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The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where SIJ is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, when the SIJ might be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the SIJ(s)-a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this Perspective article argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models with contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes., (© 2019 American Physical Therapy Association.)

Background & Aims: The role of sphincter of Oddi manometry (SOM) in the management of patients with idiopathic recurrent acute pancreatitis requires clarification. We evaluated the therapeutic effects of endoscopic sphincterotomy in patients with recurrent acute pancreatitis and the prognostic significance of pancreatic sphincter dysfunction (SOD)., Methods: We performed a randomized trial of endoscopic retrograde cholangiopancreatography with SOM for patients with idiopathic recurrent acute pancreatitis. Patients with pancreatic SOD (n = 69) were assigned randomly to groups that received only biliary sphincterotomy (BES) or a combination of biliary and pancreatic sphincterotomy (DES); patients who underwent normal SOM (n = 20) were assigned randomly to groups that received BES or a sham surgery. The primary outcome was incidence of recurrent acute pancreatitis during the follow-up period (minimum, 1 year; maximum, 10 years). We also determined the incidence of chronic pancreatitis and analyzed factors associated with recurrence of acute pancreatitis., Results: Among the 69 patients with SOD, 48.5% who received BES and 47.2% who received DES had recurrent acute pancreatitis (95% confidence interval, -22.3 to 24.9; P = 1.0). In patients with normal SOM (n = 20), 27.3% of those who received BES and 11.1% of those who received the sham surgery had recurrent acute pancreatitis (95% confidence interval, -49.5 to 17.2; P = .59). Overall, 16.9% of subjects developed chronic pancreatitis during a median follow-up period of 78 months (interquartile range, 35-108 mo). The odds of recurrent acute pancreatitis during follow-up evaluation were significantly greater among patients with SOD than those with normal SOM (unadjusted hazard ratio, 3.5; 95% confidence interval, 1.07-11.4; P < .04), and remained so after adjusting for potential confounders (hazard ratio, 4.3; 95% confidence interval, 1.3-14.5; P < .02)., Conclusions: Among patients with pancreatic SOD, DES and BES have similar effects in preventing recurrence of acute pancreatitis. Pancreatic SOD is an independent prognostic factor, identifying patients at higher risk for recurrent acute pancreatitis., Clinical Trials Registration: Clinicaltrials.gov (NCT01583517)., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Many advances have been made in pancreatobiliary imaging and endoscopy techniques. However, little is known about trends in use of endoscopic retrograde cholangiopancreatography (ERCP)., Methods: We performed a retrospective cohort study that analyzed data from 33,596 ERCPs performed at Indiana University Medical Center from 1994 to 2009. Data from all patients were entered into an endoscopy database. We compared changes in patient demographics, indications for ERCP, and utilization of specific ERCP therapies during this time period., Results: The annual volume of ECRP increased steadily from 1175 in 1994 to 2802 in 2009 (P < .0001). Of all patients, 33.9% had previously undergone an ERCP at a different facility; 42.3% of these were unsuccessful. The odds of having undergone a failed ERCP at another facility increased slightly each year (odds ratio, 1.02; P < .001). Among patients who had a failed ERCP elsewhere, the success rate at Indiana University Medical Center was 96.1%. The frequency of patients with American Society of Anesthesiologists class ≥3 (odds ratio, 1.12; P < .001) who received anesthesia-administered sedation increased each year (odds ratio, 1.25; P < .001). Most ERCPs were performed for common bile duct stones or strictures and suspected sphincter of Oddi dysfunction (77.2%). The most rapid increase was among procedures for common bile duct strictures or leaks, pancreatic duct stones or strictures, and suspected sphincter of Oddi dysfunction. Rates of biliary sphincterotomy did not change (P = .252), but the frequency of pancreatic sphincterotomy, common bile duct, or pancreatic duct stent placement and pancreatic duct stricture dilation increased during this time (P < .001 for each)., Conclusions: At a referral center, ERCP has become increasingly complex. From 1994 to 2009, increasing numbers of ERCPs have been performed for patients with more comorbidities, higher-grade disease, history of failed ERCPs, and on those receiving endotherapy., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To quantitate disease-specific hospital-based medical costs in 34 patients with chronic pancreatitis before and after treatment by either duodenal-preserving pancreatic head resection (DPPHR) or pylorus-preserving pancreaticoduodenectomy (PPPD)., Summary Background Data: Pancreatic head resection in selected patients with chronic pancreatitis provides pain relief and improves quality of life, but the effect on healthcare costs is unknown., Methods: This observational cohort study comprised 34 selected patients with chronic pancreatitis followed up exclusively at the authors' institution treated by either DPPHR or PPPD between 1992 and 1997., Results: Twenty-one patients had DPPHR and 13 had PPPD. Patients in the PPPD group were slightly older, but other clinical characteristics were similar. Before surgery, the mean number of admissions per patient per year, days in the hospital per patient per year, and disease-specific hospital-based medical costs per patient per year were not significantly different between groups. After surgery, those three variables were similar between the groups but significantly less than preoperative values. Pain control remained significantly improved after 36 months of follow-up., Conclusions: In selected patients with chronic pancreatitis, DPPHR and PPPD are equally effective in providing long-term pain relief and decreasing disease-specific hospital-based costs.

Background and Purpose: Controversy exists around exercises and clinical tests that attempt to differentially activate the upper or lower portions of the rectus abdominis muscle. The purpose of this study was to assess the activation of the upper and lower portions of the rectus abdominis muscle during a variety of abdominal muscle contractions., Subjects: Subjects (N = 11) were selected from a university population for athletic ability and low subcutaneous fat to optimize electromyographic (EMG) signal collection., Methods: Controlling for spine curvature, range of motion, and posture (and, therefore, muscle length), EMG activity of the external oblique muscle and upper and lower portions of rectus abdominis muscle was measured during the isometric portion of curl-ups, abdominal muscle lifts, leg raises, and restricted or attempted leg raises and curl-ups. A one-way repeated-measures analysis of variance was used to test for differences in activity between exercises in the external oblique and rectus abdominis muscles as well as between the portions of the rectus abdominis muscle., Results: No differences in muscle activity were found between the upper and lower portions of the rectus abdominis muscle within and between exercises. External oblique muscle activity, however, showed differences between exercises., Discussion and Conclusion: Normalizing the EMG signal led the authors to believe that the differences between the portions of the rectus abdominis muscle are small and may lack clinical or therapeutic relevance.

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis or pancreatic-type pain. Endoscopic manometry as performed at endoscopic retrograde cholangiography is the most commonly used method to identify sphincter dysfunction. Noninvasive testing, such as secretin-stimulated ultrasound analysis of duct diameter, is less reliable and of relatively low sensitivity. Two-thirds of patients with sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. Patients with suspected or documented sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but warrant evaluation of their pancreatic sphincter if symptoms persist after therapy. Whether such pancreatic and biliary sphincters should be treated at the first treatment session is controversial. Pancreatic sphincterotomy is associated with a complication rate very similar to that of biliary sphincterotomy except that the pancreatitis rate is two- to fourfold higher. Prophylactic pancreatic stenting diminishes such pancreatitis by approximately 50%.

Objective: To provide current information on the risks of endoscopic sphincterotomy for stone., Summary Background Data: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients., Methods: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria., Results: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm., Conclusion: Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Background & Aims: Cost-effectiveness of colorectal cancer screening will be maximized by selecting the widest screening intervals that effectively prevent cancer mortality. However, data on the incidence of neoplasia in persons with no abnormal findings on initial examination are limited. The aim of this study was to describe the incidence of colonic neoplasia 5 years after negative screening colonoscopy in asymptomatic average-risk persons., Methods: We previously reported the results of screening colonoscopy in 496 asymptomatic average-risk persons, 368 of whom had no neoplasia identified. Colonoscopy to the cecum was performed in 154 of these persons at a mean of 66 months after the initial negative colonoscopy., Results: Forty-one (27%) had at least one adenoma, but only 1 person had an adenoma > or = 1 cm and none had cancer, severe dysplasia, or villous or tubulovillous histology. Hyperplastic polyps at the initial examination did not predict incident adenomas. Regular nonsteroidal anti-inflammatory drug use was associated with a decreased rate of incident adenomas., Conclusions: In average-risk persons, the interval between screening examinations can be safely expanded beyond 5 years, provided the initial examination is a carefully performed complete colonoscopy that is negative for colonic adenomas or cancer.

Choledochal cysts have generally been described to communicate with the biliary system. We recently saw three adult patients in whom we could not demonstrate biliary communication between the cyst and the biliary tree, despite a carefully performed endoscopic cholangiopancreatography (ERCP). These cases may represent a variant of type II choledochal cysts. During the 5-year period of review of ERCP records, 30 choledochal cysts were diagnosed, of which 3 (10%) were the noncommunicating cases described in this report.

Background/aims: The American Cancer Society recommends that asymptomatic persons aged > or = 50 years undergo sigmoidoscopy every 3-5 years. However, the yield of a second examination 3 years later in persons who are initially negative is unknown. The aim of this study was to determine the yield of a second flexible sigmoidoscopy in average-risk persons aged > or = 50 years after an initial negative examination., Methods: Two hundred fifty-nine asymptomatic, average-risk persons who had undergone a negative screening flexible sigmoidoscopy examination at age > or = 50 years underwent a second examination at least 2 years later (mean, 3.4 years)., Results: The second examination found adenomas in 15 (6%) screenees, but no cancers or large (> 1 cm) or severely dysplastic adenomas were detected. Persons aged > or = 60 years at the time of the second examination were more likely (10%) to have adenomas than those < 60 years (3%) (odds ratio, 3.76; 95% confidence interval, 1.17-12.2), but no advanced lesions were found in persons aged > or = 60 years., Conclusions: These data suggest that the American Cancer Society should consider changing its recommendation for screening flexible sigmoidoscopy in asymptomatic, average-risk persons to 5-year intervals after a negative examination.

The significance of distal colonic hyperplastic polyps was investigated in 482 asymptomatic average-risk subjects, aged 50-75 years, in whom fecal occult blood test results were negative and who underwent screening colonoscopy. The incidence of adenomas in the colon proximal to the sigmoid-descending colon junction in subjects with hyperplastic polyps distal to that point was 18% and was similar to the incidence of proximal colonic adenomas in subjects with no distal colonic polyps (15%). The incidence of proximal colonic adenomas in subjects with no distal colonic adenomas was 38% and was significantly greater than the incidence found in individuals with no distal colonic polyps or only hyperplastic polyps. Our data do not support distal colonic hyperplastic polyps as markers for proximal colonic adenomas in asymptomatic average-risk subjects.

Mostly retrospective series with limited use of sphincter of Oddi manometry have indicated that early complications are more common when endoscopic sphincterotomy is performed for sphincter of Oddi dysfunction than for common duct stones. The current study was undertaken to prospectively evaluate the frequency and type of complications of endoscopic sphincterotomy performed for sphincter of Oddi dysfunction compared with endoscopic sphincterotomy performed for other conditions. Four hundred twenty-three patients underwent sphincterotomy for sphincter of Oddi dysfunction (166), common duct stone(s) (163), tumor (60), and miscellaneous reasons (34). Patients were observed in the hospital for at least 24 hours after the procedure, and 30-day follow-up data were obtained. The overall complication rate was 6.9%, but complications were more frequent when sphincterotomy was performed for sphincter of Oddi dysfunction than for all other indications (10.8% vs. 4.3%; P = 0.009). Precut sphincterotomy was more frequently required in the sphincter of Oddi dysfunction group (21.1% vs. 11.7%, P = 0.009) but was no more likely to result in a complication (6.2%) than standard sphincterotomy. The risk of a complication was considerable for a small-diameter common bile duct (less than or equal to 5 mm), particularly when sphincterotomy was performed for sphincter of Oddi dysfunction (37.5%). The overall 30-day mortality rate was 1.7%, but the procedure-related mortality rate was believed to be 0.2%. It is concluded that endoscopic sphincterotomy for sphincter of Oddi dysfunction is more hazardous than for other conditions, particularly when a small common bile duct is present.

Colonoscopy was performed on 210 asymptomatic average-risk persons, aged 50-75 years, who had negative fecal occult blood test results. Colonoscopy was complete to the cecum in 209 subjects. Fifty-three subjects (25%) had adenomas and two had cancer. All of the adenomas greater than or equal to 1 cm in size and both cancers occurred in subjects aged greater than or equal to 60 years. Fifty-one percent of subjects with adenomas and one with cancer had no neoplasms distal to the sigmoid-descending colon junction. One subject had a major postpolypectomy hemorrhage that stopped spontaneously. Screening colonoscopy, therefore, has a high yield for detection of neoplasms in asymptomatic average-risk persons aged greater than or equal to 60 years with negative fecal occult blood test results. The yield is low in persons aged 50-54 years and intermediate in persons aged 55-59 years.

Vehicle license plate numbers and the shoulder belt use of front-seat occupants were recorded unobtrusively when parents delivered and picked up their children at a Montessori school during 5-day baseline, intervention, and follow-up phases. Practicing and presenting a 15-min safety belt skit increased the safety belt use of those 6 kindergarten children who were not consistent belt users 82% above their preintervention baseline belt use mean of 47%. The belt use of these children's parents (who watched the skit) increased to 56% above their baseline mean of 36%. Also, mean safety belt use of 11 primary school children who watched the skit increased to 70% above their baseline of 28%. Mean safety belt use of the older children's parents (who didn't watch the skit) remained at approximately 31% for each phase, regardless of whether children were vehicle occupants. The follow-up observations, taken 3 months after the intervention, revealed 60% belt use for the kindergartners, 48% for the primary school children, and 71% for the kindergartners' parents when the children were vehicle occupants but only 30% when the parents were driving alone.

A randomized, controlled trial was performed to compare the diagnostic yields and cost-effectiveness of two strategies for the evaluation of nonemergent lower gastrointestinal bleeding. Three hundred eighty patients aged greater than or equal to 40 yr were randomized to undergo initial flexible sigmoidoscopy plus air contrast barium enema or colonoscopy; 332 completed the initial studies. Initial colonoscopy detected more cases of polyps less than 9 mm in size, adenomas, and arteriovenous malformations but fewer cases of diverticulosis. No significant difference was found between strategies in the number of patients detected with cancers or polyps greater than or equal to 9 mm in size. In both strategies, cancers were more common in subjects aged greater than or equal to 55 yr (8% overall) than in those aged less than 55 yr (1%). Among patients aged less than 55 yr with suspected lower gastrointestinal bleeding, initial flexible sigmoidoscopy plus air contrast barium enema is a more cost-effective strategy for the detection of colonic neoplasms than initial colonoscopy. However, initial colonoscopy is more cost effective for those aged greater than or equal to 55 yr.

The anatomical extent of fiberoptic sigmoidoscopy was determined by placing a clip on the colonic mucosa and subsequently locating the clip on barium enema. A 60 cm exam viewed the entire sigmoid colon in 81% of patients. Exams of 50-55 cm, 40-45 cm, and 30-35 cm extent viewed the entire sigmoid colon in 68%, 27%, and 13%, respectively. The 50-55 cm and 60 cm exams collectively viewed 90% and 95% of the sigmoid colon surface, respectively. The 30-35 cm and 40-45 cm exams collectively viewed 53% and 70% of the sigmoid colon surface respectively. The anatomical extent of fiberoptic sigmoidoscopy clearly exceeds that of rigid sigmoidoscopy. These data help to define the diagnostic potential of fiberoptic sigmoidoscopy.