Accessible Summary Patients with severe learning disabilities may lose weight and become malnourished for a variety of reasons. Insertion of a feeding tube through the abdomen, directly into the stomach can provide a reliable and permanent route for nutrition to be delivered. Our study of 42 patients has shown that in every case the procedure was performed following a team based assessment of each patient, as is recommended by national advisory groups. We found that the procedure is generally very safe but can require a general anaesthetic. However, complications relating to problems with the feeding tube were very common, and some patients did not gain weight. It is unclear from the literature what effect this intervention has on quality of life and we did not assess this in our study. Summary Percutaneous endoscopic gastrostomy insertion is an effective method of providing enteral nutrition to patients with neurologically unsafe swallowing or failure of feeding. Patients with severe learning disabilities may develop unsafe swallowing and benefit from percutaneous endoscopic gastrostomy placement. It is unclear whether this intervention improves quality of life. We aimed to describe the efficacy and safety of percutaneous endoscopic gastrostomy insertion in patients with learning disabilities and determine whether multidisciplinary team assessment occurred as per British Society of Gastroenterology recommendations. We performed a retrospective case note audit of 42 patients with severe learning disabilities who underwent percutaneous endoscopic gastrostomy insertion. Forty two patients underwent 117 procedures: 38 index percutaneous endoscopic gastrostomy insertions, 43 percutaneous endoscopic gastrostomy replacements, 35 percutaneous endoscopic gastrojejunostomy replacements and 1 percutaneous endoscopic gastrostomy removal [six procedures (5.1%) were unsuccessful]. General anaesthetic was required for 34 (29%) procedures. Mean weight pre‐percutaneous endoscopic gastrostomy was 39.8 kg and mean weight after a median follow‐up of 21.5 months was 46.1 kg (mean weight gain = 2.3 kg). Thirty day mortality was zero. Complications were common (74%) and included perforation n = 1, aspiration pneumonia n = 13, tube displacement n = 10, and percutaneous endoscopic gastrostomy site infection n = 4. In two cases of unsuccessful percutaneous endoscopic gastrostomy insertion, surgical feeding gastrostomy was required. Ongoing vomiting occurred in six patients (14.3%) prompting conversion to percutaneous endoscopic gastrojejunostomy in five cases. A best interests meeting or multidisciplinary team assessment occurred for all patients. In this cohort, percutaneous endoscopic gastrostomy placement appears to be safe and results in a modest weight gain. Complications occur in the majority. Percutaneous endoscopic gastrojejunostomy should be considered for those with ongoing vomiting.
We describe an unusual cause of diarrhoea and segmental colitis in a previous well adult man. Mesenteric inflammatory veno-occlusive disease is a rare cause of gastrointestinal tract ischaemia of unknown aetiology. We review the literature of this condition and other mesenteric venous pathologies.
The majority of patients of northern European descent with hereditary hemochromatosis are homozygous for the C282Y mutation in the HFE gene product. A significant proportion of patients with this genotype have elevated iron indices; however, most will not develop symptoms or organ damage. Age, gender and alcohol are the key factors known to influence this wide variation in clinical penetrance. The authors describe the three stages of disease ranging from only genetic abnormality to overt disease and review the other factors that modify the genotype–phenotype relationship. Algorithms for use in clinical practice are included to aid clinicians in diagnosis, risk stratification and treatment. Key Concepts: Mutations in the HFE gene are relatively common. The vast majority of patients with iron overload are homozygous for the C282Y mutation in the HFE gene product. Biochemical penetrance, that is, elevated iron stores are present in 70–91% of males and 30–60% of females who are C282Y homozygotes. End‐organ damage is less common and occurs in approximately one‐quarter of males and 1% of females. End‐organ damage is extremely unlikely if serum ferritin is less than 1000 µg l −1 . The principal modifiers of disease are gender, age and alcohol. The wide variation in expression of clinical disease is largely unexplained. Various genes have been shown to have variable modifying effects on disease penetrance. Phlebotomy is a safe and effective treatment that depletes iron stores, prevents end‐organ damage and confers normal life expectancy. It is best initiated on discovery of elevated iron stores, that is, stage‐II or stage‐III disease.
initiation of PN. Simple remedial actionwas introduced and the audit cycle was completed to assess the impact of mandatory minimal set documentation prior to initiation of PN. Methods A mandatory request sticker was introduced which prompted the clinical team to document why enteral nutrition is inappropriate and duration of inadequate enteral intake, the clinical purpose and goal of PN and expected duration of PN. A prospective re-audit was performed to assess any change over the same six month period. Results The initial audit included 43 patients and 34 patients received PN during the reaudit period. Administration of PN was predominantly in surgical (47%) or critical care (20%) areas. The indication was documented in the case notes in 88% of cases (initially 43%), and considered appropriate by the nutrition team in 94% of cases (initially 67%). There were unreasonable delays in 21% of cases (initially 29%), mostly related to delays in placing appropriate central venous access. The treatment goal was documented in 82% of cases (initially 36%). Alternatives were considered in 100% of cases (initially 64%) and an appropriate assessment was made in 97% of cases (initially 69%). TPN was reviewed and monitored appropriately in the initial audit and there was no change in the re-audit. Metabolic complications occurred in 38% of cases (initially 52%), all cases were managed appropriately. Nine percent of patients received PN for fewer than 5 days (initially 12%) but the vast majority received an appropriate course length. Seventy four percent of patients were weaned onto oral diet (initially 67%) and 6% of patients died during their stay (initially 17%). Conclusion A relatively simple intervention, involving no additional cost, vastly improved the delivery of PN in our hospital. Mandatory information prior to starting helped to focus the thoughts of the requesting clinicians to decide on the appropriateness of using PN. This simple win-win strategy can be easily adopted in other hospitals to improve delivery of PN.
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