Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are nonmodifiable preexisting or concurrent conditions. Early extubation, small endotracheal tube size, and small bore of nasogastric tube potentially decrease the risk of PED. The majority of patients receive treatment based on only bedside swallow evaluations, which has an uncertain diagnostic accuracy as opposed to gold standard instrumental tests. Therefore, the treatment decision for patients may not be appropriately directed for each individual. Current treatments are mainly focused on dietary modifications and postural changes/compensatory maneuvers rather than interventions, but recent studies have shown limited proven benefits. Direct therapies in oromotor control, such as therapeutic exercises and neuromuscular stimulations, should be considered as potential effective treatments. P ostextubation dysphagia (PED) is defi ned as the difficulty or inability to eff ectively and safely transfer food and liquid from the mouth to the stomach after extubation. It is commonly seen in trauma and critical care patients requiring endotracheal intubation for mechanical ventilation, especially after cardiac surgery (1, 2). PED may result in aspiration and its ensuing complications, such as aspiration pneumonia, chemical pneumonitis, transient hypoxemia, bronchospasm, or mechanical obstruction with atelectasis. As a result, malnutrition, prolonged hospital stays, fi nancial burden, and increased mortality occur (3, 4). Understanding the treatment modalities and screening tests is essential to minimize complications, improve quality of treatment, and develop standard screening guidelines. INCIDENCEOf 220,000 survivors of acute respiratory failure requiring mechanical ventilation each year in the US (5), 3% to 62% develop PED. Th e wide range of incidence could be explained by the diff erences in the population studied, diff erences in the sensitivity of diagnostic methods and the timing of the assessment, and the duration of intubation. Th e patients who required prolonged intubation from all diagnosis subtypes were found to have a higher incidence of PED compared to postoperative patients with a shorter duration of intubation (6). MECHANISMSTh e mechanisms of PED are multifactorial and include mechanical causes, cognitive disturbances, and residual eff ects of narcotics and anxiolytic medications (7). Mechanical causes are directly related to the duration of intubation and endotracheal tube size, since these tubes cause mucosal infl ammation leading to loss of architecture, oropharyngeal muscle atrophy from disuse during intubation, diminished proprioception, decreased laryngeal sensation, and laryngeal injury (edema, granuloma, and vocal cord paralysis) (6). Traumatic brain injury or critical illness may also cause PED by damaging peripheral and bulbar nerves, altering cognition, or causing the dysregulation of the swallowing refl ex (8). RISK FACTORSP...
We carried out the first meta-analysis comparing the technical success and clinical outcomes of endoscopic ultrasound-guided drainage (EUD) and conventional transmural drainage (CTD) for pancreatic pseudocysts. We searched PubMed, Embase, Scopus, and the Cochrane library to identify relevant prospective trials. The technical success rate, short-term (4-6 weeks) success, and long-term (at 6 months) success in symptoms and the radiologic resolution of pseudocysts, complication rates, and death rates were compared. Two eligible randomized-controlled trials and two prospective studies including 229 patients were retrieved. The technical success rate was significantly higher for EUD than for CTD [risk ratio (RR)=12.38, 95% confidence interval (CI): 1.39-110.22]. When CTD failed because of the nonbulging nature of pseudocysts, a crossover was carried out to EUD (n=18), which was successfully performed in all these cases. All patients with portal hypertension and bleeding tendency were subjected to EUD to avoid severe complications. EUD was not superior to CTD in terms of short-term success (RR=1.03, 95% CI: 0.95-1.11) or long-term success (RR=0.98, 95% CI: 0.76-1.25). The overall complications were similar in both groups (RR=0.98, 95% CI: 0.52-1.86). The most common complications were bleeding and infection. There were two deaths from bleeding after CTD. The short-term and long-term treatment success of both methods is comparable only if proper drainage modality is selected in specific clinical situations. For bulging pseudocysts, either EUD or CTD can be selected whereas EUD is the treatment of choice for nonbulging pseudocysts, portal hypertension, or coagulopathy.
Background and Aim Same‐visit colonoscopy and esophagogastroduodenoscopy (EGD) have become common. Recent studies showed conflicting results regarding the performance, safety, and efficacy of different sequences. We conducted this meta‐analysis to determine the most favorable performance and discomfort between an EGD followed by colonoscopy (E‐C) and colonoscopy followed by EGD (C‐E). Methods The authors searched the databases of MEDLINE and EMBASE. Outcomes of interest were performance (including cecal intubation time, adenoma detection rate, and polyp detection rate), discomfort score (patients and endoscopists; Likert scale), and sedation uses. Pooled mean differences (MD) or odds ratios (OR) were calculated with 95% confidence intervals (CI). Results Six randomized controlled trials were included in the meta‐analysis. The authors found that there was significantly lower sedative use including fentanyl (14.70; 95% Cl: 8.20–21.20) and propofol (15.58; 95% Cl: 3.27–27.89) in the E‐C group compared with the C‐E group. There was a significantly better discomfort score in patients and endoscopists after both procedures in the E‐C group than in the C‐E group with pooled MD of 0.64 points (95% Cl: 0.09–1.20) and 0.47 (95% Cl: 0.05–0.90), respectively. There were no differences in cecal intubation time, adenoma detection rate, or polyp detection rate between the two groups. Conclusion The present study found that the discomfort score was better in the E‐C group. However, there was no difference in polyp and adenoma detection. Therefore, the E‐C group is the optimal sequence.
Background Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) have been widely used for multiple purposes. Recent studies have suggested an association between these medications and the risk of pancreatic cancer. However, the results have been inconclusive. Aim We, therefore, conducted a study to assess the risk of developing pancreatic cancer in patients who used PPI and H2RA. Design A systematic review and meta-analysis. Methods A literature search was performed using MEDLINE and EMBASE databases from inception through February 2019. Studies that reported risk ratio comparing the risk of pancreatic cancer in patients who received PPI or H2RA versus those who did not receive treatments were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effect generic inverse variance method. Sensitivity analysis, excluding one study at a time, was performed. Results After screening abstracts from the searching methods, seven studies (six case–control studies and one cohort study) were included in the analysis with total 546 199 participants. Compared to patients who did not take medications, the pooled RR of developing pancreatic cancer in patients receiving PPI and H2RA were 1.73 (95% CI: 1.16–2.57) and 1.26 (95% CI: 1.02–1.57), respectively. However, the sensitivity analysis of PPI changed the pooled RR to 1.87 (95% CI: 1.00–3.51) after a study was dropped out. Likewise, H2RA sensitivity analysis also resulted in non-significant pooled RR. Conclusions This meta-analysis did not find the strong evidence for the associations between the use of PPI and H2RA and pancreatic cancer.
Colonoscopy is a common procedure that gastroenterologists perform on a daily basis. It is considered a low-risk outpatient procedure and patients can be discharged on the same day after the procedure. Colonoscopy has become more feasible with the increasing application of standard screening for colon cancer and diagnostic procedures for large intestinal disease. There are reported possible risk factors of splenic rupture during the procedure. However, splenic injury after colonoscopy is considered a rare complication and less than 100 cases have been reported in international literature. Interestingly, this is the first case report demonstrating systemic lupus erythematosus (SLE) as a possible risk factor leading to splenic rupture post-colonoscopy. Failure to recognise this possibility even in its rarity can lead to life-threatening complications. We present a case of an acute splenic rupture with massive intraperitoneal bleeding after colonoscopy in a patient with SLE.
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