Boudewijn De Waele

Endoscopic Volume Adjustment of Intragastric Balloons for Intolerance

Background: A new type of saline-filled, sphericalshaped balloon, which moves freely within the stomach, has been increasingly used as a tool to assist weight reduction. Balloon intolerance is an infrequent complication, characterized by continuous nausea and vomiting or abdominal pain, uncontrollable by medical therapy. This has usually been followed by puncture, deflation and extraction of the balloon. Methods and Results: We present 4 patients in whom intolerance was treated by endoscopic volume adjustment of the device. After partial defilling of the balloon, epigastric symptoms disappeared rapidly, while the patients respectively lost 5.2, 14.4, 5.9 and 15.8 kg of body weight at the end of the treatment. Practical recommendations are provided to ensure a successful endoscopic reintubation of the balloons valve. Conclusion: Early intolerance to an intragastric balloon can be successfully treated by endoscopic volume adjustment of the device.

Colonic Ischemia and Perforation Associated With Enteral Feeding Through an Ileal Tube

Reported complications of enteral feeding through a jejunostomy include diarrhea, intraperitoneal leaks, bowel obstruction, fistula formation, wound infection, tube occlusion, and other mechanical malfunctions. However, the incidence of these complications is very low, and many physicians prefer to feed their patients by means of a jejunal tube instead of parenteral nutrition. A potentially lethal complication is ischemia of the bowel distal to the site of insertion of the feeding catheter. The described cases of bowel ischemia secondary to enteral nutrition invariably occurred at the level of the jejunum. This report describes an unusual case of perforation of the colon in a patient fed through an erroneously placed feeding catheter in the distal ileum, just proximal to the ileocecal valve. After weeks of continuous and intractable diarrhea and progressive weight loss, the patient developed diffuse colonic ischemia with subsequent free perforation of the left colon and peritonitis. Surgical treatment consisted of placement of a new feeding tube in the proximal jejunum and removal of the old one together with a short segment of small bowel, left hemicolectomy, and end colostomy. The patient tolerated the procedure well, the tube feedings were gradually restarted, and at the 6-month postoperative visit gastrointestinal function was normal. This case illustrates possible complications of an inadvertently placed feeding tube. Not only may it cause unexplained diarrhea and undernutrition, but it may lead to more serious events like colonic ischemia and perforation.

Biliary tract infection in patients with acute biliary pancreatitis.

BACKGROUND The presence of infective microorganisms in the bilio-pancreatic tract is believed to be important in both the onset and outcome of acute biliary pancreatitis. In this study, the characteristics of bile colonization or infection in human pancreatitis were investigated in order to optimize prophylactic antibiotic therapy. METHODS In 174 patients, 22 clinical and biological factors were recorded prospectively on admission and compared with the bacteriological findings at the time of surgery. RESULTS There was a significant difference between patients with negative or positive bile cultures in six parameters: Age (57.7 +/- 1.7 vs. 68.5 +/- 1.5 years, p < 0.001), serum concentrations of glucose (132 +/- 4 vs. 149 +/- 6 mg/dL, p < 0.02) and alanine aminotransferase (ALT) (304 +/- 28 vs. 226 +/- 25 IU/L, p < 0.05) and hematocrit (43.4 +/- 0.4% vs. 41.7 +/- 0.5%, p < 0.05), Glasgow pancreatitis score (1.58 +/- 0.11 vs. 1.97 +/- 0.10, p < 0.01) and APACHE II score (6.20 +/- 0.38 vs. 7.82 +/- 0.35, p < 0.005). The prediction of the presence of bacteria in bile by each of these individual parameters, however, was of variable accuracy. From 82 patients with positive bile cultures, a total of 150 microorganisms were isolated, including 66 gram-positive aerobes, 66 gram-negative facultative anaerobes, 15 obligate anaerobes, and three fungi. The most common organisms were Escherichia coli (20.6%), followed by enterococci (18%) and streptococci (15.3%). CONCLUSION Patients with acute biliary pancreatitis who manifest abnormalities of one or more of the above-mentioned risk factors are more likely to have positive bile cultures. Whether such patients might benefit from early antibiotic therapy directed against both gram-negative bacilli and gram-positive cocci needs to be determined.