Colorectal Cancer Screening / Diverticulitis / Post-TIPS Hepatic Encephalopathy / Decompensated Cirrhosis / AKI

Educational Objectives

After hearing and assimilating this program, the listener will be better able to: 

1. Increase his/her basic knowledge of important advances in medicine.
2. Identify a broad range of clinical research reported in the medical literature.
3. Synthesize research findings through one-on-one interviews with authors, editorialists, or experts in the field.
4. Integrate new treatments reviewed in the summaries into current practice.
5. Challenge oneself with thoughtful, clinically relevant questions.

Summary

Summary Narrators

Carole Wyand

Tom Linden, MD
Professor of Medical Journalism
University of North Carolina, Chapel Hill

EFFECT OF SCREENING WITH FIT ON COLORECTAL CANCER OUTCOMES

Several countries around the world, and some healthcare organizations in the U.S., employ fecal immunochemical testing (commonly known by its acronym, FIT); FIT can be used for large-scale screening for colorectal cancer. In a study on the website of Gut (https://doi.org/10.1136/gutjnl-2020-322545), researchers in Taiwan report the incidence of advanced-stage colorectal cancer (stage II or higher) and colorectal cancer-related mortality among 3 million patients between the ages of 50 and 69 who underwent FIT screening (offered biennially) from 2004 to 2009 and were followed through 2014. About half of the patients underwent 2 or more screenings.

Compared with 2.3 million similar patients who weren’t screened, the screened patients had a lower incidence of advanced-stage colorectal cancer (48 vs. 76 per 100,000 person-years) and lower colorectal cancer-related mortality (20 vs. 41 per 100,000 person-years). Plus, when evaluated according to anatomical site, the differences in advanced colorectal cancer incidence and mortality were more pronounced for distal colorectal cancer than for proximal cancer.

In the U.S., most colorectal cancer screening is opportunistic, but organized screening increases participation rates while effectively lowering the incidence of colorectal cancer and colorectal cancer-related mortality (www.jwatch.org/na47210). The American College of Physicians recently endorsed biennial FIT as a screening option for colorectal cancer (www.jwatch.org/na50251). The present study provides clinicians with numerical estimates of anticipated benefit to share with patients about colorectal cancer prevention.

Charles J. Kahi, MD, MS

GUIDELINE WATCH: MANAGING ACUTE DIVERTICULITIS

The last time the American Gastroenterological Association published a guideline on managing acute diverticulitis was in 2015 (https://doi.org/10.1053/j.gastro.2015.10.003). Now, in the February 2021 issue of Gastroenterology (https://doi.org/10.1053/j.gastro.2020.09.059), the American Gastroenterological Association has provided an update that outlines 14 “best practices.”

Key Recommendations

• Computed tomography (CT) scans should be considered when diverticulitis is suspected, because alternate diagnoses are identified in about half of cases.
• Antibiotics should be used “selectively rather than routinely” for mild cases of diverticulitis. The indications for antibiotic use in uncomplicated diverticulitis include the presence of comorbidities or immunosuppression, a C-reactive protein level greater than 140 mg/L, a white blood cell count greater than 15,000/mm3, the presence of fluid collection, or a long segment of inflammation on imaging.
• When symptoms persist after an episode of acute diverticulitis, a CT scan and colonoscopy are recommended to exclude ongoing inflammation. (But the authors acknowledge that most chronic symptoms are likely related to visceral hypersensitivity.)
• • Clinicians should not recommend segmental colectomy based solely on the number of diverticulitis episodes a patient has experienced. Rather, decisions regarding colectomy should reflect the individual patient’s disease severity, the operative risks and benefits, and values and preferences.
• Measures to prevent recurrence include a high-quality diet (for example, high-fiber or vegetarian), regular physical activity, achieving a normal body-mass index, not smoking, and avoiding nonsteroidal anti-inflammatory drugs (except aspirin for secondary cardiovascular disease prevention). A “low-roughage diet” does not lower the risk for recurrence.
• No medications are proven to lower the risk for recurrence.

This clinical practice update, which is similar to past guidelines from the American Gastroenterological Association, reflects a continued shift toward individualized, patient-centered decision-making in managing acute diverticulitis. The authors more forcefully question resection for patients with recurrent diverticulitis and provide criteria for antibiotic use in mild diverticulitis. But clinicians are often slow to adopt new recommendations: The rates of elective colectomy after acute diverticulitis continue to increase (https://www.jwatch.org/na49929), and antibiotics are still widely used for mild cases.

Molly S. Brett, MD

ORAL ANTIBIOTICS FOR OUTPATIENT DIVERTICULITIS

Traditionally, clinicians have used either metronidazole plus a quinolone or amoxicillin-clavulanate for managing diverticulitis in outpatients, but no strong evidence favors one regimen over the other. Now that many experts suggest avoiding quinolones, researchers took a careful look at the outcomes associated with each choice. Details appear on the website of the Annals of Internal Medicine (https://doi.org/10.7326/M20-6315).

An analysis of two large insurance databases showed that, of 140,000 immunocompetent adults with uncomplicated diverticulitis who were treated with either antibiotic regimen between 2001 and 2018, the vast majority (89%) got metronidazole plus a quinolone. The incidence of subsequent diverticulitis-related emergency department visits, and the rates of any hospital admission, urgent surgery, or elective surgery in the next 3 years, were similar in the two groups. The rates of subsequent Clostridioides difficile infection were also similar in younger adults. But in patients 65 or older, the quinolone combination was associated with a significantly higher risk for C. difficile infection (1.2% vs. 0.6%). The nature of the data didn’t allow for conclusions about liver toxicity (which is possible with either regimen). Interestingly, the data showed no evidence that the quinolone regimen became any less popular over the duration of the study.

Recent data (www.jwatch.org/na51524) and a 2021 guideline from the American Gastroenterological Association (www.jwatch.org/na53266) tell clinicians that antibiotics aren’t usually necessary for managing uncomplicated diverticulitis in immunocompetent patients. If they are needed, amoxicillin-clavulanate performs well and avoids the spectrum of quinolone-associated toxicities.

Abigail Zuger, MD

RIFAXIMIN PREVENTS POST-TIPS HEPATIC ENCEPHALOPATHY

Transjugular intrahepatic portosystemic shunt procedures (known by the acronym TIPS) are necessary for some patients with cirrhosis who have developed intractable ascites or bleeding gastric varices, but TIPS is complicated by post-TIPS hepatic encephalopathy (HE) in as many as half of patients. No prophylactic interventions have been shown to prevent postprocedural hepatic encephalopathy. So in a study on the website of the Annals of Internal Medicine (https://doi.org/10.7326/M20-0202), researchers in France randomized nearly 200 patients with cirrhosis (most were alcohol-induced) and undergoing TIPS to either rifaximin or placebo, starting 2 weeks before their procedures and continuing for 6 months.

Overt hepatic encephalopathy — which was defined as grade 2 or higher by West Haven modified criteria (https://www.mdcalc.com/hepatic-encephalopathy-grades-stages) or isolated asterixis — was seen significantly less often in the rifaximin group (34% vs. 53%; number needed to treat, 6). In a subgroup of 24 patients who had hepatic encephalopathy before they enrolled in the trial, post-TIPS hepatic encephalopathy developed in a third of the rifaximin patients and in 80% of the placebo patients (that’s not a statistically significant difference), but the study wasn’t powered to detect subgroup differences.

Unfortunately, these researchers classified isolated asterixis as grade 2 hepatic encephalopathy (although it isn’t clear if that finding in isolation is clinically relevant), but the incidence of higher-grade hepatic encephalopathy (i.e., grades 3 and 4) was also lower with rifaximin. Because hepatic encephalopathy is a morbid complication of transjugular intrahepatic portosystemic shunts, rifaximin should probably be started before the procedure in patients with alcoholic cirrhosis (and possibly other etiologies of cirrhosis), acknowledging that the drug’s high cost — especially for a 6-month course — might be prohibitive.

Daniel D. Dressler, MD, MSc, MHM, FACP

SHOULD PATIENTS HOSPITALIZED FOR DECOMPENSATED CIRRHOSIS GET IV ALBUMIN?

Guidelines recommend intravenous (IV) albumin for patients with cirrhosis after large-volume paracentesis and for patients with spontaneous bacterial peritonitis or hepatorenal syndrome (https://doi.org/10.1002/hep.26359). In vitro studies have suggested that albumin’s anti-inflammatory effects might ameliorate inflammation, infection, or kidney injury in patients with cirrhosis. In a study in the March 4, 2021 New England Journal of Medicine (https://doi.org/10.1056/NEJMoa2022166), researchers in the United Kingdom randomized nearly 800 patients with serum albumin levels lower than 3 g/dL who were admitted for decompensated cirrhosis (i.e., new or worsening ascites, encephalopathy, or variceal bleeding) to either standard care or IV albumin infusions every day (a targeted 20% human albumin solution of 100 to 400 mL/day; titrated, based on serum albumin level, to a goal of 3.5 g/dL, for as long as 14 days or until hospital discharge).

In an intent-to-treat analysis, the researchers found no significant difference between the albumin group and the standard-care group for the composite endpoint of infection, kidney dysfunction, or inpatient death (30% in each group); plus, the researchers found no differences in individual outcomes within the composite endpoint. Mortality at 1, 3, and 6 months was similar in the two groups, but more albumin patients developed pulmonary edema or fluid overload (6% vs. 2%).

Most of the patients in this study had alcohol as the etiology of cirrhosis, leaving open the question of whether these results apply to cirrhosis from other etiologies. Even so, the findings clearly show that IV albumin infusion — which is a very high–cost intervention — has no benefit in patients with decompensated cirrhosis and shouldn’t be used outside of other guideline recommendations.

Daniel D. Dressler, MD, MSc, MHM, FACP

HEALTH RECORD–BASED ALERT TO IMPROVE RECOGNITION OF AKI IN HOSPITALIZED PATIENTS

Acute kidney injury in hospitalized patients is associated with poor outcomes, but it’s often unrecognized. In a multicenter U.S. study on the website of The BMJ (https://doi.org/10.1136/bmj.m4786), researchers randomized more than 6000 adult inpatients with acute kidney injury (as defined by the Kidney Disease: Improving Global Outcomes creatinine criteria; https://kdigo.org/guidelines/acute-kidney-injury/) either to an electronic health record–based “pop-up” provider alert for acute kidney injury or to usual care. The pop-up included an associated acute kidney injury order set with options for kidney imaging as well as blood and urine testing.

There were no differences between the two groups in the composite outcome (which was the progression of acute kidney injury, getting dialysis, or death within 2 weeks of randomization). Intravenous (IV) fluids and urinalysis were ordered more often in the pop-up alert group, suggesting that the alerts were noticed by the providers, but the magnitude of these changes was relatively small. When nonteaching hospitals were analyzed separately, the patients in the alert group had a significantly higher risk for death.

The electronic health record-based pop-up alert described in this study provided no benefit and possibly led to patient harm. Given the heterogeneity of acute kidney injury, alerts might prompt providers to take unnecessary action that they would have otherwise avoided.

Andrew S. Parsons, MD, MPH

Readings

Disclosures

The planning committee members reported that they had nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

JW320703

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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