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Research by Andrew Meltzer, MD, Focuses on Improving Diagnostic Testing for Patients in the Emergency Department with Gastrointestinal Emergencies

Two studies published by Andrew Meltzer, MD, associate professor of emergency medicine at the George Washington University School of Medicine and Health Sciences, focus on improving physicians’ abilities to perform rapid diagnostics for patients who present to the emergency department (ED) with abdominal disorders.

The most recent study, published in the American Journal of Emergency Medicine in February, addresses the differences between patients who present at the ED with first-time acute pancreatitis and those who present with recurrent acute pancreatitis.

In reviewing charts, treatment course, and CAT scans of patients, Meltzer said he and fellow researchers noticed that patients with recurrent acute pancreatitis had more significant findings on their CAT scans.

“Basically, the disease appeared more severe in patients with recurrent acute pancreatitis,” he said. “That would make sense, because the first time there’s cumulative damage with recurrent episodes and as it keeps happening you’re seeing more and more damage to your pancreas and secondary signs of inflammation.”

He said they also found that patients with recurrent pancreatitis needed more pain medication.

However, he added, despite more significant findings on CAT scans and a greater requirement for pain medication, the patients who presented with first time acute pancreatitis were more likely to require intensive care.

“It makes us think the patients who present with this disease the first time are sicker, while the patients with the reoccurring episodes present more for pain management and due to the chronic changes associated with this disease,” he said.

With these findings, he added, it’s a reminder that when patients present for the first time, it’s important to eliminate any modifiable risk factor to prevent the disease from progressing to a more chronic state. He said they want to learn more about how to best manage early stages of acute pancreatitis in the emergency department, including optimal fluid requirements and the yield of an early abdominal CAT scan to risk stratify disease.

Another study, focusing on infectious diarrhea in ED, also was published by Meltzer late last year in the American Journal of Emergency Medicine.

Through the study, Meltzer said he wanted to look at diagnostic testing of diarrhea in the ED, because often the condition is caused by a virus and not a more serious bacteria like salmonella or E.coli.

“Because of the likelihood of a viral disease we don’t do much testing in the ED. In addition, the standard is stool cultures which take about two days to come back and does not change ED management,” he explained. “Therefore, we often have to make a decision how to manage infectious gastroenteritis without a whole lot of information.”

However, in the last couple years new diagnostic tests have been created that enable physicians to determine whether the disease is caused by a virus or a bacteria much more quickly. “We were interested as a first study to see how this novel test is being used, how the patients who were getting this test differed from the people who weren’t getting it, and what infectious etiologies are showing up when we do the test,” he said.

What they found was that patients who were getting the rapid tests were sicker than the patients who weren’t getting it, and they were more likely to have recently traveled and more likely to have bloody diarrhea.

In addition, in 66 percent of patients who had the test, the reason for the diarrhea was able to quickly be identified.

“We found a high rate of bacterial diarrhea in patients in whom the clinician decided to do the rapid test, we saw that the test was not being used indiscriminately but being used in sicker patients, and we found that we were more likely to give antibiotics to patients who took the test,” he summarized.

Now as a follow up study, Meltzer said he is looking at patients who come in with infectious gastro enteritis or infectious diarrhea, and randomizing them into two study groups: one that receives the rapid diagnostic test, and one that receives the traditional diagnostic tests.

“Then we’re going to look at the two groups to determine if there’s a difference in antibiotic utilization and if there’s a difference in symptom improvement. We’ll check in with the patients two days, seven days, and 30 days after their ED visit to see whether or not they actually get better quicker because we know what we’re treating,” he said.

The first paper, “Assessing the CT findings and clinical course of ED patients with first-time versus recurrent acute pancreatitis,” is available at www.ncbi.nlm.nih.gov/pubmed/30471931.

The second paper, “Multiplex polymerase chain reaction test to diagnose infectious diarrhea in the emergency department,” is available at www.ncbi.nlm.nih.gov/pubmed/30587396.