Helicobacter pylori infection: patient management

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One discussion this week involved the management of patients with helicobacter pylori infection.

Reference: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. T114484, Helicobacter pylori infection; [updated 2018 Dec 04, cited 2019 Apr 05]. Emory login required. [NOTE: direct link is not functional. Go to DynaMed Plus main page and search “helicobacter pylori infection” to access full content.]

Summary: Management overview (DynaMed Plus, 2018)

  • offer treatment to all patients who test positive for active infection with Helicobacter pylori (ACG Strong recommendation)(1); the clinical efficacy of H. pylori eradication varies among associated conditions
    • peptic ulcer disease
      • in patients with H. pylori-positive duodenal ulcers, H. pylori eradication therapy (alone or in addition to ulcer-healing drugs) may increase ulcer healing, and eradication therapy alone may reduce ulcer recurrence (level 3 [lacking direct] evidence)
      • in patients with H. pylori-positive gastric ulcers, addition of H. pylori eradication therapy to ulcer-healing drugs may not improve ulcer healing but H. pylori eradication therapy alone may reduce ulcer recurrence (level 3 [lacking direct] evidence)
      • peptic ulcer bleeding
        • H. pylori eradication therapy appears more effective than short-term antisecretory therapy or long-term ranitidine in preventing recurrent peptic ulcer bleeding in patients not taking nonsteroidal anti-inflammatory drugs (NSAIDs) (level 2 [mid-level] evidence)
        • H. pylori eradication therapy appears less effective than daily proton pump inhibitor (PPI) for preventing recurrent peptic ulcer bleeding in patients who continue long-term NSAIDs (level 2 [mid-level] evidence)
    • precancerous gastric lesions – H. pylori eradication may reduce progression of lesions (level 3 [lacking direct] evidence)
    • iron deficiency anemia – eradicating H. pylori may improve response to oral iron therapy
    • nonulcer dyspepsia – H. pylori eradication improves but does not eliminate symptoms (level 1 [likely reliable] evidence)
    • chronic gastritis – H. pylori eradication may decrease histologic evidence of gastritis in multiple clinical settings (level 3 [lacking direct] evidence), but may not be associated with improved symptoms in children (level 2 [mid-level] evidence)
    • long-term PPI use – H. pylori eradication reduces healthcare use and may reduce dyspepsia symptoms but not reflux symptoms (level 1 [likely reliable] evidence)
    • long-term NSAID use – H. pylori eradication prevents ulcers and ulcer complications in patients starting NSAIDs (level 1 [likely reliable] evidence) but may be less effective than long-term PPI use (level 2 [mid-level] evidence)
    • immune thrombocytopenia – H. pylori eradication improves platelet count (level 2 [mid-level] evidence)
    • gastroesophageal reflux disease (GERD) – H. pylori eradication does not clearly cause, improve, or worsen GERD symptoms (level 2 [mid-level] evidence)
    • asymptomatic patients – H. pylori eradication may prevent future dyspepsia (level 2 [mid-level] evidence), but low overall risk (< 15%) may not warrant such therapy
  • when choosing therapy, consider all of following(1)
    • patient’s history of penicillin allergy, and history of macrolide exposure
    • patient’s ability to adhere to a multidrug regimen with potential adverse effects
    • sensitivity of regional H. pylori strain to the combination of antibiotics administered (H. pylori clarithromycin resistance is > 15% in many areas of North America); see Antimicrobial resistance considerations in Recommendations section for details

Additional Reading: Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobactor pylori infection. American Journal of Gastroenterology. 2017 Feb;112(2):212-239. doi: 10.1038/ajg.2016.563.

Management of elective surgery for diverticulitis

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One discussion this week was on the management of elective surgery for acute diverticulitis.

Reference: Wieghard N, Geltzeiler CB, Tsikitis VB. Trends in the surgical management of diverticulitis. Annals of Gastroenterology. 2015 Jan-Mar;28(1):25-30.

Summary: Wieghard et al (2015) state that sigmoid diverticulitis is an increasingly common Western disease associated with a high morbidity and cost of treatment. Improvement in the understanding of the disease process, along with advances in the diagnosis and medical management has led to recent changes in treatment recommendations. The natural history of diverticulitis is more benign than previously thought and despite current recommendations of more restrictive indications for surgery, practice trends indicate an increase in elective operations for the treatment of diverticulitis. Due to diversity in disease presentation, in many cases, optimal surgical treatment of acute diverticulitis remains unclear with regard to patient selection, timing, and technical approach in both elective and urgent settings.

The table below (Wieghard et al, 2015, p.28) provides direct comparison between ASCRS and ACPGBI recommendations for surgical treatment:

diverticulitis 1

diverticulitis 2

Additional Reading: Xai J, Paul Olson TJ, Rosen SA. Robotic-assisted surgery for complicated and uncomplicated diverticulitis: a single-surgeon case series. Journal of Robotic Surgery. 2019 Jan 23. doi: 10.1007/s11701-018-00914-x. [Epub ahead of print]

Hyperkalemia: a review of outcomes

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One discussion this week included serum potassium levels in the setting of chronic kidney disease (CKD).

Reference: Montford JR, Linas S. How dangerous is hyperkalemia? Journal of the American Society of Nephrology. 2017 Nov; 28(11):3155-3165. doi: 10.1681/ASN.2016121344

Summary: A recent review article by Montford and Linas (2017) summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation. Below are some points from the section on CKD.

One of the first studies to demonstrate an independent association of hyperkalemia and risk of subsequent death involved a large retrospective study of Japanese patients with advanced CKD presenting for dialysis initiation. An initial serum potassium level >5.5 meq/L at dialysis vintage was the strongest single independent predictor of mortality after an average of 15 years of follow-up. In patients on hemodialysis, potassium levels >5.6 and >5.7 meq/L have been associated with higher mortality. This is also reflected in patients on peritoneal dialysis, with one study suggesting hyperkalemia >5.5 meq/L is associated with a heightened risk of death. Potassium increases during longer intradialytic intervals, and many have attempted to link these fluctuations to the higher incidence of sudden cardiac death in patients with ESRD.

A recently published retrospective observational trial of 52,734 patients on a Monday/Wednesday/Friday hemodialysis schedule revealed that serum potassium levels 5.5–6.0 meq/L were associated with higher risk for subsequent hospitalization, emergency department visits, and mortality within 4 days of measurement.

Management of massive and submassive PE

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A discussion this week included the management of massive and submassive pulmonary embolism (PE).

Reference: Aggarwal V, et al. Acute management of pulmonary embolism. American College of Cardiology. 2017 Oct 24.

Summary: The severity of PE is stratified into massive (PE causing hemodynamic compromise), submassive (PE causing right ventricular dysfunction demonstrable by echocardiography, computed tomography or elevated cardiac biomarkers) and non-massive or low-risk (PE without evidence of RV dysfunction or hemodynamic compromise). The International Cooperative Pulmonary Embolism Registry (ICOPER) demonstrated 90-day mortality rates of 58.3% in patients with massive PE versus 15.1% in sub-massive PE.

Anticoagulation 

Anticoagulation therapy is the primary treatment option for most patients with acute PE. The utilization of factor Xa antagonists and direct thrombin inhibitors, collectively termed Novel Oral Anticoagulants (NOACs) are likely to increase as they become incorporated into societal guidelines as first line therapy.

Inferior vena cava filters

The role of inferior vena cava filters (IVCF) in the contemporary management of acute VTE has not been truly defined owing to a paucity of high quality evidence. At present the benefit of IVCF use seems to be in reducing the risk of acute PE in patients who have a clear contraindication to anticoagulation in the form of active bleeding.54,55 In the absence of such a contraindication there appears to be no clear benefit and non-retrieval of IVCF exposes the patient to risk of recurrent VTE, PTS and other mechanical complications such as filter fracture or migration.

Percutaneous Mechanical Thrombectomy (PMT) for Massive and Submassive Acute PE

Several percutaneous approaches have been used alone or in combination in patients with an absolute contraindication to thrombolysis: thrombus fragmentation, aspiration thrombectomy, rheolytic thrombectomy, and suction embolectomy.

Caution must be exercised during the placement of all catheters into the pulmonary arterial circulation. Ensuring proper positioning is vital in order to prevent the risk of catastrophic vessel injury as well as distal embolization of thrombus when using high-pressure injection systems. For this reason, the American College of Cardiology (Aggarwal et al, 2017) advocate the use of available computed tomography to help guide the optimal placement of any drug delivery system. Suction embolectomy devices such as the Greenfield catheter benefit from being large bore catheters capable of achieving thrombus removal without the side effects associated with fragmentation and rheolytic techniques. Despite this, technical difficulties related to catheter size have precluded its widespread adoption.

Ultrasound-Assisted CDT (UA-CDT) for Acute PE

For patients without an absolute contraindication to systemic thrombolysis, UA-CDT can be considered. Low energy ultrasound disaggregates fibrin within acute thrombi, this is exploited by the EKOS device (EkoSonic, Bothell, WA), which combines emission of low energy ultrasound and infusion of a thrombolytic agent via a multi side-hole containing catheter. This strategy has been evaluated in the ULTIMA (Ultrasound-Assisted, Catheter-Directed Thrombolysis for Acute Intermediate-Risk Pulmonary Embolism) trial, which demonstrated superiority to anticoagulation alone in improving hemodynamics without a significant increase in bleeding complications.

IOC vs MRCP for evaluation of the common bile duct during cholecystectomy

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One discussion this week included cholangiography (IOC) versus magnetic resonance cholangiopancreatography (MRCP) for the evaluation of the common bile duct during cholecystectomy.

References: Lin C, et al. Initial cholecystectomy with Cholangiography Decreases Length of Stay Compared to Preoperative MRCP or ERCP in the Management of Choledocholithiasis. American Surgery. 2015 July;81(7):726-731.

Sirinek KR, Schwesinger WR. Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography? Journal of the American College of Surgeons. 2015 Apr;220(4):522-528.

Summary: There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated.  In a study of 126 patients with suspected choledocholithiasis, Lin et al (2015) found that:

  • 97 patients who underwent initial LC ± IOC had an average LOS of 3.9 days
  • IOC was negative in 47.4% of patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001)
  • Laparoscopic common bile duct exploration was successful in 64.7% and had a shorter LOS compared with postoperative ERCP patients (P = 0.01)
  • Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days
  • Preoperative ERCP was performed in 8 patients with an average LOS of 7 days

In conclusion, initial LC+IOC was associated with a shorter LOS compared to preoperative MRCP or ERCP (Lin et al, 2015).

Additionally, a retrospective analysis of 7,427 patients undergoing laparoscopic cholecystectomy (LC) over 10 years  at a single tertiary care center evaluates the changing practice patterns over time of IOC, MRCP, and ERCP (Sirinek and Schwesinger, 2015).

Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure.

Additional Reading: Badger WR, et al. Utility of MRCP in clinical decision making of suspected choledocholithiasis: An institutional analysis and literature review. American Journal of Surgery. 2017 Aug;214(2):251-255.

Risk of acute kidney injury in patients on vancomycin

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One discussion this week included the use of vancomycin in the setting of acute kidney injury (AKI).

Reference: Navalkele B, et al. Risk of acute kidney injury in patients on concomitant vancomycin and piperacillin-tazobactam compared to those on vancomycin and cefepime. Clinical Infectious Diseases. 2017 Jan 15;64(2):116-123. doi:10.1093/cid/ciw709.

Summary: In a retrospective, matched, cohort study of 558 patients, Navlkele et al (2017) compared the incidence of AKI among patients receiving combination therapy with vancomycin + piperacillin-tazobactam (VPT) to a matched group receiving vancomycin + cefepime (VC).

AKI rates were significantly higher in the VPT group than the VC group (81/279 [29%] vs 31/279 [11%]). In multivariate analysis, therapy with VPT was an independent predictor for AKI (hazard ratio = 4.27; 95% confidence interval, 2.73-6.68). Among patients who developed AKI, the median onset was more rapid in the VPT group compared to the VC group (3 vs 5 days P =< .0001).

Types of perirectal abscesses

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One discussion this week involved perirectal abscesses.

Reference: Calandrella C, La Gamma N. Abscess, Perirectal. In StatPearls [NCBI Bookshelf]. Last updated: 2018 Oct 27.

Summary: Although often thought of as the same, perianal abscess and perirectal abscesses differ in both complexity and care options. Except for perianal abscess which can be simply incised and drained as definitive care, all others usually require intravenous antibiotics, surgical evaluation, and drainage. A majority of abscesses are diagnosed clinically based on skin findings and palpitation of the affected area alone, but some require advanced imaging to determine the extent of infiltration.

A perirectal abscess can be further divided into a category based on anatomical location: ischiorectal abscess, intersphincteric abscess, and supralevator abscess. Given the variability in location and severity of the abscess, it is important to consider the presence of fistulas or tracts which may contribute to the spread of the infection. Perianal abscesses are the most common type, followed by ischiorectal, and intersphincteric abscesses.

Alternatively, the Park’s classification system which groups the fistulas into 4 types based on the course of the fistula and the relationship to the anal sphincters.

  • Intersphincteric (70%): Between the internal and external sphincters
  • Trans-sphincteric (25%): Extends thru the external sphincter into the ischiorectal fossa
  • Suprasphincteric (5%): Lasses from the rectum to the skin through the levator ani
  • Extrasphincteric (1%): Extends from the intersphincteric plane through the puborectalis

EPIDEMIOLOGY: The incidence of anorectal abscesses is 1:10,000, resulting in approximately 68,000 to 96,000 cases in the United States per year with a male prevalence of 3:1 during the third and fourth decades of life. The condition is seen more in the summer and spring months. Although often a concern of the patient, data does not support that there is an increased risk from hygiene, anal-receptive intercourse, diabetes, obesity, race, or altered bowel habits.