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Nishiyama S, Uchino S, Sasabuchi Y, Masuyama T, Lefor AK, Sanui M. Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study. PLoS One 2024; 19:e0295952. [PMID: 38170714 PMCID: PMC10763934 DOI: 10.1371/journal.pone.0295952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. METHODS In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation. RESULTS A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71-3.75, p < 0.001]. CONCLUSION The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.
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Affiliation(s)
- Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tomoyuki Masuyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Omiya, Saitama, Japan
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Watanabe J, Kakehi E, Okamoto M, Ishikawa S, Kataoka Y. Electromagnetic-guided versus endoscopic-guided postpyloric placement of nasoenteral feeding tubes. Cochrane Database Syst Rev 2022; 10:CD013865. [PMID: 36189639 PMCID: PMC9527636 DOI: 10.1002/14651858.cd013865.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine. Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access. OBJECTIVES To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement. SEARCH METHODS We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. We contacted the study authors for missing data. SELECTION CRITERIA We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach. MAIN RESULTS We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials. Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence). Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.
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Affiliation(s)
- Jun Watanabe
- Center for Community Medicine, Jichi Medical University, Tochigi, Japan
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Tochigi, Japan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Eiichi Kakehi
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Masaru Okamoto
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
| | | | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
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3
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Yan Y, Chen Y, Zhang X. The effect of opioids on gastrointestinal function in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:370. [PMID: 34689805 PMCID: PMC8543814 DOI: 10.1186/s13054-021-03793-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 12/31/2022]
Abstract
Gastrointestinal (GI) dysfunction is common in the critical care setting and is highly associated with clinical outcomes. Opioids increase the risk for GI dysfunction and are frequently prescribed to reduce pain in critically ill patients. However, the role of opioids in GI function remains uncertain in the ICU. This review aims to describe the effect of opioids on GI motility, their potential risk of increasing infection and the treatment of GI dysmotility with opioid antagonists in the ICU setting.
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Affiliation(s)
- Yun Yan
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yu Chen
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
| | - Xijing Zhang
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
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Gupta P, Sankar J, Kumar BK, Jat KR, Mukherjee A, Kapil A, Kabra SK, Lodha R. Twenty-Four-Hour Esophageal pH Measurement in Mechanically Ventilated Children: A Prospective Cohort Study. Pediatr Crit Care Med 2021; 22:e203-e212. [PMID: 33534390 DOI: 10.1097/pcc.0000000000002664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To assess the prevalence of gastroesophageal reflux in mechanically ventilated children using 24-hour esophageal pH-metry and its role as a risk factor for ventilator-associated pneumonia. DESIGN Prospective cohort study. SETTING PICU of a tertiary care hospital from North India. PATIENTS Mechanically ventilated children 1-15 years old in PICU from July 2015 to June 2017, excluding those receiving acid suppressants, known cases of gastroesophageal reflux disease, having upper gastrointestinal bleed. INTERVENTION Demographic details, baseline investigations, diagnosis, treatment details, and Pediatric Risk of Mortality III score were recorded at enrollment. Gastroesophageal reflux was evaluated using 24-hour esophageal pH-metry. Children were followed up for 7 days or 48 hours after extubation for development of ventilator-associated pneumonia using Centers for Disease Control and Prevention criteria. Pathologic acidic gastroesophageal reflux was defined as fall in esophageal pH less than 4 for more than 4% of total time, whereas pathologic alkaline gastroesophageal reflux as rise in esophageal pH greater than 7 for more than 17% of total time. MEASUREMENTS AND MAIN RESULTS Sixty-one children (median [interquartile range], age 73 mo [30-132 mo]; 44 boys [72%]) were enrolled. Median Pediatric Risk of Mortality III score was 10.0 (3-16). Median duration of ventilation was 6 days (3-9 d). Pathologic gastroesophageal reflux (acidic or alkaline) was present in 47 children (77%). Twelve children (19.7%) met criteria for pathologic acidic gastroesophageal reflux, whereas 44 children (72.1%) had pathologic alkaline gastroesophageal reflux; nine children (14.7%) had both pathologic acidic and alkaline gastroesophageal reflux. Of the enrolled children, 17 (27.9 %) developed ventilator-associated pneumonia. No patient had both pathologic acidic gastroesophageal reflux and ventilator-associated pneumonia. Of 17 children who developed ventilator-associated pneumonia, 12 (70.5%) had pathologic alkaline gastroesophageal reflux as compared to 32 children (72.7%) among the 44 children who did not develop ventilator-associated pneumonia (p = 0.87). CONCLUSIONS The current study shows high incidence of gastroesophageal reflux on 24-hour esophageal pH-metry in mechanically ventilated children with medical diagnoses. The significance of this finding and its impact on ventilator-associated pneumonia and other ventilator-associated events need to be examined in larger studies.
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Affiliation(s)
- Priyanka Gupta
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - B Kiran Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arti Kapil
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Watanabe J, Kakehi E, Okamoto M, Ishikawa S, Kataoka Y. Electromagnetic guided versus endoscopic guided postpyloric placement of nasoenteral feeding tubes. Hippokratia 2021. [DOI: 10.1002/14651858.cd013865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jun Watanabe
- Center for Community Medicine; Jichi Medical University; Tochigi Japan
| | - Eiichi Kakehi
- Department of General Medicine; Tottori Municipal Hospital; Tottori Japan
| | - Masaru Okamoto
- Department of General Internal Medicine; Tottori Prefectural Central Hospital; Tottori Japan
| | | | - Yuki Kataoka
- Department of Respiratory Medicine; Hyogo Prefectural Amagasaki General Medical Center; Hyogo Japan
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Siddiqui AH, Ahmed M, Khan TMA, Abbasi S, Habib S, Khan HM, Rajdev K, Narula N, Siddiqui F. Trends and Outcomes of Gastrointestinal Bleeding Among Septic Shock Patients of the United States: A 10-Year Analysis of a Nationwide Inpatient Sample. Cureus 2020; 12:e8029. [PMID: 32399377 PMCID: PMC7212718 DOI: 10.7759/cureus.8029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Gastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking. Methods We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB. Results The weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) [70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively]. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay [20.56 (0.61) vs. 15.76 (0.13) P < 0.001], higher mortality [54% vs. 45% P < 0.001], and higher admission costs in United States dollar ($) (mean/SEM) [$192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001]. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB [odds ratio: 0.57, P = 0.0008]. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS. Conclusion GIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.
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Affiliation(s)
- Abdul Hasan Siddiqui
- Pulmonary and Critical Care Medicine, University of Illinois Urbana Champaign, Champaign, USA
| | - Moiz Ahmed
- Gastroenterology, Icahn School of Medicine at Elmhurst Hospital Center, Elmhurst, USA.,Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Tahir Muhammad Abdullah Khan
- Internal Medicine, Marshfield Medical Center, Marshfield, USA.,Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Saqib Abbasi
- Hematology/Oncology, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Saad Habib
- Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Hafiz M Khan
- Gastroenterology and Hepatology, Guthrie Medical Group/Robert Packer Hospital, Sayre, USA
| | - Kartikeya Rajdev
- Pulmonary and Critical Care Medicine, University of Nebraska Medical Center, Omaha, USA
| | - Naureen Narula
- Pulmonary and Critical Care Medicine, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Faraz Siddiqui
- Pulmonary and Critical Care Medicine, Robert Packer Hospital, Sayre, USA
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Liu Y, Li D, Wen A. Pharmacologic Prophylaxis of Stress Ulcer in Non-ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Clin Ther 2020; 42:488-498.e8. [PMID: 32046894 DOI: 10.1016/j.clinthera.2020.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Acid-suppressive medications are widely used in non-intensive care unit (non-ICU) patients for stress ulcer (SU) prophylaxis. However, SU prophylaxis in this population is still controversial. The purpose of this study was to systematically evaluate the efficacy and tolerability of these agents for SU prophylaxis in non-ICU patients. METHODS Electronic databases including Cochrane, ClinicalTrials.gov, Ovid-Medline, Embase, Chinese CNKI, and Wanfang Data were systematically searched on July 10, 2019, for randomized controlled trials (RCTs) that evaluated acid-suppressive medications in non-ICU patients. Network meta-analysis and pairwise meta-analysis were performed to calculate odds ratios (ORs) and 95% CIs. A random-effects model was used for generating pooled estimates. The primary outcome was occurrence of SU bleeding, and the adverse drug events (ADEs) were described as the secondary outcome. FINDINGS A total of 17 RCTs involving 1985 patients were eligible. Meta-analysis results indicated that the occurrence of SU bleeding was significantly decreased with all acid-suppressive medications compared with placebos (gastric mucosa protectants, OR = 0.29 [95% CI, 0.14-0.61]; H2-receptor antagonists, OR = 0.3 [95% CI, 0.18-0.50]; proton pump inhibitors [PPIs]: OR = 0.08 [95% CI, 0.04-0.16]). The occurrence of SU bleeding was significantly decreased with PPIs compared with gastric mucosa protectants (OR = 0.29; 95% CI, 0.12-0.72) and H2-receptor antagonists (OR = 0.28; 95% CI, 0.16-0.48). There was no significant difference between any 2 classes of PPIs on SU bleeding or any 2 acid-suppressive medications on ADEs. IMPLICATIONS PPIs could significantly decrease SU bleeding risk without increasing ADEs than other acid-suppressive medications for SU prophylaxis in non-ICU patients. However, RCTs of high quality were required to confirm the findings of this investigation.
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Affiliation(s)
- Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients. Results from the MOTION trial. Intensive Care Med 2020; 46:747-755. [PMID: 32016532 PMCID: PMC7223905 DOI: 10.1007/s00134-019-05913-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Purpose Constipation can be a significant problem in critically unwell patients, associated with detrimental outcomes. Opioids are thought to contribute to the mechanism of bowel dysfunction. We tested if methylnaltrexone, a pure peripheral mu-opioid receptor antagonist, could reverse opioid-induced constipation. Methods The MOTION trial is a multi-centre, double blind, randomised placebo-controlled trial to investigate whether methylnaltrexone alleviates opioid-induced constipation (OIC) in critical care patients. Eligibility criteria included adult ICU patients who were mechanically ventilated, receiving opioids and were constipated (had not opened bowels for a minimum 48 h) despite prior administration of regular laxatives as per local bowel management protocol. The primary outcome was time to significant rescue-free laxation. Secondary outcomes included gastric residual volume, tolerance of enteral feeds, requirement for rescue laxatives, requirement for prokinetics, average number of bowel movements per day, escalation of opioid dose due to antagonism/reversal of analgesia, incidence of ventilator-associated pneumonia, incidence of diarrhoea and Clostridium difficile infection and finally 28 day, ICU and hospital mortality. Results A total of 84 patients were enrolled and randomized (41 to methylnaltrexone and 43 to placebo). The baseline demographic characteristics of the two groups were generally well balanced. There was no significant difference in time to rescue-free laxation between the groups (Hazard ratio 1.42, 95% CI 0.82–2.46, p = 0.22). There were no significant differences in the majority of secondary outcomes, particularly days 1–3. However, during days 4–28, there were fewer median number of bowel movements per day in the methylnaltrexone group, (p = 0.01) and a greater incidence of diarrhoea in the placebo group (p = 0.02). There was a marked difference in mortality between the groups, with ten deaths in the methylnaltrexone group and two in the placebo group during days 4–28 (p = 0.007). Conclusion We found no evidence to support the addition of methylnaltrexone to regular laxatives for the treatment of opioid-induced constipation in critically ill patients; however, the confidence interval was wide and a clinically important difference cannot be excluded. Electronic supplementary material The online version of this article (10.1007/s00134-019-05913-6) contains supplementary material, which is available to authorized users.
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Siddiqui F, Ahmed M, Abbasi S, Avula A, Siddiqui AH, Philipose J, Khan HM, Khan TMA, Deeb L, Chalhoub M. Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis. J Clin Med Res 2018; 11:42-48. [PMID: 30627277 PMCID: PMC6306132 DOI: 10.14740/jocmr3660] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 12/24/2022] Open
Abstract
Background The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB. Methods ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions. Results We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB. Conclusion Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.
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Affiliation(s)
- Faraz Siddiqui
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Moiz Ahmed
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Saqib Abbasi
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Akshay Avula
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Abdul Hasan Siddiqui
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Jobin Philipose
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Hafiz M Khan
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, NY, USA
| | - Tahir M A Khan
- Department of Internal Medicine, Marshfield Clinic, WI, USA
| | - Liliane Deeb
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, NY, USA
| | - Michel Chalhoub
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
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10
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Marr AB, McQuiggan MM, Kozar R, Moore FA. Gastric Feeding as an Extension of an Established Enteral Nutrition Protocol. Nutr Clin Pract 2017; 19:504-10. [PMID: 16215146 DOI: 10.1177/0115426504019005504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Indiscriminate gastric feeding in ICU patients imposes unacceptable risks of aspiration. Believing that a subset of ICU patients can be fed safely via the stomach, we have developed a protocol to identify appropriate patients and guide the bedside clinician in how to safely and effectively feed via the stomach. METHODS A literature search was done to identify appropriate medical literature. High grade evidence along with local expert opinions were used to develop a protocol. This protocol has been refined and implemented. RESULTS Based on perceived risk of aspiration, patients are assigned enteral access (ie, stomach vs. distal post-pyloric). Enteral formula is selected based on patient characteristics. It is then advanced by a standard protocol with specific precautions while monitoring for symptoms of intolerance. Management of intolerance is dictated by the type and severity of intolerance. CONCLUSION We have implemented a gastric feeding into a subset of our ICU patients. Gastric feeding requires certain precautions but appears to be safe. With more experience and better understanding of the pathogenesis gastroparesis, we believe that most ICU patients should be able to safely feed into the stomach. This is logistically easier than post-pyloric feeding and offers physiologic advantages.
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Affiliation(s)
- Alan B Marr
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, USA
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11
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Gastric reflux: association with aspiration and oral secretion pH as marker of reflux: a descriptive correlational study. Dimens Crit Care Nurs 2016; 34:84-90. [PMID: 25650493 DOI: 10.1097/dcc.0000000000000096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Gastric reflux leading to pulmonary aspiration is a frequent event in mechanically ventilated, gastric-fed patients, which can lead to ventilator-associated complications and pneumonia. OBJECTIVES The objectives of this study were to determine the association between gastric reflux and aspiration using the presence of pepsin in oral or tracheal secretions as a marker of reflux or aspiration and to determine the association between the pH (range, 0-14) and the presence of pepsin in oral secretions. METHODS A descriptive correlational study was conducted in mechanically ventilated surgical or medical patients receiving gastric tube feedings. Oral secretions were suctioned hourly and tracheal secretions every 2 to 3 hours for 12-hour periods over 1 to 2 days in 15 patients. RESULTS There were 142 paired samples of oral tracheal secretions. A majority of samples (60%) had the same results, with 32% both pepsin-positive and 27% both pepsin-negative. The range of pH measurements was 4 to 8, with a mean of 6.3 ± 0.05. Ninety oral specimens had a pH of 4 to 6. Forty-seven of the oral specimens with pH measures between 4 and 6 (52%) were pepsin-positive. The correlation of pH percent pepsin-positive oral secretions was not significant. CONCLUSION Aspiration events were more frequent than reflux events. Measurement of actual pepsin concentration to detect new reflux and aspiration events is recommended in future studies. Bedside pH measures of oral secretions are not a valid marker of gastric reflux.
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Patel PB, Brett SJ, O'Callaghan D, Anjum A, Cross M, Warwick J, Gordon AC. Protocol for a randomised control trial of methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients (MOTION). BMJ Open 2016; 6:e011750. [PMID: 27412108 PMCID: PMC4947806 DOI: 10.1136/bmjopen-2016-011750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Gastrointestinal dysmotility and constipation are common problems in intensive care patients. The majority of critical care patients are sedated with opioids to facilitate tolerance of endotracheal tubes and mechanical ventilation, which inhibit gastrointestinal motility and lead to adverse outcomes. Methylnaltrexone is a peripheral opioid antagonist that does not cross the blood-brain barrier and can reverse the peripheral side effects of opioids without affecting the desired central properties. This trial will investigate whether methylnaltrexone can reverse opioid-induced constipation and gastrointestinal dysmotility. METHODS This is a single-centre, multisite, double-blind, randomised, placebo-controlled trial. 84 patients will be recruited from 4 intensive care units (ICUs) within Imperial College Healthcare NHS Trust. Patients will receive intravenous methylnaltrexone or placebo on a daily basis if they are receiving opioid infusion to facilitate mechanical ventilation and have not opened their bowels for 48 hours. All patients will receive standard laxatives as per the clinical ICU bowel protocol prior to randomisation. The primary outcome of the trial will be time to significant rescue-free laxation following randomisation. Secondary outcomes will include tolerance of enteral feed, gastric residual volumes, incidence of pneumonia, blood stream and Clostridium difficile infection, and any reversal of central opioid effects. ETHICS AND DISSEMINATION The trial protocol, the patient/legal representative information sheets and consent forms have been reviewed and approved by the Harrow Research Ethics Committee (REC Reference 14/LO/2004). An independent Trial Steering Committee and Data Monitoring Committee are in place, with patient representation. On completion, the trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. TRIAL REGISTRATION NUMBER 2014-004687-37; Pre-results.
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Affiliation(s)
- Parind B Patel
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - David O'Callaghan
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - Aisha Anjum
- Imperial Clinical Trials Unit, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Mary Cross
- Imperial Clinical Trials Unit, Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Jane Warwick
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Anthony C Gordon
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
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Hallal C, Chaves VS, Borges GC, Werlang IC, Fontella FU, Matte U, Goldani MZ, Carvalho PR, Trotta EA, Piva JP, Barros SGS, Goldani HAS. Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children. Chest 2015; 148:333-339. [PMID: 25654241 DOI: 10.1378/chest.14-1967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.
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Affiliation(s)
- Cristiane Hallal
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil.
| | - Veridiana S Chaves
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Gilberto C Borges
- Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Isabel C Werlang
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Fernanda U Fontella
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Ursula Matte
- Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Marcelo Z Goldani
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Paulo R Carvalho
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Eliana A Trotta
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Jefferson P Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Sergio G S Barros
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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14
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[Enteral nutrition therapy in critical care : Current knowledge, controversies, and practical implementation]. Med Klin Intensivmed Notfmed 2015; 111:330-40. [PMID: 26091922 DOI: 10.1007/s00063-015-0048-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 01/05/2023]
Abstract
Nutrition therapy is a cornerstone in critical care. Early enteral feeding in patients who are unable to meet caloric requirements from oral intake is associated with better clinical outcomes. However, there are still uncertainties about optimal timing, dose, and formula selection of enteral nutrition in critically ill patients. In the present article, an overview of current knowledge and practical strategies for successful implementation of enteral nutrition in intensive care patients is given.
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Silk DBA, Quinn DG. Dual-Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes. JPEN J Parenter Enteral Nutr 2014; 39:531-43. [PMID: 25261414 DOI: 10.1177/0148607114551966] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 08/18/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The importance of early postoperative nutrition in surgical patients and early institution of enteral nutrition in intensive care unit (ICU) patients have recently been highlighted. Unfortunately, institution of enteral feeding in both groups of patients often has to be postponed due to delayed gastric emptying and the need for gastric decompression. The design of current polyvinylchloride (PVC) gastric decompression tubes (Salem Sump [Covidien, Mansfield, MA] in the United States; Ryles [Penine Health Care Ltd, Derby, UK] in the United Kingdom and Europe) make them unsuitable for their subsequent use as either nasogastric enteral feeding tubes or for continued gastric decompression during postpyloric enteral feeding. To overcome these problems, we have designed a range of polyurethane (PU) dual-purpose gastric decompression and enteral feeding tubes that include 2 nasogastric tubes (double lumen to replace Salem Sump; single lumen to replace Ryles). Two novel multilumen nasogastrojejunal tubes (triple lumen for the United States; double lumen for the United Kingdom and Europe) complete the range. By using PU, a given internal diameter (ID) and flow area can be incorporated into a lower outside diameter (OD) compared with that achieved with PVC. The ID and lumen and flow area of an 18Fr (OD 6.7 mm) PVC Salem Sump can be incorporated into a 14Fr (OD 4.7 mm) PU tube. The design of aspiration/infusion ports of current PVC and PU tubes invites occlusion by gastrointestinal mucosa and clogging by mucus and enteral feed. To overcome this, we have designed long, single, widened, smooth, and curved edge ports with no "dead space" to trap mucus or curdled diet. Involving up to 214° of the circumference, these ports have up to 11 times the flow areas of the aspiration ports of current PVC tubes. CONCLUSION The proposed designs will lead to the development of dual-purpose nasogastric and nasojejunal tubes that will significantly improve the clinical and nutrition care of postoperative and ICU patients.
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Affiliation(s)
- David B A Silk
- Department of Academic Surgery, Imperial College London, United Kingdom
| | - David G Quinn
- Research & Development, Radius International LP, Grayslake, Illinois
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Silk DBA. The Canadian Critical Care Nutrition Guidelines in 2013: Importance of Nasojejunal Enteral Feeding Tube Design in Improving Rates of Small Bowel Enteral Feeding in Patients With High Gastric Residual Volumes. Nutr Clin Pract 2014; 29:559-560. [PMID: 25030739 DOI: 10.1177/0884533614538286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Abstract
Advances in surgery, anesthesia and intensive care have led to a dramatic increase in the number of patients who spend time in our intensive care units (ICU). Gastrointestinal (GI) motility disorders are common complications in the intensive care setting and are predictors of increased mortality and length of the stay in the ICU. Several risk factors for developing GI motility problems in the ICU setting have been identified and include sepsis, being on mechanical ventilation and the use of vasopressors, opioids or anticholinergic medications. Our focus is on the most common clinical manifestations of GI motor dysfunction in the ICU patient: gastroesophageal reflux, gastroparesis, ileus and acute pseudo-obstruction of the colon.
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Affiliation(s)
- Abimbola Adike
- Department of Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas, USA
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Abstract
Gastroesophageal reflux (GER) is a common occurrence in critically ill, mechanically ventilated patients. Reflux can lead to pulmonary aspiration of gastric contents and subsequent pneumonia. Several characteristics of patients, interventions provided in the intensive care unit setting, and factors associated with feeding increase a patient's risk for reflux. Critical care nurses and clinical nurse specialists can identify patients at highest risk for GER by utilizing the patient's history, reviewing the medications, and assessing the current status to provide interventions to reduce the risk of GER and its sequelae of aspiration pneumonia. This article reviews the physiology of GER, risk factors, and interventions to decrease GER in the critically ill patient.
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Solana MJ, Sánchez C, López-Herce J, Crespo M, Sánchez A, Urbano J, Botrán M, Bellón JM, Carrillo A. Multichannel intraluminal impedance to study gastroesophageal reflux in mechanically ventilated children in the first 48 h after PICU admission. Nutrition 2013; 29:972-6. [PMID: 23453552 DOI: 10.1016/j.nut.2013.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 01/03/2013] [Accepted: 01/04/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of this study was to determine the incidence, characteristics, related factors, and clinical implications of gastroesophageal reflux (GER) in critically ill children using esophageal pH monitoring and multichannel intraluminal impedance. METHODS A prospective observational clinical study was performed including 36 non-enterally fed critically ill children with mechanical ventilation, aged 1 mo to 7 y, in the first 48 h after admission in the pediatric intensive care unit (PICU). Esophageal pH monitoring and multichannel intraluminal impedance were used. RESULTS Multichannel intraluminal impedance detected 352 episodes of GER (20.1% acid, 53.8% weak acid, 26% alkaline), whereas pH monitoring detected 171 episodes (100% acid). There were no differences in the type of reflux according to age and no differences in the number or type of reflux according to the administration of inotropic or sedatives drugs or the duration of mechanical ventilation. Patients treated with vecuronium had fewer episodes of GER than those without muscle relaxant drugs. CONCLUSIONS The incidence of GER in non-enterally fed critically ill children with mechanical ventilation is high in the first 48 h after admission to the PICU. Multichannel intraluminal impedance is more sensitive than pH monitoring for establishing the diagnosis of GER because the refluxate is alkaline or weak acid in the majority of episodes. Patients who received muscle relaxants had a lower frequency of GER.
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Affiliation(s)
- Maria José Solana
- Pediatric Intensive Care Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Gastroesophageal reflux in critically ill children: a review. ISRN GASTROENTEROLOGY 2013; 2013:824320. [PMID: 23431462 PMCID: PMC3572643 DOI: 10.1155/2013/824320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/10/2013] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile.
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21
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Mutlu GM, Mutlu EA, Factor P. Prevention and Treatment of Gastrointestinal Complications in Patients on Mechanical Ventilation. ACTA ACUST UNITED AC 2012; 2:395-411. [PMID: 14719992 DOI: 10.1007/bf03256667] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.
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Affiliation(s)
- Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Evanston Northwestern Healthcare, Evanston Illinois and Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Nakabayashi T, Mochiki E, Kamiyama Y, Kuwano H. Gastric motor activity in gastric pull-up esophagectomized patients with and without reflux symptoms. Ann Thorac Surg 2012; 94:1114-7. [PMID: 22884594 DOI: 10.1016/j.athoracsur.2012.05.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 05/28/2012] [Accepted: 05/31/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients frequently experience reflux symptoms of heartburn and regurgitation after a gastric pull-up esophagectomy. The pathogenesis of reflux symptoms is not fully understood. The gastrointestinal tract exhibits a temporally coordinated cyclic motor pattern, termed interdigestive migrating motor contraction, during the interdigestive state. Phase III of interdigestive migrating motor contraction is important in cleaning indigestible solids and basal secretions. Impairment of phase III may result in reflux symptoms of heartburn and regurgitation. The present study evaluated whether gastropyloroduodenal motility after gastric pull-up esophagectomy influences the pathogenesis of reflux symptoms. METHODS Gastropyloroduodenal motility was recorded by manometry in 20 patients after a gastric pull-up esophagectomy. Esophagectomized patients were questioned about the presence of heartburn or regurgitation, or both. RESULTS Of 20 patients, 8 (40%) were considered the symptomatic group. Phase III, in which contractions originating from the antrum migrate to the pylorus and then move to the duodenum, was observed in only 1 of 8 patients. In the asymptomatic group, phase III was observed in 8 of 12 patients. A significant correlation was found between the presence of reflux symptoms and the paucity of phase III activity (p=0.02). CONCLUSIONS The presence of reflux symptoms after gastric pull-up esophagectomy is significantly associated with the paucity of gastric phase III. Gastric motor activity is important in the occurrence of reflux symptoms.
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Affiliation(s)
- Toshihiro Nakabayashi
- Department of Surgery, Gunma Prefectural Cardiovascular Center, Gunma University, Graduate School of Medicine, Maebashi, Japan.
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Sawh SB, Selvaraj IP, Danga A, Cotton AL, Moss J, Patel PB. Use of methylnaltrexone for the treatment of opioid-induced constipation in critical care patients. Mayo Clin Proc 2012; 87:255-9. [PMID: 22386181 PMCID: PMC3498420 DOI: 10.1016/j.mayocp.2011.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 11/28/2011] [Accepted: 11/28/2011] [Indexed: 01/15/2023]
Abstract
Gastrointestinal dysmotility and constipation are common problems in critical care patients. The majority of critical care patients are treated with opioids, which inhibit gastrointestinal (GI) motility and lead to adverse outcomes. We reasoned that methylnaltrexone (MNTX), a peripheral opioid antagonist approved for the treatment of opioid-induced constipation in patients with advanced illness receiving palliative care when response to laxative therapy has not been sufficient, could improve GI function in critically ill patients. The present study included all patients in our intensive care unit who required rescue medication for GI stasis during the 10-week period from September 1 to November 15, 2009. We compared conventional rescue therapy with subcutaneous MNTX. We performed a retrospective chart review of the 88 nonsurgical critical care patients receiving fentanyl infusions, 15 (17%) of whom met the criteria of absence of laxation within 72 hours of intensive care unit admission despite treatment with senna and sodium docusate. Eight of these 15 patients subsequently received conventional rescue therapy (combination of sodium picosulfate [5 mg] and 2 glycerin suppositories [4-g mold]), and 7 patients received MNTX (subcutaneous injection, 0.15 mg/kg). Laxation occurred within 24 hours in 6 of the 7 MNTX patients (86%) but in none of the 8 patients receiving conventional rescue therapy (P=.001). The median difference in time to laxation between the 2 groups was 3.5 days (P<.001). Although not statistically significant, all 7 patients treated with MNTX, but only 4 of 8 (50%) who received conventional rescue therapy, progressed to full target enteral feeding (P=.08). Intensive care unit mortality was 2 of 7 MNTX patients (29%) vs 4 of 8 (50%) in the standard therapy group (P=.61). We hypothesize that MNTX may play an important role in restoration of bowel function in critically ill patients.
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Affiliation(s)
- Sergio B. Sawh
- Department of Emergency Medicine, Charing Cross Hospital, London, United Kingdom
| | - Ibrahim P. Selvaraj
- Department of Advanced Pain, Hillingdon Hospital, Uxbridge, Middlesex, United Kingdom
| | - Akila Danga
- Department of Medicine, Queens Hospital, London, United Kingdom
| | - Alison L. Cotton
- Department of Pharmacology, Hammersmith Hospital, London, United Kingdom
| | - Jonathan Moss
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Parind B. Patel
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Correspondence: Address to Parind B. Patel, MBBS, FRAC, FFICM, Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, DuCane Rd, London W12 0HS, United Kingdom
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24
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Petit L, Sztark F. Nutrition des traumatisés crâniens graves. NUTR CLIN METAB 2011. [DOI: 10.1016/j.nupar.2011.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Chapman MJ, Nguyen NQ, Deane AM. Gastrointestinal dysmotility: clinical consequences and management of the critically ill patient. Gastroenterol Clin North Am 2011; 40:725-39. [PMID: 22100114 DOI: 10.1016/j.gtc.2011.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastrointestinal dysmotility is a common feature of critical illness, with a number of significant implications that include malnutrition secondary to reduced feed tolerance and absorption, reflux and aspiration resulting in reduced lung function and ventilator-associated pneumonia, bacterial overgrowth and possible translocation causing nosocomial sepsis. Prokinetic agent administration can improve gastric emptying and caloric delivery, but its effect on nutrient absorption and clinical outcomes is, as yet, unclear. Postpyloric delivery of nutrition has not yet been demonstrated to increase caloric intake or improve clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia.
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The histological and immunohistochemical aspects of bile reflux in patients with gastroesophageal reflux disease. Gastroenterol Res Pract 2011; 2011:905872. [PMID: 21822428 PMCID: PMC3142670 DOI: 10.1155/2011/905872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 06/03/2011] [Indexed: 11/17/2022] Open
Abstract
Introduction. The pathogenesis of GERD is strongly related with mixed acid and bile reflux. Benign and malignant esophageal and gastric lesions have been associated with synergetic activity between those parameters. Bile reflux causes reactive gastropathy evaluated with Bile Reflux Index (BRI). The aim was to investigate if the sequence: bile reflux-intestinal metaplasia-GERD-esophagitis, is associated with apoptotic/oncogenetic disturbances. Materials/Methods. Fifteen asymptomatic subjects and 53 GERD patients underwent gastroscopy with biopsies. The specimens examined histologically and immunohistochemically for p53, Ki-67, Bax, and Bcl-2. Results. Elevated BRI score detected in 47% (25/53) of patients with GERD and in 13% (2/15) of controls (P = 0.02). Severe esophageal lesions were significantly more common in BRI (+) patients (14/25) compared to BRI (-) ones (P = 0.0049). Immunohistochemical analysis did not show associations between BRI score and biomarker expression. Conclusions. Bile reflux gastropathy is associated with GERD severity, but not with oncogene expression or apoptotic discrepancies of the upper GI mucosa.
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Silk DBA. The Evolving Role of Post–Ligament of Trietz Nasojejunal Feeding in Enteral Nutrition and the Need for Improved Feeding Tube Design and Placement Methods. JPEN J Parenter Enteral Nutr 2011; 35:303-7. [DOI: 10.1177/0148607110387799] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- D. B. A. Silk
- Department of Biosurgery and Surgical Technology, Department of Academic Surgery, Imperial College London, London, United Kingdom
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A direct role for secretory phospholipase A2 and lysophosphatidylcholine in the mediation of LPS-induced gastric injury. Shock 2010; 33:634-8. [PMID: 19940811 DOI: 10.1097/shk.0b013e3181cb9266] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Endotoxemia from sepsis can injure the gastrointestinal tract through mechanisms that have not been fully elucidated. We have shown that LPS induces an increase in gastric permeability in parallel with the luminal appearance of secretory phospholipase A2 (sPLA2) and its product, lysophosphatidylcholine (lyso-PC). We proposed that sPLA2 acted on the gastric hydrophobic barrier, composed primarily of phosphatidylcholine (PC), to degrade it and produce lyso-PC, an agent that is damaging to the mucosa. In the present study, we have tested whether lyso-PC and/or sPLA2 have direct damaging effects on the hydrophobic barriers of synthetic and mucosal surfaces. Rats were administered LPS (5 mg/kg, i.p.), and gastric contents were collected 5 h later for analysis of sPLA2 and lyso-PC content. Using these measured concentrations, direct effects of sPLA2 and lyso-PC were determined on (a) surface hydrophobicity as detected with an artificial PC surface and with intact gastric mucosa (contact angle analysis) and (b) cell membrane disruption of gastric epithelial cells (AGS). Both lyso-PC and sPLA2 increased significantly in the collected gastric juice of LPS-treated rats. Using similar concentrations to the levels in gastric juice, the contact angle of PC-coated slides declined after incubation with either pancreatic sPLA2 or lyso-PC. Similarly, gastric contact angles seen in control rats were significantly decreased in sPLA2 and lyso-PC-treated rats. In addition, we observed dose-dependent injurious effects of both lyso-PC and sPLA2 in gastric AGS cells. An LPS-induced increase in sPLA2 activity in the gastric lumen and its product, lyso-PC, are capable of directly disrupting the gastric hydrophobic layer and may contribute to gastric barrier disruption and subsequent inflammation.
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Douzinas EE, Andrianakis I, Livaditi O, Bakos D, Flevari K, Goutas N, Vlachodimitropoulos D, Tasoulis MK, Betrosian AP. Reasons of PEG failure to eliminate gastroesophageal reflux in mechanically ventilated patients. World J Gastroenterol 2009; 15:5455-60. [PMID: 19916176 PMCID: PMC2778102 DOI: 10.3748/wjg.15.5455] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate factors predicting failure of percutaneous endoscopic gastrostomy (PEG) to eliminate gastroesophageal reflux (GER).
METHODS: Twenty-nine consecutive mechanically ventilated patients were investigated. Patients were evaluated for GER by pH-metry pre-PEG and on the 7th post-PEG day. Endoscopic and histologic evidence of reflux esophagitis was also carried out. A beneficial response to PEG was considered when pH-metry on the 7th post-PEG day showed that GER was below 4%.
RESULTS: Seventeen patients responded (RESP group) and 12 did not respond (N-RESP) to PEG. The mean age, sex, weight and APACHE II score were similar in both groups. GER (%) values were similar in both groups at baseline, but were significantly reduced in the RESP group compared with the N-RESP group on the 7th post-PEG day [2.5 (0.6-3.8) vs 8.1 (7.4-9.2, P < 0.001)]. Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups (P = 0.031 and P = 0.020, respectively). Histology revealed no significant differences between the two groups.
CONCLUSION: Endoscopic grading of GEFV and the presence of severe reflux esophagitis are predisposing factors for failure of PEG to reduce GER in mechanically ventilated patients.
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[Lung diseases and gastro-oesophageal reflux disease]. REVISTA PORTUGUESA DE PNEUMOLOGIA 2009; 15:899-921. [PMID: 19649547 DOI: 10.1016/s0873-2159(15)30185-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Gastro -oesophageal Reflux Disease is a consequence of pathological reflux from stomach to oesophagus. Whenever the refluxed contents extended beyond the oesophagus itself, is called Extraoesophageal Reflux Disease. The author proposes a review about pulmonary disorders and gastroesophageal reflux. Previously, it is evaluated in an abridged way, the concepts of each diseases and after that, in a systematic form, it is discussed the prevalence of gastro -oesophageal reflux in lung diseases, all the mechanisms studies and the impact of gastro -oesophageal treatment on lung disorders. The author concludes that is undeniable the link between Gastro -oesophageal reflux and lung diseases and further reaserch is mandatory in order to corroborate this association.
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Abdel-Gawad TA, El-Hodhod MA, Ibrahim HM, Michael YW. Gastroesophageal reflux in mechanically ventilated pediatric patients and its relation to ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R164. [PMID: 19840378 PMCID: PMC2784395 DOI: 10.1186/cc8134] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 09/04/2009] [Accepted: 10/19/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The objective was to determine the frequency of gastroesophageal reflux (GER) in mechanically ventilated pediatric patients and its role as a risk factor for ventilator-associated pneumonia (VAP), which may be enhanced among those patients. METHODS The study is a prospective cohort study of mechanically ventilated pediatric patients in the pediatric intensive care unit (PICU) of Ain Shams University Children's Hospital. It was conducted in 24 mechanically ventilated patients (16 of them developed VAP and 8 did not, with mean age of 16.6 +/- 20.5 and 18.6 +/- 22.4 months respectively). Esophageal 24-hour pH-metry beside clinical and laboratory evaluation of their underlying problem and severity of their condition were carried out. RESULTS All VAP patients had GER (50% alkaline reflux, 12.5% acidic reflux and 37.5% combined reflux) compared to 75% of non-VAP ones (100% alkaline reflux). The mean total reflux time was significantly longer among VAP (50 minutes) versus non-VAP (3 minutes) patients. There was significant increase in acidic reflux parameters among non-survivors versus survivors (P < 0.001). For VAP mortality, total acidic reflux at a cut-off value of 28.6 minutes is found to be a mortality predictor with a sensitivity of 100% and a specificity of 100%. CONCLUSIONS GER is a constant incident in mechanically ventilated pediatric patients, with alkaline reflux being more common than acidic reflux. Both acidic and alkaline refluxes were found to be associated with the development of VAP and total reflux time was found to be a reliable predictor of VAP. Moreover, acidic reflux was found to be more related to mortality than alkaline reflux.
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Affiliation(s)
- Tarek A Abdel-Gawad
- Pediatric Department, Ain Shams Faculty of Medicine, Abbassia Ramsis St, Cairo 11566, Egypt.
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Jiang M, Chen J, Chen F, Yu J, Liang J, Zhang Y, Ou B. Bile and acid reflux in the pathogenesis of reflux oesophagitis in children. J Paediatr Child Health 2009; 45:64-7. [PMID: 19208069 DOI: 10.1111/j.1440-1754.2008.01431.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to investigate the role of bile and acid reflux in the pathogenesis of reflux oesophagitis (RE) in children. METHODS A total of 44 patients aged 5-17 years with gastro-oesophageal reflux symptoms were enrolled. Simultaneous 24-h oesophageal Bilitec 2000 (Medtronic Instruments, Minneapolis, MN, USA) bilirubin monitoring and pH monitoring, in biopsy of oesophageal mucosa by gastro-endoscopy, were performed in all patients. RESULTS According to the diagnostic criteria of pathological acid reflux and pathological bile reflux, 10 of 44 cases (22.7%) had acid reflux, 10 (22.7%) had isolated bile reflux, 16 (36.4%) had mixed acid and bile reflux, and the other eight (18.2%) had no reflux. Significant difference was observed in the ratio of different patterns of reflux between the RE group (26 cases) and the non-erosive reflux disease (NERD) group (18 cases) (chi(2) = 9.096, P < 0.01). All the parameters of acid reflux in the RE group were higher significantly than that in the NERD group (P < 0.05 or P < 0.01). A total of 20 out of 26 cases (76.9%) with RE had oesophageal acid reflux as against six out of 18 cases (33.3%) in patients with NERD (P < 0.01). The difference of each parameter of bile reflux had not reached significance between the two groups. CONCLUSIONS Mixed reflux is the predominant form of reflux in the causation of oesophageal mucosal injury in children. Isolated bile reflux also plays a role in the development of RE, although only in patients without acid reflux.
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Affiliation(s)
- Mizu Jiang
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Pathophysiological mechanisms of extraesophageal reflux in otolaryngeal disorders. Eur Arch Otorhinolaryngol 2008; 266:17-24. [DOI: 10.1007/s00405-008-0770-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 07/03/2008] [Indexed: 12/19/2022]
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Klebl FH, Schölmerich J. Therapy insight: Prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients. ACTA ACUST UNITED AC 2007; 4:562-70. [PMID: 17909533 DOI: 10.1038/ncpgasthep0953] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 08/06/2007] [Indexed: 12/15/2022]
Abstract
Stress-induced gastrointestinal bleeding is associated with increased morbidity and mortality in critically ill patients. Within the past few decades, the incidence of stress-induced gastrointestinal bleeding has decreased. Prophylaxis of stress-induced gastrointestinal bleeding, which is aimed at preventing morbidity and mortality, has to be achieved with as few adverse effects as possible. Data indicate that not all critically ill patients need prophylaxis for stress-induced gastrointestinal bleeding. The main risk factors associated with clinically important hemorrhage are mechanical ventilation for >48 h, and coagulopathy (thrombocyte count <50/nl, partial thromboplastin time (PTT) >2 times the upper limit of the normal range, international normalized ratio (INR) >1.5). Ranitidine is more effective than sucralfate for the prevention of clinically important bleeding. Immediate-release omeprazole is as effective as cimetidine, and is more efficient at increasing the intragastric pH. As yet, however, there is no firm evidence that any of the drugs used for prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients decrease mortality or the length of hospital stay. When to stop prophylaxis is decided on clinical grounds rather than on the basis of data from clinical studies.
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Affiliation(s)
- Frank H Klebl
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany.
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Hoffman I, Tertychnyy A, Ectors N, De Greef T, Haesendonck N, Tack J. Duodenogastro-esophageal reflux in children with refractory gastro-esophageal reflux disease. J Pediatr 2007; 151:307-11. [PMID: 17719945 DOI: 10.1016/j.jpeds.2007.03.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 01/22/2007] [Accepted: 03/16/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the role of duodenogastro-esophageal reflux (DGER) in the pathogenesis of refractory gastro-esophageal reflux disease (GERD) in children. STUDY DESIGN Twenty-two patients (12 boys, mean age, 13.2 years) with GERD symptoms that persisted on omeprazole (1 mg/kg) underwent upper gastrointestinal endoscopy and barium x-ray, 24-hour pH and DGER (Bilitec) monitoring, and a 13C octanoic acid gastric emptying breath test. RESULTS Patients presented mainly with epigastric pain, regurgitation, and nausea. Endoscopy revealed persistent esophagitis in 15 patients (68%). Pathologic acid and DGER exposure were present in 12 (55%) and 15 (68%) children, respectively, with combined pathologic reflux in 10 (45%). Acid exposure did not differ according to the presence of esophagitis, but patients with grade II esophagitis had significantly higher DGER exposure than those without esophagitis (9.1 +/- 5.3% vs 26.7 +/- 10.9% of the time, P < .05). Gastric emptying rate was not associated to acid or DGER exposure or persisting esophagitis. Symptoms improved after adding a prokinetic drug to the proton pump inhibitor therapy or referral for surgery (n = 5). CONCLUSIONS DGER may play a role in the pathophysiology of proton pump inhibitor-refractory GERD and esophagitis in children.
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Affiliation(s)
- Ilse Hoffman
- Division of Pediatrics, University Hospitals Leuven, Belgium.
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Chapman MJ, Nguyen NQ, Fraser RJL. Gastrointestinal motility and prokinetics in the critically ill. Curr Opin Crit Care 2007; 13:187-94. [PMID: 17327741 DOI: 10.1097/mcc.0b013e3280523a88] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Enteral nutrition is frequently unsuccessful in the critically ill due to gastrointestinal dysfunction. Current treatment strategies are often disappointing. In this article upper gastrointestinal function in health together with abnormalities seen during critical illness are reviewed, and potential therapeutic options summarized. RECENT FINDINGS Reflux oesophagitis occurs frequently due to reduced or absent lower oesophageal sphincter tone. In the stomach a number of motor patterns contribute to slow gastric emptying. The fundus has reduced compliance, there are less frequent contractions in both the proximal and distal stomach, isolated pyloric activity is increased and the organization of duodenal motor activity is abnormal. In response to nutrients, enterogastric feedback is enhanced, fundic relaxation and subsequent recovery is delayed, antral motility is further reduced and localized pyloric contractions stimulated. Elevated concentrations of hormones such as cholecystokinin and peptide YY are potential mediators for these phenomena. Rapid tachyphylaxis occurs with the commonly used prokinetics, metoclopramide and erythromycin, and novel agents are under investigation. Independent of gastric emptying, nutrient absorption is reduced. SUMMARY There has been considerable progress in understanding the pathogenesis of mechanisms causing feed intolerance in critical illness, but this is yet to be translated into therapeutic benefit.
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Orel R, Vidmar G. Do acid and bile reflux into the esophagus simultaneously? Temporal relationship between duodenogastro-esophageal reflux and esophageal pH. Pediatr Int 2007; 49:226-31. [PMID: 17445043 DOI: 10.1111/j.1442-200x.2007.02338.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Duodenogastro-esophageal reflux (DGER) is an important factor in the pathogenesis of reflux esophagitis. Animal studies have demonstrated that the injurious effect of duodenal juice components depends on pH. The purpose of the present study was to investigate the temporal relationship between DGER and esophageal pH. METHODS Seventy-six children with symptoms of gastro-esophageal reflux disease (27 without, 31 with mild, 18 with severe esophagitis) underwent 24 h simultaneous esophageal pH and bilirubin monitoring with Bilitec 2000. The recordings were analyzed for (i) pH at the beginning of DGER episodes; (ii) relative duration of DGER in eight defined pH intervals of 1 pH unit; and (iii) differences in relative duration of DGER between the three groups of children. RESULTS DGER episodes most frequently began at pH between 6 and 7. DGER was present in the esophagus across the spectrum of esophageal pH, with the biggest relative duration between pH 3 and 5. However, in children without esophagitis relative duration of DGER was longest between pH 5 and 6, in children with mild esophagitis between pH 4 and 5, while in those with severe esophagitis it was between pH 2 and 4 (P < 0.001). CONCLUSIONS DGER appears across the whole esophageal pH spectrum. The more severe the esophagitis, the lower the pH at which DGER occurs, resulting in simultaneous damaging effects of acid and duodenal juice components.
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Affiliation(s)
- Rok Orel
- Department of Gastroenterology, Division of Pediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia.
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Cardin F, Minicuci N, Siviero P, Bertolio S, Gasparini G, Inelmen EM, Terranova O. Esophagitis in frail elderly people. J Clin Gastroenterol 2007; 41:257-63. [PMID: 17426463 DOI: 10.1097/01.mcg.0000225611.48728.1e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
INTRODUCTION We studied the clinical course of elderly patients acutely hospitalized for various diseases, assessing any differences between patients with and without esophagitis. STUDY A case-control study on the presence of esophagitis was conducted on the clinical records of all in-patients undergoing gastroduodenoscopy at Padova Geriatric Hospital from 1997 to 2001. Data were examined on 338 sex-matched patients: 169 with a diagnosis of esophagitis and 169 with a negative endoscopy. RESULTS Admissions for acute respiratory disorders [odds ratios (OR) 2.68; 95% confidence interval (CI) 0.89-8.01], a remote diagnosis of esophagitis (OR 11.34; 95%CI 2.68-48.07), obesity (OR 3.36; 95%CI 0.91-12.48), and being bedridden (OR 6.84; 95%CI 3.27-14.29) were found to be independent risk factors for the presence of esophagitis. The symptoms prompting the endoscopic diagnoses included: gastrointestinal bleeding (OR 7.61; 95%CI 2.76-21.0), heartburn (OR 4.58; 95%CI 1.86-11.28), and cough (OR 3.59; 95%CI 1.34-9.62). Steroids (OR 2.68; 95%CI 1.11-6.44) and calcium antagonists (OR 1.50; 95%CI 0.79-2.87) were associated with esophagitis as risk factors, whereas proton pump inhibitors (OR 0.46; 95%CI 0.25-0.87), nitrates (OR 0.14; 95%CI 0.02-0.78), and sucralfate in males (OR 0.09; 95%CI 0.01-0.92) were associated as protective factors. Patients with esophagitis were discharged with an endocrinologic/metabolic-type diagnosis. Deaths were significantly higher among patients with esophagitis (25 vs. 9); more severe esophagitis was characterized by a higher Charlson comorbidity index and a greater presence of anorexia and nausea. CONCLUSIONS These findings seem to substantiate the theory that esophagitis is a characteristic which exacerbates frailty in hospitalized elderly people and its identification may be helpful in these patients.
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Affiliation(s)
- Fabrizio Cardin
- Geriatric Department, Division of Geriatric Surgery, University of Padova, Padova, Italy.
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Tack J. Review article: the role of bile and pepsin in the pathophysiology and treatment of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2006; 24 Suppl 2:10-6. [PMID: 16939428 DOI: 10.1111/j.1365-2036.2006.03040.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gastro-oesophageal reflux disease is a multifaceted and multifactorial disorder which results from the reflux of gastric contents into the oesophagus. Animal studies suggest that synergism between acid and pepsin and conjugated bile acids have the greatest damaging potential for oesophageal mucosa, although unconjugated bile acids may be caustic at more neutral pH. Human studies are compatible with a synergistic action between acid and duodenogastric reflux in inducing lesions. During prolonged monitoring studies, typical gastro-oesophageal reflux symptoms are more related to acid reflux events than to non-acid reflux events. However, symptoms that persist during acid suppressive therapy are often related to non-acid reflux events. The therapeutic options for the non-acid component of the refluxate, including acid suppression, prokinetics, baclofen, surgery and mucosal protective agents like alginates, are discussed.
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Affiliation(s)
- J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.
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Abstract
The most dreaded complication of tube feedings is tracheobronchial aspiration of gastric contents. Strong evidence indicates that most critically ill tube-fed patients receiving mechanical ventilation aspirate gastric contents at least once during their early days of tube feeding. Those who aspirate frequently are about 4 times more likely to have pneumonia develop than are those who aspirate infrequently. Although a patient’s illness might not be modifiable, some risk factors for aspiration can be controlled; among these are malpositioned feeding tubes, improper feeding site, large gastric volume, and supine position. A review of current research-based information to support modification of these risk factors is provided.
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Bruley des Varannes S. [Functional exploration of esophageal reflux]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:742-9. [PMID: 16801896 DOI: 10.1016/s0399-8320(06)73307-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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Abstract
Gastro-oesophageal reflux disease is defined as the presence of symptoms or lesions that can be attributed to the reflux of gastric contents into the oesophagus. Aspiration and prolonged monitoring studies in humans have shown that reflux of gastric contents is comprised of both acid and non-acid components, in healthy as well as diseased people. Methods to monitor the non-acid component of the refluxate are described in detail. Experimental models suggest that synergism between acid and pepsin and conjugated bile acids have the greatest damaging potential for oesophageal mucosa, although unconjugated bile acids may be caustic at a more neutral pH. Human studies are compatible with a synergistic action between acid and duodenogastric reflux in inducing lesions. During prolonged monitoring studies, typical gastro-oesophageal reflux disease symptoms are more related to acid reflux events than to non-acid reflux events. However, symptoms that persist during acid-suppressive therapy are often related to non-acid reflux events. The therapeutic options for the non-acid component of the refluxate, including acid suppression, prokinetics, baclofen and surgery, are discussed.
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Affiliation(s)
- J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.
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Todd JA, Basu KK, de Caestecker JS. Normalization of oesophageal pH does not guarantee control of duodenogastro-oesophageal reflux in Barrett's oesophagus. Aliment Pharmacol Ther 2005; 21:969-75. [PMID: 15813832 DOI: 10.1111/j.1365-2036.2005.02406.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton-pump inhibitors are effective at preventing the acid component of gastro-oesophageal refluxate from entering the oesophagus. It is not clear whether proton-pump inhibitors prevent duodenogastro-oesophageal reflux. AIM To measure oesophageal exposure to duodenogastro-oesophageal refluxate while on proton-pump inhibitors in patients with Barrett's oesophagus. METHODS Twenty-five patients (23 male) with Barrett's oesophagus underwent 24 h oesophageal pH and Bilitec 2000 monitoring while on omeprazole 40 mg/day (n = 19) or omeprazole 60 mg/day (n = 6). All patients were undergoing argon plasma ablation of their Barrett's epithelium as part of a clinical trial and the Bilitec measurements were only carried out after the ablation had been completed. RESULTS 20 of 25 (80%) patients had a normal oesophageal pH profile. Fifteen of the 25 (60%) had abnormal oesophageal exposure to bile as measured by Bilitec 2000. Of the 20 patients who had a normal 24 h oesophageal pH profile, 11 (55%) had pathological exposure to bile in their oesophagus. CONCLUSION Complete acid suppression does not guarantee elimination of duodenogastro-oesophageal reflux.
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Affiliation(s)
- J A Todd
- Digestive Diseases Centre, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester LE5 4PW, UK
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Nind G, Chen WH, Protheroe R, Iwakiri K, Fraser R, Young R, Chapman M, Nguyen N, Sifrim D, Rigda R, Holloway RH. Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients. Gastroenterology 2005; 128:600-6. [PMID: 15765395 DOI: 10.1053/j.gastro.2004.12.034] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Gastroesophageal reflux is a major problem in mechanically ventilated patients and may lead to pulmonary aspiration and erosive esophagitis. Transient lower esophageal sphincter relaxations are the most common mechanism underlying reflux in nonventilated patients. The mechanisms that underlie reflux in critically ill ventilated patients have not been studied. The aim of this study was to determine the mechanisms underlying gastroesophageal reflux in mechanically ventilated patients in the intensive care unit. METHODS In 15 mechanically ventilated intensive care unit patients, esophageal motility, pH, and intraluminal impedance (11/15 patients) were recorded for 1 hour before and 5 hours during continuous nasogastric feeding. RESULTS Basal lower esophageal sphincter pressure was uniformly low (2.2 +/- 0.4 mmHg). The median (interquartile range) acid exposure (pH <4) was 39.4% (0%-100%) fasting and 32% (7.5%-94.2%) fed. Acid reflux occurred in 10 patients, but slow drifts in esophageal pH were also an important contributor to acid exposure. If esophageal pH decreased to pH <4, it tended to remain so for prolonged periods. A total of 46 acid reflux events were identified. Most (55%) occurred because of absent lower esophageal sphincter pressure alone; 45% occurred during straining or coughing. CONCLUSIONS Gastroesophageal reflux in mechanically ventilated patients is predominantly due to very low or absent lower esophageal sphincter pressure, often with a superimposed cough or strain. These data suggest that measures that increase basal LES pressure may be useful to prevent reflux in ventilated patients.
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Affiliation(s)
- Garry Nind
- Department of Gastroenterology, Hepatology and General Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Abstract
Barrett's esophagus (BE) is an acquired disease of the esophagus, in which esophageal squamous epithelium is changed by injury from reflux to metaplastic intestinal type columnar epithelium. BE is the premalignant lesion of adenocarcinoma of the esophagus. It is widely accepted that the long-standing reflux of gastric acid is a catalyst for the development of BE. More recent work points toward the reflux of duodenal secretions as a catalyst in this disease process as well. Moreover, the time course for the development of BE once a patient has reflux is not known. Our case challenges the currently defined time course of "long-standing" reflux symptoms for the development of BE, and supports the role of duodenal secretions alone in the development of BE. A 68-yr-old Caucasian man was admitted with weight loss, left upper quadrant pain, a hemoglobin of 6.8, and heme-positive stool. Esophagogastroduodenoscopy (EGD) revealed normal esophageal mucosa and a mass in the gastric cardia. Biopsies showed moderately differentiated gastric adenocarcinoma. The patient underwent a total gastrectomy, distal esophagectomy, and a Roux-en-Y esophagojejunostomy. Pathology confirmed gastric adenocarcinoma (T1 N0 Mx). The distal esophagus and gastroesophageal junction in the resected specimen were grossly and microscopically normal. Six months later an EGD, prompted by new complaints of regurgitation and dyspepsia, revealed distal esophageal mucosa lined by red-colored columnar tissue. Biopsies showed intestinal type epithelium. Thus, our case report's contribution to the current literature is twofold. It provides evidence of development of BE solely from duodenal reflux, and it documents a relatively short time span to development of BE.
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Affiliation(s)
- Brenda C Westhoff
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, Missouri 64128, USA
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Tack J, Koek G, Demedts I, Sifrim D, Janssens J. Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett's esophagus: acid reflux, bile reflux, or both? Am J Gastroenterol 2004; 99:981-8. [PMID: 15180713 DOI: 10.1111/j.1572-0241.2004.04171.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs. METHODS Sixty-five patients (32 men, 44 +/- 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec monitoring while PPIs were continued. RESULTS Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux. CONCLUSIONS Combined pH and Bilitec monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.
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Affiliation(s)
- J Tack
- Center for Gastroenterological Research, Catholic University Leuven, B-3000 Leuven, Belgium
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Abstract
Duodenogastric reflux is the retrograde flow of duodenal contents into the stomach that then mix with acid and pepsin. These agents can reflux into the esophagus (ie, duodenogastroesophageal reflux ) and cause gastroesophageal reflux disease (GERD) and its complications, including stricture, Barrett's esophagus, and adenocarcinoma of the esophagus. Medical and surgical treatments of DGER can be difficult. Best medical treatment is proton-pump inhibitors, which decrease DGER by inhibiting both gastric acidity and volume, making less gastric contents available to reflux into the esophagus. The addition of the gamma-aminobutyric (GABA(B)) receptor agonist baclofen may further reduce DGER in patients not responding to proton-pump inhibitors. Bile acid-binding agents (aluminum-containing antacids, cholestyramine, sucralfate, urosodeoxycholic acid) have physiologic rationale, but their efficacy is unproven. Prokinetic agents can reduce DGER and its upper gastrointestinal symptoms by promoting increased gastric emptying. In patients with medically refractory symptoms, a Roux-en-Y diversion or duodenal switch operation may be helpful.
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Affiliation(s)
- Joel E. Richter
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, 9500 Euclid Avenue, S-40, Cleveland, OH 44195, USA.
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Meissner W, Dohrn B, Reinhart K. Enteral naloxone reduces gastric tube reflux and frequency of pneumonia in critical care patients during opioid analgesia. Crit Care Med 2003; 31:776-80. [PMID: 12626983 DOI: 10.1097/01.ccm.0000053652.80849.9f] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Opioid analgesia impairs gastrointestinal motility. Enteral administration of naloxone theoretically allows selective blocking of intestinal opioid receptors caused by extensive presystemic metabolism. Therefore, we studied the effect of enteral naloxone on the amount of gastric tube reflux, the frequency of pneumonia, and the time until first defecation in mechanically ventilated patients with fentanyl analgesia. DESIGN Prospective, randomized, double-blinded study. SETTING University hospital intensive care unit. PATIENTS Eighty-four mechanically ventilated, fentanyl-treated patients without gastrointestinal surgery or diseases. INTERVENTIONS Patients were assigned to receive 8 mg naloxone or placebo four times daily via a gastric tube during fentanyl administration. MEASUREMENTS AND MAIN RESULTS Thirty-eight patients received naloxone and 43 placebo; three patients were excluded because of protocol violation. Median gastric tube reflux volume (54 vs. 129 mL, p =.03) and frequency of pneumonia (34% vs. 56%, p =.04) were significantly lower in the naloxone group. In both groups, time until first defecation, ventilation time, and length of intensive care unit stay did not differ. There was no difference in fentanyl requirements between the naloxone and the placebo group (7 vs. 6.5 microg/kg/hr, p =.15). CONCLUSIONS Our results provide evidence that the administration of enteral opioid antagonists in ventilated patients with opioid analgesia might be a simple-and possibly preventive-treatment of increased gastric tube reflux and reduces frequency of pneumonia.
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Affiliation(s)
- Winfried Meissner
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Jena, Germany
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Xin Y, Dai N, Zhao L, Wang JG, Si JM. The effect of famotidine on gastroesophageal and duodeno-gastro-esophageal refluxes in critically ill patients. World J Gastroenterol 2003; 9:356-8. [PMID: 12532466 PMCID: PMC4611346 DOI: 10.3748/wjg.v9.i2.356] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of famotidine on gastroesophageal reflux (GER) and duodeno-gastro-esophageal reflux (DGER) and to explore it's possible mechanisms. To identify the relevant factors of the reflux.
METHODS: Ninteen critically ill patients were consecutively enrolled in the study. Dynamic 24 h monitoring of GER and DGER before and after administration of famotidine was performed. The parameters of gastric residual volume,multiple organ disorder syndrome (MODS) score, acute physiology and chronic health evaluation II (APACHE II) score and PEEP were recorded. Paired t test; Wilcoxon signed ranks test and Univariate analysis with Spearman's rank correlation were applied to analyse the data.
RESULTS: Statistical significance of longest acid reflux, reflux time of pH < 4 and fraction time of acid reflux was observed in ten critically ill patients before and after administration. P value is 0.037, 0.005, 0.005 respectively. Significance change of all bile reflux parameters was observed before and after administration. P value is 0.007, 0.024, 0.005, 0.007, 0.005. GER has positive correlation with APACHE II score and gastric residual volume with correlation coefficient of 0.720, 0.932 respectively.
CONCLUSION: GER and DGER are much improved after the administration of famotidine. GER is correlated with APACHE II score and gastric residual volume.
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Affiliation(s)
- Ying Xin
- Department of Gastroenterology,Sir Run Run Shaw Hospital, Hangzhou 310016, Zhejiang Province, China.
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