Podcast # 477: Postpolypectomy Electrocoagulation Syndrome

Author:  Nick Hatch, MD

Educational Pearls:

  • Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy
  • Occurs when cautery causes transmural thickening from a contact burn
  • Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc.
  • CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging
  • Treatment is often with antibiotics and supportive care – in severe cases, hospitalization may be required.

References

Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 471: Cyclic Vomiting

Author: Don Stader, MD

Educational Pearls:

  • Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two.
  • CHS is thought to be caused by activation of THC receptors in the gut
  • CVS is associated with migraines and therefore responds to similar medications
  • Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol)
  • Amitriptyline, as well as anti-epileptics can be used to prevent CVS
  • Opioids worsen CVS

References

Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28.

Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 468: Typhlitis

Educational Pearls:

  • Typhlitis refers to the presence of enterocolitis in the setting of neutropenia – also known as neutropenic enterocolitis
  • Commonly a result of chemotherapy for hematologic malignancies.
  • The infection is usually polymicrobial/fungal and can lead to septic shock
  • Usually presents with fever, abdominal pain, with associated GI complaints
  • Workup includes CBC for the ANC (usually <500), and a CT abdomen (look for bowel thickening)
  • Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
  • Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 450: Probiotics in Gastroenteritis

Author: Sam Killian, MD

Educational Pearls:

  • Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease.
  • Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group.
  • There was no difference in the rates of severe gastroenteritis between the two groups
  • Probiotics are likely unhelpful for kid with viral gastroenteritis

References:

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 427: Cookie Dough is Delicious

Author: Eric Miller, MD

Educational Pearls:

  • Recent CDC statement warns against consumption of cookie dough
  • Two common ingredients can pose risk: eggs and flour
  • Flour in dough is a raw agricultural product not treated to kill E. coli
  • A 2016 E. coli outbreak was linked to flour

 

References:

https://www.cdc.gov/features/no-raw-dough/index.html

https://www.cdc.gov/ecoli/2016/o121-06-16/index.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #399: Hunting for pancreatitis

Author: Michael Hunt, MD

Educational Pearls:

  • Alcohol and gallstones are most common causes of pancreatitis
  • Diagnosis is not simply based on lipase alone – must have at least two the the three criteria:
    • Elevated lipase (greater than 3x upper limit of reference range)
    • Typical pain (epigastric pain, radiating to back, etc.)
    • Radiographic findings suggestive of pancreatitis (CT, MRI, US)
  • BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following:
    • BNP > 25
    • Impaired mental status
    • SIRS criteria, more than 2
    • AGE > 60
    • Pleural effusion
  • BISAP score of 0 has < 1% mortality

Editor’s note: The severity of pancreatitis does not correlate with serum lipase levels – notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis.

References:

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216.

Papachristou GI, Muddana V, Yadav D, O’Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson’s, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954.

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

Check out this episode!

Podcast #388: Antibiotics for Appendicitis

Author:  Aaron Lessen, MD

Educational Pearls:

  • 5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years
  • Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

 

Editor’s note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #385: Probiotics

Author:  John Winkler, MD

Educational Pearls:

  • Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.
  • Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.
  • Probiotics should not be given as a one-size-fits-all treatment.

 

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Podcast # 348: Steakhouse Syndrome

Author: Don Stader, MD

Educational Pearls:

  • Steakhouse syndrome is an impacted esophageal food bolus.
  • Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
  • Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
  • Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
  • Complications of NTG are hypotension and headache.

 

References

Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.

Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.

Podcast # 331: Oral Rehydration Therapy (ORT)

Author: Nick Hatch, MD

Educational Pearls:

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.