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PubMed1977

Transient bacteremia and endocarditis prophylaxis. A review.

Transient, usually asymptomatic bacteremia occurs in a wide variety of procedures and manipulations, particularly those associated with mucous membrane trauma. It may also occur with such daily functions as tooth brushing and bowel movements. These brief bacteremias are especially common in tooth extraction and other dental procedures. Although numerical risk is uncertain, these bacteremias can occasionally give rise to infective endocarditis in the susceptible patient. While no proof exists that antibiotics given prior to procedures causing bacteremia prevent endocarditis in humans, experimental evidence in rabbits supports their use. Therefore, in situations where bacteremia is highly predictable, it would seem wise to administer prophylactic antimicrobials. Procedures in the susceptible host where prophylactic antibiotics seem prudent include dental manipulations and urinary tract instrumentation. Whether patients with acquired valvular or congenital heart disease who are to undergo abdominal surgical procedures should routinely receive prophylactic antibiotics is unclear. However, until the incidence of transient bacteremia associated with various abdominal procedures is further defined, endocarditis-prone patients should probably receive prophylaxis. Furthermore, patients with prosthetic valves who are subjected to upper gastrointestinal endoscopy, sigmoidoscopy, liver biopsy, or barium enema should also probably have antibiotic pretreatment. For dental procedures and for upper gastrointestinal endoscopy in patients with prosthetic valves, a combination of penicillin and streptomycin or vancomycin alone is recommended. For urinary tract instrumentation in all patients and for sigmoidoscopy, liver biopsy, or barium enema in patients with prosthetic valves, prophylaxis should be with ampicillin and gentamicin or vancomycin and gentamicin.

Anti-Bacterial Agents↗
PubMedDate not supplied

pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement.

BACKGROUND: The purpose of this study was to determine the extent to which pepsin and trypsin concentrations in feeding tube aspirates, in addition to pH, contribute to predicting feeding tube position. METHODS: Aspirates from 742 feeding tubes (nasogastric, n = 343; nasointestinal, n = 399) were tested for pH and enzyme concentrations. Also tested were aspirates from two feeding tubes inadvertently positioned into the lung (one in the pleural space and one in the tracheobronchial tree) and 146 samples of tracheobronchial and pleural fluids collected by other methods. Enzyme assays were conducted in a research laboratory. Results of the pH and enzyme tests were compared with radiologic reports of tube location. RESULTS: Gastric fluid had a mean low pH (4.06), a high mean pepsin concentration (349.1 micrograms/mL), and a low mean trypsin concentration (19.3 micrograms/mL). In contrast, intestinal fluid had a mean high pH (7.40), a high mean trypsin concentration (143.0 micrograms/mL), and a low mean pepsin concentration (24.2 micrograms/mL). Respiratory samples also had a high mean pH (7.89) but contained little or no pepsin or trypsin. Using a logistic regression equation with all three variables to differentiate between respiratory and gastrointestinal placement, it was possible to correctly classify 100% of the respiratory cases and 93.4% of the gastrointestinal cases. Another equation used to differentiate between gastric and intestinal sites was able to classify correctly 91.2% of the gastric cases and 91.5% of the intestinal cases. CONCLUSIONS: The results clearly indicate that laboratory-determined enzyme concentrations in feeding tube aspirates are helpful in predicting tube location. Thus, it is desirable that inexpensive, simple bedside tests be developed so that they can be used in conjunction with pH measurements to help predict tube position.

Enteral Nutrition↗
PubMed1990

Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate.

A bloody nasogastric aspirate is believed to imply active upper gastrointestinal tract bleeding, while a nonbloody yellow-green nasogastric aspirate that contains duodenal secretions suggests the absence of bleeding proximal to the ligament of Treitz. To validate these beliefs, physicians were asked to predict the presence of active gastrointestinal tract bleeding and whether bile was present in a nasogastric aspirate obtained immediately before endoscopy in 73 episodes of bleeding in 62 patients. A relationship was found between the physician's assessment of the presence of active bleeding demonstrated endoscopically and the appearance of the nasogastric aspirate. However, the sensitivity and specificity were low (79% and 55%, respectively). No association between the assessment of bile in the nasogastric aspirate and the presence of bile acids was demonstrated. These data do not support the placement of a nasogastric tube to determine whether or not a patient is bleeding, the location of the bleeding, and whether endoscopy should be performed.

Bile↗
PubMed2001

Efficacy of gastric aspiration in reducing posttonsillectomy vomiting.

OBJECTIVE: To determine the effectiveness of postoperative gastric decompression in reducing the incidence and complications associated with vomiting following tonsillectomy. DESIGN: A prospective, randomized controlled study. SETTING: Private office and clinic of a university teaching hospital and research center. PATIENTS: Eighty pediatric patients ranging in age from 22 months to 11 years, American Society of Anesthesiologists class I or II, undergoing tonsillectomy with or without adenoidectomy were enrolled in the study. Six were excluded from the final analysis, 5 because of failure of the parents to complete and return the data forms and 1 because of postoperative bleeding. Of the 74 patients included in the study, 35 were in the control group and 39 were in the study group. INTERVENTIONS: The 39 patients in the study group underwent postoperative aspiration of gastric contents with an orogastric tube placed under direct visualization while the patient was still under general anesthesia. The 35 patients in the control group did not undergo gastric aspiration following surgery. MAIN OUTCOME MEASURES: The incidence of vomiting, the number of episodes of vomiting before and after hospital discharge, the total volume of emesis, the postoperative length of stay, the need for rescue antiemetic prophylaxis, and the number of readmissions to the hospital for persistent vomiting were noted. RESULTS: No statistically significant difference (P<.05) was noted between the control group and the study group for the percentage of patients experiencing vomiting (74% vs 85%), the mean number of episodes of vomiting before (2.6 vs 2.8) and after (0.8 vs 0.7) hospital discharge, the mean volume of emesis (157 mL vs 222 mL), the postoperative length of stay (394 minutes vs 334 minutes), the percentage of patients requiring rescue antiemetics (34% [12 patients] vs 33% [13 patients]), and the percentage of unplanned admissions because of vomiting (9% [3 patients] vs 15% [6 patients]). CONCLUSION: Our results indicate that gastric aspiration does not decrease the incidence of vomiting following tonsillectomy.

Child↗
PubMed1995

Peptide YY release after intraduodenal, intraileal, and intracolonic administration of nutrients in rats.

Peptide YY (PYY) release was studied by measuring radioimmunoassayable PYY in the arterial plasma of anaesthetized rats receiving into the duodenum, ileum or colon either a complete semi-liquid meal (3ml, 21kJ) or elemental nutrients as isocaloric or isoosmolar solutions. PYY release induced by the intraduodenal meal peaked at 60min and lasted more than 120min. The integrated response of PYY over 120min was larger when the meal was administered into the duodenum than into the ileum. The undigested meal induced no release of PYY over a 120-min period when administered into the colon. When injected into the duodenum in isocaloric amounts to the meal, glucose and amino acids led to the release of as much PYY as did the meal, whereas oleic acid led to the release of less PYY. Part of these responses were due to osmolarity, since administration of intraduodenal hyperosmolar saline led to the release of about half as much PYY as did hyperosmolar glucose. In moderate amounts, and injected as a solution isoosmolar to plasma, oleic acid was a major PYY releaser; the amounts released were at least two times larger when oleic acid was administered into the duodenum than into the ileum and colon. Isoosmolar glucose and amino acids led to the release of no PYY when injected into the duodenum, but were nearly as active as oleic acid in the colon. Short-chain fatty acids induced the release of PYY when injected into the colon, but not into the ileum. Hexamethonium suppressed PYY release induced by the intraduodenal meal, but did not change PYY release induced by glucose or oleic acid in the colon. Urethane anaesthesia did not reduce PYY release induced by the intraduodenal meal. These results suggest that two mechanisms at least contribute to PYY release in the rat. An indirect, neural mechanism, involving nicotinic synapses, is prominent in the proximal small intestine; the stimulation is transmitted to ileal and colonic L-cells by undetermined pathways, but contact of nutrients with L-cells is not needed. Another mechanism, probably direct and quantitatively smaller, occurs in the distal intestine when nutrients come into contact with the mucosa containing L-cells. Glucose, fatty acids and amino acids stimulate differentially the proximal and distal mechanisms.

Anesthesia↗
PubMed1993

Perioperative gastric aspiration increases postoperative nausea and vomiting in outpatients.

The efficacy of aspiration of gastric contents to reduce postoperative nausea and vomiting was investigated in a controlled randomized, double-blind study of 265 outpatients. Patients in the treated group had their stomachs aspirated with an orogastric tube. In the control group no tube was inserted. Data on the incidence of nausea and vomiting were collected in the recovery room, the day surgery unit and the day after surgery. The overall incidence of postoperative nausea and vomiting was comparable in the two groups. It was also comparable in the recovery room and the day surgery unit. However, treated patients had a higher incidence of both nausea (26.5% vs 12.0%, P < 0.005) and vomiting (16.7% vs 6.8%, P < 0.02) after their discharge from the day surgery unit. We conclude that aspiration of gastric contents with an orogastric tube does not decrease postoperative nausea and vomiting in outpatients and may increase it after discharge of the patient.

Adult↗
PubMedDate not supplied

Enteroclysis: a multidisciplinary approach.

We developed a method for passing the enteroclysis catheter at endoscopy in patients requiring upper endoscopy and enteroclysis. This method reduced patient discomfort, the time needed for fluoroscopic tube placement, and overall radiation doses. We conclude that endoscopy and enteroclysis performed together is practical in these patients.

Barium Sulfate↗
PubMed2002

Computed tomography enteroclysis in comparison with ileoscopy in patients with Crohn's disease.

BACKGROUND AND AIMS: Enteroclysis and computed tomography (CT) have been recently combined in to assess small bowel alterations. We compared the accuracy of CT enteroclysis to that of endoscopy in detecting bowel wall alterations of the terminal or neoterminal ileum in Crohn's disease (CD) patients and assessed whether postcontrast wall density is related to clinical activity of CD. PATIENTS AND METHODS: A total of 39 patients referred for either established or suspected CD were enrolled. Diagnosis used ileocolonoscopy with histology; clinical activity was measured by CDAI. Contrast-enhanced spiral CT of the abdomen was performed after distension of the small bowel with an enema of methylcellulose. Retrograde ileocolonoscopy diagnosed 30 patients with CD of the ileum, while 9 patients served as controls. RESULTS: CT enteroclysis detected CD in 26 patients (86.7%) and in none of the control group. Three of four patients with false-negative findings on CT enteroclysis had postsurgical CD recurrence. The overall sensitivity and specificity of CT enteroclysis for ileal CD detection were 86.7% and 100%, respectively (PPV=100%; NPV=69.2%), and 94.1% and 100% (PPV=100%; NPV=90%), excluding those patients with postsurgical recurrence. The postcontrast wall density was significantly higher in CD patients than in the controls and was significantly correlated with the severity of CD. CONCLUSION: CT enteroclysis proved highly accurate in detecting terminal ileal CD involvement, particularly in patients without previous surgery, and to allow assessment of the degree of intramural and clinical activity.

Adult↗
PubMed1990

The effect of terminal ileal triglyceride infusion on gastroduodenal motility and the intragastric distribution of a solid meal.

The infusion of triglyceride emulsions into the terminal ileum in concentrations that approximate those found in malabsorption results in the slowing of gastric emptying. The aim of this study was to characterize the changes in gastroduodenal motility responsible for this effect. Antropyloroduodenal pressures in 8 healthy volunteers were recorded with a manometric assembly incorporating a sleeve sensor across the pylorus and side holes in the antrum and duodenum. Each subject ingested a 100-g, 99m Tc-labeled solid meal; when approximately 25% of the meal had emptied from the stomach, a triglyceride emulsion (20% Intralipid) was infused into the terminal ileum at 1 ml/min for 45 min. Gastric emptying slowed markedly 15-30 min after the start of the lipid infusion (p = 0.01), and there was retrograde movement of the solid meal from the distal to the proximal portion of the stomach. During lipid infusion, there was a decrease in antral (p = 0.01), duodenal (p less than 0.05), and propagated antropyloroduodenal pressure waves (p less than 0.05) and an increase in isolated pyloric pressure waves (p less than 0.05). The rate of gastric emptying correlated with antral pressure waves (r = 0.92, p less than 0.001), duodenal pressure waves (r = 0.80, p less than 0.01), and propagated pressure waves (r = 0.88, p = 0.0025) and correlated inversely with the number of isolated pyloric pressure waves (r = -0.60, p = 0.05). The changes in antral, pyloric, and duodenal motility and the intragastric redistribution of a solid meal associated with ileal lipid infusion are likely to contribute to the delay in gastric emptying caused by this stimulus.

Adult↗