Antisecretory Medications Research Articles

Outcome for Asymptomatic Recurrence Following Laparoscopic Repair of Very Large Hiatus Hernia

BackgroundRadiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20–30 %, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls. MethodsOne hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6–60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up. ResultsOutcomes were available at 1 year for 98.2 % and 5 years or the latest follow-up (range 6–237 months) for 100 %. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6 % of the recurrent hernia group vs. 98.5 % without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery. ConclusionsPatients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.

Is Antisecretory Therapy After Pancreatoduodenectomy Necessary? Meta-analysis and Contemporary Practices of Pancreatic Surgeons

BackgroundMarginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons. Methodsthe MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons. ResultsAfter a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5 % (confidence interval (CI) 1.8–3.2 %) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0 % (CI 1.0–2.9 %), while “classic” PD procedures report an overall rate of 2.6 % (CI 1.6–3.6 %). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4 % (CI 0.1–1.7 %). One hundred forty-four of 200 (72 %) surveys were returned, from which it was determined that 92 % of pancreatic surgeons have dealt with this complication, and 86 % routinely prescribe prophylactic antisecretory medication after PD. ConclusionsThe incidence of MU after PD is 2.5 % with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86 %) routinely prescribe prophylactic gastric antisecretory medication.

Strategies for discontinuation of proton pump inhibitors: a systematic review.

Proton pump inhibitors (PPIs) are considered to be overprescribed. Consensus on how to attempt discontinuation is, however, lacking. We therefore conducted a systematic review of clinical studies on discontinuation of PPIs. Systematic review based on clinical studies investigating discontinuation strategies and discontinuation rates for users of antisecretory medication judged eligible for withdrawal. The databases Medline, Embase and Cochrane Library were searched to December 2013 using the terms antisecretory, anti-ulcer, PPI, acid suppressant, discontinuation, step-down, step down, cessation, tapering, withdrawal and withhold. Search terms were used either singularly or in combination. Papers written in English or Scandinavian were included. Concurrent hand searching was undertaken to pursue references of references. The website ClinicalTrials.gov was searched for unpublished results and ongoing studies. A total of 371 abstracts were scrutinized to determine relevancy. The thorough search resulted in six clinical studies on strategies for discontinuation of PPIs. All discontinuation regimens used in the studies differed, and several interventions have been tested in order to decrease use of PPIs. Discontinuations were reported across all studies ranging from 14% to 64% without deteriorating symptom control. Tapering seems to be a more effective discontinuation strategy than abrupt discontinuation. Discontinuation of PPIs is feasible in a clinical setting, and a substantial number of the patients treated without a clear indication can safely reduce or discontinue treatment. Tapering seems to be the most effective way of doing this.

Tu1606 Hypopharyngeal Multichannel Intraluminal Impedance Improves the Outcome of Antireflux Surgery on Patients With Laryngeal Symptoms

Introduction: Patient selection is critical for the successful surgical treatment of gastroesophageal reflux disease (GERD). Previously, we established the normative data of laryngopharyngeal reflux (LPR) and high-esophageal reflux (HER: reflux up to 2cm distal to upper esophageal sphincter) events for 24-hour hypopharyngeal multichannel intraluminal impedance (HMII). Based on the data, we have constructed the criteria to define abnormal proximal exposure (APE) as LPR ≥1/day and/or HER ≥5/day. Previous retrospective analyses have suggested that HMII may increase the sensitivity in selecting patients with LPR symptoms who likely respond antireflux surgery (ARS). The purpose of this study was to objectively evaluate the outcome of ARS on patients selected based on our criteria by using validated questionnaires. Methods: This is a retrospective review of prospectively collected data from patients who underwent HMII. Patients with APE as measured by HMII and subsequently underwent ARS, were identified. The outcome of surgery included improvement in clinical symptoms and quality of life, both of which were assessed based on the personal interview and the validated questionnaires such as GERD-HRQL, Respiratory Symptom Index (RSI) and SF-36 before and after ARS. Results: From September 2012 to October 2013, 171 patients underwent HMII. Of 118 patients with APE, 26 patients underwent ARS (7 men and 19 women; mean age 51.6). Twenty-one patients (81%) had LPR symptoms including cough (n=20), throat burning (n=3), cervical dysphagia (n=3), throat tightness/pressure (n= 2), and hoarseness (n=1). Of 21 with LPR symptoms, 11 (42%) had concomitant typical GERD symptom such as heartburn and regurgitation. The mean DeMeester score was 15.7 (range 1-54.8) and 15 patients (58%) had negative DeMeester score. Clinical symptoms completely resolved in 20 patients (77%) and significantly improved in 5 patients (19%) at 6 weeks after the surgery. Anti-secretory medications were discontinued in 25 patients (96%) at a mean follow-up period of 2.1 months (0.36-5.3). Complete validated questionnaires before and after ARS were available for 11 patients. Of them, there was a significant improvement in GERD-HRQL (Pre-op 20.7; post-op 6.9, p= 0.016) and RSI scores (Pre-op 23.9; post-op 15, p=0.001) post-operatively. However, there was no significant difference in SF-36 scores on either physical component scores (pre-op 33.6; post-op 32.8, p=0.853) or mental component scores (pre-op 44.7; post-op 47.5, p=0.49). Conclusion: APE as measured by HMII, regardless of whether there is positive DeMeester score, may identify patients with laryngeal symptoms, who likely respond ARS, potentially improving the surgical outcome. Data set is currently being expanded and will be presented at the conference.

Tu1854 Patients With Dental Erosions Have Significant Silent Gastroesophageal Reflux As Quantified by Multichannel Intraluminal Impedance and pH-Monitoring

G A A b st ra ct s parameters were dichotomized, IPF was associated with increased abnormal distal nonacid reflux (57.9% vs. 26.3%, p=0.03). Trends in increased abnormal proximal bolus reflux (21.1% vs. 5.3%) and abnormal distal bolus reflux (31.6% vs. 15.8%) in IPF compared to NF were also observed but did not reach statistical significance. Conclusion: Increased reflux parameters on pre-lung transplant MII-pH were observed in IPF patients compared to NF patients with similar pulmonary function. IPF patients also had significantly more abnormal nonacid reflux compared to NF subjects. Our results suggest that microaspiration likely plays a role in chronic inflammation and fibrosis in IPF patients. The majority of IPF patients had abnormal nonacid reflux, which may explain the inconsistent response to acid suppression. Anti-reflux therapy such as fundoplication may provide more clinical benefit compared to anti-secretory medications in these patients.

Rapidly increasing prescribing of proton pump inhibitors in primary care despite interventions: A nationwide observational study

Background: Guideline and reimbursement modifications have been introduced to optimize prescribing of antisecretory medication in Danish general practice. Impacts of the interventions have not been evaluated.Objectives: To analyse developments in prescribing of antisecretory medication in Denmark 2001–2011 and to assess the impacts of interventions on prescribing of antisecretory medication.Methods: Register-based cohort study covering the entire Danish population of currently 5.5 million inhabitants. Developments in the prescribing of antisecretory medication over time in Denmark between 2001 and 2011 and association with age and gender of users along with the impact of interventions on the prescribing of drug subgroups are analysed.Results: 96.8% of all antisecretory drugs sold are proton pump inhibitors (PPIs) and 94.4% of the PPIs are prescribed in primary care. Prescribing of PPIs has increased substantially during the past decade. Both number of users and the average individual use have increased. The prescribing of ulcerogenic drugs to the elderly has stagnated in the same time range. Reimbursement modifications and scientific guidelines do not seem to have had a substantial influence on the steadily increasing prescribing of PPIs.Conclusion: Use of PPIs has increased substantially during the past decade, without a change in indications for use of PPIs in the same time range. Interventions to enhance adherence to guidelines and promote rational use of PPIs do not seem to have had a substantial influence on the overall prescribing rate.

Pharmacologic Options in the Management of Upper Gastrointestinal Bleeding: Focus on the Elderly

Despite the major advances in the treatment of peptic ulcer disease, its complication in the elderly has increased. This is because of the increasing use of nonsteroidal anti-inflammatory drugs, and the high prevalence of Helicobacter pylori infection. The presentation of peptic ulcers in the elderly patients can be subtle, and late presentation with upper gastrointestinal bleeding of peptic ulcers is not uncommon in the elderly population. The aim of this article is to review the current treatment options for upper gastrointestinal bleeding, and to discuss the place of drug therapy in both the acute and ongoing management of individual patients. Its focus will be on the benefits and risks of each option in the elderly. There is significant evidence to suggest that anti-secretory medications are useful in the treatment of peptic ulcers and associated complications in the elderly. Although a large number of studies have reported potential adverse effects of proton pump inhibitors, this evidence comes from retrospective observational studies, and such reports should be regarded with caution, and randomized controlled studies are required to confirm or refute these results. Nonetheless, it will be important to practice the appropriate use of acid suppression therapy, and identify which patients will gain maximum benefit from proton pump inhibitor therapy.

Transoral Mucosal Excision Sutured Gastroplasty

Introduction. An outpatient transoral endoscopic procedure for gastroesophageal reflux disease (GERD) and obesity would be appealing if safe, effective, and durable. We present the first in human experience with a new system. Methods. Eight patients with GERD (3) and obesity (5) were selected according to a preapproved study protocol. All GERD patients had preprocedure manometry and pH monitoring to document GERD as well as quality of life and symptom questionnaires. Obese patients (body mass index >35) underwent a psychological evaluation and tests for comorbidities. Under general anesthesia, a procedure was performed at the gastroesophageal junction including mucosal excision, suturing of the excision beds for apposition, and suture knotting. Results. One patient with micrognathia could not undergo the required preprocedural passage of a 60 F dilator and was excluded. The first 2 GERD patients had incomplete procedures due to instrument malfunction. The subsequent 5 subjects had a successfully completed procedure. Four patients were treated for obesity and had an average excess weight loss of 30.3% at 2-year follow-up. Of these patients, one had an 8-mm outlet at the end of the procedure recognized on video review—a correctable error—and another vomited multiple times postoperatively and loosened the gastroplasty sutures. The treated GERD patient had resolution of reflux-related symptoms and is off all antisecretory medications at 2-year follow-up. Her DeMeester score was 8.9 at 24 months. Conclusion. The initial human clinical experience showed promising results for effective and safe GERD and obesity therapy.

Laparoscopic Roux-en-Y gastric bypass for treatment of symptomatic paraesophageal hernia in the morbidly obese: medium-term results

BackgroundThe ideal surgical approach for treatment of symptomatic paraesophageal hernias (PEH) in obese patients remains elusive. The objective of this study was to assess the safety, feasibility, and effectiveness of combined laparoscopic PEH repair and Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients. MethodsFourteen patients with symptomatic PEH and morbid obesity (body mass index [BMI]>35 kg/m2) underwent laparoscopic PEH repair with RYGB between 2008 and 2011. Demographic characteristics and preoperative and perioperative details were analyzed. Patients were contacted in October 2013 for follow-up. BMI, reflux symptoms, and disease-specific quality of life (QoL) data were obtained. ResultsThere were 11 females (79%). Median age and preoperative BMI were 48 years and 42 kg/m2, respectively. Mean operative time was 180 minutes, with median length-of-stay of 4 days. There were no perioperative deaths, and 5 patients experienced postoperative complications including 1 gastrojejunostomy leak. Complete follow-up with a median follow-up interval of 35 months was available in 9 (64%) patients. The median % excess weight loss was 67.9%. Thirty-three percent required antisecretory medications for reflux control, compared to 89% preoperatively. Seventy-eight percent of patients reported good to excellent QoL outcomes assessed by the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire. Overall, 89% of patients were satisfied with their operation and would undergo the procedure again. ConclusionCombined laparoscopic PEH repair and RYGB is a safe, feasible, and effective treatment option for morbidly obese patients with symptomatic PEH, and offers good to excellent disease-specific quality-of-life outcomes at medium-term follow-up. To date, this is the largest series with the longest follow-up in this unique patient population.

Introduction of Mechanical Sphincter Augmentation for Gastroesophageal Reflux Disease into Practice: Early Clinical Outcomes and Keys to Successful Adoption

A new device for mechanical sphincter augmentation (MSA) of the lower esophageal sphincter was approved by the FDA on March 22, 2012. We report early experience with MSA, specifically addressing postoperative management. Between October 1, 2011 and June 1, 2013, 150 patients were evaluated for MSA. Of these, 66 patients underwent device implantation; the first implant was April 10, 2012. All patients had objectively confirmed gastroesophageal reflux disease (GERD) with pH testing, acceptable esophageal motility, and no significant hiatal hernia (>3 cm). All patients experienced clinical improvement on antisecretory medication, but incomplete symptom control or medication intolerance. All patients were successfully implanted without intra- or perioperative complications. Average length of hospital stay was 0.7 days. At an average follow-up of 5.8 months (range 1 to 18.6 months), 92% of patients are satisfied or neutral with their GERD condition, and 83% are proton pump inhibitor free. The GERD-Health-Related Quality of Life (HRQL) scores are similar to those of patients without GERD. There were no device ulcers or erosions and no devices explanted. Thirteen patients underwent additional testing for dysphagia or persistent symptoms. Calls with questions and nursing involvement in the first 6 months postoperatively were 3 times what is typical for fundoplication patients. Dysphagia and regurgitation were the most common concerns. All these symptoms were improving over time. Single-center early results are promising and parallel those from a multicenter trial. There is significant interest in MSA, with referrals and direct patient appointments specifically for MSA. Outcomes improve over time after implantation. The surgeon learning curve is different than with the Nissen, both in operative technique and postoperative management. This is a promising new offering for patients with GERD, and surgeons will need to learn how to integrate this into their practices.

A Cross-sectional Analysis of the Prevalence of Barrett Esophagus in Otolaryngology Patients With Laryngeal Symptoms

Populations at risk for esophageal adenocarcinoma remain poorly defined. Laryngeal symptoms can be secondary to laryngopharyngeal reflux (LPR) and can occur without associated gastroesophageal reflux symptoms such as heartburn and regurgitation. We sought to determine the prevalence of Barrett esophagus (BE) in otolaryngology patients with laryngeal symptoms±typical gastroesophageal reflux disease (GERD) symptoms. We performed a cross-sectional study of otolaryngology clinic patients who reported laryngeal symptoms. Symptoms, medications, and exposure histories were obtained. Unsedated transnasal endoscopy was performed. Suspected BE was biopsied and confirmed histologically. Risk factors and prevalence of BE were assessed. Two hundred ninety-five patients were enrolled [73% male, median age 60 y (interquartile range 51 to 68 y)]. The overall prevalence of BE was 11.8% (n=33). Antisecretory medication use was present in 56% (n=156) of patients at enrollment. Compared with patients without BE, patients with BE were more likely to be male (P=0.01) and to report occupational lung injury (P=0.001). Duration, but not severity of laryngeal symptoms, significantly increased the odds of BE (odds ratio, 5.64; 95% confidence interval, 1.28-24.83; for a duration of symptoms >5 y). Of patients with BE, 58% (n=19) had coexisting LPR and GERD symptoms and 30% (n=10) had only LPR symptoms. Presence and size of hiatal hernia and length of columnar-lined esophagus were significant risk factors for BE. Long-standing laryngeal symptoms are associated with the presence of BE in otolaryngology patients. Patients with chronic laryngeal symptoms and no identifiable ear, nose, or throat etiology for those symptoms may benefit from endoscopic screening regardless of whether typical GERD symptoms are present.

P111 Terminal opioid and sedative titration in two hospices

IntroductionThere was anecdotal observation by professionals working across both sites that there was a difference to practice with opioid and sedative titration at the end of life. As an extension...

Use of Biodegradable Stent in Refractory Benign Oesophageal Stricture

Introduction: Oesophageal strictures are commonly seen in patients with accidental or intentional ingestion of corrosive substances. Long-term anti-secretory therapy and recurrent pneumatic balloon dilatations are the mainstay of management, if not surgery. There is anecdotal evidence in using biodegradable stents in this setting. Medical and endoscopic records (using Unisoft software) of a patient with benign refractory oesophageal stricture related to caustic ingestion were reviewed. We describe a 42-year-old woman with benign refractory oesophageal stricture related to intentional industrial bleach ingestion. This patient required 46 oesophageal pneumatic balloon dilatations over 5 years with frequent recurrence of clinical symptoms at short intervals. She manifested excellent response to biodegradable stent which gave her dysphagia-free survival for 18 months in addition to anti-secretory medications without any complication. Diagnosing and staging of corrosive upper gastrointestinal surgery is managed on individual basis. Use of biodegradable stent earlier in this setting prevents long-term morbidity and provides clinical remission effectively.

Use of proton pump inhibitors and subsequent risk of celiac disease

The prevalence of celiac disease and the use of medications that inhibit acid secretion have both increased in recent decades. To explore the association between antisecretory medication exposure and subsequent development of celiac disease. In this population-based case control study, we identified patients with celiac disease diagnosed at all pathology departments in Sweden from July 2005 through February 2008. Patients were matched by age and gender with up to 5 controls. We identified prior prescriptions for proton pump inhibitors and histamine-2 receptor antagonists in all subjects. We used conditional logistic regression to measure the association between these prescriptions and the subsequent diagnosis of celiac disease. Prior proton pump inhibitor prescription was strongly associated with celiac disease (OR 4.79; 95% CI 4.17-5.51). Patients prescribed both proton pump inhibitors and histamine-2 receptor antagonists had a higher risk of celiac disease (OR 5.96; 95% CI 3.58-9.91) than those prescribed proton pump inhibitors alone (OR 4.91; 95% CI 4.26-5.66) or histamine-2 receptor antagonists alone (OR 4.16; 95% CI 2.89-5.99). Exposure to antisecretory medications is associated with a subsequent diagnosis of celiac disease. The persistence of this association after excluding prescriptions in the year preceding the celiac disease diagnosis suggests a causal relationship.

An Overview of Short Bowel Syndrome Management: Adherence, Adaptation, and Practical Recommendations

Short bowel syndrome (SBS) refers to the clinical consequences resulting from loss of small bowel absorptive surface area due to surgical resection or bypass. The syndrome is characterized by maldigestion, malabsorption, and malnutrition. Survival of patients with SBS is dependent on adaptation in the remaining bowel and a combination of pharmacologic and nutrition therapies. Individual plans of care are developed based on the length and sites of remaining bowel, the degree of intestinal adaptation, and the patient's ability to adhere to the medication and dietary regimens. Antisecretory and antidiarrheal medications are prescribed to slow intestinal transit times and optimize fluid and nutrient absorption. Based on postsurgical anatomy, enteral feedings, parenteral infusions, complex diet plans, and vitamin and mineral supplementation are used in various combinations to nourish patients with SBS. In the acute care setting, registered dietitians (RDs) assist with infusion therapy, diet education, and discharge planning. Long-term, as the small intestine adapts, RDs revise the nutrition care plan and monitor for nutrient deficiencies, metabolic bone disease, and anemia. The frequent monitoring and revision of care plans, plus the appreciable benefits from proper medical nutrition therapy, make this patient population extremely challenging and rewarding for RDs to manage. This article provides a brief, case study-based overview of the medical and nutrition management of SBS.

Where Is the Acid Coming from? Esophago-Gastric Fistula Following Laparoscopic Nissen Fundoplication

A 61-year-old Caucasian female presented for evaluation of worsening retrosternal chest pain, heartburn, acid regurgitation, and dysphagia. She described a sensation of a bubble getting stuck in the bottom of her throat and chest after swallowing liquids. She also noted early satiety, belching, and nausea aggravated by greasy meals, weight loss, and frequent episodes of diarrhea. Three years prior, she had undergone a combined laparoscopic Nissen fundoplication, hiatal hernia repair, and cholecystectomy. Immediately after the operation, she experienced persistent nausea and vomiting, followed by recurrent reflux symptoms. Since a computed tomography scan obtained on the second post-operative day was unremarkable, she was reassured. She consulted a gastroenterologist due to progressive symptoms worsening over the ensuing 6 months. After a reportedly normal endoscopy, antisecretory drug therapy was started but failed to alleviate her symptoms. Over the next 30 months, her symptoms continued to worsen until she was evaluated in our unit. Her past medical and surgical histories were significant for overactive bladder, oral herpes, hypertension, hysterectomy, tubal ligation with subsequent reversal, carpal tunnel repair, and tendon repairs of both her hands. Having no known allergies, she was taking oxybutynin, acyclovir, lisinopril, and hydrochlorothiazide. Retired and living with her husband and daughter, she enjoyed gardening. She reported a 30-pack-year smoking history and denied alcohol and recreational drug use. Her family history was remarkable for Parkinson’s disease, breast cancer, and cholelithiasis. Further review of systems was unremarkable. Her physical exam was significant for a blood pressure 190/93 but was otherwise normal. Upper endoscopy revealed a fistula connecting her distal esophagus to her gastric cardia and a non-displaced but erythematous and tight fundoplication (Fig. 1a, b). The fistula was noted just proximal to the wrap, with an exit point at the level of the cardia, which was confirmed by a barium swallow that showed a 17-mm connection between the distal esophagus and the gastric fundus bypassing the lateral aspect of the wrap, consistent with an esophagogastric fistula (Fig. 1c). Esophageal manometry revealed a lower esophageal sphincter (LES) pressure of 23.3 mmHg (normal 10–30 mmHg) with a residual LES pressure of 17 mmHg and 40 % relaxation (normal [70 %) with swallowing, likely secondary to her prior fundoplication and consistent with an effective anti-reflux procedure. Nevertheless, an ambulatory pH study off anti-secretory medications revealed severe, mostly upright, pathologic acid reflux with a DeMeester score of 113.4 and a percentage fraction of time with a pH of \4.0 in the distal esophagus of 31.9 %. There was an excellent correlation between symptoms and acid events; the intra-gastric pH was normal when the patient was off protein-pump inhibitor therapy. C. L. Chun (&) Department of Internal Medicine, Oregon Health and Science University, Portland, OR, USA e-mail: chun@ohsu.edu

Increased Intestinal Absorption in the Era of Teduglutide and Its Impact on Management Strategies in Patients With Short Bowel Syndrome–Associated Intestinal Failure

Short bowel syndrome-associated intestinal failure (SBS-IF) as a consequence of extensive surgical resection of the gastrointestinal (GI) tract results in a chronic reduction in intestinal absorption. The ensuing malabsorption of a conventional diet with associated diarrhea and weight loss results in a dependency on parenteral nutrition and/or intravenous fluids (PN/IV). A natural compensatory process of intestinal adaptation occurs in the years after bowel resection as the body responds to a lack of sufficient functional nutrient-processing intestinal surface area. The adaptive process improves bowel function but is a highly variable process, yielding different levels of symptom control and PN/IV independence among patients. Intestinal rehabilitation is the strategy of maximizing the absorptive capacity of the remnant GI tract. The approaches for achieving this goal have been limited to dietary intervention, antidiarrheal and antisecretory medications, and surgical bowel reconstruction. A targeted pharmacotherapy has now been developed that improves intestinal absorption. Teduglutide is a human recombinant analogue of glucagon-like peptide 2 that promotes the expansion of the intestinal surface area and increases the intestinal absorptive capacity. Enhanced absorption has been shown in clinical trials by a reduction in PN/IV requirements in patients with SBS-IF. This article details the clinical considerations and best-practice recommendations for intestinal rehabilitation, including optimization of fluids, electrolytes, and nutrients; the integration of teduglutide therapy; and approaches to PN/IV weaning.

The Distressing Overuse of Gastric Acid Inhibitors

Gastric acid secretion by parietal cells is an energy consuming process that concentrates H? one million-fold. The energy required is produced by abundant mitochondria. High gastric acidity in combination with the proteolytic enzyme, pepsin, and the lipolytic enzyme, lipase, plays a key role in killing ingested microorganisms including bacteria [1, 2], viruses [3], and prions [4]. This corrosive juice can, however, overwhelm mucosal defense mechanisms leading to erosion and ulceration. Stress ulcers and less severe damage to the gastric mucosa may develop in critically ill patients. The damage, which occurs predominantly in the oxyntic mucosa, is thought to be caused by tissue hypoxia [5, 6]. Hypovolemic or hypotensive patients are at obvious risk of developing such ulcers, but severe illness also increases the risk of stress ulcers [7, 8], particularly in patients requiring mechanical ventilation. Experimental studies have suggested that antisecretory medications, e.g. proton pump inhibitors (PPIs) and histamine H2-receptor antagonists (H2RAs), reduce development of ulcers in the oxyntic mucosa by decreasing energy expenditure as well as raising intragastric pH [9, 10]. In this issue of Digestive Diseases and Sciences, Koczka et al. [11] report the overuse of stress ulcer prophylaxis in a large medical center. This adds to a large body of literature reporting the inappropriate overprescription of PPIs. Although the use of gastric acid inhibitors may reduce the risk of stress ulcers, it is important to target the therapy to patients at significant risk since PPIs have recently been associated with numerous adverse events, including infections. Gastric hypoacidity leads to bacterial overgrowth in the stomach and small intestine, in particular, an increase in gram negative and anaerobic bacteria [12, 13]. PPIs also increase the risk for Clostridium difficile infection (CDI) [14] and may predispose cirrhotic patients for spontaneous bacterial peritonitis [15, 16]. PPIs may also be associated with increased risk for respiratory infections, although the data are less clear [17, 18]. Nevertheless, in patients disposed to develop stress ulcers (that is patients with hypovolemia and/or hypoxia), it seems justified to prescribe prophylaxis with PPIs since the benefits of preventing a significant bleed in these very sick patients outweigh potential risks [19]. Critically ill patients probably profit from PPI stress ulcer prophylaxis, whereas in less ill patients with a minute risk of development of stress ulcers, the side effects may represent a greater risk for the patients than a possible small reduction in the risk of stress ulcer bleeding. In the present issue Koczka et al. [11] compared the attitude to stress ulcer prophylaxis between attending physicians and residents in a medical center in New York, reporting that half of the attending physicians thought that stress ulcer prophylaxis was indicated outside critical care settings. Perhaps even more problematic than short-term overuse of PPIs during the hospital stay is the fact that most of these patients are discharged on PPIs and thus probably remain on these drugs for prolonged periods without a proper indication [20, 21]. After patients are on PPIs for more than 3 months, stopping may be difficult due to rebound acid hypersecretion-induced dyspepsia [22, 23]. In conclusion, stress ulcer prophylaxis with PPIs is indicated in critically ill patients with hypovolemia and/or R. Fossmark H. Waldum (&) Department of Gastroenterology and Hepatology, St. Olavs Hospital, Prinsesse Kristinas Gate 1, 7006 Trondheim, Norway e-mail: helge.waldum@ntnu.no

Statements of the Malaysian Society of Gastroenterology & Hepatology and the National Heart Association of Malaysia task force 2012 working party on the use of antiplatelet therapy and proton pump inhibitors in the prevention of gastrointestinal bleeding

The working party statements aim to provide evidence and guidelines to practising doctors on the use of antiplatelet therapy and proton pump inhibitors (PPIs) in patients with cardiovascular risk as well as those at risk of gastrointestinal (GI) bleeding. Balancing the GI and cardiovascular risk and benefits of antiplatelet therapy and PPIs may sometimes pose a significant challenge to doctors. Concomitant use of anti-secretory medications has been shown to reduce the risk of GI bleeding but concerns have been raised on the potential interaction of PPIs and clopidogrel. Many new data have emerged on this topic but some can be confusing and at times controversial. These statements examined the supporting evidence in four main areas: rationale for antiplatelet therapy, risk factors of GI bleeding, PPI-clopidogrel interactions and timing for recommencing antiplatelet therapy after GI bleeding, and made appropriate recommendations.

Educational Intervention to Reduce the Inappropriate Use of Anti-Secretory Medication

Educational Intervention to Reduce the Inappropriate Use of Anti-Secretory Medication