • AASLD Position Paper : Liver Biopsy
    AASLD POSITION PAPER Liver Biopsy Don C. Rockey,1 Stephen H. Caldwell,2 Zachary D. Goodman,3 Rendon C. Nelson,4 and Alastair D. Smith5 This position paper has been approved by the AASLD and College of Cardiology and the American Heart Associa- represents the position of the association. tion Practice Guidelines3).4 Introduction Preamble Histological assessment of the liver, and thus, liver bi- These recommendations provide a data-supported ap- opsy, is a cornerstone in the evaluation and management proach. They are based on the following: (1) formal re- of patients with liver disease and has long been considered view and analysis of the recently published world to be an integral component of the clinician’s diagnostic literature on the topic; (2) American College of Physi- armamentarium. Although sensitive and relatively accu- cians Manual for Assessing Health Practices and De- rate blood tests used to detect and diagnose liver disease signing Practice Guidelines1; (3) guideline policies, have now become widely available, it is likely that liver including the AASLD Policy on the Development and biopsy will remain a valuable diagnostic tool. Although Use of Practice Guidelines and the American Gastro- histological evaluation of the liver has become important enterological Association Policy Statement on Guide- in assessing prognosis and in tailoring treatment, nonin- lines2; and (4) the experience of the authors in the vasive techniques (i.e., imaging, blood tests) may replace specified topic. use of liver histology in this setting, particularly with re- Intended for use by physicians, these recommenda- gard to assessment of the severity of liver fibrosis.5,6 Sev- tions suggest preferred approaches to the diagnostic, ther- eral techniques may be used to obtain liver tissue; a table apeutic, and preventive aspects of care.
    [Show full text]
  • Chyle Leak Post Laparoscopic Cholecystectomy: a Case Report, Literature Review and Management Options
    7 Case Report Page 1 of 7 Chyle leak post laparoscopic cholecystectomy: a case report, literature review and management options Ferdinand Ong1, Amitabha Das1, Kheman Rajkomar2 1Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Sydney, NSW, Australia; 2Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia Correspondence to: Dr. Kheman Rajkomar. Eldridge Road, Bankstown-Lidcombe Hospital, Bankstown NSW 2200, Sydney, Australia. Email: [email protected]. Abstract: Chyle leak after a laparoscopic cholecystectomy (LC) is very rarely reported. However, it is needs to be recognised promptly and managed as otherwise it can lead to further metabolic and infective complications. We present the case of a 48 years old man who was admitted with ultrasound proven acute calculous cholecystitis. His vital signs were within normal range but his murphy’s sign was positive. His white cell count (WCC) and liver function tests were within normal limit. He underwent an uneventful standard LC with cholangiography during the same admission with no anomalous biliary or hepatic arterial anatomy noted during the procedure. Post operatively he was noted to have 125 mL of white fluid in his drain. The fluid triglyceride was 23.2 mmol/L, cholesterol level was 2.8 mmol/L, and drain/serum triglyceride of 15.5, hence confirming it to be chyle. He was clinically otherwise very well. He was managed conservatively as a low volume chyle leak with a fat free diet. The triglyceride content in the drain effluent decreased to 1.3mmol/L by day 6 and the fluid turned straw coloured in that interval. The drain was removed and the patient discharged home without any further issues.
    [Show full text]
  • Perforated Duodenal Ulcer an Alternative Therapeutic Plan
    SPECIAL ARTICLE Perforated Duodenal Ulcer An Alternative Therapeutic Plan Arthur J. Donovan, MD; Thomas V. Berne, MD; John A. Donovan, MD n alternative plan for the treatment of a perforated duodenal ulcer is proposed. We will focus on the now-recognized role of Helicobacter pylori in the genesis of the ma- jority of duodenal ulcers and on the high rate of success of therapy with a combina- tion of antibiotics and a proton-pump inhibitor or histamine2 blocker in treatment of suchA ulcers. Knowledge that half the cases of perforated duodenal ulcer may have securely sealed spontaneously at the time of presentation is incorporated in the therapeutic plan. Patients with a perforated duodenal ulcer who have already been evaluated for H pylori and are not infected or, if infected, have received appropriate therapy should undergo an ulcer-definitive operation if they are suitable surgical candidates. Most authorities recommend surgical closure of the perforation and a parietal cell vagotomy. The remaining patients should have a gastroduodenogram with water- soluble contrast medium. If the perforation is sealed, the patient can be treated nonsurgically. If the perforation is leaking, secure surgical closure of the perforation is necessary. Following recov- ery from the immediate consequences of the perforation, evaluation for H pylori should be con- ducted. If the patient is infected, combined medical therapy is recommended. If the patient is not infected, Zollinger-Ellison syndrome should be ruled out and medical therapy is recommended if the ulcer has not been treated previously. Elective ulcer-definitive surgery should be considered for the occasional uninfected patient who has already received appropriate medical therapy for the ulcer.
    [Show full text]
  • Postoperative Management After Hepatic Resection Lindsay J
    Journal of Gastrointestinal Oncology, Vol 3, No 1, March 2012 41 Review Article Postoperative management after hepatic resection Lindsay J. Wrighton, Karen R. O’Bosky, Jukes P. Namm, Maheswari Senthil Department of Surgery, Loma Linda University, Loma Linda, California, USA ABSTRACT Hepatic resection has become the mainstay of treatment for both primary and certain secondary malignancies. Outcomes after hepatic resection have significantly improved with advances in surgical and anesthetic techniques and perioperative care. Metabolic and functional changes after hepatic resection are unique and cause significant challenges in manage- ment. In-depth understanding of hepatic physiology is essential to properly address the postoperative issues. Strategies implemented in the postoperative period to improve outcomes include adequate nutritional support, proper glycemic control, and interventions to reduce postoperative infectious complications among several others. This review article fo- cuses on the major postoperative issues after hepatic resection and presents the current management. KEY WORDS Management; postoperative; hepatic resection; liver resection J Gastrointest Oncol 2012;3:41-47. DOI: 10.3978/j.issn.2078-6891.2012.003 Introduction are further accentuated by derangements of liver function. Maintenance of adequate fluid balance and normal renal Outcomes after hepatic resection have significantly function is critical. Cirrhotics are prone to fluid shifts, improved over the last few decades (1-4). Although, no vasodilation and resultant hypotension. In this setting, single factor is solely responsible, overall advances in colloids rather than crystalloids should be administered surgical and anesthetic techniques, better understanding to restore intravascular volume. New onset postoperative of hepatic physiology and improvement in perioperative ascites frequently occurs in cirrhotic patients.
    [Show full text]
  • Noacs/Doacs*: Peri-Operative Management
    NOACS/DOACS*: PERI-OPERATIVE MANAGEMENT OBJECTIVE: To provide guidance for the peri-operative management of patients who are receiving a newer direct oral anticoagulant (DOAC) and require an elective surgery/procedure. For guidance on management of patients who require an urgent or emergency surgery/procedure, please refer to the Perioperative Anticoagulant Management Algorithm found on the Thrombosis Canada website under the “Tools” tab. BACKGROUND: Four DOACs (apixaban, dabigatran, edoxaban and rivaroxaban) are approved for clinical use in Canada based on findings from large randomized trials. The peri-operative management of DOAC-treated patients aims to interrupt anticoagulant therapy (if necessary) so there is no (or minimal) residual anticoagulant effect at the time of surgery, and to ensure timely but careful resumption after surgery so as to not incur an increased risk for post- operative bleeding. There are 3 important considerations for peri-operative management of patients taking a DOAC: 1) Reliable laboratory tests to confirm the absence of a residual anticoagulant effect of DOACs are not widely available. 2) Half-lives of DOACs differ and increase with worsening renal function, affecting when the drug should be stopped before surgery. 3) DOACs have rapid onset of action, with a peak anticoagulant effect occurring 1-2 hours after oral intake. In the absence of laboratory tests to reliably measure their anticoagulant effect, the peri-operative administration of DOACs should be influenced by: 1) Drug elimination half-life (with normal renal function), 2) Effect of renal function on drug elimination half-life, and 3) Bleeding risk associated with the surgery/procedure type (Table 1), and 4) Whether patient is to receive spinal/epidural anesthesia.
    [Show full text]
  • 5. Guidelines for the Management of Malignant Ascites in Palliative Care
    5. GUIDELINES FOR THE MANAGEMENT OF MALIGNANT ASCITES IN PALLIATIVE CARE 5.1 GENERAL PRINCIPLES Ascites is the accumulation of fluid in the peritoneal cavity. 1, 2 Malignancy is the underlying cause in approximately 10% of all cases of ascites. About 15- 50% of patients with malignancy will develop ascites. 3 Cancers commonly associated with the development of ascites include breast, colorectal, endometrial, gastric, ovarian and pancreatic. 3 Non-malignant causes of ascites include liver disease, congestive cardiac failure, nephrotic syndrome, pancreatitis, tuberculosis and bowel perforation. 2, 3 Several different pathophysiological mechanisms are implicated in the development of malignant ascites. These include: 4 − peritoneal lymphatic obstruction. − hypoalbuminaemia leading to a reduction in oncotic pressure. − increased capillary permeability. − increased portal vein pressure with activation of the renin-angiotensin pathway. Symptoms resulting from an accumulation of ascitic fluid include abdominal bloating / swelling, pain, nausea and vomiting, anorexia, fatigue, peripheral oedema, heartburn and dyspnoea. 5 Malignant ascites carries a poor prognosis. Management should be aimed at maximising patient comfort and quality of life. 7 Management options for malignant ascites include diuretic therapy, therapeutic paracentesis and peritoneovenous shunts. 8 Oncological interventions may be helpful in ovarian carcinoma and lymphoma. Hormonal therapy may be useful in hormone sensitive malignancies such as some breast cancers. 2, 7 9 There is no evidence that any particular therapeutic option is more effective than another. 5.2 GUIDELINES 5.2.1 Diuretic therapy Diuretic therapy should be considered in every patient with malignant ascites particularly those with a prognosis of greater than 4 weeks. Urea and electrolytes should be checked before starting treatment and during treatment as appropriate.
    [Show full text]
  • Chylous Ascites and Chylothorax After Pancreaticoduodenectomy: Case Report and Literature Review
    Open Access Austin Journal of Surgery Special Article - Surgical Case Reports Chylous Ascites and Chylothorax after Pancreaticoduodenectomy: Case Report and Literature Review Ian Greenwalt*, Jana Hambley and John Ammori University Hospitals Case Medical Center, USA Abstract *Corresponding author: Ian Greenwalt, University Chyle leak is a lesser known complication of pancreaticoduodenectomy. The Hospitals Case Medical Center, USA, Email: greenwalti@ purpose of this case report is to describe the unusual complication of chyle leak gmail.com associated with pancreaticoduodenectomy, discuss our team’s management of this complication and review the literature describing postoperative chyle leaks. Received: April 21, 2015; Accepted: June 01, 2015; Published: June 10, 2015 Keywords: Chylous ascites; Chylothorax; Chyle leak Introduction The patient underwent percutaneous drainage of the abdominal fluid collection and thoracentesis. Fluid triglyceride was 907 mg/ th Beginning with Codivilla and Kausch at the end of the 19 and dL confirming chyle leak with chylous ascites and chylothorax. A th early 20 century, the evolution of the pancreaticoduodenectomy wound manager was placed over the opened midline incision to has been marked by significant advances in operative technique control continued drainage. Daily output from the abdominal drain as well as description and management of the mortality and and wound manager ranged from 1-3.8L. Therefore, the patient was morbidity associated with this procedure. Chyle leak is a lesser allowed nothing per
    [Show full text]