Per Rectum Research Articles

ThP6.4 - Psoas Sarcopaenia as a Predictor of Mortality in Patients Over 65 with PR Bleeding: A Retrospective Case Controlled Study

Abstract Aims Sarcopaenia has been examined as a predictor for functional baseline and frailty in surgical patients and may predict mortality. The hypothesis of this study is that sarcopaenia is associated with increased risk of death after per rectal (PR) bleeding. Methods Patients over 65 who were admitted between January 2017 and December 2022, having had an episode of PR bleeding, that underwent cross sectional imaging were identified from the Southern health and social care trust database. Cross sectional imaging was accessed via PACS and total psoas area (TPA) calculated at the third lumbar vertebra by a radiology trainee and validated by a consultant radiologist. Clinical, mortality and demographic data was obtained from Northern Ireland Electronic Care Record (NIECR). Psoas muscle index (PMI) was then calculated by TPA and standardising for height in mm2/m2. Sarcopaenia was defined as PMI male < 545 mm2/m2 female < 385 mm2/m2. Results 77 Patients were included in this study. Patients were excluded based on the ability to standardise TPA for height. 27% (n 21) of patients were identified as sarcopaenic, 66% (n 14) of these patients have died. The median PMI showed differences between female mortality (490.44 mm2/m2) and non-mortality (559.49 mm2/m2) groups. Male patients also showed lower median PMI between mortality (599.79 mm2/m2) and non-mortality (643.05 mm2/m2 ) groups. Conclusions Sarcopaenia as a predictor for frailty is an important risk factor for all-cause mortality in PR bleeding. Cross-sectional imaging provides an opportunity to quantify risk as well as investigate aetiology for PR bleeding. Although radiation risk and cost effectiveness may limit use, it should be considered when imaging is available.

Sonographic evaluation of retained products of conception within 48h following delivery: a retrospective cohort study.

Early diagnosis of retained products of conception (RPOC) is critical for directing clinical management and for preventing associated complications. This study aimed to evaluate the utility of post-delivery ultrasound in patients with risk factors for RPOC. A retrospective cohort-study was conducted in asingle tertiary university-affiliated hospital (January 2016-September 2022). Sonographic evaluation, including endometrium thickness measurement and color Doppler, were reviewed of women with risk factors for RPOC: postpartum hemorrhage, a hemoglobin drop > 4g/dl, manual removal of the placenta, and suspicious placenta. Results of early postpartum ultrasound (within 48h), misoprostol administration and hysteroscopies were evaluated. Of the 591 women included, RPOC was suspected in 141 (24%). Endometrial thickness > 5mm was associated with sonographic RPOC diagnosis in 58%. Suspected sonographic RPOC was concluded for 100%, 92% and 7% of the women with marked, moderate, and undetectable vascularity, respectively, p < 0.001. Misoprostol 1000mcg per rectum (PR) was administered to 86% of those with suspected RPOC; only 11% of them needed an operative hysteroscopy for removal of the RPOC. RPOC on a pathology report was confirmed for 71% of those who underwent hysteroscopy. Postpartumtransabdominal ultrasonography within 48h of deliverywas effective for assessing RPOC. For appropriate triage, color Dopplergrading increased the accuracy of RPOC diagnosis. Misoprostol treatment was successful in 88% of women with suspected sonographic RPOC. The combination of sonographic evaluation and misoprostol treatment for suspected RPOC might lower the rate of unnecessary invasive procedures.

Rectal thionamide administration in the setting of thyroid storm: a case report and review of the literature.

Thyroid storm is a clinical diagnosis characterized by life-threatening multisystemic organ involvement in the setting of uncontrolled hyperthyroidism. Current estimates suggest a mortality rate of up to 30%. Treatment often consists of the administration of thionamide medications, iodine solution(s), corticosteroids, and beta-blockers; in extreme circumstances, both plasmapheresis and thyroidectomy are subsequent therapeutic options. Thionamides are typically administered orally, with the intent of preventing further thyroid hormone synthesis; however, in the literature, there are instances whereby oral access cannot be obtained, and alternative routes of administration are required. We present a case of a patient who presented with a thyroid storm due to lack of adherence to methimazole. During admission, he was found to have significant abdominal pain and ultimately a duodenal perforation requiring strict nil-per-os (NPO) status, due to which he was unable to receive oral thionamides. Due to the lack of availability of intravenous formulations of thionamides in the United States, this patient was treated with an enema compound of propylthiouracil for a total of five per rectum (PR) doses. He would later develop hepatocellular injury, requiring discontinuation and eventual transition to oral methimazole. The literature pertaining to alternative-route thionamide administration is scant, and therefore this case report and literature review is written to provide an up-to-date review and further educate all levels of clinicians about this infrequent (but emergent) situation. Thyroid storm is a clinical diagnosis for which urgent recognition is required to prevent untoward mortality. Treatment for thyroid storm requires prompt administration of thionamides, iodine, corticosteroids, and beta-blockers. In extreme circumstances, treatment considerations include plasmapheresis and thyroidectomy. Infrequently, patients with a thyroid storm may not be able to tolerate oral medications, for which alternative routes of access are required. Currently, available alternatives include intravenous methimazole (in Europe and Japan), as well as both enema and suppository preparations of propylthiouracil and methimazole.

GIANT SOLITARY RECTAL ULCER: COMPLICATIONS AND ROLE OF RADIOLOGICAL INTERVENTION

Solitary Rectal Ulcer Syndrome (SRUS) is a chronic and benign condition of rectum with an estimated incidence of one per 100000 people per year. Symptoms range from perianal pain, constipation, incomplete evacuation to severe bleeding per rectum and related complications. Giant SRUS is further rare with average size measuring &gt;4 cm in diameter. There is absolute paucity of data for role of radiological intervention in SRUS and complications associated with giant SRUS. Here we discuss a case of giant SRUS which was refractory to standard modalities of treatment, was associated with complications like severe bleeding per rectum (PR), perianal abscess and stulae formation. He also required radiological as well as surgical intervention in form of trans-arterial embolization and Incision and drainage of perianal abscess / stulotomy, respectively

Colonoscopy an Audit: Wiser the Decision Better the Outcome

Background and Aim of the Study: In a developing country like India, wherein routine screening colonoscopy is not a norm and prevalence of colonic polyps is considered to be rare, we conducted a study to analyse the indications, findings and our compliance with selected key performance indicators (KPI’s): Cecal intubation, polyp detection rate, colonoscopy withdrawal time, adverse events and bowel preparation at a large tertiary care hospital in Bengaluru, India which would aid in improving the quality of our practice. Materials and Methods: A retrospective study was conducted on 185 patients either admitted or seen on outpatient basis at Bowring and Lady Curzon hospital attached to Bangalore medical college and research institute (BMCRI), Bengaluru. The colonoscopy reports of all patients at our center from September 2017 to August 2018 were reviewed to obtain information on demographics, indications, findings and KPI’s and the data was analyzed using appropriate statistical methods. Results: Among 185 patients who underwent colonoscopy 63% were male and 53% were 31-59 years old. The major indications were bleeding per rectum (PR) [24%], colonic wall thickening on imaging(19%), chronic diarrhea (11%) and colorectal growth (8%). 82% of the patients had excellent bowel preparation with the cecal intubation achieved in 84%.The common pathological findings in the above mentioned indications were Colorectal cancer(CRC) [11%], ulcer(9%), Inflammatory bowel disease(IBD) [6%] and polyp(6%). Conclusions: Colonoscopy is very much essential to evaluate lower GI symptoms. The quality of practice lies on the bowel preparation as well as cecal intubation. Bleeding PR was the most common indication whereas colorectal cancer was the most common pathological finding although more than half of the examinations were normal.

RCT Assessing Efficacy of Perioperative Hydrocortisone and Indomethacin Treatment in Reducing Major Complications after Whipple’s Pancreaticoduodenectomy

Introduction: After Whipple’s Pancreaticoduodenectomy (PD), pancreatic anastomotic leak leading to postoperative pancreatic fistula (POPF), Post pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE) and Sepsis cause major morbidity. Hydrocortisone and indomethacin have been postulated to reduce post-operative pancreatitis and thus Pancreatic leak. This RCT compares their role in preventing major complications in high-risk patients, Methods: Between January 2018 to April 2019, 146 patients undergoing Whipple’s PD were randomized into 3 arms, intravenous (i.v) hydrocortisone, per rectal (PR) indomethacin, or placebo. Only high-risk patients (n= 105) with >40% of acini (a marker of the soft pancreas) based on the intraoperative frozen section were included. All patients received a total of 8 doses of i.v. treatment (8 hourly) and 6 doses of PR treatment (12 hourly). Primary end-points were major complications (Clavien–Dindo 2-5) Results: As compared to placebo The Hydrocortisone group, had significantly less major complications (14.3% vs 40.0%; P value = 0.003). Clinically significant POPF (8.6% vs 20%) and DGE (14.3% vs 22.9%) were lower. The Indomethacin group did not show decrease in major complications (37.2% vs 40%; p value = 1.00) except for DGE (14.3% vs 22.9%; p value = 0.001). Clinically significant POPF (17.1% vs 20%) and PPH (11.4% vs 14.3%) are not significantly lower in indomethacin group. No 30 day mortality in either group. Conclusion: This RCT shows that Hydrocortisone treatment is significantly better than Indomethacin in reducing the major postoperative complications in high-risk patients after Whipple’s PD.

1405 Improving Documentation of Per Rectal (PR) Exams in An Acute Surgical Unit

Abstract Aim A PR exam is routinely performed as part of the complete examination of surgical patients. The General Medical Council (GMC) has provided guidance on the use of chaperone during intimate exams stating that consent should be obtained, and a chaperone offered to all patients and documented accordingly. We aimed to assess and improve our documentation of PR exams. Method Data was collected prospectively from surgical admission documentation. The number of patients with consent and presence of chaperone documented during PR exam was recorded. Following a period of data collection, a proforma was implemented with education on correct documentation as per guidelines. A second audit cycle was performed where formal inclusion of the sticker in the admission booklet was implemented. Results 20 patients were included in the initial data collection, 95% of which had incomplete documentation of PR exam on admission. A sticker was designed to prompt accurate documentation and inserted into the acute admissions booklet. Following this, 50% of PR exams were correctly documented. The remaining 50% without documentation had no sticker in the admission booklet. The second intervention included changing the hardcopy of the admission booklet. Following this, 80% of patients had consent documented and 90% had documented chaperone. Conclusions GMC guidelines state that documentation of consent and the presence of chaperones during intimate medical examinations are crucial. The implementation of a prompt in our admissions booklet has greatly improved our documentation in PR examination.

Rectal Acetaminophen Improves Shunt Volume and Reduces Patent Ductus Arteriosus Ligation in Extremely Preterm Infants.

An alternative therapy for preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA) is needed when cyclooxygenase inhibitors fail or where treatment is contraindicated due to coexisting renal failure, necrotizing enterocolitis, and/or intestinal perforation. No studies have evaluated the efficacy of per rectum (PR) acetaminophen. The study aimed to evaluate the efficacy of PR acetaminophen in modulating the risk of PDA ligation. A retrospective matched case-control study was conducted to compare neonates born <29 weeks' gestation with evidence of hsDA, in an era when rescue rectal acetaminophen was used (January 2014-March 2018) as a treatment strategy, versus historical controls (July 2006-August 2012). All patients underwent comprehensive echocardiography assessment of ductal shunt volume according to a standardized protocol. Acetaminophen treated neonates were matched according to demographics, gestation, preintervention echocardiography features, and comorbidities. Control patients were selected when an echocardiography was performed at an equivalent postnatal age. Infants with a genetic syndrome, severe congenital malformation, or major forms of congenital heart disease excluding small atrial septal defect or ventricular septal defect, PDA, or patent formale ovale were excluded. The primary outcome was surgical ligation of the PDA. Secondary outcomes included echocardiography indices of hemodynamic significance, the composite of death, or severe BPD (defined by ventilator dependence at 36 weeks postmenstrual age). Descriptive statistics and univariate (t-tests, Fisher's exact test, and Mann-Whitney U test) analyses were used to evaluate clinical and echocardiography characteristics of the groups and compare outcomes. Forty infants (20 cases and 20 controls), with similar demographic and echocardiography features, were compared. Cases received 6.8 ± 0.7 days (60 mg/kg/day) of PR acetaminophen. Responders (n = 12, 60%) had echocardiography evidence of reduced ductal diameter (2.2 mm [1.9-2.6] to 1.1 mm [0-1.7], p = 0.002), left ventricular output (363 ± 108-249 ± 61 mL/min/kg; p = 0.002) and left atrium to aortic root ratio (1.7 ± 0.3-1.3 ± 0.2; p = 0.002) following treatment. The rate of PDA ligation was 50% lower (p = 0.02) and composite outcome of death or severe bronchopulmonary dysplasia was reduced (p = 0.04) in the acetaminophen group. Rectal acetaminophen was associated with improvement in echocardiography indices of PDA shunt volume, a 50% reduction in PDA ligation rates and a reduction in the composite outcome of death or severe BPD. Pharmacologic and further prospective clinical studies are needed. · Many preterm infants encounter the clinical consequences of a hemodynamically significant PDA.. · The merits and optimal timing of PDA ligation remains an area of controversy amongst neonatologists.. · Cyclooxygenase inhibitors are associated with adverse events or are often contraindicated..

Efficacy of Peri Operative Hydrocortisone and Indomethacin Treatment in Reducing Major Complications after Whipple's Pancreaticoduodenectomy, Randomized Controlled Clinical Trial

Introduction: Post Whipple's Pancreatico-duodenectomy (PD) the major concern is pancreaticojejunostomy (PJ) leak which leads to post operative pancreatic fistula (POPF), post pancreatectomy haemorrhage(PPH), delayed gastric emptying (DGE) ,sepsis. sometimes mortality.Hydrocortisone and indomethacin have been postulated to reduce post operative pancreatitis and thus PJ leak. Methods: Between Jan 2018 - April 2019, 146 patients for Whipple's PD were included. Only high risk patient (n= 105)with >40% of acini (marker of soft pancreas) on frozen section of transection margin were randomized to intravenous (iv) hydrocortisone, per rectal (PR) indomethacin or placebo (3 groups ,35 in each group). All patients received total 8 doses of iv treatment (8 hourly) and 6 doses of PR treatment (12 hourly). 100 ml NS and glycerin suppository were the placebo drugs. Primary end-points were overall major complications(Clavien Dindo 2-5). Results: Hydrocortisone group had less major complications compared to placebo(overall 14.3% vs 40.0%; P value = 0.003). POPF (8.6% vs 20%) and DGE (14.3% vs 22.9%) were also lower in hydrocortisone group Indomethacin group did not reduce major complications compared to placebo (overall, 37.2% vs 40%; p value = 1.00). POPF (17.1% vs 20%) and PPH (11.4% vs 14.3%) Although, DGE is significantly less in indomethacin group (14.3% vs 22.9%; p value = 0.001). 30 day mortality was zero in all the groups. Conclusions: Hydrocortisone treatment significantly reduces major postoperative complications in high risk patients after Whipple's PD whereas Indomethacin treatment does not as compared to placebo.

Pharmacokinetics of Pimobendan and Its Metabolite O-Desmethyl-Pimobendan Following Rectal Administration to Healthy Dogs.

Objective: This study describes the pharmacokinetics of parent pimobendan (PIM) and its active metabolite, o-desmethyl-pimobendan (ODMP), after oral and rectal administration of pimobendan to healthy dogs.Animals: A total of eight healthy privately owned dogs were used in this study.Procedures: The dogs received a single dose (0.5 mg/kg) of a commercially available pimobendan tablet per os (PO). Twelve blood samples were collected over a 12-h period for pharmacokinetic analysis. After a 24-h washout period, the dogs received the same dose of pimobendan solution per rectum (PR), and samples were obtained at the same time for analysis.Results: For PIM, PO vs. PR, respectively, the mean maximum plasma concentration (Cmax, ng/ml) was 49.1 ± 28.7 vs. 10.1 ± 2, the time to reach a maximum concentration (Tmax, h) was 2.1 ± 0.9 vs. 1 ± 0.4, the disappearance half-life (t1/2, h) was 1.8 ± 0.8 vs. 2.2 ± 0.6, and the area under the concentration–time curve (AUC, ng*h/ml) was 148.4 ± 71.6 vs. 31.1 ± 11.9, with relative bioavailability (F, %) of 25 ± 8. For ODMP, PO vs. PR, respectively, Cmax was 30.9 ± 10.4 vs. 8.8 ± 4.8, Tmax was 3.2 ± 1.6 vs. 1.7 ± 1.1, and t1/2 was 5.0 ± 2.7 vs. 8.3 ± 4.8, with AUC of 167.8 ± 36.2 vs. 50.1 ± 19.2 and F of 28 ± 6. The differences between PO and PR were significant (P < 0.03) for AUC and Cmax for both PIM and ODMP.Conclusions and Clinical Relevance: The pharmacokinetics of PIM and ODMP were described following PO and PR administration. The findings suggest that pimobendan PR might achieve effective concentrations and, as such, warrant future studies of clinical effectiveness in treating dogs with congestive heart failure and which are unable to receive medication PO.

Single-dose pharmacokinetics of orally and rectally administered misoprostol in adult horses.

To characterize the pharmacokinetics of a clinically relevant dose of misoprostol administered PO or per rectum (PR) to horses. 8 healthy adult horses. In a randomized 3-way crossover design, horses received a single dose of misoprostol (5 μg/kg) administered PO (with horses fed and unfed) and PR, with a minimum 3-week washout period separating the experimental conditions. Blood samples were obtained before and at various points after drug administration (total, 24 hours), and plasma concentrations of misoprostol free acid were measured. Mean maximum plasma concentration of misoprostol was significantly higher in the PR condition (mean ± SD, 967 ± 492 pg/mL) and unfed PO condition (655 ± 259 pg/mL) than in the fed PO condition (352 ± 109 pg/mL). Mean area under the concentration-versus-time curve was significantly lower in the PR condition (219 ± 131 pg•h/mL) than in the unfed (1,072 ± 360 pg•h/mL) and fed (518 ± 301 pg•h/mL) PO conditions. Mean time to maximum concentration was ≤ 30 minutes for all conditions. Mean disappearance half-life was shortest in the PR condition (21 ± 29 minutes), compared with values for the unfed (170 ± 129 minutes) and fed (119 ± 51 minutes) PO conditions. No adverse effects were noted. Misoprostol was rapidly absorbed and eliminated regardless of whether administered PO or PR to horses. Rectal administration may be a viable alternative for horses that cannot receive misoprostol PO, but this route may require more frequent administration to maintain therapeutic drug concentrations.

Management of per rectal bleeding is resource intensive

Haematochezia or per rectal (PR) bleeding is the most common presentation of lower gastrointestinal bleeding. This study analyses the hospital resources used in the management of patients with PR bleeding. A retrospective analysis was performed on patients who presented with PR bleeding from June 2012 to December 2013 to a single tertiary centre in Sydney, Australia. Age, gender, comorbidities, use of antiplatelet or anticoagulant medications, vital signs, and haematological data were recorded. The objective factors available on initial patient assessment were analysed for their relationship with the following outcomes: use of computed tomography mesenteric angiogram, formal angiography and embolization, transfusion of blood products, endoscopy, operative management and length of stay. There were 523 confirmed presentations of PR bleeding. Four hundred and fifty-two of these presented directly to emergency department, while 71 were referred from another hospital. One in five patients had blood transfusion (19%), 13% had computed tomography mesenteric angiogram, 4% had embolization and 13% underwent diagnostic and/or therapeutic colonoscopy. Patients referred from other facilities were more comorbid (55% versus 30%), more likely to be on antiplatelet or anticoagulant (69% versus 33%) with a higher rate of embolization (28% versus 4%), more packed cell transfusions (2.1 versus 0.7 units) and longer length of stay (7.9 versus 5.7 days) but mortality was the same (1%). The management of patients with PR bleeding is resource intensive. Better identification and allocation of resources in patients who present with PR bleeding may lead to better efficiency in managing this growing clinical problem.

A hospital-based study on caregiver preferences on acute seizure rescue medications in pediatric patients with epilepsy: Intranasal midazolam versus rectal diazepam

RationaleAbout 20 per 100,000 children have convulsive status epilepticus every year, a life-threatening condition. Benzodiazepines are the first-line treatment for prolonged and recurrent seizures. Our study was designed to gain understanding of caregiver perception of acute seizure treatments. MethodsOur project uses a cross-sectional survey study design using the electronic medical record and a survey at a large academic tertiary children's medical center. Subjects were patients with epilepsy prescribed intranasal (IN) midazolam and/or per rectum (PR) diazepam. The survey was administered to caregivers of children with epilepsy regarding information on the comfort, efficacy, ease of use, and time of administration for patients receiving both abortive seizure medications. Exact binomial tests were employed to determine whether or not differences in caregiver preference exist. ResultsOne hundred and sixty responses were obtained. Incomplete and duplicate surveys were excluded, leaving 153 responses. Of those responses, 59 respondents reported administering both medications. Among parents who expressed a preference for one medication over the other, more parents felt overall greater comfort with IN midazolam compared with rectal diazepam (p = 0.0004 and p = 0.001), IN midazolam was perceived as easier to use (68%, p = 0.0038 and 74%, p = 0.0004) and more effective (87%, p < 0.0001) than rectal diazepam. Intranasal midazolam was found to be superior to rectal diazepam in several other categories as well. ConclusionsThese parents of children with epilepsy report increased ease of use, comfort, and efficacy with IN midazolam as compared with rectal diazepam suggesting that a readily available form of IN midazolam would be well received in the pediatric population.

Rigid Sigmoidoscopic Examination, an Investigation Down but Not Out: A 5-Year Single-Center Experience on 9418 Patients

ABSTRACT Background: Rigid sigmoidoscopy (RS) in the present era of flexible sigmoidoscopies is falling out of favor although it continues to be used in some centers as an outpatient (OP) department procedure. Aims: This study aims to determine the utility of RS for diagnosis of rectosigmoidal pathologies in the OP setting with emphasis on neoplastic lesions. Methods: We retrospectively studied the RS records and histopathology reports (HPRs) of 5 years (July 2013–June 2018) done in the Department of Gastroenterology at Medical College Calicut. Results: During the study period, 9418 RS examinations were done, and a total of 6921 abnormalities were picked up, giving a diagnostic yield of 73.5%. Most common indication was bleeding per rectum (PR) (51%), followed by constipation (29%). The most common lesion found was hemorrhoids 39.8% followed by proctitis 13.7%, neoplasms 9.7%, and others 10.3% while 26.5% studies were normal. HPRs showed 7.7% to be malignant, 5.8% were adenoma, 12.2% were inflammatory bowel disease ulcerative colitis (IBD UC), 2.2% were solitary rectal ulcer syndrome, 1.2% nonspecific colitis, 1.7% nonneoplastic polyps, 2.7% were normal, and 1.4% were inconclusive. Of the 4812 patients with complaints of bleeding PR, 4739 (98.5%) had a diagnosis after RS, of which hemorrhoids (72.7%) was the most common cause followed by proctitis (14.2%), neoplasm (9%), and others (4.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of RS in detecting neoplasia was 98.2%, 96.8%, 66.1%, and 99.9%, respectively, when HPR was gold standard. RS was found to be effective for assessing activity in IBD UC. Conclusion: RS is a simple, cheap, and effective tool for diagnosing various rectosigmoid pathologies. RS can be used as an effective screening test for rectosigmoid pathologies, especially neoplasia and IBD UC.

Pharmacokinetics of Intrarectal Altrenogest in Horses

Hospitalized pregnant mares being held nil per os (PO) because of medical or surgical events present a dilemma for pregnancy maintenance therapy, which commonly includes oral altrenogest. Rectal administration of medications is a recognized route for achieving systemic concentrations, but there are no data on the pharmacokinetics of rectal altrenogest administration in horses. The purpose of this study was to determine the pharmacokinetics of altrenogest following PO or per rectum (PR) administration in mares. Using a randomized two-way crossover study design, six horses received altrenogest (0.088 mg/kg; PO or PR q 24 hours for 5 days), with a 7-day washout period, and the concentrations of altrenogest were determined by an ultrahigh performance liquid chromatography with tandem mass spectrometry. Plasma concentrations persisted above presumed therapeutic concentrations for a mean of 36 hours (range 24–72 hours) and 5.5 hours (range 3–8 hours) for PO and PR administration, respectively. The calculated half-life (T ½) of PO administration (7.01 ± 3.13 hours) was correspondingly increased when compared to PR administration (2.82 ± 1.07 hours). Relative bioavailability of altrenogest following PR administration was only 5.47%. Altrenogest is rapidly absorbed following PR administration in the horse and reaches therapeutic concentrations, making this a viable method of treatment in NPO mares. The decreased bioavailability and shorter detection time suggest 0.088 mg/kg PR q 4–8 hours would be necessary to maintain therapeutic concentrations over a 24-hour period.

Opioid Sparing in Cleft Palate Surgery.

This study aimed to determine whether intraoperative acetaminophen was able to decrease opioid consumption, pain scores, and length of stay while increasing oral intake in cleft palate surgery. One hundred consecutive patients with cleft palate who underwent a von Langenbeck or 2-flap palatoplasty and intravelar veloplasty at a tertiary medical center by the 2 senior authors from 2010 to 2015 were reviewed. Three intraoperative treatment groups were analyzed: intravenous (IV) acetaminophen, per rectal (PR) acetaminophen, and no acetaminophen. All patients received long-acting local anesthesia infiltration before incision. Additionally, all patients were admitted overnight and given weight-based per oral (PO) acetaminophen and oxycodone and IV morphine as needed based on pain scores. The study outcomes included pain scores, opioid requirement, length of stay, and oral intake. The treatment groups were comprised of 40 patients who received IV acetaminophen, 22 PR acetaminophen, and 35 none. Concerning demographic data, there was no statistical difference between treatment groups. There was no statistically significant difference for opioid intake, although both IV and PR acetaminophen groups had decreased pain scores ( P = .029). There was no difference in oral intake ( P = .13) or length of stay ( P = .31) between treatment groups. In this study, intraoperative administration of acetaminophen was associated with decreased pain scores, but no opioid-sparing effect. As other studies have shown an opioid-sparing effect with postoperative acetaminophen, we recommend withholding the intraoperative dose and beginning therapy in the immediate postoperative period.

AB192. 182. PR exam in colonoscopy—what are we missing?

Background: The British Society for Gastroenterology and the Joint Advisory Group on GI endoscopy in their 2016 recommendations, have highlighted that per rectum (PR) examination should be documented in 100% of colonoscopies. The primary aim of this study was to examine PR documentation in colonoscopy reports at this institution.

'Holiday sickness'-reported exploratory outcome of over 500 United Kingdom holidaymakers with travellers' diarrhoea.

To ascertain any predictors of potential food poisoning pathogens and development of post-infective irritable bowel syndrome (IBS) in UK travellers. An analysis was undertaken on prospectively collected data on 527 patients reporting symptoms of suspected food poisoning between June 2012 and June 2015. Positive stool sample indicative of food poisoning pathogens and diagnosis of post-infective IBS. Data on 527 patients were examined. The large majority of patients did not provide a stool sample on return from holiday (n = 430, 81.6%) as few visited a Doctor locally or in the UK. Only 18 patients (18.6%, 95% confidence interval [CI] 11.4-27.7) who provided a stool sample were positive for microbiological food poisoning pathogens. Univariate analysis indicated a significant relationship between a positive stool sample and whether the individual sought any medical assistance at the resort (odds ratio [OR] 0.24, 95% CI 0.08-0.70) and whether they took any treatment (including self-medicated), (OR 0.21, 95% CI 0.06-0.67). Of the 527 patients only 30 (5.7%, 95% CI 3.9-8.1) experienced post-infective IBS. Univariate regression indicated a significant relationship between experiencing Per Rectal (PR) bleeding and a diagnosis of post-infective IBS (OR 3.64, 95% CI 1.00-10.49). Univariate regression also indicated an increase in the risk of developing post-infective IBS with increasing duration of symptoms (OR 1.04, 95% CI 1.02-1.05). No significant relationship was found between a positive stool sample and developing post-infective IBS (P = 0.307). Very few patients provide a stool sample after experiencing holiday sickness abroad. Of those that do, only a small proportion have a positive stool sample indicative of a food poisoning microorganism. Around 6% of individuals were diagnosed with post-infective IBS. Those individuals with PR bleeding and symptoms persisting for longer durations were significantly more at risk of developing post-infective IBS, whilst medical aid and treatment abroad was found to reduce the odds of a positive stool sample.

Impact on ED Utilization and Associated Costs of Abortive Seizure Medications Using an Accountable Care Organization Database

Intranasal (IN) midazolam and per rectum (PR) diazepam abort seizures in the outpatient setting. IN midazolam is easier to use, has fewer side effects, and is more cost-effective than PR diazepam. The aim of this study is to determine if outpatient IN midazolam impacts emergency department (ED) utilization and health care costs compared with PR diazepam by utilizing a claims database. We retrospectively reviewed 5 years of data for 929 patients extracted from a claims database of an accountable care organization, Partners for Kids, whose population covers central and southeastern Ohio. Data elements consisted of demographics, ED visits, health care costs, and number of prescriptions. We found that using IN midazolam was not associated with increased ED utilization or increased health care costs. PR diazepam was associated with higher prescription costs. These findings support previous studies and show that both IN midazolam and PR diazepam are viable treatment options for patients at risk for prolonged seizures, but that IN midazolam is more cost-effective.

Pharmacokinetics of Metoclopramide After IntraARTERIAL, Intramuscular, Subcutaneous, and Perrectal Administration in Rabbits

The objective of this investigation was to compare the pharmacokinetics of metoclopramide (MET) after intraarterial (IA), intramuscular (IM), subcutaneous (SC), and perrectal (PR) administrations to normal rabbits. In this study, 6 normal New Zealand white rabbits were used in a random crossover design (4 × 4 Latin square) with a 1-week washout period between trials. Each rabbit had been administered MET at a dose of 2mg/kg IA, IM, and SC, and 4mg/kg PR. The plasma concentrations of MET were determined by high-performance liquid chromatography. The mean plasma profiles of MET after IA, IM, and SC administrations were similar. The bioavailability of MET when administered IM and SC was 96% and 112%, respectively. The plasma concentrations within the PR group were quite variable, resulting in an extremely low and variable bioavailability with an average of 12%. IM and SC administrations of MET may be useful in treating gastrointestinal disorders in rabbits when arterial or venous access is not available, but PR administration is likely to be unreliable.