Medline ® Abstracts for References 2-4
of 'What's new in gastroenterology and hepatology'
Randomized Comparison of 3 High-Level Disinfection and Sterilization Procedures for Duodenoscopes.
Snyder GM, Wright SB, Smithey A, Mizrahi M, Sheppard M, Hirsch EB, Chuttani R, Heroux R, Yassa DS, Olafsdottir LB, Davis RB, Anastasiou J, Bapat V, Bidari K, Pleskow DK, Leffler D, Lane B, Chen A, Gold HS, Bartley A, King AD, Sawhney MS
Gastroenterology. 2017;153(4):1018. Epub 2017 Jul 13.
BACKGROUND AND AIMS: Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDRO). We compared the frequency of duodenoscope contamination with MDRO or any other bacteria after disinfection or sterilization by 3 different methods.
METHODS: We performed a single-center prospective randomized study in which duodenoscopes were randomly reprocessed by standard high-level disinfection (sHLD), double high-level disinfection (dHLD), or standard high-level disinfection followed by ethylene oxide gas sterilization (HLD/ETO). Samples were collected from the elevator mechanism and working channel of each duodenoscope and cultured before use. The primary outcome was the proportion of duodenoscopes with an elevator mechanism or working channel culture showing 1 or more MDRO; secondary outcomes included the frequency of duodenoscope contamination with more than 0 and 10 or more colony-forming units (CFU) of aerobic bacterial growth on either sampling location.
RESULTS: After 3 months of enrollment, the study was closed because of the futility; we did not observe sufficient events to evaluate the primary outcome. Among 541 duodenoscope culture events, 516 were included in the final analysis. No duodenoscope culture in any group was positive for MDRO. Bacterial growth of more than 0 CFU was noted in 16.1% duodenoscopes in the sHLD group, 16.0% in the dHLD group, and 22.5% in the HLD/ETO group (P = .21). Bacterial growth or 10 or more CFU was noted in 2.3% of duodenoscopes in the sHLD group, 4.1% in the dHLD group, and 4.2% in the HLD/ETO group (P = .36). MRDOs were cultured from 3.2% of pre-procedure rectal swabs and 2.5% of duodenal aspirates.
CONCLUSIONS: In a comparison of duodenoscopes reprocessed by sHLD, dHLD, or HLD/ETO, we found no significant differences between groups for MDRO or bacteria contamination. Enhanced disinfection methods (dHLD or HLD/ETO) did not provide additional protection against contamination. However, insufficient events occurred to assess our primary study end-point. ClinicalTrials.gov no: NCT02611648.
Division of Infection Control/Hospital Epidemiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
Safety of Large-Volume, Same-Day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study.
Tandon K, Khalil C, Castro F, Schneider A, Mohameden M, Hakim S, Shah K, To C, O'Rourke C, Jacobs J
Anesth Analg. 2017;125(2):469.
BACKGROUND: Colonoscopy quality is directly related to the bowel preparation. It is well established that bowel preparations are improved when at least part of the laxative is ingested on the day of the procedure. However, there is concern that this can result in higher gastric residual volumes (GRV) and increase the risk of pulmonary aspiration. The aim of this study is to evaluate GRV and gastric pH in patients who received day-before bowel preparation versus those ingesting their laxative on the day of colonoscopy under anesthesiologist-directed propofol deep sedation.
METHODS: This is a prospective observational study for patients undergoing same-day upper endoscopy and colonoscopy. All included patients had large-volume polyethylene glycol lavage preparation and received propofol sedation. Gastric fluid was collected during the upper endoscopy for volume and pH measurement.
RESULTS: The study included 428 patientswith 56% receiving same-day laxative preparation and the remainder evening-before preparation. Mean±SD GRV was 18.1±10.2 mL, 16.3±16.5 mL in each of these preparation groups, respectively (P = .69). GRV≥25 mL or higher than expected GRV adjusted by weight (0.4 mL/kg) were also not different among the study groups (P = .90 and P = .87, respectively). Evaluating GRV based on time since last ingestion of preparation (3-5, 5-7,>7 hours) did not result in any differences (P = .56). Gastric pH was also similar between the bowel preparation groups (P = .23), with mean±SD of 2.5±1.4 for evening-before and 2.5±1.3 for the same-day preparation. There were more inadequate bowel preparations in day before bowel preparations (P = .001).
CONCLUSIONS: A large-volume bowel preparation regimen finished on the day of colonoscopy as close as 3 hours before the procedure results in no increase in GRV or decrease in gastric pH.
From the *Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida;†Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; and‡Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida.
ACG and CAG Clinical Guideline: Management of Dyspepsia.
Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N
Am J Gastroenterol. 2017;112(7):988. Epub 2017 Jun 20.
We have updated both the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline. We suggest that patients≥60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age. Alarm features should not automatically precipitate endoscopy in younger patients but this should be considered on a case-by-case basis. We recommend patients<60 years of age have a non-invasive test Helicobacter pylori and treatment if positive. Those that are negative or do not respond to this approach should be given a trial of proton pump inhibitor (PPI) therapy. If these are ineffective tricyclic antidepressants (TCA) or prokinetic therapies can be tried. Patients that have an endoscopy where no pathology is found are defined as having functional dyspepsia (FD). H. pylori eradication should be offered in these patients if they are infected. We recommend PPI, TCA and prokinetic therapy (in that order) in those that fail therapy or are H. pylori negative. We do not recommend routine upper gastrointestinal (GI) motility testing but it may beuseful in selected patients.
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.