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Papers by Abhishek Choudhary

Research paper thumbnail of Low-volume Polyethylene Glycol and Bisacodyl for Bowel Preparation Prior to Colonoscopy: A Meta-Analysis

American Journal of Gastroenterology, 2011

Background Quality of bowel preparation prior to colonoscopy is essential. Studies have shown a r... more Background Quality of bowel preparation prior to colonoscopy is essential. Studies have shown a reduced volume of polyethylene glycol (PEG) with bisacodyl may improve visualization and tolerability, but results have varied. Therefore, a meta-analysis was performed to analyze the efficacy of a low-volume PEG bowel preparation with bisacodyl for bowel preparation prior to colonoscopy. Methods Multiple databases were searched (June 2012). Only randomized controlled trials in peer-reviewed journals on adult subjects comparing low-volume PEG (2 L) with bisacodyl versus 4 L PEG were included. Meta-analysis for the efficacy of low-volume PEG with bisacodyl and 4 L PEG were analyzed by calculating pooled estimates of number of satisfactory, excellent, and poor bowel preparations as well as adverse patient events (abdominal pain, nausea, vomiting, bloating). Results Six studies (N=1,540) met the inclusion criteria. No statistically significant differences were noted between low-volume PEG (2 L) with bisacodyl and 4 liters PEG for number of satisfactory (OR 0.86; 95% CI: 0.45-1.63, P=0.64), excellent (OR 1.08; 95% CI: 0.78-1.50, P=0.63), or poor bowel preparations (OR 0.68; 95% CI: 0.35-1.34, P=0.27). A statistically significant decrease in nausea (OR 0.57; 95% CI: 0.36-0.89, P=0.01), vomiting (OR 0.57; 95% CI: 0.40-0.81, P<0.01), and bloating (OR 0.65; 95% CI: 0.49-0.87, P<0.01) was noted for the low-volume PEG with bisacodyl as compared to 4 L PEG. No statistically significant differences were noted between the two groups for abdominal pain (P=0.62). Conclusion Low-volume PEG (2 L) with bisacodyl demonstrates less nausea, vomiting, and bloating without adversely affecting the bowel preparation.

Research paper thumbnail of Sa1371 Early Aggressive Fluid Resuscitation for Acute Pancreatitis - Is It Time for Large Multicenter Randomized Trial?

Gastroenterology, 2013

scoreand BiSAP, need for endoscopic procedures, length of hospitalization and mortality were eval... more scoreand BiSAP, need for endoscopic procedures, length of hospitalization and mortality were evaluated. The use of NSAID was also recorded. The primary outcome was to determine the severity of AP in statin users vs. non-users. Secondary outcomes were length of hospitalization, occurrence of complications and 30 day & 1 year mortality. Results A total of 1471 patients were hospitalized with AP. 297 AP patients met inclusion criteria. Mean age was 59.7 yrs, 280 (94%) were men. Etiology of AP was alcohol in 91 (30.6%), biliary in 89 ( 29.9% ) and 117 ( 39.3% ) were due to other causes. 107(36%) took statins and 114 took NSAIDs (38.3%) at admission for AP. Statin users had significantly higher Ranson scores than non-users, even after controlling for NSAIDs use (F(1,291)=4.2,p=.04). There was a 14% reduction in complications of AP in patients taking statins but it was not different to patients not taking statins and after controlling for NSAIDs (see Table). There was no significant difference between statin users and non-users on the BiSAP score, even after controlling for NSAIDs use and Charlson score. Length of hospitalization was also not significantly different. Conclusion: In this retrospective study of 297 patients with AP, statin use was associated with a 14% reduction in complications of AP, but it was not statistically significant. Since we relied on EMR to determine if patients were taking their medication prospective data is needed to determine the actual effect of statins on the severity and complications of AP. A larger trial could also possibly reach a significant decrease of complications.

Research paper thumbnail of Sa1152 The Value of the Trendelenburg Position During Routine Colonoscopy: A Pilot Study

Research paper thumbnail of Sa1456 Does Use of Glucagon During Colonoscopy Improve Quality Indicators? a Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2015

Research paper thumbnail of Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding

Southern medical journal, 2014

Multiple studies have demonstrated that feeding ≤4 hours after placement of a percutaneous endosc... more Multiple studies have demonstrated that feeding ≤4 hours after placement of a percutaneous endoscopic gastrostomy (PEG) tube is a reasonable option. Many physicians, however, continue to delay feedings until the next day or 24 hours; therefore, we evaluated the safety and effect of early feeding (≤4 hours) after PEG placement in our tertiary care center. A retrospective study of 444 patients who underwent PEG between June 2006 and December 2011 was performed. Early feeding was defined as feeding ≤4 hours and delayed feeding was defined as feeding >4 hours. Statistical analysis was performed using the Fisher exact test and the Student t test. A total of 444 patients underwent PEG between June 2006 and December 2011. A majority of PEGs were performed on inpatients by gastroenterologists. The mean time of feeding after PEG was 3.2 ± 0.9 hours for the early group (n = 197) and 17.0 ± 10.0 hours for the delayed group (n = 247). No statistically significant differences were noted betwe...

Research paper thumbnail of Prophylactic Antibiotics in Necrotizing Pancreatitis: A Meta-analysis

Southern Medical Journal, 2008

The authors concluded that prophylactic antibiotics did not reduce mortality, rate of infected ne... more The authors concluded that prophylactic antibiotics did not reduce mortality, rate of infected necrosis or the need for surgical intervention in patients with necrotising pancreatitis, but that they did reduce the risk of non-pancreatic infections and length of hospital stay. Given the unclear quality of the included trials, the reliability of the authors' conclusions is unclear. Searching MEDLINE, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched to May 2007. Search terms were reported. Abstracts of conference proceedings from at least 11 relevant conferences were also searched. Bibliographies of selected studies and previously published meta-analyses were scanned. Study selection Randomised controlled trials (RCT) that compared treatment with prophylactic intravenous (IV) antibiotics to treatment without prophylactic antibiotics in patients with acute necrotising pancreatitis, confirmed by contrast enhanced computed tomography, were eligible for inclusion. Trials investigating head-to-head antibiotic usage, gut decontamination or timing of antibiotic administration were excluded. Outcomes of interest were infected pancreatic necrosis, mortality, number of non-pancreatic infections, surgical intervention and mean hospital stay. Prophylactic antibiotics used in the included trials were meropenem, cefuroxime, imipenem, ciprofloxacin plus metronidazole, imipenem plus cilastatin or ofloxacin plus metronidazole, administered for between seven and 21 days (where reported). Both multi-centre and single centre trials in North American and Europe were included. The authors did not state how the studies were selected for the review, or how many reviewers performed the study selection. Data were independently extracted by two reviewers, with a third reviewer examining for agreement. Differences were resolved through discussion between the three reviewers. Authors were contacted for further information. Methods of synthesis Pooled odds ratios with 95% confidence intervals were used to combine dichotomous data. Weighted mean differences with 95% confidence intervals were used to combine continuous data. Both fixed-effect and random-effects models were used. Statistical heterogeneity was assessed using the I 2 statistic. Publication bias was assessed using funnel plots and the Harbour-Egger method. Results of the review Seven randomised controlled trials (RCTs) were included for the review (n=429 patients); two placebo-controlled

Research paper thumbnail of Effect ofHelicobacter pyloritreatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials

Scandinavian Journal of Gastroenterology, 2012

Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of ac... more Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD. Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56-1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72-1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35-0.87, p = 0.01). Funnel plot revealed no publication bias. Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Research paper thumbnail of Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: A meta-analysis of randomized controlled trials

Saudi Journal of Gastroenterology, 2013

Upper gastrointestinal bleeding (UGIB) is a common medical emergency that accounts for more than ... more Upper gastrointestinal bleeding (UGIB) is a common medical emergency that accounts for more than 500,000 hospital admissions each year. [1] Despite advances in medical therapy, a significant mortality (5-10%) with severe upper gastrointestinal (GI) bleeding still exists. [2] Therefore, in the setting of UGIB, urgent endoscopy with adequate gastric mucosal visualization is pivotal for identification and treatment of bleeding lesions. Erythromycin, a macrolide antibiotic, facilitates the motility of the gastric antrum and duodenum by acting as a motilin receptor agonist. [3] Erythromycin, even in lower doses (70 mg), has been shown to accelerate gastric emptying. [4] Although various other modalities, including gastric lavage and metoclopramide, have been studied on gastric emptying, erythromycin may be more effective for enhancing gastric motility in UGIB. [5,6] Various studies have been done for evaluating the effectiveness of erythromycin infusion before endoscopy to improve visibility and the therapeutic potential of endoscopy; however, the results have been controversial. [7-13] In addition, three meta-analyses have been performed examining the use of prokinetics with UGIB with varying results. [14-16] To evaluate further, we performed ABSTRACT Background/Aim: Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. Methods: Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). Results: Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01). Conclusions: Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Research paper thumbnail of Immediate Versus Delayed Percutaneous Coronary Intervention for Patients with Non-ST Segment Elevation-Acute Coronary Syndrome: Meta-Analysis of Randomized Controlled Trials

Journal of the American College of Cardiology, 2011

Background: Studies indicate that an early invasive strategy is favorable over a selective invasi... more Background: Studies indicate that an early invasive strategy is favorable over a selective invasive strategy for Non-ST segment elevation acute coronary syndromes (NSTE-ACS). However, there is no general consensus on precisely how early should the revascularization be performed. Randomized controlled trials (RCTs) performed to compare the outcomes of revascularization less than 24 hours of presentation (group A) versus between 24 hours and seven days after presentation (group B) for NSTE-ACS show conflicting results. Methods: MEDLINE, PubMed and abstracts from major cardiology conferences were searched. RCTs comparing the composite of death or myocardial infarctions (MI) between group A and group B within 30 days of revascularisation were included. The effects of both methods were analyzed by calculating pooled estimates for death, MI, repeat revascularisation, bleeding and composite of death or MI. Separate analyses were performed for each outcome by using odds ratio (OR) by fixed and random effects models. Publication bias was assessed by funnel plots. All were graded by jaded score. Heterogeneity among studies was assessed by calculating I measure of inconsistency. Results: Seven studies with a total of 13,762 patients met our inclusion criteria. The incidence of the composite of death or MI was not different between group A [607/7710 (7.9%)] compared to group B [823/6052(13.6%)], (OR 0.83, 95% CI 0.62-1.10, P=0.20). Similar results were obtained for death (OR 0.58, 95% CI 0.24-1.39, P=0.22) and MI (OR 0.93, 95% CI 0.64-1.34, P=0.69) separately. In group A there was a decrease (OR 1.33 (95% CI 1.13-1.56, p=0.0004) in the incidence of repeat revascularization [405/7398(5.5%)] as compared to group B [337/5734(5.9%)]. Group A experienced lower incidence of bleeding 5.3% (293 in 5497) as compared to 6.9% (232/3376) in group B (OR-0.76, 95% CI, 0.63-0.91, P=0.003). Conclusions: Coronary artery revascularization within 24 hours of presentation does not reduce death and MI at 30 days in NSTE-ACS as compared to intervention after 24 hours. Early intervention groups had significantly lower rate of repeat revascularization and bleeding as compared to the delayed intervention group.

Research paper thumbnail of Enteral Feeding Within Three Hours After Percutaneous Endoscopic Gastrostomy Placement

Journal of Clinical Gastroenterology, 2011

Background: Traditionally, tube feedings have been delayed after gastrostomy placement to the nex... more Background: Traditionally, tube feedings have been delayed after gastrostomy placement to the next day and up to 24 hours postprocedure. However, results from various randomized clinical trials (RCTs) indicate earlier feeding may be an option. Therefore, we conducted a meta-analysis to analyze the effect of earlier feedings (r3 h) after percutaneous endoscopic gastrostomy (PEG) placement. Methods: Various medical databases and recent abstracts from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early (r3 h) versus delayed or nextday feedings after PEG placement were included. Meta-analysis was performed using pooled estimates of complications, death r72 hours, and significant increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.0 was utilized for statistical analysis. Results: Five studies (N=355) met the inclusion criteria. No significant differences were noted between early (r3 h) and delayed or next day feedings for patient complications [OR 0.78; 95% confidence interval (CI), 0.39-1.53; P=0.47], death in r72 hours (OR 0.60; 95% CI, 0.18-1.99; P=0.40), and number of significant gastric residual volume during day 1 (OR 1.46; 95% CI, 0.75-2.84; P=0.27). No publication bias and no significant heterogeneity were noted. Conclusions: Early tube feeding r3 hours after PEG placement has no significant differences to delayed or next-day feeding in respect to complications, death in r72 hours, or number of significant gastric residual volumes at day 1.

Research paper thumbnail of Tu1372 Steroid Use for Prevention of Strictures Post Endoscopic Submucosal Dissection : a Meta Analysis

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Sa1526 The Effect of Indomethacin in the Prevention of Post-ERCP Pancreatitis: a Meta-Analysis

Gastrointestinal Endoscopy, 2013

Research paper thumbnail of Accuracy of Nodal Staging in Gastroesophageal Junction Cancers By Endoscopic Ultrasound: A Meta-Analysis and Systematic Review

Gastrointestinal Endoscopy, 2009

mg midazolam and 105.6 AE 38.6 mcg fentanyl. Table 1 lists results from the Bravo pH monitoring s... more mg midazolam and 105.6 AE 38.6 mcg fentanyl. Table 1 lists results from the Bravo pH monitoring studies. Patients receiving CS (nZ128) demonstrated significantly higher DeMeester score, (pZ0.02) total % time pH!4, (pZ0.05) upright (pZ0.04) and supine % pH!4 (pZ0.05) on day #1 versus day #2. Patients without CS (nZ86) did not show significant differences in DeMeester score (pZ0.45) or any other variables between the two days. Subjects with abnormal Bravo studies who received CS (nZ82) had significantly higher DeMeester scores (p!0.01) on day #1 versus day #2. Patients with abnormal Bravo pH studies without CS and patients with normal Bravo studies regardless of the use of CS, did not show significant differences. Further analysis of the day #1 scores demonstrated significant differences between patients with and without sedation, while the day #2 scores did not differ. Conclusions: Patients who received CS at time of Bravo implantation had significantly more pathologic reflux on day #1. These effects were exaggerated in patients with abnormal Bravo studies, but were not apparent in patients without CS or in patients with normal pH studies. The implications of this study may include adjusted interpretation of Bravo pH readings when CS is used. Results of Bravo pH Monitoring with and without CS DeMeester Score Total % pH!4 Upright % pH!4

Research paper thumbnail of M1530: Early Precut Prevents Post-ERCP Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2010

Gastrointestinal Endoscopy, Volume 71, Issue 5, Pages AB246, April 2010, Authors:Abhishek Choudha... more Gastrointestinal Endoscopy, Volume 71, Issue 5, Pages AB246, April 2010, Authors:Abhishek Choudhary; Nicholas M. Szary; Murtaza Arif; Hazem T. Hammad; Ghassan M. Hammoud; Matthew L. Bechtold; Jamal A. Ibdah. Gastrointestinal ...

Research paper thumbnail of Prophylactic Octreotide for Prevention of Post-ERCP Pancreatitis: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

Background: Acute pancreatitis is a common complication of ERCP. Over the years, attempts have be... more Background: Acute pancreatitis is a common complication of ERCP. Over the years, attempts have been made to identify an agent to prevent this complication. Octreotide, an inhibitor of exocrine secretion with anti-inflammatory and cytoprotective effects, has been studied in ...

Research paper thumbnail of Early Versus Delayed Feeding After Placement of a Percutaneous Endoscopic Gastrostomy: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

This review compared early versus delayed feeding after PEG placement. It showed that early feedi... more This review compared early versus delayed feeding after PEG placement. It showed that early feeding was associated with a higher incidence of significant residual gastric volume on the first day. The review contained several methodological limitations and its conclusions do not seem to be reliable. Searching MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), DARE, HealthSTAR and CINHAL were searched up to 2006. Abstracts from conference proceedings of the Digestive Disease week and the American College of Gastroenterology National Meeting from 1993 to 2007 were handsearched. Search terms were reported. There were no apparent language restrictions. Study selection Randomised controlled trials (RCT) that compared early (≤4h) versus delayed or next-day feeding after PEG placement in adult patients (>18 years) were eligible. Death within 72 hours, complications and the incidence of significant gastric residual volumes during day one represented the outcomes for inclusion. Types of complications were not defined. Significant residual volumes was defined as it appeared in each article. Age of the participating patients ranged from 63 to 76 years. Time of early feeding ranged from less than one hour to four hours. Delayed feeding ranged from from 24 hours to next day. Significant volume definition varied from more than 60ml to 50% of the last volume administered. Length of follow-up was not described. Two authors independently selected the articles after an initial examination. It was unclear how many authors were involved in the initial selection. Assessment of study quality Studies were assessed for description and appropriateness of randomisation, blinding and dropouts using the Jadad scale. It appeared that two reviewers independently evaluated study quality. Data extraction Two authors independently extracted data in a predefined review form. Differences were resolved by consensus. The numbers of patients who experienced complications, died or had significant residual volumes were extracted to calculate odds ratios (OR). Methods of synthesis The pooled odds ratios and their corresponding 95% confidence intervals (CI) of each outcome were calculated using both fixed-effect and random-effects models. The results from the fixed-effect and random-effects models were consistent; only the random-effects model results were reported. Statistical heterogeneity was assessed using the I 2 test. An I 2 of 50% or more was considered significant. Authors stated that publication bias was assessed using a funnel plot for the outcome all complications.

Research paper thumbnail of Prophylactic Somatostatin for Prevention of Post-ERCP Pancreatitis: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

Research paper thumbnail of S1448: EUS-Guided Biliary Access and Drainage (EBAD) At a Tertiary Care Center

Gastrointestinal Endoscopy, 2010

Research paper thumbnail of S1383: Split-Dose Polyethylene Glycol for Bowel Preparation Prior to Colonoscopy: A Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2010

Background: Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfor... more Background: Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large volume solution may reduce patient compliance, resulting in suboptimal preparation and increased patient discomfort. In an effort to reduce such negative factors and improve overall patient tolerance and satisfaction, split-dosing of PEG was studied in various randomized controlled trials (RCTs). However, results have been conflicting. Therefore, we conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation prior to colonoscopy. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, CINAHL, PubMed, and recent abstracts from major conference proceedings were searched (10/09). RCTs on adults comparing fulldose versus split-dose of PEG for bowel preparation prior to colonoscopy were included. Standard forms were used to extract data by two independent reviewers. The effects were analyzed by calculating pooled estimates of quality of bowel preparation, compliance with the preparation, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random effects models. Publication bias was assessed by funnel plots. All randomized trials studies were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.Results: Four trials met inclusion criteria (Nϭ827) with mean age ranging from 47.8-57 years. Trials were of adequate quality (Jadad score Ն 2). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.40; 95% CI: 1.60-7.22, pϽ0.01) as compared to full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.33; 95% CI: 0.16-0.69, pϽ0.01) and nausea (OR 0.58; 95% CI: 0.39-0.84, pϽ0.01) as compared to full-dose PEG. No statistically significant differences were noted between the two groups in regards to willingness to repeat bowel preparation (pϭ0.31), abdominal cramping (pϭ0.76), abdominal bloating (pϭ0.47), vomiting (pϭ0.12), sleep disturbance (pϭ0.42), or missing school/work (pϭ0.37). Funnel plot did not reveal any publication bias. Heterogeneity was noted at times requiring the use of the random effects model. Conclusions: The use of a split-dose PEG for bowel preparation prior to colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea as compared to the full-dose PEG. Therefore, split-dose PEG appears superior to full-dose PEG for bowel preparation prior to colonoscopy.

Research paper thumbnail of Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

Gastrointestinal Endoscopy, 2011

Background: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled t... more Background: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. Objective: We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. Design: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random-or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I 2 measure of inconsistency. Setting: Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. Patients: Adult patients undergoing ERCP. Interventions: Pancreatic stent placement for the prevention of post-ERCP pancreatitis. Main Outcome Measurements: Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. Results: Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P Ͻ .01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, Ϫ309.22; 95% CI, Ϫ350.95 to Ϫ267.49; P Յ .01). Similar findings were also noted from the nonrandomized studies. Limitations: Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. Conclusions: Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Research paper thumbnail of Low-volume Polyethylene Glycol and Bisacodyl for Bowel Preparation Prior to Colonoscopy: A Meta-Analysis

American Journal of Gastroenterology, 2011

Background Quality of bowel preparation prior to colonoscopy is essential. Studies have shown a r... more Background Quality of bowel preparation prior to colonoscopy is essential. Studies have shown a reduced volume of polyethylene glycol (PEG) with bisacodyl may improve visualization and tolerability, but results have varied. Therefore, a meta-analysis was performed to analyze the efficacy of a low-volume PEG bowel preparation with bisacodyl for bowel preparation prior to colonoscopy. Methods Multiple databases were searched (June 2012). Only randomized controlled trials in peer-reviewed journals on adult subjects comparing low-volume PEG (2 L) with bisacodyl versus 4 L PEG were included. Meta-analysis for the efficacy of low-volume PEG with bisacodyl and 4 L PEG were analyzed by calculating pooled estimates of number of satisfactory, excellent, and poor bowel preparations as well as adverse patient events (abdominal pain, nausea, vomiting, bloating). Results Six studies (N=1,540) met the inclusion criteria. No statistically significant differences were noted between low-volume PEG (2 L) with bisacodyl and 4 liters PEG for number of satisfactory (OR 0.86; 95% CI: 0.45-1.63, P=0.64), excellent (OR 1.08; 95% CI: 0.78-1.50, P=0.63), or poor bowel preparations (OR 0.68; 95% CI: 0.35-1.34, P=0.27). A statistically significant decrease in nausea (OR 0.57; 95% CI: 0.36-0.89, P=0.01), vomiting (OR 0.57; 95% CI: 0.40-0.81, P<0.01), and bloating (OR 0.65; 95% CI: 0.49-0.87, P<0.01) was noted for the low-volume PEG with bisacodyl as compared to 4 L PEG. No statistically significant differences were noted between the two groups for abdominal pain (P=0.62). Conclusion Low-volume PEG (2 L) with bisacodyl demonstrates less nausea, vomiting, and bloating without adversely affecting the bowel preparation.

Research paper thumbnail of Sa1371 Early Aggressive Fluid Resuscitation for Acute Pancreatitis - Is It Time for Large Multicenter Randomized Trial?

Gastroenterology, 2013

scoreand BiSAP, need for endoscopic procedures, length of hospitalization and mortality were eval... more scoreand BiSAP, need for endoscopic procedures, length of hospitalization and mortality were evaluated. The use of NSAID was also recorded. The primary outcome was to determine the severity of AP in statin users vs. non-users. Secondary outcomes were length of hospitalization, occurrence of complications and 30 day & 1 year mortality. Results A total of 1471 patients were hospitalized with AP. 297 AP patients met inclusion criteria. Mean age was 59.7 yrs, 280 (94%) were men. Etiology of AP was alcohol in 91 (30.6%), biliary in 89 ( 29.9% ) and 117 ( 39.3% ) were due to other causes. 107(36%) took statins and 114 took NSAIDs (38.3%) at admission for AP. Statin users had significantly higher Ranson scores than non-users, even after controlling for NSAIDs use (F(1,291)=4.2,p=.04). There was a 14% reduction in complications of AP in patients taking statins but it was not different to patients not taking statins and after controlling for NSAIDs (see Table). There was no significant difference between statin users and non-users on the BiSAP score, even after controlling for NSAIDs use and Charlson score. Length of hospitalization was also not significantly different. Conclusion: In this retrospective study of 297 patients with AP, statin use was associated with a 14% reduction in complications of AP, but it was not statistically significant. Since we relied on EMR to determine if patients were taking their medication prospective data is needed to determine the actual effect of statins on the severity and complications of AP. A larger trial could also possibly reach a significant decrease of complications.

Research paper thumbnail of Sa1152 The Value of the Trendelenburg Position During Routine Colonoscopy: A Pilot Study

Research paper thumbnail of Sa1456 Does Use of Glucagon During Colonoscopy Improve Quality Indicators? a Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2015

Research paper thumbnail of Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding

Southern medical journal, 2014

Multiple studies have demonstrated that feeding ≤4 hours after placement of a percutaneous endosc... more Multiple studies have demonstrated that feeding ≤4 hours after placement of a percutaneous endoscopic gastrostomy (PEG) tube is a reasonable option. Many physicians, however, continue to delay feedings until the next day or 24 hours; therefore, we evaluated the safety and effect of early feeding (≤4 hours) after PEG placement in our tertiary care center. A retrospective study of 444 patients who underwent PEG between June 2006 and December 2011 was performed. Early feeding was defined as feeding ≤4 hours and delayed feeding was defined as feeding >4 hours. Statistical analysis was performed using the Fisher exact test and the Student t test. A total of 444 patients underwent PEG between June 2006 and December 2011. A majority of PEGs were performed on inpatients by gastroenterologists. The mean time of feeding after PEG was 3.2 ± 0.9 hours for the early group (n = 197) and 17.0 ± 10.0 hours for the delayed group (n = 247). No statistically significant differences were noted betwe...

Research paper thumbnail of Prophylactic Antibiotics in Necrotizing Pancreatitis: A Meta-analysis

Southern Medical Journal, 2008

The authors concluded that prophylactic antibiotics did not reduce mortality, rate of infected ne... more The authors concluded that prophylactic antibiotics did not reduce mortality, rate of infected necrosis or the need for surgical intervention in patients with necrotising pancreatitis, but that they did reduce the risk of non-pancreatic infections and length of hospital stay. Given the unclear quality of the included trials, the reliability of the authors' conclusions is unclear. Searching MEDLINE, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched to May 2007. Search terms were reported. Abstracts of conference proceedings from at least 11 relevant conferences were also searched. Bibliographies of selected studies and previously published meta-analyses were scanned. Study selection Randomised controlled trials (RCT) that compared treatment with prophylactic intravenous (IV) antibiotics to treatment without prophylactic antibiotics in patients with acute necrotising pancreatitis, confirmed by contrast enhanced computed tomography, were eligible for inclusion. Trials investigating head-to-head antibiotic usage, gut decontamination or timing of antibiotic administration were excluded. Outcomes of interest were infected pancreatic necrosis, mortality, number of non-pancreatic infections, surgical intervention and mean hospital stay. Prophylactic antibiotics used in the included trials were meropenem, cefuroxime, imipenem, ciprofloxacin plus metronidazole, imipenem plus cilastatin or ofloxacin plus metronidazole, administered for between seven and 21 days (where reported). Both multi-centre and single centre trials in North American and Europe were included. The authors did not state how the studies were selected for the review, or how many reviewers performed the study selection. Data were independently extracted by two reviewers, with a third reviewer examining for agreement. Differences were resolved through discussion between the three reviewers. Authors were contacted for further information. Methods of synthesis Pooled odds ratios with 95% confidence intervals were used to combine dichotomous data. Weighted mean differences with 95% confidence intervals were used to combine continuous data. Both fixed-effect and random-effects models were used. Statistical heterogeneity was assessed using the I 2 statistic. Publication bias was assessed using funnel plots and the Harbour-Egger method. Results of the review Seven randomised controlled trials (RCTs) were included for the review (n=429 patients); two placebo-controlled

Research paper thumbnail of Effect ofHelicobacter pyloritreatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials

Scandinavian Journal of Gastroenterology, 2012

Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of ac... more Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD. Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56-1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72-1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35-0.87, p = 0.01). Funnel plot revealed no publication bias. Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Research paper thumbnail of Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: A meta-analysis of randomized controlled trials

Saudi Journal of Gastroenterology, 2013

Upper gastrointestinal bleeding (UGIB) is a common medical emergency that accounts for more than ... more Upper gastrointestinal bleeding (UGIB) is a common medical emergency that accounts for more than 500,000 hospital admissions each year. [1] Despite advances in medical therapy, a significant mortality (5-10%) with severe upper gastrointestinal (GI) bleeding still exists. [2] Therefore, in the setting of UGIB, urgent endoscopy with adequate gastric mucosal visualization is pivotal for identification and treatment of bleeding lesions. Erythromycin, a macrolide antibiotic, facilitates the motility of the gastric antrum and duodenum by acting as a motilin receptor agonist. [3] Erythromycin, even in lower doses (70 mg), has been shown to accelerate gastric emptying. [4] Although various other modalities, including gastric lavage and metoclopramide, have been studied on gastric emptying, erythromycin may be more effective for enhancing gastric motility in UGIB. [5,6] Various studies have been done for evaluating the effectiveness of erythromycin infusion before endoscopy to improve visibility and the therapeutic potential of endoscopy; however, the results have been controversial. [7-13] In addition, three meta-analyses have been performed examining the use of prokinetics with UGIB with varying results. [14-16] To evaluate further, we performed ABSTRACT Background/Aim: Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. Methods: Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). Results: Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01). Conclusions: Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Research paper thumbnail of Immediate Versus Delayed Percutaneous Coronary Intervention for Patients with Non-ST Segment Elevation-Acute Coronary Syndrome: Meta-Analysis of Randomized Controlled Trials

Journal of the American College of Cardiology, 2011

Background: Studies indicate that an early invasive strategy is favorable over a selective invasi... more Background: Studies indicate that an early invasive strategy is favorable over a selective invasive strategy for Non-ST segment elevation acute coronary syndromes (NSTE-ACS). However, there is no general consensus on precisely how early should the revascularization be performed. Randomized controlled trials (RCTs) performed to compare the outcomes of revascularization less than 24 hours of presentation (group A) versus between 24 hours and seven days after presentation (group B) for NSTE-ACS show conflicting results. Methods: MEDLINE, PubMed and abstracts from major cardiology conferences were searched. RCTs comparing the composite of death or myocardial infarctions (MI) between group A and group B within 30 days of revascularisation were included. The effects of both methods were analyzed by calculating pooled estimates for death, MI, repeat revascularisation, bleeding and composite of death or MI. Separate analyses were performed for each outcome by using odds ratio (OR) by fixed and random effects models. Publication bias was assessed by funnel plots. All were graded by jaded score. Heterogeneity among studies was assessed by calculating I measure of inconsistency. Results: Seven studies with a total of 13,762 patients met our inclusion criteria. The incidence of the composite of death or MI was not different between group A [607/7710 (7.9%)] compared to group B [823/6052(13.6%)], (OR 0.83, 95% CI 0.62-1.10, P=0.20). Similar results were obtained for death (OR 0.58, 95% CI 0.24-1.39, P=0.22) and MI (OR 0.93, 95% CI 0.64-1.34, P=0.69) separately. In group A there was a decrease (OR 1.33 (95% CI 1.13-1.56, p=0.0004) in the incidence of repeat revascularization [405/7398(5.5%)] as compared to group B [337/5734(5.9%)]. Group A experienced lower incidence of bleeding 5.3% (293 in 5497) as compared to 6.9% (232/3376) in group B (OR-0.76, 95% CI, 0.63-0.91, P=0.003). Conclusions: Coronary artery revascularization within 24 hours of presentation does not reduce death and MI at 30 days in NSTE-ACS as compared to intervention after 24 hours. Early intervention groups had significantly lower rate of repeat revascularization and bleeding as compared to the delayed intervention group.

Research paper thumbnail of Enteral Feeding Within Three Hours After Percutaneous Endoscopic Gastrostomy Placement

Journal of Clinical Gastroenterology, 2011

Background: Traditionally, tube feedings have been delayed after gastrostomy placement to the nex... more Background: Traditionally, tube feedings have been delayed after gastrostomy placement to the next day and up to 24 hours postprocedure. However, results from various randomized clinical trials (RCTs) indicate earlier feeding may be an option. Therefore, we conducted a meta-analysis to analyze the effect of earlier feedings (r3 h) after percutaneous endoscopic gastrostomy (PEG) placement. Methods: Various medical databases and recent abstracts from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early (r3 h) versus delayed or nextday feedings after PEG placement were included. Meta-analysis was performed using pooled estimates of complications, death r72 hours, and significant increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.0 was utilized for statistical analysis. Results: Five studies (N=355) met the inclusion criteria. No significant differences were noted between early (r3 h) and delayed or next day feedings for patient complications [OR 0.78; 95% confidence interval (CI), 0.39-1.53; P=0.47], death in r72 hours (OR 0.60; 95% CI, 0.18-1.99; P=0.40), and number of significant gastric residual volume during day 1 (OR 1.46; 95% CI, 0.75-2.84; P=0.27). No publication bias and no significant heterogeneity were noted. Conclusions: Early tube feeding r3 hours after PEG placement has no significant differences to delayed or next-day feeding in respect to complications, death in r72 hours, or number of significant gastric residual volumes at day 1.

Research paper thumbnail of Tu1372 Steroid Use for Prevention of Strictures Post Endoscopic Submucosal Dissection : a Meta Analysis

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Sa1526 The Effect of Indomethacin in the Prevention of Post-ERCP Pancreatitis: a Meta-Analysis

Gastrointestinal Endoscopy, 2013

Research paper thumbnail of Accuracy of Nodal Staging in Gastroesophageal Junction Cancers By Endoscopic Ultrasound: A Meta-Analysis and Systematic Review

Gastrointestinal Endoscopy, 2009

mg midazolam and 105.6 AE 38.6 mcg fentanyl. Table 1 lists results from the Bravo pH monitoring s... more mg midazolam and 105.6 AE 38.6 mcg fentanyl. Table 1 lists results from the Bravo pH monitoring studies. Patients receiving CS (nZ128) demonstrated significantly higher DeMeester score, (pZ0.02) total % time pH!4, (pZ0.05) upright (pZ0.04) and supine % pH!4 (pZ0.05) on day #1 versus day #2. Patients without CS (nZ86) did not show significant differences in DeMeester score (pZ0.45) or any other variables between the two days. Subjects with abnormal Bravo studies who received CS (nZ82) had significantly higher DeMeester scores (p!0.01) on day #1 versus day #2. Patients with abnormal Bravo pH studies without CS and patients with normal Bravo studies regardless of the use of CS, did not show significant differences. Further analysis of the day #1 scores demonstrated significant differences between patients with and without sedation, while the day #2 scores did not differ. Conclusions: Patients who received CS at time of Bravo implantation had significantly more pathologic reflux on day #1. These effects were exaggerated in patients with abnormal Bravo studies, but were not apparent in patients without CS or in patients with normal pH studies. The implications of this study may include adjusted interpretation of Bravo pH readings when CS is used. Results of Bravo pH Monitoring with and without CS DeMeester Score Total % pH!4 Upright % pH!4

Research paper thumbnail of M1530: Early Precut Prevents Post-ERCP Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2010

Gastrointestinal Endoscopy, Volume 71, Issue 5, Pages AB246, April 2010, Authors:Abhishek Choudha... more Gastrointestinal Endoscopy, Volume 71, Issue 5, Pages AB246, April 2010, Authors:Abhishek Choudhary; Nicholas M. Szary; Murtaza Arif; Hazem T. Hammad; Ghassan M. Hammoud; Matthew L. Bechtold; Jamal A. Ibdah. Gastrointestinal ...

Research paper thumbnail of Prophylactic Octreotide for Prevention of Post-ERCP Pancreatitis: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

Background: Acute pancreatitis is a common complication of ERCP. Over the years, attempts have be... more Background: Acute pancreatitis is a common complication of ERCP. Over the years, attempts have been made to identify an agent to prevent this complication. Octreotide, an inhibitor of exocrine secretion with anti-inflammatory and cytoprotective effects, has been studied in ...

Research paper thumbnail of Early Versus Delayed Feeding After Placement of a Percutaneous Endoscopic Gastrostomy: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

This review compared early versus delayed feeding after PEG placement. It showed that early feedi... more This review compared early versus delayed feeding after PEG placement. It showed that early feeding was associated with a higher incidence of significant residual gastric volume on the first day. The review contained several methodological limitations and its conclusions do not seem to be reliable. Searching MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), DARE, HealthSTAR and CINHAL were searched up to 2006. Abstracts from conference proceedings of the Digestive Disease week and the American College of Gastroenterology National Meeting from 1993 to 2007 were handsearched. Search terms were reported. There were no apparent language restrictions. Study selection Randomised controlled trials (RCT) that compared early (≤4h) versus delayed or next-day feeding after PEG placement in adult patients (>18 years) were eligible. Death within 72 hours, complications and the incidence of significant gastric residual volumes during day one represented the outcomes for inclusion. Types of complications were not defined. Significant residual volumes was defined as it appeared in each article. Age of the participating patients ranged from 63 to 76 years. Time of early feeding ranged from less than one hour to four hours. Delayed feeding ranged from from 24 hours to next day. Significant volume definition varied from more than 60ml to 50% of the last volume administered. Length of follow-up was not described. Two authors independently selected the articles after an initial examination. It was unclear how many authors were involved in the initial selection. Assessment of study quality Studies were assessed for description and appropriateness of randomisation, blinding and dropouts using the Jadad scale. It appeared that two reviewers independently evaluated study quality. Data extraction Two authors independently extracted data in a predefined review form. Differences were resolved by consensus. The numbers of patients who experienced complications, died or had significant residual volumes were extracted to calculate odds ratios (OR). Methods of synthesis The pooled odds ratios and their corresponding 95% confidence intervals (CI) of each outcome were calculated using both fixed-effect and random-effects models. The results from the fixed-effect and random-effects models were consistent; only the random-effects model results were reported. Statistical heterogeneity was assessed using the I 2 test. An I 2 of 50% or more was considered significant. Authors stated that publication bias was assessed using a funnel plot for the outcome all complications.

Research paper thumbnail of Prophylactic Somatostatin for Prevention of Post-ERCP Pancreatitis: A Meta-Analysis

Gastrointestinal Endoscopy, 2008

Research paper thumbnail of S1448: EUS-Guided Biliary Access and Drainage (EBAD) At a Tertiary Care Center

Gastrointestinal Endoscopy, 2010

Research paper thumbnail of S1383: Split-Dose Polyethylene Glycol for Bowel Preparation Prior to Colonoscopy: A Meta-Analysis of Randomized Controlled Trials

Gastrointestinal Endoscopy, 2010

Background: Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfor... more Background: Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large volume solution may reduce patient compliance, resulting in suboptimal preparation and increased patient discomfort. In an effort to reduce such negative factors and improve overall patient tolerance and satisfaction, split-dosing of PEG was studied in various randomized controlled trials (RCTs). However, results have been conflicting. Therefore, we conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation prior to colonoscopy. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, CINAHL, PubMed, and recent abstracts from major conference proceedings were searched (10/09). RCTs on adults comparing fulldose versus split-dose of PEG for bowel preparation prior to colonoscopy were included. Standard forms were used to extract data by two independent reviewers. The effects were analyzed by calculating pooled estimates of quality of bowel preparation, compliance with the preparation, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random effects models. Publication bias was assessed by funnel plots. All randomized trials studies were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.Results: Four trials met inclusion criteria (Nϭ827) with mean age ranging from 47.8-57 years. Trials were of adequate quality (Jadad score Ն 2). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.40; 95% CI: 1.60-7.22, pϽ0.01) as compared to full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.33; 95% CI: 0.16-0.69, pϽ0.01) and nausea (OR 0.58; 95% CI: 0.39-0.84, pϽ0.01) as compared to full-dose PEG. No statistically significant differences were noted between the two groups in regards to willingness to repeat bowel preparation (pϭ0.31), abdominal cramping (pϭ0.76), abdominal bloating (pϭ0.47), vomiting (pϭ0.12), sleep disturbance (pϭ0.42), or missing school/work (pϭ0.37). Funnel plot did not reveal any publication bias. Heterogeneity was noted at times requiring the use of the random effects model. Conclusions: The use of a split-dose PEG for bowel preparation prior to colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea as compared to the full-dose PEG. Therefore, split-dose PEG appears superior to full-dose PEG for bowel preparation prior to colonoscopy.

Research paper thumbnail of Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

Gastrointestinal Endoscopy, 2011

Background: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled t... more Background: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. Objective: We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. Design: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random-or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I 2 measure of inconsistency. Setting: Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. Patients: Adult patients undergoing ERCP. Interventions: Pancreatic stent placement for the prevention of post-ERCP pancreatitis. Main Outcome Measurements: Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. Results: Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P Ͻ .01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, Ϫ309.22; 95% CI, Ϫ350.95 to Ϫ267.49; P Յ .01). Similar findings were also noted from the nonrandomized studies. Limitations: Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. Conclusions: Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.