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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: June 18, 2014
Expiration Date: June 18, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237F

Last week 505 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 225 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

In Patients With Unexplained Abdominal Pain After Cholecystectomy, Sphincterotomy Does Not Reduce Disability Due to Pain
Reference: JAMA 2014 May 28;311(20):2101 (level 1 [likely reliable] evidence)

Gallbladder disease is estimated to result in more than 1 million hospitalizations and over 700,000 operations in the United States each year (J Gastrointest Surg 2012 Nov;16(11):2011). A pooled analysis of 2 randomized trials reported that over 25% of patients having cholecystectomy have persistent pain 5 years after surgery (J Gastrointest Surg 2005 Jul-Aug;9(6):826), often with no significant abnormalities on imaging or standard laboratory tests. Patients with persistent burdensome pain may have endoscopic retrograde cholangiopancreatography (ERCP) to identify another pathology or to assess potential sphincter of Oddi dysfunction, and some of these patients may also have subsequent sphincterotomy, though this procedure has not been shown to be beneficial in the absence of abnormal imaging or lab findings. A recent randomized trial compared sphincterotomy to sham surgery in 214 adults (92% women) with unexplained abdominal pain after cholecystectomy.

The trial included patients with unexplained abdominal pain for > 3 months after cholecystectomy and no prior sphincter intervention. All patients had ERCP prior to randomization. Patients were randomized to sphincterotomy (141 patients) vs. sham surgery (73 patients) and followed for 1 year. A total of 99 patients with elevated pancreatic sphincter pressure in sphincterotomy group were further randomized to biliary (single) sphincterotomy vs. biliary and pancreatic (dual) sphincterotomy. Treatment success was defined as < 6 days of disability due to pain without narcotic use or further sphincter intervention for 3 months.

The rate of treatment success at 1 year was 23% with sphincterotomy vs. 37% with sham (p = 0.01). There were no significant differences between sphincterotomy and sham groups in need for repeat ERCP intervention (37% vs. 25%) or rate of pancreatitis (11% vs. 15%). In addition, there were no significant differences in treatment success comparing single vs. dual sphincterotomy in the subgroup of patients with elevated pancreatic sphincter pressure.

The management of unexplained postcholecystectomy pain can be frustrating for both the patient and their physicians, and data supporting current diagnostic options or treatment approaches are limited. The findings of this trial show that sphincterotomy does not reduce pain-related disability in patients with unexplained abdominal pain after cholecystectomy. About 12% of patients overall had pancreatitis following ERCP, consistent with previous data suggesting increased risk of both pancreatitis and perforation with this procedure (N Engl J Med 1996 Sep 26;335(13):909 full-text). Given the potential risks involved with sphincterotomy, its use in this patient population for the management of unexplained pain is not warranted.

For more information see the Cholecystectomy topic in DynaMed.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

For more information and technical support, visit the PEMSoft Mobile Access page. To view the official press release, click here.

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.