Continuous Proton Pump Research Articles

Comparative Analysis of Continuous versus Intermittent Proton Pump Inhibitor Therapy in Patients with Upper Gastrointestinal Bleeding Due to Ulcers

Comparative Analysis of Continuous versus Intermittent Proton Pump Inhibitor Therapy in Patients with Upper Gastrointestinal Bleeding Due to Ulcers

Precise application of topical tranexamic acid to enhance endoscopic hemostasis for peptic ulcer bleeding: a randomized controlled study (with video)

Peptic ulcer recurrent bleeding occurs in 20% to 30% of patients after standard endoscopic hemostasis, particularly within 4 days after the procedure. The application of additional tranexamic acid (TXA) to the ulcer may enhance hemostasis. This study investigated the effectiveness of TXA powder application on bleeding ulcers during endoscopic hemostasis. This study enrolled patients who had peptic ulcer bleeding between March 2022 and February 2023. After undergoing standard endoscopic therapy, the patients were randomly assigned to either the TXA group or the standard group. In the TXA group, an additional 1.25 g of TXA powder was sprayed endoscopically on the ulcer. Both groups then received 3 days of high-dose (8 mg/h) continuous infusion proton pump inhibitor therapy. Second-look endoscopy was conducted on days 3 to 4. The primary end point of early treatment failure was defined as ulcer recurrent bleeding within 4 days or major stigmata of recent hemorrhage on the second-look endoscopy. Sixty patients (30 in each group) with peptic ulcer bleeding and balanced baseline characteristics were randomly assigned to a treatment group. The early treatment failure rate was lower in the TXA group (6.7%) than in the standard group (30%) (P= .042). The freedom from treatment failure periods for 4 and 28 days was significantly longer in the TXA group than in the standard group (P= .023). No adverse events from TXA were recorded. The precise delivery of topical TXA alongside standard endoscopic hemostasis reduced the early treatment failure rate in patients with bleeding peptic ulcers. (Clinical trial registration number: NCT05248321.).

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A retrospective study.

To compare the effectiveness of intermittent and continuous proton pump inhibitors (PPIs) infusion on the outcomes of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). The study was a single-centred retrospective study in adult patients with active upper gastrointestinal bleeding who received intermittent or continuous PPI infusion at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2013 to October 2019. The outcomes assessed were rebleeding, length of hospital stays and mortality within 30 days of admission, and were compared between the treatment groups. A statistically significant p-value was set at 0.05. The study involved 97 patients with NVUGIB treated with intermittent (n=56) and continuous (n=41) PPI infusions, with mean (±SD) ages of 66.0±16.1 and 58.0±19.5 years, respectively. The baseline and clinical characteristics between the 2 treatment groups; age (p=0.116), gender (p=0.345) and comorbidities (p=0.401), were comparable. There were no significant differences in rebleeding rates within 30 days (5 [8.9%] versus 1 [2.4%], p=0.396), length of hospital stays (4 vs 5, p=0.067), and mortality rate (1 [1.7%] vs 3 [7.3%], p=0.308) between the 2 groups. The management of NVUGIB with intermittent and continuous PPI infusions demonstrated comparable outcomes in reducing rebleeding rate, length of hospital stays, and mortality rate among patients attending the university hospital in Saudi Arabia.

Restoration for the foregut surgery: bridging gaps between foregut surgery practice and academia.

Foregut surgery largely involves benign diseases, and not only malignant diseases. However, for foregut surgeons in Asia, this fact has not been extensively utilized in their clinical practice due to the high burden of gastric cancer surgery. Although the prevalence of gastroesophageal reflux disease (GERD) in Eastern Asia, including Korea, is increasing, antireflux surgery (ARS) is still a fairly rare procedure in Korea. ARS is effective as proton pump inhibitors and is cost-effective compared to continuous double-dose proton pump inhibitors in patients with severe GERD. Therefore, we should focus on ARS as a treatment option for GERD also in Asian population. Similarly, although bariatric/metabolic surgery is effective in weight reduction and diabetes mellitus (DM) remission in patients with morbid obesity or DM, bariatric/metabolic surgery is only performed in a limited number of patients. Given that the prevalence of obesity and DM is continuously increasing in Korea, bariatric/metabolic surgery should become an interest among Korean foregut surgeons and should be considered a treatment for obesity and DM. Furthermore, there are new surgical fields that can control both benign and malignant diseases. Oncometabolic surgery is a field under foregut surgery that treats both malignant and benign components of a condition, an example being the control of metabolic syndrome while performing gastric cancer surgery. Therefore, in future gastric cancer treatment, oncometabolic surgery can be applied to patients with gastric cancer accompanied by obesity or metabolic syndrome.

Esophageal Stricture: Not Your Usual Culprit?

Question: A 60-year-old woman with past medical history of ATTR amyloidosis and status post heart and liver transplantation presented with complaints of progressive esophageal dysphagia to solids and liquids. She was on tacrolimus, mycophenolate mofetil (MMF), and prednisone. Other pertinent medications included trimethoprim sulfamethoxazole and valganciclovir for infection prophylaxis. Physical examination and laboratory data were unremarkable. Esophagogastroduodenoscopy (EGD) with histopathologic examination of biopsies from the middle third of the esophagus showed the findings presented in Figure A and B. Despite high-dose proton pump inhibitor therapy and repeated dilations, symptoms were unchanged and little progress was made in maintaining an increase in luminal diameter. What is the most likely diagnosis? Look on page 400 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The EGD demonstrates a long, benign-appearing, intrinsic moderate stenosis with extensive fibrotic stricturing in the middle one-third of the esophagus (8 mm inner diameter × 4 cm in length) (Figure A). The stenosis was dilated with a through the scope dilator to 11 mm. Esophageal biopsies demonstrated extensive ulceration with fibrinopurulent exudate and inflamed granulation tissue (Figure B). No fungal or viral infection or malignancy was seen. The patient underwent placement of a percutaneous gastrostomy tube. Over the next year, despite continuous high-dose proton pump inhibitor therapy, she continued to experience dysphagia and required monthly dilations. After ruling out an infectious etiology, MMF was suspected as the possible culprit. Immediately upon withdrawal of MMF, the patient reported significant clinical improvement. A follow-up EGD 4 months later showed a widely patent esophageal lumen with only mild mucosal variance characterized by flattening and scarring in the mid esophagus. MMF has well-known gastrointestinal (GI) adverse effects, including nausea, vomiting and diarrhea. Although the entire GI tract is susceptible to MMF-related toxicity, the colon and, less commonly, the small bowel are the most affected areas.1Nguyen T. Park J.Y. Scudiere J.R. Montgomery E. Mycophenolic acid (CellCept and Myofortic) induced injury of the upper GI tract.Am J Surg Pathol. 2009; 33: 1355-1363Crossref PubMed Scopus (59) Google Scholar A variety of mucosal changes can be seen in the lower GI tract, ranging from inflammatory bowel disease–like changes to features akin to graft-versus-host disease. Upper GI tract toxicities of MMF have included features ranging from those compatible with nonsteroidal anti-inflammatory drug use with topical irritation and damage to ulcerative esophagitis, reactive gastropathy, and duodenal ulceration.2Panarelli N.C. Drug-induced injury in the gastrointestinal tract.Semin Diagn Pathol. 2014; 31: 165-175Crossref PubMed Scopus (24) Google Scholar MMF-related esophageal strictures are rare.3Kim J.J. Mulki R.H. Sebastian K.M. Recalcitrant esophageal stricture secondary to mycophenolate mofetil.Case Rep Gastrointest Med. 2020; 2020: 8817801PubMed Google Scholar This case highlights an uncommon cause of a refractory esophageal stricture that should be considered as a potential etiology for dysphagia, especially in a transplant recipient, when more common etiologies have been excluded or when esophagitis is refractory to proton pump inhibitor therapy.

Long-term Continued Proton Pump Inhibitor Use is Common in Patients Diagnosed with Eosinophilic Esophagitis Despite Failure of Histologic Response: Data from a two-centre study: Long-term PPI Use in Patients with EoE.

Treatment paradigms for proton pump inhibitors (PPIs) in eosinophilic esophagitis (EoE) are evolving. We aimed to determine patterns of long-term PPI use after EoE diagnosis in PPI histologic non-responders. We conducted a retrospective review at University of Colorado (UCH) and University of North Carolina (UNC) of EoE patients who were histologic non-responders to PPIs. Data were extracted from electronic medical records related to demographics, PPI use, and reasons for continuing or stopping PPI. Of 67 patients in the UCH cohort, PPIs were initially discontinued in 9 (13%). Of 58 remaining on PPI, 48% were not instructed to discontinue therapy and 26% continued for symptom improvement. Of 675 patients at UNC, PPI was stopped in 185 (27%). Of patients remaining on PPI, 15% were not told to discontinue therapy and 62% were continued for symptom improvement. At last contact, >50% of patients remained on PPI at both centres with most common reasons for continuation being symptom improvement and not telling patients to discontinue. In the UNC cohort, clinical features associated with remaining on PPI included children younger than 18 years (p=0.01), males (p<0.001), heartburn symptoms (p<0.001) and hiatal hernia (p=0.004). Patients with dysphagia were less likely to remain on PPIs (p<0.001). Long-term PPI use is common in EoE patients even without histologic response. Failure to instruct patients to discontinue therapy was a common reason for long-term use, thus PPI use should be revisited in all EoE patients to confirm clinical benefit.

The effects of continuous proton pump inhibitor therapy on small intestinal bacterial overgrowth in elderly

Objective: Long-term proton pump inhibitor(PPI) therapy may increase the risk of small intestinal bacterial overgrowth(SIBO). Few studies on the effect of on-demand and continuous PPI therapy are available in elderly. To investigate the prevalence of SIBO and the effect of on-demand and continuous PPI therapy on SIBO in elderly. Methods: A total of 200 elderly outpatients admitted to Department of Gastroenterology at the Second Medical Center of PLA General Hospital were enrolled and divided into 3 groups: continuous PPI group, on-demand PPI group and control group. SIBO was diagnosed according to methane and hydrogen lactulose breath test (LBT).The prevalence of SIBO in the 3 groups was analyzed. Results: The prevalence of SIBO was 71.5% in 200 elderly. PPI therapy and diabetes mellitus (DM) were independent risk factors for SIBO. The prevalence of SIBO was 77.1% (108/140) in elderly who underwent long-term PPI therapy and 58.3% (35/60) in those without PPI therapy (P<0.01).The prevalence of SIBO was significantly higher in continuous PPI therapy group than that in on-demand PPI group and control group(88.6% vs. 65.7% and 58.3%, all P<0.01).However, no significant difference was found in the prevalence of SIBO between on-demand PPI group and control group (P>0.05). In elderly who underwent long-term PPI therapy, the prevalence of SIBO increased significantly if administration time was longer than 61 months. Conclusions: SIBO usually occurs in elderly patients who receive continuous PPI rather than on-demand use. If elderly require long-term PPI therapy, on demand administration is suggested as long as primary diseases are properly treated.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.

The main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD. University Hospital and Private Hospital, France and Private Hospital, Italy. This retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medicaltreatment and were converted to laparoscopic Roux-en-Y gastric bypass. The studyinvolved 2 French university hospitals, 4 French private centers, and an Italian public hospital. A total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pumpinhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio =3.69). The results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.

Is administration of proton pump inhibitors in functional dyspepsia worth the risk of developing gastric cancer: a Markov model to bridge the gap between scientific evidence and clinical practice

ObjectiveTo formulate a decision analysis model based on recently published data that addresses the dilemma, whether improvement in quality of life rationalises continued proton pump inhibitors (PPI) use despite the...

Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report

BackgroundSpontaneous esophageal rupture is a rare but serious disease with high mortality. Conservative treatment and endoscopic therapy have been reported, but surgical treatment is still a basic modality of therapy. In addition to thoracotomy, recent studies have reported treatment with thoracoscopic surgery and laparoscopic transhiatal repair. In this study, we report a patient who underwent laparoscopic transhiatal suture closure for spontaneous esophageal rupture with favorable postoperative course. We also discuss indication for laparoscopic surgery for spontaneous esophageal rupture.Case presentationA 70-year-old man visited our hospital with chief complaints of epigastric pain and vomitus niger. He was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus by computed tomography and upper gastrointestinal (GI) series. At 11 h after the onset of symptoms, we performed laparoscopic transhiatal suture closure and lavage drainage. We performed transhiatal esophageal replacement using the 5-hole approach. We observed a perforation of 2 cm in diameter at the site of the rostral portion approximately 4 cm from the esophageal hiatus. All layers were closed with three stitches using 3–0 absorbable sutures. No perforation was observed in the thoracic cavity. The total operative time was 178 min, and total bleeding was 2 ml. He had no postoperative complications and was discharged on day 15 after the procedure. He received continuous proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by esophagogastroscopy. The patient was advised to improve his lifestyle and has shown no signs of recurrence over 2 years from the date of surgery.ConclusionsSimple closure of all the layers using laparoscopic transhiatal simple closure was useful in the treatment of esophageal rupture as a less invasive approach for patients who meet the following conditions: stable general condition, intrathoracic perforation, and the perforation site is identified as the lower esophagus by pre-operative examination.

612 Impact of a Pharmacist-Managed Protocol Limiting Continuous Infusion of Proton Pump Inhibitor Use in Patients With an Upper Gastrointestinal Bleed

INTRODUCTION: In patients with an upper gastrointestinal bleed, previous reports have shown that there is no difference among clinically significant endpoints when prescribed a continuous infusion of pantoprazole versus intermittent bolus administration. Our study evaluates the impact of a pharmacist-managed protocol aimed at reducing continuous infusion proton pump inhibitor use in upper gastrointestinal bleeds. METHODS: We performed a retrospective analysis of patients receiving intravenous pantoprazole for suspected upper gastrointestinal bleeding before and after the implementation of a pharmacist managed protocol. Prior to implementation, patients were continued on pantoprazole continuous infusions (8 mg/hr) at the physician's discretion. After implementation, all hemodynamically stable patients were allowed one dose of pantoprazole as a continuous infusion (8 mg/hr for 10 hours) and then were transitioned by the pharmacist to intermittent 40 mg IV injections twice daily. The primary endpoint assessed was the incidence of upper gastrointestinal re-bleeding within 7 days of treatment. Secondary endpoints included the number of pantoprazole continuous infusions and IV push injections, number of blood transfusions, number of endoscopic interventions, length of hospital stay, and mortality. RESULTS: After screening 702 patients, 222 patients met inclusion criteria (115 in the pre-protocol group and 107 in the post-protocol group). The re-bleeding rate at day 7 was 7% in the pre-protocol group, compared to 4% in the post-protocol group (P = 0.17). As expected, use of the protocol reduced the median number of continuous infusions per patient [4 (IQR 2-4) vs 2 (IQR 1-3); P &lt; 0.001] and increased the median number of IV push injections [2 (IQR 2-4) vs 4 (IQR 2-7); P &lt; 0.001] in the pre- and post-protocol groups, respectively. There were no significant differences between the pre- and post-intervention groups regarding blood transfusions (65% vs. 63%; P = 0.78), endoscopic interventions (79% vs. 79%; P = 1.0), hospital length of stay [4 days (IQR 3-8) vs. 4 days (IQR 2-8); P = 0.521], or hospital mortality (5% vs. 2%; P = 0.28) (See Tables 1 and 2). CONCLUSION: Implementation of this pharmacy-managed protocol, allowing automatic transition from pantoprazole continuous infusions to intermittent injections in hemodynamically stable patients with an upper gastrointestinal bleed, had no detrimental effect on the incidence of re-bleeding within 7 days.

588 Skipping the Drip: Intravenous Bolus Proton Pump Inhibitor Therapy Produces Similar Outcomes to Continuous Infusions With Less Healthcare Resource Utilization

INTRODUCTION: Continuous proton pump inhibitor (PPI) infusions remain the most commonly employed therapeutic strategy for administration of PPIs in upper gastrointestinal (GI) bleeding. Recent data has pointed towards non-inferiority of intravenous (IV) bolus regimens, but real-world data is lacking. Cost effectiveness and resource utilization data is also unavailable and projections made by estimation have shown low potential for cost savings. METHODS: A retrospective cohort study to evaluate the impact of a shift in institutional practice from PPI infusions to bolus was conducted. As part of a quality improvement initiative, an electronic medical record-based order set was employed; this involved an IV PPI twice daily for 72 hours subsequently defaulting to an oral regimen. After obtaining institutional review board (IRB) approval, patients admitted with upper GI bleeding at our institution from January 2017 to December 2018 were identified with relevant ICD 10 codes. All patients with peptic ulcer disease as the cause of bleeding were included and divided into two groups on the basis of PPI administration strategy. Clinical and resource utilization outcomes were compared between the two groups. Univariate and multivariable analyses were performed to assess independent associations. RESULTS: Of the 368 patients included the mean age was 62.68 years (SD: 5.3 years) and 170 (46.1%) were male. On univariate analysis, age, gender, smoking status, use of anticoagulants, and PPI administration strategy were not associated with inpatient mortality, readmissions, re-bleeding at 3, 7 and 30 days, need for endoscopic hemostatic therapy and need for re-intervention or surgery (all P values &gt; 0.05). Multivariable logistic regression revealed that smoking (OR 2.12 95% CI 1.13- 3.70), anticoagulation use (OR: 2.27 95% CI 1.17- 4.62) and age (OR: 1.03, 95% CI 1.01-1.04) were significantly associated with in-hospital packed red blood cell transfusions. Bolus PPI use was associated with less pharmacy cost of drug calculated per patient, earlier de-escalation to oral PPI, and shorter hospital stay (P &lt; 0.05). CONCLUSION: Our real world, tertiary care experience ascertains non-inferiority of IV bolus PPI regimen compared to continuous infusion for acid suppression therapy in managing upper GI bleeds. The use of simpler bolus regimens can result in a decrease in healthcare resource utilization. A practice shift to such a regimen can therefore serve as a good quality improvement initiative in health care settings.

Acute hiatal hernias

In surgical practice, hiatal hernias are often related to gastro esophageal reflux disease treatment in which continuous proton pump inhibitor administration is very successful. In large hiatal hernias, life threatening complications may occur. However, planned surgical repair of hiatal hernias is associated with very good functional outcomes with alow risk of postoperative complications. The incidence of large hiatal hernias grows with increasing age of the patient. In geriatric patients, internal comorbidities are also more frequent, including serious conditions. In these patients, one may hesitate whether to perform surgery with regard to the possible risk of postoperative complications. Conservative treatment of hiatal hernias is associated with ahigher risk of stomach volvulus or severe bleeding as the most frequent complications. We performed aretrospective study of patients operated on for alarge hiatal hernia at the Department of Surgery, University Hospital Brno, between 2010 and 2016 (86 months). The patients were divided into 2 groups depending on the type of operation: acute (A) and elective (B). We evaluated demographic data, the nature of preoperative symptoms, type of surgery and postoperative complications. 120 patients were operated on for large hiatal hernia in this period of time. Group Ainvolved 22 operated patients, group B 98 patients. There was asignificantly higher number of laparotomies in the acute patient group compared to the elective group B (72.7% vs. 23.5%, p.

Proton Pump Inhibitors Diminish Barrett's Esophagus Length: Our Experience.

AIM:Our main objectives were to evaluate the influence of two-year proton pump inhibitors (PPI) therapy in patients with Barrett’s oesophagus on its length, in both types, short and long segment.METHODS:In this single-centre, prospective interventional controlled study were analysed data collected prospectively over two years from patients with Barrett’s oesophagus diagnosed by endoscopy. Patients who received continuous proton pump inhibitors (PPI) for 2 years were included. At each patient visit symptoms were recorded, and at each endoscopy, the length of Barrett’s oesophagus (BE) was measured. Biopsies were taken along the length of the oesophagus at intervals of 1 cm. In total, 50 patients with Barrett’s oesophagus were included in the study: 10 of whom had long-segment Barrett’s oesophagus, and 40 patients had short-segment Barrett’s oesophagus. The mean number of endoscopies performed was 3 per patient.RESULTS:The length of Barrett’s esophagus (BE) was influenced by PPI therapy: Circumferential extension in BE patients short-segment Barrett’s esophagus (SSBE) (before treatment was 1.5 cm and after treatment was 0.8 cm Maximum proximal extension in SSBE group before treatment was 2.3 cm (SD ± 1.1 cm), and 1.1 cm (SD ± 0.9 cm), respectively. Squamous islands were detected in 25% of patients examined after 2 years on PPIs.CONCLUSIONS:PPIs achieve a reduction to the length of Barrett’s oesophagus, in both types, and the development of squamous islands is commonly associated with their use.

Do sleeve gastrectomy and gastric bypass influence treatment with proton pump inhibitors 4 years after surgery? A nationwide cohort

BackgroundGastroesophageal reflux disease (GERD) is a common obesity-related co-morbidity that routinely is treated by continuous proton pump inhibitor (PPI) therapy. A number of concerns have been raised regarding the risk of de novo GERD or exacerbation of preexisting GERD after sleeve gastrectomy (SG). ObjectiveTo assess PPI use at 4 years after bariatric surgery. SettingFrench National Health Insurance. MethodsData were extracted from the French National Health Insurance database. All adult obese patients who had undergone gastric bypass (GBP) (n = 8250) or SG (n = 11,923) in 2011 in France were included. Patients were considered to be on continuous PPI therapy when PPIs were dispensed≥6 times per year. Logistic regression models were used to compute odds ratios for potential risk factors for PPI reimbursement 4 years after surgery. ResultsOverall, continuous use of PPIs increased from baseline to 4 years after SG and GBP, from 10.9% to 26.5% (P<.001) and from 11.4% to 21.9% (P<.001), respectively. Among patients who underwent PPI therapy before surgery, those who had undergone SG were more likely to continue PPI therapy 4 years after surgery compared with those who underwent GBP (72.7% versus 59.2%; P<.001). In multivariate analyses, the major risk factors for persistent continuous PPI treatment 4 years after surgery were the following: SG (odds ratio [OR] = 1.87; 95% confidence interval [CI] 1.55–2.25), higher body mass index (OR 1.85; 95% CI 1.35–2.5), and preoperative antidepressant treatment (OR 1.89; 95% CI 1.56–2.29). ConclusionAt a nationwide scale, continuous PPI treatment is used by 1 of 10 obese patients before bariatric surgery, but by 1 of 4 patients 4 years after surgery. SG compared with GBP, higher body mass index, and other coexisting conditions are the 3 major risk factors for medium-term continuous PPI therapy.

Non-Helicobacter pylori, Non-nonsteroidal Anti-inflammatory Drug Peptic Ulcer Disease

Non-Helicobacter pylori, non-NSAID peptic ulcer disease (PUD), termed idiopathic PUD, is increasing in Korea. Diagnosis is based on exclusion of common causes such as H. pylori infection, infection with other pathogens, surreptitious ulcerogenic drugs, malignancy, and uncommon systemic diseases with upper gastrointestinal manifestations. The clinical course of idiopathic PUD is delayed ulcer healing, higher recurrence, higher re-bleeding after initial ulcer healing, and higher mortality than the other types of PUD. Genetic predisposition, older age, chronic mesenteric ischemia, cigarette smoking, concomitant systemic diseases, and psychological stress are considered risk factors for idiopathic PUD. Diagnosis of idiopathic PUD should systematically explore all possible causes. Management of this disease is to treat underlying disease followed by regular endoscopic surveillance to confirm ulcer healing. Continuous proton pump inhibitor therapy is an option for patients who respond poorly to the standard ulcer regimen.

Changing how we confirm ngt placement: impact on nutrition delivered

Confirming the position of Nasogastric tubes (NGT) in critical care is a controversial area. The National Patient Safety Agency (NPSA) guidance [1] advocates pH testing although use is limited in ICU due to continuous enteral feeding and proton pump inhibitor therapy. Chest X-ray is therefore commonly used with trainee doctors often being responsible for confirming tube position. Following three incidents of undetected NGT misplacement (outside of our ICU), our trust stipulated a change in practice so that only radiologists or ICU consultants were allowed to confirm placement. We were concerned that this could negatively influence tube confirmation times and enteral nutrition (EN) provision. Cumulative calorie deficits contribute to malnutrition [2]. Under-nutrition in critically ill patients is associated with increased mortality, infections and length of stay [3].

Cardiopexy with Ligamentum Teres in Patients with Hiatal Hernia and Previous Sleeve Gastrectomy: An Alternative Treatment for Gastroesophageal Reflux Disease.

Fifty percent of patients who have undergone sleeve gastrectomy have gastroesophageal reflux disease (GERD). Surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. Here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous sleeve gastrectomy and hiatal hernia. Included in the study were 15 patients (age, 35.6 ± 15.2 years; 13 females [86.6 %]; mean pre-cardiopexy body mass index, 21.94 kg/m(2)) with sleeve gastrectomy who presented with hiatal hernia and gastroesophageal reflux disease and underwent ligamentum teres cardiopexy. In this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last 3-5 cm of esophagus in the abdomen. The distal ligamentum teres is fixed with one stitch to the apex of the angle of His, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. The remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. The procedure concludes with diaphragmatic crus closure. After 6 months, 13 patients (86.6 %) achieved successful results, defined as resolution of GERD, no proton-pump inhibitor (PPI) use, and manometry measurement over 12 mmHg after surgery. Two patients (13.3 %) required continued proton-pump inhibition. Ligamentum teres cardiopexy combined with closure of the gastric crus is a good alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia.

Review: In high-risk ulcers, intermittent and continuous PPI therapy do not differ for recurrent bleeding

Source Citation Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: A systematic review and meta-analysis. JAMA Intern Med. 2014;174:1755-62. 25201154

Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: Sachar H, Vaidya K, Laine L. JAMA Intern Med 2014;4056. [Epub ahead of print

Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: Sachar H, Vaidya K, Laine L. JAMA Intern Med 2014;4056. [Epub ahead of print