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Halle (Saale), Germany

Loser Chr.,Medizinische Klinik

Malnutrition is a frequent and highly relevant independent risk factor in elderly people with significant clinical consequences. Individual adequate nutritional intervention is based on the established step-wise treatment algorithm where artificial nutrition via percutaneous endoscopic gastrostomy (PEG) tubes stands at the end of the therapeutic options. Placement of PEG tubes requires a clear medical indication as well as ethical justification within a critical, individual decision-making process. To our present knowledge, nutrition via PEG is from its character supportive, early, preventive and mainly transient but should not be placed in very old, multimorbid and demented patients. Artificial nutrition with a PEG tube is not a terminal or even a symbolic treatment at the end of human life or in patients with progressive stages of incurable diseases. © Springer-Verlag 2012. Source

Within the 32 years of its existence our attitude towards artificial enteral nutrition via PEG-tubes has changed in a fundamental way: in our modern understanding nutrition via PEG is supportive, early, preventive, and in many cases temporary. PEG-feeding is not an alternative but a possible supplement to normal oral food intake and requires an individual medical indication as well as an ethical justification. This does not follow standardised algorithmic thinking but is decided on an individual base taking personal wishes, resources, and needs of the individual patient into account. Nutrition via PEG-tube is not a terminal basic or even symbolic treatment at the end of life. The present dilemma of the PEG is that the public discussion primarily focus one-sided on the problems of PEG-placement in multimorbid, elderly, and/or demented patients or patients in end-stage tumour diseases where indeed PEG-placement is neither medically nor ethically justified - we still place PEG-tubes to often in the wrong patients! On the other hand we still consider supportive and in many cases temporary nutrition via PEG too rare and even too late in those patients which clearly could benefit from an early, supportive, and preventive PEG-treatment on the base of our present evidence-based scientific knowledge - we still consider PEG-treatment not adequately and in most cases too late in the right patients! Placing a PEG-tube is not the second last step before death and physicians have to accept the ethically given limits of medical treatment by realizing our modern understanding of the benefits and limits of supportive artificial nutrition via PEG. © Georg Thieme Verlag KG Stuttgart . New York. Source

Irritable bowel syndrome is a heterogeneous disease with a complex underlying pathophysiology and multiple symptoms - that is, clinical manifestation patterns. As such, management of irritable bowel syndrome requires a flexible approach tailored to the individual patient. This article reviews rational, evidence-based management strategy and treatment options for this variable condition. © 2013 Informa UK Ltd. Source

Background: Diverticular bleeding is the most common cause of acute severe lower gastrointestinal bleeding. Diagnostic and therapeutic approaches have not been standardized. Objective: Development of an evidence-based management algorithm. Materials and methods: A systematic search of the literature (PubMed 1998-2013) was carried out and a review with consideration of current guidelines is given. Results: The lifetime risk of clinically relevant bleeding is estimated to be 5 % in persons with colonic diverticula. Patients with clinically suspected diverticular hemorrhage should be admitted to hospital. Diverticular bleeding will cease spontaneously in around 70-90 % of the cases. In patients with severe lower gastrointestinal tract bleeding, defined as instability of the circulation, persistent bleeding after 24 h, drop of the hemoglobin level to ≥ 2 g/dl or the necessity for transfusion, endoscopy of the upper and lower gastrointestinal tract within the first 12-24 h is recommended. In patients with active diverticular bleeding or signs of recent hemorrhage (e.g. visible vessel or adherent clot) endoscopic therapy is strongly recommended because it significantly decreases the rate of early and late rebleeding. Angiography with superselective embolization is a therapeutic option in patients where endoscopy failed. Surgery should be considered in patients with ongoing bleeding and failure of interventional treatment and in patients who suffered from recurrent severe diverticular bleeding. Conclusions: Diverticulosis coli remains the most common cause of lower gastrointestinal bleeding. Colonoscopy is recommended as first-line diagnostic and therapeutic approach. In the vast majority of patients diverticular hemorrhage can be readily managed either conventionally or by interventional therapy. © 2014 Springer-Verlag Berlin Heidelberg. Source

Layer P.,Medizinische Klinik | Stanghellini V.,University of Bologna
Alimentary Pharmacology and Therapeutics

Background: Irritable bowel syndrome with constipation (IBS-C) represents a significant burden to patients and healthcare systems due to its prevalence and lack of successful symptomatic resolution with established treatment options. Linaclotide 290 μg has recently been approved by the European Medicines Agency (EMA) for moderate-to-severe IBS-C and by the US Food and Drug Administration for IBS-C (290 μg dose) and for chronic constipation (145 μg dose). Aim: To summarise data leading to the approval of linaclotide for IBS-C, with focus on EMA-pre-specified outcome measures. Methods: Literature search of a peer-review database (PubMed) and review of congress abstracts on linaclotide preclinical and clinical trial data in IBS-C. Results: Preclinical studies suggest that the guanylate cyclase C agonist (GCCA) linaclotide acts through elevation of cyclic guanosine monophosphate (cGMP) levels, leading to accelerated gastrointestinal (GI) transit through increased fluid secretion and reduced visceral hypersensitivity. Clinical trial data demonstrate that linaclotide improves abdominal symptoms (pain, bloating) and bowel symptoms (constipation) compared with placebo in patients with IBS-C. The most frequent side effect, diarrhoea, results from the therapeutic action of linaclotide. Linaclotide acts locally in the GI tract with minimal systemic exposure, resulting in low oral bioavailability and thus a low risk of relevant systemic adverse effects. Conclusion: Linaclotide, a first-in-class GCCA, is a promising new drug with a novel, dual mechanism of action that, unlike more well-established agents, can relieve the abdominal pain, bloating and constipation associated with IBS-C and has a low propensity for systemic side effects. © 2014 John Wiley & Sons Ltd. Source

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