DOCSLIB.ORG

GASTROINTESTINAL SYSTEM/NUTRITION-2012 Dipali Yeh M.S., PA-C University of Medicine and Dentistry of New Jersey

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
GASTROINTESTINAL SYSTEM/NUTRITION-2012 Dipali Yeh M.S., PA-C University of Medicine and Dentistry of New Jersey GASTROINTESTINAL SYSTEM/NUTRITION-2012 Dipali Yeh M.S., PA-C University of Medicine and Dentistry of New Jersey ESOPHAGUS ESOPHAGITIS Infectious esophagitis General Considerations Rare, except in immunocompromised Risks Aids Leukemia/Lymphoma Solid organ transplant Uncontrolled DM Chronic systemic steroid use Causes Fungal-Candida Viral-HSV, CMV Clinical Features Odynophagia (painful swallowing) Dysphagia (difficulty swallowing) substernal chest pain involvement of colon/retina-CMV herpes labialis-HSV Diagnosis Endoscopy Large/deep ulcers-CMV/HIV Multiple shallow ulcers-HSV White plaques-Candida 1 Treatment Etiology Initial treatment Refractory Candida Fluconazole/ketoconazole Itraconazole/amphotericin HSV Acyclovir Foscarnet CMV Gancyclovir Foscarnet (neutropenia) (Renal failure, ↓Ca+, ↓Mg+) Pill-induced esophagitis General Considerations Offending agents: NSAIDs, KCl, antibiotics, iron Risks Swallowed without water Supine Hospitalized/bed-bound patients Clinical Features Odynophagia/Dysphagia Retrosternal chest pain Diagnosis Endoscopy-deep/shallow ulcers can treat empirically Treatment Prevention: 4oz water, remain upright x 30 min Reflux esophagitis-covered in GERD MOTILITY DISORDERS General Considerations Factors involved Neurological Intrinsic/external blockage Peristalsis malfunction Distal Esophagus=more susceptible Types Achalasia Scleroderma Esophageal spasms Zenker’s diverticulum-mechanical disorder 2 Achalasia General considerations Usually b/w 30-60yrs old Idiopathic LES ↑, peristalsis ↓ Clinical features gradual, progressive dysphagia > solids + liquids adopt compensatory maneuvers regurgitation (+)weight loss Diagnosis Barium swallow: “parrot beak” appearance Treatment Botox injection Pneumatic dilatation Surgical myotomy Scleroderma General considerations Most common GI organ affected CREST syndrome Clinical features “Heartburn” 20% develop Barrett’s esophagus Diagnosis Barium swallow: aperistalsis Manometry: ↓LES sphincter Treatment Cornerstone: PPI-omeprazole (Prilosec) Lifestyle modifications- small, frequent meals & avoid nighttime meals Esophageal Spasms General considerations ? deficiency of NO in esophageal body Clinical features Dysphagia/intermittent chest pain May/may not be associated with eating Diagnosis 3 Barium swallow: “corkscrew” esophagus Manometry: (+)contractions/(-)progression Treatment Empirically, smooth muscle relaxants Hycosamine, Ca+-channel antagonists (nifedipine), nitroglycerin Anti-depressants>low-dose tricyclics Imipramine (Tofranil) Zenker’s Diverticulum General considerations Outpouching posterior hypopharynx Older patients/insidious onsent Clinical features Halitosis Regurgitate undigested food several hrs postprandially Diagnosis Barium radiograph Treatment Asymptomatic=no treatment Surgery-myotomy/diverticulectomy Complications Aspiration/bronchiectasis/lung abscess MALLORY-WEISS TEAR General Considerations Tear in gastroesophageal junction Secondary to forceful vomiting/retching Associated with etoh abuse Clinical features-hematemesis Diagnosis-endoscopy Treatment Most heal spontaneously w/in 48 hours Endoscopic epinephrine/thermal coagulation 4 ESOPHAGEAL NEOPLASMS General Considerations 50-70 yrs old M:F=3:1 Two types Squamous cell carcinoma: 95% Adenocarcinoma Mets>mediastinum (esophagus has no serosa) Risk factors Squamous cell: smoking/ETOH abuse Adenocarcinoma: obesity, Barrett’s esophagus Clinical features Progressive dysphagia>solid food + weight loss Pneumonia/voice hoarseness Lymphadenopathy/hepatomegali=mets Diagnosis Initial-biphasic barium study Confirm-biopsy Treatment Surgical-esophagectomy Radiation/adjunct chemo Prognosis 5yr survival rate: <20% ESOPHAGEAL STRICTURES General Considerations Complication of esophagitis Clinical presentation Resolution of heartburn Progressive sold food dyphagia-months>years Diagnosis Biopsy-r/o etiol from cancer Treatment Endoscopic dilation Long term PPI Refractory: endoscopic triamcinolone injection 5 ESOPHAGEAL VARICES General Consideration Develop secondary to portal hypertension Most common cause of GIB secondary to portal HTN Found in 50% of patients with cirrhosis 30% of patients with varices bleed, but 50% of those will spontaneously cease without treatment Risk factors which increase chance of bleeding Size of varices Presence of red wale markings Severity of liver disease Active alcohol abuse Clinical features: acute GI hemorrhage Diagnosis: Established clinically: patient with cirrhosis presents with hematemesis Treatment Hemodynamic support Pharmacological therapy Vasoactive medications-octreotide to reduce blood flow and portal pressure Vitamin K-cirrhosis patients with abnormal PT; 10mg SQ Lactulose-for encephalopathy Antibiotic prophylaxis-fluoroquinolon/3rd generation cephalosporin Endoscopic support-banding or sclerotherapy Mechanical tamponade with NGT balloon Transvenous intrahepatic portosystemic shunt procedure: reserved for bleeding refractory to treatment Mortality st 30% during 1 episode of bleeding 50% within 6 weeks STOMACH GERD/Reflux Esophagitis General Considerations Recurrent reflux of gastric contents into distal esophagus LES relaxed 10% of general population; 50% infants have reflux Clinical Features Heartburn-most common 6 Hoarseness Halitosis Cough Atypical chest pain Diagnosis Clinical based on history Endoscopy for alarm symptoms: Refractory heartburn Dysphagia Weight loss GI bleed/anemia 45+ years old w/ new onset symptoms Treatment #1: appropriate lifestyle modification Weight loss due to ↑ association with obesity PPI’s: superior to H2 blockers; 4weeks empirically -for short term relief & long-term tx -most powerful anti-GERD medication -first-line treatment Omeprazole (Prilosec) 20mg/d Lansoprazole (Prevacid) 30mg/d Pantoprazole (Protonix) 40mg/d HEARTBURN/ACID REFLUX ↓ (+)Alarm Symptoms (-) Alarm Symptoms ↓ ↓ Immediate endoscopy Lifestyle changes ↓ ↓ Successful Not successful ↓ ↓ Continue Trial of PPI’s (superior to H2 blockers) 7 GASTRITIS/DUODENITIS General Considerations Histological evidence of inflammation Causes H. pylori NSAID’s Stress Alcohol use Pernicious anemia Clinical features Dyspepsia Abdominal pain Generally reflects underlying etiology Diagnosis Endoscopy with biopsy Presence of H. pylori (urea breath test) Specific tests to r/o etiology (i.e. vitamin B12 & CBC for pernicious anemia) Treatment Remove the causative agent (i.e. NSAIDs, alcohol) Treat the underlying condition H. PYLORI Gram-negative, spiral shaped bacillus Leads to gastric mucosal inflammation with PMNs and lymphocytes Associated with PUD/Gastric adenocarcinoma Urease-producing agent=detected by Urea breath test Can also do fecal antigen assay/serology Treatment -Triple therapy: PPI/Bismuth + 2 antibiotics -Quadruple therapy: PPI + Bismuth + metronidazole (Flagyl) + tetracycline Or PPI + Bismuth + levofloxacin (Levaquin)+ doxycycline *If symptoms persist, continue antisuppressive therapy when antibiotic therapy is complete 8 PEPTIC ULCER DISEASE General Considerations Refers to gastric or duodenal ulcers 80-90% of patients have dyspepsia Most NSAID ulcers are asymptomatic H. pylori is the most common cause of PUD Other causes:NSAIDs, stress, irritant, alcohol M: F is equal Clinical features Hallmark is epigastric pain “gnawing/hungerlike” Duodenal ulcer: improves with food Gastric ulcer: worsens with food/associated with weight loss Diagnosis Endoscopy is definitive/procedure of choice Barium study: 30% false negative rate; less sensitive Urea breath test for H. pylori Treatment Avoid irritating factors: smoking, NSAIDs, alcohol See combination therapy for H. pylori Misoprostol Prostaglandin analog Prophylactic treatment Indications of use: Patients who require daily NSAID use Hx complications (bleeding) Use of chronic steroids/anticoagulants GASTRIC NEOPLASMS Predominantly malignant 90-95% are adenocarcinomas Also: Zollinger-Ellison Syndrome (Gastrinoma) Gastric adenocarcinoma General Considerations Typically occurs between 50-70 yrs old Uncommon in 30yrs and younger M:F=2:1 5-year survival is <20% 9 Risk Factors Environmental H. pylori infection Diet: excess salt/nitrates, deficient fruits/vegetables Low socioeconomic status Cigarette smoking Genetic Familial history Associated with hereditary nonpolyposis colorectal CA Clinical features Generally asymptomatic until disease is advanced Dyspepsia + weight loss + GI bleed Signs of metastasis: Virchow’s node: L supraclavicular lymph node Sister Mary Joseph Nodule: umbilical nodule Krukenberg tumor: mets to the ovaries Diagnosis Iron deficiency anemia Endoscopy: malignant ulcer: irregular base and irregular folds Treatment Surgery Only chance for cure for 25-30% of patients Medical therapy Somewhat responsive to chemotherapy Radiation alone is ineffective Combination chemo + radiation improves survival from 27 mo to 36 mo vs surgery alone Gastric Lymphoma General considerations Can be primary or mets from elsewhere by lymph spread 95% are non-Hodgkin B cell lymphoma Risk factor: H. pylori infection increased by 6-fold Clinical presentation Same as adenocarcinoma Dyspepsia, weight loss or anemia Diagnosis Endoscopic biopsy Findings: thickened folds, mass, ulcer 10 Treatment Depends on staging With or without radiation or chemo ZES (Gastrinoma) General considerations Gastrin-secreting tumor Consider this diagnosis in patients with refractory PUD Only 1% of PUD cases are caused by ZES Most common locations: duodenum/pancreas 1/3 associated with MEN-1 Clinical manifestations PUD symptoms refractory to treatment Hearburn 20% Secretory diarrhea
Load more

Recommended publications
  • Is Pylorus Resecting Pancreaticoduodenectomy a Better Surgical Alternative Than Pylorus Preserving Pancreaticoduodenectomy Regarding Delayed Gastric Emptying?
    Editorial Page 1 of 3 Is pylorus resecting pancreaticoduodenectomy a better surgical alternative than pylorus preserving pancreaticoduodenectomy regarding delayed gastric emptying? Shengliang He, Jin He Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Correspondence to: Jin He, MD, PhD, FACS. Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 665, Baltimore, MD 21287, USA. Email: [email protected]. Provenance: This is an invited Editorial commissioned by Section Editor Dr. Ang Li (Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing 100053, China). Comment on: Hackert T, Probst P, Knebel P, et al. Pylorus Resection Does Not Reduce Delayed Gastric Emptying After Partial Pancreatoduodenectomy: A Blinded Randomized Controlled Trial (PROPP Study, DRKS00004191). Ann Surg 2018;267:1021-7. Received: 28 February 2018; Accepted: 19 March 2018; Published: 19 July 2018. doi: 10.21037/dmr.2018.07.04 View this article at: http://dx.doi.org/10.21037/dmr.2018.07.04 Pylorus preserving pancreaticoduodenectomy (PPPD) incidences (5). has been popularized as the surgical approach for patients As the currently largest, randomized controlled trial, with periampullary lesions by Traverso and Longmire PROPP study included 188 patients with statistical since 1978 (1). It was first hypothesized to reduce the superiority hypothesis (pylorus resection is associated occurrence of dumping, diarrhea, bile reflux gastritis and with less DGE than pylorus preservation). In the control improve overall nutritional status compared with classic group, duodenum was divided 2 cm distal to the pylorus. pancreaticoduodenectomy, also known as classic Whipple An antecolic end-to-side (ETS) duodenojejunostomy (CW). Based on the Cochrane database review in 2016, was performed 50 cm distal to the hepaticojejunostomy.
    [Show full text]
  • Vomiting in Children
    Vomiting in Children T. Matthew Shields, MD,* Jenifer R. Lightdale, MD, MPH* *Division of Pediatric Gastroenterology and Nutrition, UMass Memorial Children’s Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA Education Gaps 1. There are at least 4 known physiologic pathways that can trigger vomiting, 3 of which are extraintestinal. 2. Understanding which pathway is causing a patient’s vomiting will help determine best treatment options, including which antiemetic is most likely to be helpful to mitigate symptoms. 3. Bilious emesis in a newborn should indicate bowel obstruction. 4. Cyclic episodes of vomiting may be indicative of a migraine variant. Objectives After completing this article, readers should be able to: 1. Understand the main pathways that trigger vomiting via the emetic reflex. 2. Differentiate among acute, chronic, and cyclic causes of vomiting. 3. Create a broad differential diagnosis for vomiting based on a patient’s history, physical examination findings, and age. 4. Recognize red flag signs and symptoms of vomiting that require emergent evaluation. 5. Recognize when to begin an antiemetic medication. AUTHOR DISCLOSURE Dr Shields has 6. Select antiemetic medications according to the presumed underlying disclosed no financial relationships relevant to this article. Dr Lightdale has disclosed that she mechanism of vomiting. has a research grant from AbbVie and receives honorarium as a speaker for Mead Johnson. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Vomiting is a common symptom of numerous underlying conditions for which children frequently present for healthcare. Although vomiting can originate from ABBREVIATIONS the gastrointestinal (GI) tract itself, it can also signal more generalized, systemic 5-HT 5-hydroxytryptamine disorders.
    [Show full text]
  • Journal of Pediatric Surgery Case Reports 40 (2019) 71–75
    Journal of Pediatric Surgery Case Reports 40 (2019) 71–75 Contents lists available at ScienceDirect Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc Laparoscopic resection of pancreatic neck lesion with Roux-en-Y T pancreatico-jejunostomy ∗ ∗ Martin Sidlera, , Pratik Shahb, Michael Ashworthc, Paolo De Coppia, a Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, United Kingdom b Paediatric Endocrinology, Great Ormond Street Hospital, London, United Kingdom c Paediatric Histopathology, Great Ormond Street Hospital, London, United Kingdom ABSTRACT Background: Congenital hyperinsulinism is a rare disease and patients not re- sponding to medical treatment need near-total or partial pancreatectomy, dependent on whether they have diffuse or focal hyperinsulinism, respectively. While laparoscopic technique for distal and for total pancreatectomy has been developed, minimally invasive resection of the pancreatic neck with pancreatico-jejunostomy has not been reported in children before. Case summary: A 2-year old boy suffered from congenital hyperinsulinism, which was refractory to high-dose medical treatment. The nuclear-medicine scanrevealed a focal lesion of the pancreatic neck, hence partial pancreatectomy was indicated. On laparoscopy, a slightly prominent tissue mass was apparent in the area of the pancreatic neck. We proceeded with laparoscopic mobilisation of the pancreas from the underlying splenic vessels and resected the pancreatic neck and adjacent parts of the body and the head. After macroscopic resection of the mass, the patient's intraoperative blood glucose levels increased to a point where insulin had to be substituted. To drain the pancreatic tail, we formed an end-to-side anastomosis in the proximal Jejunum and brought the open end to the pancreatic tail and performed a laparoscopic pancreatico-jejunostomy.
    [Show full text]
  • Gastroparesis and Dumping Syndrome: Current Concepts and Management
    Journal of Clinical Medicine Review Gastroparesis and Dumping Syndrome: Current Concepts and Management Stephan R. Vavricka 1,2,* and Thomas Greuter 2 1 Center of Gastroenterology and Hepatology, CH-8048 Zurich, Switzerland 2 Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland * Correspondence: [email protected] Received: 21 June 2019; Accepted: 23 July 2019; Published: 29 July 2019 Abstract: Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. Although gastroparesis results from delayed gastric emptying and dumping syndrome from accelerated emptying of the stomach, the two entities share several similarities among which are an underestimated prevalence, considerable impairment of quality of life, the need for a multidisciplinary team setting, and a step-up treatment approach. In the following review, we will present an overview of the most important clinical aspects of gastroparesis and dumping syndrome including epidemiology, pathophysiology, presentation, and diagnostics. Finally, we highlight promising therapeutic options that might be available in the future. Keywords: gastroparesis; dumping syndrome; pathophysiology; clinical presentation; treatment 1. Introduction Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. While gastroparesis results from significantly delayed gastric emptying, dumping syndrome is a consequence of increased flux of food into the small bowel [1,2]. The two entities share several important similarities: (i) gastroparesis and dumping syndrome are frequent, but also frequently overlooked; (ii) they affect patient’s quality of life considerably due to possibly debilitating symptoms; (iii) patients should be taken care of within a multidisciplinary team setting; and (iv) treatment should follow a step-up approach from dietary modifications and patient education to pharmacological interventions and, finally, surgical procedures and/or enteral feeding.
    [Show full text]
  • Endoscopic Approaches to Gastroparesis
    Endoscopic Approaches to Gastroparesis Kevin Liu, MD,1 Thomas Enke, MD,2 and Aziz Aadam, MD1 1Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 2Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois Corresponding author: Abstract: Gastroparesis is a complex syndrome with multiple Dr Aziz Aadam underlying etiologies and pathophysiologies that can cause signif- 676 North Saint Clair St, Suite 1400 icant morbidity for patients. Currently, there are limited effective Chicago, IL 60611 and durable medical and surgical treatments for patients with Tel: (312) 695-3364 E-mail: [email protected] gastroparesis. As such, there has been recent innovation and development in minimally invasive endoscopic treatments for gastroparesis. Endoscopic therapies that have been investigated for gastroparesis include enteral feeding tube placement, intrapyloric botulinum toxin injection, transpyloric stenting, gastric peroral endoscopic myotomy, and gastric electrical stimulation. This article aims to assess the effectiveness of current endoscopic therapies, as well as discuss future directions for endoscopic therapies, in the management of gastroparesis. astroparesis is defined as a complex syndrome of symp- toms, including early satiety, postprandial fullness, nausea, vomiting, bloating, and upper abdominal pain, with a Gcorresponding objective delay in gastric emptying in the absence of mechanical obstruction.1 The primary etiologies
    [Show full text]
  • Laparoscopic Vs. Open Pyloromyotomy in Treatment of Infantile Hypertrophic Pyloric Stenosis
    ORIGINAL RESEARCH published: 21 August 2020 doi: 10.3389/fped.2020.00426 Laparoscopic vs. Open Pyloromyotomy in Treatment of Infantile Hypertrophic Pyloric Stenosis Ibrahim Ismail, Radi Elsherbini, Adham Elsaied, Kamal Aly and Hesham Sheir* Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt Background/Purpose: Laparoscopic pyloromyotomy gained wide popularity in management of pyloric stenosis with contradictory results regarding its benefits over classic open approach. This study aimed at comparing both regarding their safety, efficiency, and outcome. Methods: This is a prospective randomized controlled study performed from April 2017 to April 2019. It included 80 patients, divided randomly into two groups, where laparoscopic pyloromyotomy was performed in group A and open pyloromyotomy Edited by: in group B. Both groups were compared regarding operative time, post-operative Henri Steyaert, pain score, time required to reach full feeding, hospital stay, complications, and Queen Fabiola Children’s University Hospital, Belgium parents’ satisfaction. Reviewed by: Results: Median operative time was 21 min in group A vs. 30 min in group B (P = 0). Oliver J. Muensterer, Johannes Gutenberg University Pain Assessment in Neonates scores were generally higher in group B with more doses Mainz, Germany of analgesics required (P = 0). Mean time needed to reach full feeding was 15.2 and Matthijs Oomen, 18.8 h in groups A and B, respectively (P = 0). Median hospital stay was 19 h in group Amsterdam University Medical Centers – AMC, Netherlands A and 22 h in group B (P = 0.004). Parents’ satisfaction also was in favor of group *Correspondence: A (P = 0.045). Although no significant difference was reported between both groups Hesham Sheir regarding early and late complications, some complications such as mucosal perforation [email protected] and incomplete pyloromyotomy occurred in the laparoscopic group only.
    [Show full text]
  • Endoscopic Pyloromyotomy for Postesopha- Gectomy Gastric Outlet Obstruction
    Cases and Techniques Library (CTL) E345 Endoscopic pyloromyotomy for postesopha- gectomy gastric outlet obstruction Fig. 1 A 54-year-old woman presented with vomiting 2 weeks after esophagectomy with gastric pull-up. a Esophagography revealed marked delay in passage of contrast through the pylorus. b Fluid retention was noted on esophago- gastroduodenoscopy (EGD) and the scope could not be passed through the pylorus. Postesophagectomy gastric outlet ob- vomiting. Esophagogastroduodenoscopy The mucosal entry was then closed using struction occurs in 20% –30% of patients (EGD) revealed significant food stasis in four endoscopic clips (●" Video 1). who undergo esophagectomy and is asso- the pulled-up stomach and again the en- On the following day, fluoroscopy showed ciated with significant morbidity and de- doscope could not be passed through the significant improvement in passage of layed recovery [1]. Recently, endoscopic pylorus. contrast (●" Fig. 3) and the gastroscope pyloromyotomy, also called gastric per- Endoscopic pyloromyotomy was per- (GIF-H260; Olympus) could pass smooth- oral endoscopic myotomy (POEM), has formed with the patient under conscious ly through the pylorus. The patient was been reported, in pigs and in a patient sedation. Saline solution mixed with indi- started on a liquid diet and was dis- with refractory diabetic gastroparesis [2, go carmine was injected on the greater charged the next day. She remains well 3]. We report a case of postesophagec- curvature 5cm proximal to the pylorus. A 10 weeks after the procedure and appro- tomy delayed gastric emptying that was 1.5-cm mucosal incision was made priately tolerates a general diet. successfully treated with endoscopic (●" Fig.2) using a DualKnife (KD-650L; pyloromyotomy.
    [Show full text]
  • Basic Surgical Techniques
    BASIC SURGICAL TECHNIQUES Textbook Authors: György Wéber MD, PhD, med. habil. János Lantos MSc, PhD Balázs Borsiczky MD, PhD Andrea Ferencz MD, PhD Gábor Jancsó MD, PhD Sándor Ferencz MD Szabolcs Horváth MD Hossein Haddadzadeh Bahri MD Ildikó Takács MD Borbála Balatonyi MD University of Pécs, Medical School Department of Surgical Research and Techniques 20 Kodály Zoltán Steet, H-7624 Pécs, Telephone: +36 72 535 820 Website:http://soki.aok.pte.hu 2008 1 PREFACE The healing is impossible without entering into suffering people’s feelings and to humble yourself in your profession. All these are completed by the ability to manage the immediate and critical situations dynamically and to analyze the diseases interdisciplinarily (e.g. diagnosis, differential diagnosis, appropriate decision among the alternative possibilities of treatment, etc.). A successful surgical intervention requires even more than this. It needs the perfect, aimful and economical coordination of operational movements. The refined technique of the handling and uniting the tissues –in the case of manual skills– is attainable by many practices, and the good surgeon works on the perfection of this technique in his daily operating activities. The most important task in the medical education is to teach the problem-oriented thinking and the needed practical ability. The graduate medical student will notice in a short time that a medical practitioner principally needs the practical knowledge and manual skill in provision for the sick. “The surgical techniques” is a popular subJect. It is a subJect in which the medical students -for the first time- will see the inside of the living and pulsating organism.
    [Show full text]
  • Endoscopic Innovations in Gastric and Pyloric Disease
    9 Review Article Page 1 of 9 Endoscopic innovations in gastric and pyloric disease Megan Lundgren, John Rodriguez General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: Both authors; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors. Correspondence to: Megan Lundgren, MD. Advanced Laparoscopic/Endoscopic Fellow, General Surgery, Digestive Disease Institute, 9500 Euclid Ave. Desk A100, Cleveland Clinic, Cleveland, OH 44195, USA. Email: [email protected]. Abstract: Endoluminal surgery has innovated the management of foregut disorders including gastric motility disorders such as gastroparesis, upper gastrointestinal (GI) neoplasms including early-stage gastric cancer, gastric outlet obstruction, and management of post-operative foregut complications. Foregut pathologies that would have otherwise required abdominal incisions can now be successfully managed in the most minimally invasive available fashion. Intramural intervention, such as that used for per-oral pyloromyotomy (POP) which will be described here, has revolutionized the treatment of motility disorders of the foregut. Many aspects of the techniques described in this chapter share and build off of one another and several of the endoscopic instruments utilized are also shared across procedures. This is one of the many reasons endoluminal surgery has blossomed over the last two decades. To truly flourish as a foregut surgeon is to have the capability to perform the open, laparoscopic and the existing and future endoscopic alternatives of procedures of this specialty, as well as to manage complications in an endoscopic fashion when possible.
    [Show full text]
  • Physicians As Assistants at Surgery: 2016 Update
    Physicians as Assistants at Surgery: 2016 Update Participating Organizations: American College of Surgeons American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of Otolaryngology – Head and Neck Surgery American Association of Neurological Surgeons American Pediatric Surgical Association American Society of Colon and Rectal Surgeons American Society of Plastic Surgeons American Society of Transplant Surgeons American Urological Association Congress of Neurological Surgeons Society for Surgical Oncology Society for Vascular Surgery Society of American Gastrointestinal Endoscopic Surgeons The American College of Obstetricians and Gynecologists The Society of Thoracic Surgeons Physicians as Assistants at Surgery: 2016 Update INTRODUCTION This is the seventh edition of Physicians as Assistants at Surgery, a study first undertaken in 1994 by the American College of Surgeons and other surgical specialty organizations. The study reviews all procedures listed in the “Surgery” section of the 2016 American Medical Association’s Current Procedural Terminology (CPT TM). Each organization was asked to review new codes since 2013 that are applicable to their specialty and determine whether the operation requires the use of a physician as an assistant at surgery: (1) almost always; (2) almost never; or (3) some of the time. The results of this study are presented in the accompanying report, which is in a table format. This table presents information about the need for a physician as an assistant at surgery. Also, please note that an indication that a physician would “almost never” be needed to assist at surgery for some procedures does NOT imply that a physician is never needed. The decision to request that a physician assist at surgery remains the responsibility of the primary surgeon and, when necessary, should be a payable service.
    [Show full text]
  • Variations Between Hospitals in Antireflux Procedures in Children
    ARTICLE Variations Between Hospitals in Antireflux Procedures in Children Adam B. Goldin, MD, MPH; Michelle Garrison, PhD; Dimitri Christakis, MD, MPH Objective: To examine the differences and trends in nonincidental appendectomies, 14 895 pyloromyoto- pediatric antireflux procedures (ARPs) across individual mies, and 23 527 gastrostomy tube placements were pediatric hospitals over time. identified. The average number of ARPs per appendec- tomy, pyloromyotomy, and gastrostomy tube place- Design: Retrospective cohort study. ment declined annually across free-standing pediatric institutions. When these annual changes are examined Setting: Administrative database containing inpatient within each hospital individually, however, it appears records with discharge dates between January 1, 2001, that such changes are not occurring equally, in that and March 31, 2006. some hospitals are performing significantly greater and some significantly fewer ARPs relative to these common Participants: Hospitalized pediatric patients younger procedures. than 18 years with primary procedure codes for ARP, ap- pendectomy, pyloromyotomy, and gastrostomy tube Conclusions: The number of ARPs being performed in placement. The comparisons with admissions for these 36 free-standing children’s hospitals is decreasing each common procedures were used to identify changes in the year relative to several operations commonly performed incidence of ARP per hospital per year. at these institutions. Despite this overall annual de- Main Outcome Measures: The ratio of ARPs to ap- crease, there is tremendous variation between indi- pendectomies, pyloromyotomies, gastrostomies, and all vidual hospitals in how frequently ARPs are being per- 3 procedures combined, in each hospital by year. formed relative to these procedures. Results: During our study period 13 691 ARPs, 41 441 Arch Pediatr Adolesc Med.
    [Show full text]
  • Long-Term Outcome of Gastric Per-Oral Endoscopic 63 6 64 7 Pyloromyotomy in Treatment of Gastroparesis 65 8 66 9 Q9 Mohamed M
    Clinical Gastroenterology and Hepatology 2020;-:-–- 1 59 2 60 3 61 4 62 5 Long-Term Outcome of Gastric Per-Oral Endoscopic 63 6 64 7 Pyloromyotomy in Treatment of Gastroparesis 65 8 66 9 Q9 Mohamed M. Abdelfatah, Alan Noll, Neil Kapil, Rushikesh Shah, Lianyong Li, 67 10 Rosemary Nustas, Baiwen Li, Hui Luo, Huimin Chen, Liang Xia, 68 11 Parit Mekaroonkamol, Nikrad Shahnavaz, Steven Keilin, Field Willingham, 69 12 Jennifer Christie, and Qiang Cai 70 13 71 14 72 Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia 15 73 16 74 BACKGROUND & AIMS: Gastric per oral endoscopic pyloromyotomy (GPOEM) is a promising treatment for gastro- 17 paresis. There are few data on the long-term outcomes of this procedure. We investigated long- 75 18 term outcomes of GPOEM treatment of patients with refractory gastroparesis. 76 19 77 20 METHODS: We conducted a retrospective case-series study of all patients who underwent GPOEM for re- 78 21 fractory gastroparesis at a single center (n [ 97), from June 2015 through March 2019; 90 79 22 patients had more than 3 months follow-up data and were included in our final analysis. We 80 23 collected data on gastroparesis cardinal symptom index (GCSI) scores (measurements of 81 24 postprandial fullness or early satiety, nausea and vomiting, and bloating) and SF-36 question- 82 25 naire scores (measures quality of life). The primary outcome was clinical response to GPOEM, 83 26 defined as a decrease of at least 1 point in the average total GCSI score with more than a 25% 84 fi 27 decrease in at least 2 subscales of cardinal symptoms.
    [Show full text]