American family physician
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Acute pancreatitis is the most common gastrointestinal-related reason for hospitalization in the United States. It is diagnosed based on the revised Atlanta classification, with the presence of at least two of three criteria (upper abdominal pain, serum amylase or lipase level greater than three times the upper limit of normal, or characteristic findings on imaging studies). Although computed tomography and other imaging studies can be useful to assess severity or if the diagnosis is uncertain, imaging is not required to diagnose acute pancreatitis. ⋯ If oral feedings are not tolerated, nasogastric or nasojejunal feedings are preferred over parenteral nutrition. Cholecystectomy is recommended during the initial admission for patients with mild acute biliary pancreatitis. Medical management is usually sufficient for necrotizing pancreatitis; however, if surgical intervention is needed, a minimally invasive approach is advised over direct endoscopic or open surgical debridement (necrosectomy) because of lower complication rates.
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This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. ⋯ In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.
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Celiac disease is an immune-mediated, multisystem disorder that affects genetically susceptible individuals who are exposed to gluten-containing grains such as wheat, barley, and rye. The condition can develop at any age. Celiac disease presents with a variety of manifestations such as diarrhea, weight loss, abdominal pain, bloating, malabsorption, and failure to thrive. ⋯ A gluten-free diet for life is the primary treatment, and patients may benefit from support groups and education on common and hidden sources of gluten, gluten-free substitutes, food labeling, balanced meal planning, dining out, dining during travel, and avoiding cross-contamination. Patients with celiac disease who do not respond to a gluten-free diet should have the accuracy of the diagnosis confirmed, have their diet reassessed, and be evaluated for coexisting conditions. Patients with refractory celiac disease should be treated by a gastroenterologist.
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Comprehensive urinalysis involves inspection of the urine, dipstick chemical analysis, and microscopy and can be performed in the office setting. When testing for urinary tract infection, midstream urine should be collected using the clean-catch technique. A urine collection bag specimen can be used for clinically stable febrile infants with suspected urinary tract infection; however, the presence of leukocyte esterase or nitrites warrants more invasive urine collection. ⋯ In patients with symptoms of a urinary tract infection, the presence of nitrites is more specific for bacterial infection, and a positive leukocyte esterase result may occur from inflammation and infection. Asymptomatic bacteriuria is often unnecessarily treated in older patients. Without symptoms of urinary tract infection, urine culture is useful only in pregnancy and preparation for endoscopic urologic procedures.
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Acute diarrheal disease accounts for 179 million outpatient visits annually in the United States. Diarrhea can be categorized as inflammatory or noninflammatory, and both types have infectious and noninfectious causes. Infectious noninflammatory diarrhea is often viral in etiology and is the most common presentation; however, bacterial causes are also common and may be related to travel or foodborne illness. ⋯ Empiric antibiotics are rarely warranted, except in sepsis and some cases of travelers' or inflammatory diarrhea. Targeted antibiotic therapy may be appropriate following microbiologic stool assessment. Hand hygiene, personal protective equipment, and food and water safety measures are integral to preventing infectious diarrheal illnesses.