Summary Background : The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with ‘benign’ disease indications for percutaneous endoscopic gastrostomy insertion. Aim : To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. Methods : Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double‐blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co‐amoxiclav (or 2 g cefotaxime if penicillin‐allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety‐nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). Conclusions : Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.

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The computed tomographic scans of 200 consecutive patients with Crohn disease were studied to determine the frequency and patterns of perirectal and perianal involvement. In 163 patients (82%) abnormalities in the perirectal-perianal region were demonstrated; findings included inflammation of fat planes (73%), bowel wall thickening (30%), fistulas or sinus tracts (22%), and abscesses (14%). Fistulas or sinus tracts occurred with equal frequency above or below the level of the anterior symphysis pubis. Abscesses, rectal thickening, and inflammatory infiltration of fat occurred more than twice as often above the symphysis pubis. However, 37% of patients had manifestations of Crohn disease below the symphysis pubis, emphasizing the importance of extending scanning sequences to the perineum.

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This article attempts to summarize the ethics of nutritional support at the end of life. Although ethics are timeless, they have to be applied or adapted to new situations arising from our ability to prolong life by the application of relatively new nutritional treatments. The application of the law, and guidance from professional bodies on withholding or withdrawing treatment remains an emotive challenge for all involved in nutritional care and for society as a whole.

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