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Mistakes in short bowel and how to avoid them

Short bowel manifests as high stomal output or diarrhoea, dehydration and malnutrition.

Short bowel is a condition that occurs after single or multiple intestinal resections. The incidence of short bowel in Europe is 2 per million of the population1–3 and it carries with it lifelong morbidity and mortality. The initial recognition and management of short bowel in the adult population tends to occur in the postoperative period and in the secondary care setting, where specialist input from clinicians experienced in short bowel is often lacking.

Normal small bowel length is 275–850 cm.4–7 It is accepted that when the length of small bowel is reduced to less than 200 cm it may be insufficient to enable adequate absorption of fluids and micronutrients. The symptoms of short bowel (often referred to in the literature as short bowel syndrome) are secondary to a reduction in intestinal surface area together with an increased motility of the remaining section of small bowel, with accompanying increased secretion into the lumen. These intestinal secretions vary in their electrolyte content and osmolality depending on the anatomical location, with the highest chloride and potassium loss from gastric secretions and high sodium loss from jejunal secretions.8 Clinically, short bowel manifests itself as a high stomal output or diarrhoea, dehydration and malnutrition. High stomal output or diarrhoea do not, however, necessarily equate immediately to short bowel; conversely, a small bowel longer than 200cm may be insufficient if it is diseased. Here, we discuss some of the pitfalls that are encountered in the recognition and management of short bowel and have suggested an algorithm for assessing and managing patients with a high stomal output. Although some of these pitfalls may appear obvious, they are addressed here because they are commonly encountered in clinical practice (summarised in table 1 at the end of the article).

A case at the crossroads of dermatology and gastroenterology

What next for a middle-aged patient with a condition affecting her skin and mouth? 

Several years ago, a middle-aged woman presented with a condition affecting her skin (photograph A) and mouth (photograph B), and she was diagnosed with lichen planus.

The patient then presented with dysphagia. A lesion was found high in the oesophagus (photograph C) and biopsy samples were taken (photograph D). Case question 1 WHAT IS THE AETIOLOGY OF THE STRICTURE? a) Benign b) Malignant 

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Mistakes in paediatric IBD and how to avoid them

Better clinical outcomes are increasingly being sought in young people with IBD

Around 1 in 10 cases of inflammatory bowel disease (IBD) will present before adulthood, with the median age at presentation being 11–12 years.1 IBD in children and young people is associated with more extensive disease, increased disease activity and a higher rate of complications compared with adult-onset IBD.2 Worldwide, estimates of paediatric IBD prevalence rates are lacking, but data suggest its incidence is increasing.3


Risk factors for paediatric IBD include immigration to high prevalence regions, particularly to countries that have Westernised diets, increasing geographical latitude, and European ancestry (versus belonging to an indigenous population).4 The risk may also be higher in children of certain ethnicities (South Asian, Hispanic, and East Asian).5

While the pathophysiology and clinical presentation of paediatric IBD is well understood, the role of genetics and personalised treatment is currently the focus of a significant amount of international research. Better clinical outcomes—including optimal nutrition, improved growth, better quality of life and increased disease remission rates with decreased occurrence of complications—are increasingly being sought in children and young people with IBD.4

This article discusses mistakes commonly made when identifying, diagnosing and managing children whom are suspected or confirmed to have IBD. The mistakes and discussion are based on published evidence where possible, plus our clinical experience of looking after children with IBD.

Prevention of cancer in the gastrointestinal tract and the liver

Learn how to manage patients with pre-neoplastic disorders.

Mistakes in tissue sampling during endoscopy and how to avoid them

Tissue acquisition is the most common manoeuvre performed during endoscopy.

Tissue sampling is the most common manoeuvre performed during endoscopic procedures and histological examination is part of almost every digestive disease investigation. The potential for mistakes is, therefore, widespread and knowledge of the adequacy of the indications and techniques used for tissue sampling during endoscopy, as well as the potential consequences, is indispensable for every gastroenterologist. As such, there are some questions that should always be posed before taking a biopsy sample or tissue acquisition during endoscopy: Why? What for? How? How many? (figure 1). This manuscript has been organized with these questions in mind. We’ve aggregated examples for the eight most frequent and most correctable mistakes made during tissue acquisition by endoscopy. In addition, most of the recommendations made in this article are supported by existing guidelines and evidence, with a few based solely on the authors’ experience. Figure 1 | Questions that should always be asked before a biopsy sample is taken or tissue acquired during endoscopy.

Mistakes in managing H. pylori infection and how to avoid them

Careful practice can overcome declining eradication rates for H. pylori treatment.

The sequelae of Helicobacter pylori infection, a known Group 1 carcinogen, can lead to significant morbidity and mortality worldwide. Billions of people are infected with H. pylori, but the incidence of H. pylori infection is declining in many parts of Europe, with a study from the Netherlands showing a decline in seroprevalence from 48% in subjects born between 1935 and 1946 to 16% in those born between 1977 and 1987.1

In recent years, however, eradication rates for H. pylori treatment have been falling, which has led to a large number of patients in the community having inadequately managed infections. Most of the problems that have led to the decline in the success of eradication treatment can be easily overcome through careful practice, supported by the robust framework provided by international guidelines. Careful practice includes the correct management of dyspepsia, the appropriate use of diagnostic tests for H. pylori, acceptable, efficacious treatments that enable good patient compliance and adequate follow up to insure eradication has been achieved in all cases. Here, we discuss the mistakes that are made when managing patients infected with H. pylori. Most of the discussion is evidence based, but where evidence is lacking the discussion is based on the authors’ clinical experience of more than 30 years in the field.

Chronic Pancreatitis

Improve your understanding of Chronic Pancreatitis.

Biomarkers of Liver Disease

Enhance your knowledge of Biomarkers of Liver Disease

Polypectomy

Improve your understanding of good polypectomy practice and the use of standardised protocols

Mistakes in NAFLD and how to avoid them

Management of NAFLD requires a multidisciplinary approach.

Nonalcoholic fatty liver disease (NAFLD) is defined as the accumulation of excess fat (triglyceride) in the liver in the absence of excessive alcohol consumption. Disease severity ranges from simple steatosis (nonalcoholic fatty liver [NAFL]) to nonalcoholic steatohepatitis (NASH), fibrosis, or cirrhosis, with the potential to develop hepatocellular carcinoma (HCC) or require liver transplantation. 

NAFLD is believed to affect up to 25% of the Western population,1 and is fast becoming the leading reason for liver transplantation worldwide.2 It affects up to 70% of those who are obese,3 and is strongly linked to the metabolic syndrome. Management of NAFLD therefore requires a multidisciplinary approach, not only to identify those patients at risk of progressive liver disease, but also to improve long-term liver and cardiovascular morbidity and mortality.  Here, we highlight some of the mistakes commonly made by medical practitioners when managing NAFLD, and give an evidence-based (where possible) or experience-based approach to management of the condition.

Thank you from UEG E-learning!

We wouldn’t be able to provide high-quality, valued content if not for our contributors.

This month has seen UEG E-learning reach a wonderful landmark, with 3,000 learners actively taking a UEG online course. Added to this are the thousands of pageviews attracted by our Mistakes in… series—more than 38,000 so far this year alone! Given UEG’s aim to enhance the education of young professionals in the field, we’re delighted that our content is being so well used.

Of course, we wouldn’t be in the position to provide such high-quality, valued content were it not for our contributors. Now, therefore, seems an appropriate time to say a big thank you to all our authors for their time, expertise and enthusiasm. Here, you’ll find a few UEG E-learning facts, figures and thoughts that demonstrate just how far the project has come in the past few years (since January 2014). At the end of this blog, you’ll find a list of the UEG E-learning content that’s currently available and the names of all our fantastic contributors. If you haven’t had a chance to look at our content then I recommend looking at the list and visiting the UEG Education website. Thank you, once more, to all our contributors—we truly appreciate your generosity and investment in UEG E-learning and look forward to working with you again in the future! Download the infographic

Mistakes in medical management of IBD and how to avoid them

The subtleties and challenges of contemporary IBD management.

The prevalence of inflammatory bowel disease (IBD) is ~0.5%–1% and rising.1 In many healthcare systems, the frequency of IBD is too rare for it to be managed solely by primary care practitioners, but still common enough to fall within the caseload of general gastroenterologists. Whilst the disease may run a relatively quiescent course, some patients face years of severe, disabling symptoms. The relatively unpredictable prognosis of IBD, combined with the ability of its extraintestinal manifestations to impact multiple organ systems, requires a nimble and individual approach to patient management. Indeed, the treating clinician must liaise closely with colleagues in other disciplines, including nursing, surgery, radiology, histopathology and numerous other medical specialties.

Advances in our understanding of IBD pathogenesis and in diagnostic modalities, therapeutic options and surgical techniques for Crohn’s disease and ulcerative colitis have fundamentally altered the landscape of IBD management in the past two decades. The challenge for physicians treating IBD is to leverage these changes to improve patient outcomes, avoiding the many potential pitfalls. Here, we discuss some of the pitfalls that may await the treating clinican, drawing upon evidence when possible and on our clinical experience. If some of these pitfalls seem contradictory, this is deliberately so, to highlight the subtleties and challenges of contemporary IBD management. Many of the pitfalls may also seem somewhat obvious when taken in isolation, and yet we believe them to be relatively common, raising important questions around how we can configure and manage our services to avoid those problems that we all still encounter in practice.

Mistakes in cases on call and how to avoid them

Evaluating and managing GI cases on call is a difficult task.

It is a difficult task and a great responsibility to evaluate and manage patients with acute - and potentially life-threatening - clinical presentations. It is even more complex to achieve high standards of care for cases on call. Indeed, on-call gastroenterologists, hepatologists and endoscopists are faced with a wide and protean range of gastrointestinal, liver and pancreatic emergencies. 

The decision-making process for cases on call is mainly based on information received over the phone, on medical knowledge and clinical experience, and on the resources available. As the degree of confidence in any information given on call may vary, it is of tremendous importance to note, and to document, with precise timing, what has been communicated by, proposed to, and eventually decided with, multiple caregivers (i.e. nurses, emergency physicians, intensive care physicians, surgeons, radiologists etc.) Here, we discuss 10 mistakes that are often seen when managing GI cases on call. Most of the proposals are based on medical evidence, but others are formed from our own clinical experience. 

Mistakes in endoscopic resection and how to avoid them

Endoscopic resection is an advanced technique used to remove superficial lesions.

Endoscopic resection is a widespread, advanced endoscopic technique that can be used to remove superficial lesions in the gastrointestinal tract. Lesions present in all parts of the gastrointestinal tract, such as the oesophagus, stomach, duodenum, small intestine and, above all, colon, can be removed by endoscopic resection. Lesion detection and characterization, the use of appropriate resection devices and methods, and the management of malignant polyps are all important parts of a multistep process that requires training, experience, expertise and a multidisciplinary approach. 

The diagnostic and therapeutic mistakes discussed here are based on our endoscopic experience. We present the most important mistakes that are often seen in endoscopic resection in our practice and have major consequences for the patient. We propose, from our experience, a simple approach to avoid these mistakes.

Mistakes in GORD diagnosis and how to avoid them

Conditions to be aware of to avoid making an erroneous diagnosis of GORD

According to the Montreal definition, “[gastro-oesophageal reflux disease (GORD)] is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.”1 GORD has a negative effect on quality of life and is frequently encountered in clinical practice, with an estimated prevalence of around 24% in Europe.2 In the US, GORD-related healthcare costs account for $9 billion per year.3 A variety of symptoms are associated with GORD—heartburn and regurgitation are typical symptoms, while chest pain, cough and sore throat are considered atypical symptoms—but none is pathognomonic.

In case of a typical presentation of GORD in a young patient, and in the absence of alarm signs (e.g. bleeding, dysphagia, weight loss), it is common practice to treat the GORD without investigation. In other cases, upper gastrointestinal endoscopy is usually the first-line examination, more to rule out mucosal complications than to make a positive diagnosis of GORD. Although the presence of erosive oesophagitis is specific to GORD, most patients in whom GORD is suspected based on their clinical presentation have normal endoscopy findings. In this situation, ambulatory reflux monitoring (either pH or pH-impedance monitoring) may be required to identify reflux episodes, to link them with symptom occurrence and then to confirm the clinical diagnosis of GORD. Another common clinical presentation is a patient with symptoms suggestive of GORD that persist despite proton pump inhibitor (PPI) therapy. Indeed 20–60% of patients with GORD-suggestive symptoms are not satisfied with PPI therapy.4,5 After evaluating a patient’s compliance with their treatment, complementary examinations are indicated to determine if resistance to treatment is secondary to persistent GORD, to reflux hypersensitivity or to an erroneous diagnosis of GORD.

Here, we report 10 conditions that clinicians should be aware of to avoid making an erroneous diagnosis of GORD. The discussion draws on a combination of published data and clinical experience.

Constipation

Enhance your knowledge of constipation.

Mistakes in CT for the acute abdomen and how to avoid them 

There are many pitfalls to be aware of when requesting/interpreting abdominal CT scans

Abdominal CT (computed tomography) is among the most common imaging tests performed for the investigation of acute abdominal pathology. There are many pitfalls that clinicians and radiologists should be aware of when requesting these studies and interpreting the findings.

This article covers ten mistakes frequently made with abdominal CT, focusing on gastrointestinal tract and hepatobiliary pathology. These mistakes and their discussions are based on the available literature where possible and thereafter on our clinical experience. 
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