No abstract

The insertion of percutaneous endoscopic gastrostomy has been well documented. The possible benefits for patient nutrition and nursing practice have, however, not been assessed. We report a study of enteral feeding by percutaneous endoscopic gastrostomy in 30 patients, the majority with a persistent vegetative state. All patients had previously been fed through a nasogastric tube using manual administration and a dietitian assessed protein calorie intake. Based upon (body mass index (weight/height2), midarm circumference and triceps skinfold thickness, 20 (67%) were malnourished, with 10 patients having a body mass index <17 (severe malnutrition); attributed to high rates of both tube displacement and feed regurgitation. Patients were observed over six to 12 months after percutaneous endoscopic gastrostomy insertion combined with overnight continuous pump feeding. All patients attained a body mass index >17, and 17 (56%) of the total number achieved the normal range with no change in protein-calorie intake (pre: 2110 kcal, post: 1880 kcal). Complications of percutaneous endoscopic gastrostomy in the study group included peritonitis (one), tube site infection (two) and displacement (two); all without serious sequelae. As part of an integrated approach percutaneous endoscopic gastrostomy proved a safe and efficient method of enteral feeding and justifies wider consideration in the United Kingdom.

Hemodynamic changes induced by a single, total paracentesis were evaluated in 21 patients with tense ascites from whom 4 to 16 L of ascites were drained over 2 to 8 hr with no serious complications. At 60 min, compared to baseline, there was an increase in cardiac output (7.7 +/- 0.5 to 8.5 +/- 0.6 L/min, p less than 0.02) and a tendency for right atrial pressure to decrease (9.3 +/- 0.8 to 7.50 +/- 0.8 mm Hg, NS), with no change in pulmonary capillary wedge pressure (10.9 +/- 0.9 to 10.7 +/- 0.9 mm Hg). Between 3 and 12 hr later, there was a drop in right atrial pressure, pulmonary capillary wedge pressure and cardiac output to 5.6 +/- 0.6 (p less than 0.02), 7.2 +/- 0.8 mm Hg (p less than 0.002) and 7.2 +/- 0.6 L/min (NS) respectively, indicative of the development of relative hypovolemia and suggesting that therapeutic plasma expansion is appropriate at this time. Two-dimensional echocardiography before paracentesis (n = 8) showed a reduction in the right to left atrium area ratio as compared with values in patients with minimal ascites (0.54 +/- 0.04 vs 0.82 +/- 0.02, p less than 0.0001). This technique may help in identifying patients with right atrial compression caused by tense ascites.

The majority of responding clinicians use EUS but overall utilization varies considerably among different countries. There is considerable variation in EUS service availability and accessibility among countries which, together with perceived usefulness of EUS, is a major determinant of EUS utilization. A shortage of trained endosonographers and the high cost are major barriers to wider EUS use. The findings of this study might help to define policies aimed at development of EUS services.

The indications for percutaneous endoscopic gastrostomy (PEG) and patient outcome, were examined prospectively in the setting of a general hospital. In the course of 26 months, 76 patients underwent PEG (median age 62 years (range 18-99)) and were followed up for 6887 patient days. The median (range) duration of PEG feeding was 93 (3-785) days. The procedure was carried out for neurological indications in 76% of cases (stroke 51%) and 53% of patients were severely malnourished (body mass index <17 kg/M2) at the time of referral. In 12 (16%) patients swallowing recovered and the PEG was removed after a median (range) of 55 days

Increasing osmolality of total parenteral nutrition did not increase episodes of thrombophlebitis in this trial and did not affect the success rate of the lines. We conclude that standard total parenteral nutrition formulas of higher osmolality than previously thought can be safely given via the peripheral route for short-term feeding and do not increase the risk of thrombophlebitis.

Toxic megacolon complicating inflammatory or infective colitis carries a high morbidity and mortality and surgical intervention is necessary in up to 80% of cases.'2 Perforation complicates toxic megacolon in about 35% of cases. After perforation, the death rate nears 50%.2 Gaseous distension ofthe bowel causes considerable discomfort to the patient and increases transmural pressure. The latter is thought to cause a reduction in blood flow and may predispose to perforation.6 The use of instruments for colonic aspiration is discouraged, because of the high risk of perforation.6 The successful use of the knee-elbow position to relieve bowel distension in two patients with toxic megacolon is described.

To investigate the relative abilities of low doses of famotidine and cimetidine to raise intragastric pH after a single postprandial evening dose, 16 healthy volunteers were recruited to a four period crossover trial of famotidine 10 mg, cimetidine 100 mg and 200 mg compared with placebo. Intragastric pH was monitored between 1800 and 0730 with a nasogastric pH electrode. Median gastric pH rose from 1.35 (interquartile range 1-1-1-65) with placebo to 1 95 (1.6-5.35, p0.2) after cimetidine 100 mg. Intragastric pH was above 3 for 34% (p<0.005) of the time after dosing with famotidine, compared with 13.6% (p>0.2) after cimetidine 200 mg, 9.5% (p>02) after cimetidine 100 mg, and 4.7% after placebo. The rise of intragastric pH after famotidine 10 mg is significantly greater than that after either 200 mg or 100 mg cimetidine when the drugs are used postprandially. (Gut 1995; 37: 325-328) Keywords: H2 receptor antagonist, intragastric pH, famotidine, cimetidine. Study designThe investigation was designed as a four period crossover study with all subjects receiving the four different preparations in a random order. The study was partially blinded in that the drugs were recognisably different but the subjects were not aware of which was which. Of the two principal investigators one (RPW) was blinded to the drugs. There was a wash out period of at least six days between studies.On each study day subjects arrived at 1700 on the investigation unit having fasted for six hours. Bipolar glass pH electrodes (Ingold M440) were calibrated in standard buffer solutions of pH 7.00 and 4.01 and calibration was verified at pH 1.69. These electrodes were passed by the nasogastric route. A drop in pH to less than 2 was taken as evidence of the tip of the probe having entered the stomach, and the electrode was advanced a further 8 cm from this point. At 1830 a standard meal was given, which consisted of a supermarket ready meal of cottage pie, peas, and carrots, followed by chocolate coated ice cream and two chocolate mints to give a total of 700 kcal, provided by 22 g protein, 70 g carbohydrate, and 37 g fat, accompanied by 250 ml mineral water.