Koshiro Saito

Predominant copper deficiency during prolonged enteral nutrition through a jejunostomy tube compared to that through a gastrostomy tube

BACKGROUND & AIMS Trace element deficiencies are known to occur during long-term enteral nutrition feeding. We compared the serum concentrations of trace elements between patients treated with gastrostomy and those treated with jejunostomy. METHODS Our subjects were 36 patients who underwent percutaneous endoscopic gastrostomy (PEG group) and 23 patients who underwent percutaneous endoscopic jejunostomy (PEJ group) and were maintained with enteral tube feeding for more than one year. The serum concentrations of copper, zinc, selenium, and iron were measured in the two groups. Clinical manifestations and the effectiveness of supplementation therapy against copper deficiency were also investigated. RESULTS From 6 months after the onset of enteral feeding, the copper concentration of the PEJ group was significantly decreased compared with that of the PEG group (p<0.001). There were no significant differences in the concentrations of zinc, selenium, or iron between the two groups. Severe copper deficiency was observed in 6 patients of the PEJ group and was accompanied with neutropenia and anemia. The copper deficiency was successfully treated in all of these patients by supplementation with 10-40 g of cocoa powder a day which was equivalent to a total daily dose of 1.36-2.56 mg of copper. CONCLUSIONS Prolonged PEJ tube nutrition tends to result in copper deficiency, and cocoa supplementation is effective for treating such copper deficiency.

Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices

BACKGROUND Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. OBJECTIVE To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. DESIGN A retrospective study. SETTING Single center: Nishimino Kosei Hospital. PATIENTS This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. INTERVENTION A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. MAIN OUTCOME MEASUREMENTS Complications and their outcomes. RESULTS Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. LIMITATIONS A single center, retrospective analysis. CONCLUSION Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.

Clinical investigation of upper gastrointestinal hemorrhage after percutaneous endoscopic gastrostomy.

Background:  Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG.

Changes in brain monoamine metabolism in rats with acute ischemic hepatic failure under artificial cardiopulmonary management

SummaryA study was conducted to investigate changes in monoamine metabolism in the brain of rats with acute ischemic hepatic failure (AHF) induced by two-stage hepatic devascularization. Strict artificial cardiopulmonary management was used to exclude possible confounding effects of hypotension, hypothermia and hypoxemia that often appear in AHF. Rats were put in an incubator at 34°C before the ligation of the hepatic artery (second stage operation), tracheotomized and ventilated artificially throughout the remaining experimental periods. No significant difference was observed in physiological parameters, including body temperature, pulse rate and systolic arterial blood pressure or PaO2 between AHF and sham operated rats. Brain levels of norepinephrine (NE) and its metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG), dopamine (DA) and its metabolites 3,4-dihydroxyphenylacetic acid (DOPAC) and homovanilic acid (HVA), and serotonin (5-hydroxytryptamine, 5HT) and its metabolite 5-hydroxyindoleacetic acid (5HIAA) were determined by HPLC-voltametry. AHF rats showed significantly higher MHPG, DOPAC, 5HIAA and lower NE levels in the brain compared to controls. In addition, a significant negative correlation between NE and tyrosine (Tyr), a significant positive correlation between MHPG and Tyr or phenylalanine (Phe), and a significant positive correlation between DOPAC and Tyr or Phe were observed. In conclusion, the changes in monoamine metabolism in the brain of AHF rats are clearly induced specifically by hepatic failure itself, possibly through an altered metabolism of amino acids.

Enhanced production of leukotriene B4 by peripheral blood mononuclear cells in patients with fulminant hepatitis

Abstract The production rate of leukotriene B4 (LTB4) was measured using peripheral blood mononuclear cells (PBMC) in patients with fulminant hepatitis (FH) or other liver diseases. LTB4 in the culture media of PBMC under stimulation with Ca‐ionophore was fractionated by HPLC and measured by radioimmunoassay. The production rate of LTB4 was elevated in 16 of 17 FH patients (3.3 ± 0.2 ng/106 cells for 5 min), while the production was below detectable level in patients with acute or chronic hepatitis and in healthy controls. In FH patients, the highest production rate of LTB4 was observed in the initial period of the disease. Enhanced LTB4 production may indicate the primed state of PBMC — the primed mononuclear cells are regarded as participating in the development of massive liver necrosis and of other organ failures in FH.

Association between increased serum GP88 (progranulin) concentrations and prognosis in patients with malignant lymphomas

BACKGROUND GP88 (progranulin; PGRN) is a secreted 88kDa glycosylated protein, with important functions, including inflammation and tumorigenesis. We assessed the significance of GP88 expression in survival outcomes of patients with malignant lymphoma (ML). METHODS Serum samples from 254 previously untreated ML patients were examined to measure GP88 concentrations using a sandwich human GP88 ELISA kit. Immunohistochemical analyses were performed to examine GP88 tumor tissue expression. RESULTS The median serum GP88 concentration of ML patients was 91.3ng/ml, and was significantly higher than that of the control group (median, 57.7ng/ml) (p<0.0001). Association between GP88 serum concentrations and overall survival (OS) was examined in patients with diffuse large B cell lymphoma (DLBCL) who had been stratified based on their serum GP88 concentrations. Kaplan Meier survival analysis showed that patients with serum GP88 concentrations of ≤116 and >116ng/ml, had 5-y OS rates of 70% and 50%, respectively (p=0.02). The immunohistochemical analyses of GP88 tumor expression revealed that DLBCL patients had lymphoma cells that were positive for GP88. CONCLUSIONS High serum GP88 concentrations are associated with poor prognosis in patients with DLBCL.

Transcecostomal colonic stent placement after US-guided percutaneous cecostomy.

Colorectal stenting for the treatment of malignant largebowel obstruction is useful for palliation or as a bridge to surgery. 1 It is more difficult to position a stent in the rightsided colon by using a retrograde placement method via the rectum compared with the distal colon. Herein, we present a case involving the successful antegrade placement of a stent in the ascending colon after US-guided percutaneous cecostomy.

Development of a Novel Scoring System for Predicting the Risk of Colorectal Neoplasia: A Retrospective Study.

Objective The purpose of this study was to develop a novel scoring system to screen subjects who have a high risk for colorectal neoplasia. Study Design and Setting We retrospectively analyzed 1061 subjects undergoing total colonoscopy (TCS) for the first time at Gihoku Kosei Hospital. The characteristics and habits of the subjects were analyzed using a multivariate logistic regression analysis. The risk score was established according to each odds ratio of the individual risk factors, and the correlations between the sum of the risk scores and the prevalence of colorectal neoplasia for each individual were evaluated. Results Age 45–59 (risk score: 2 points) and ≥60 (3 points), male gender (1 point), and habitual alcohol consumption ≥21g daily (1 point) were extracted as the significant risk factors for colorectal neoplasia. When the risk groups were determined by summing up these risk scores, the prevalence rates of colorectal neoplasia were 8.8% for the low risk group (0–2 points), 30.5% for the low-moderate risk group (3 points), 39.1% for the high-moderate risk group (4 points), and 57.6% for the high risk group (5 points). In comparison with the low risk group, the odds ratio of the low-moderate risk, the high-moderate risk, and the high risk groups were 4.6, 6.7, and 14.1 folds, respectively. Conclusion Our scoring system, which linearly correlates with the prevalence rate of colorectal neoplasia, may be an effective tool for screening the subjects who have a high risk for colorectal neoplasia. These subjects, therefore, should be recommended to undergo TCS.

ENDOSCOPIC ULTRASONOGRAPHY-GUIDED GASTROSTOMY TUBE PLACEMENT FROM THE STOMACH

Dear Editor, A 92-year-old woman with severe dementia presented difficulty of oral intake after the treatments of a right femoral neck fracture and severe esophageal ulcer. Percutaneous endoscopic gastrostomy (PEG) was not available, because her stomach had largely ascended in the thoracic cavity. Subsequently, we attempted to place a gastrostomy tube (Ponsky PEG; Bard Access Systems, Inc., Salt Lake City, UT, USA) using the technique of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA), as shown in Fig. 1.The stomach was pushed downward to the abdominal wall from a subcostal location using an echoendoscope (GF-UCT240-AL5; Olympus Optical Co.,Tokyo, Japan) under fluoroscopic guidance. The interpositioning of the intestine, liver, spleen, and vessels was avoided using the echoendoscope, and we sought an appropriate puncture position using finger indentation from the abdominal wall (Fig. 2).A 19-gauge needle for FNA (Echo Tip Ultra; Cook Endoscopy, Winston-Salem, NC, USA) was used to puncture the abdominal wall, and the loop wire was inserted through the needle from the skin surface side. The needle was withdrawn into the endoscope and pulled out from the mouth with the endoscope. A 20-F gastrostomy tube was positioned by the pull-through technique. We compressed the gastric and abdominal walls between the internal and external bolster of the tube for 7 days until a gastrocutaneous fistula was successfully formed. Major reasons for failure of PEG include a lack of transillumination due to dislocation of the stomach, the anterior interposition of other organs, previous gastric resection, or the inability to carry out endoscopic insertion to the stomach. Chaves et al. reported five cases of EUS-guided PEG in patients lacking abdominal wall transillumination. Their method was to puncture a trocar from the abdominal wall over a 22-gauge needle inserted from EUS. In the present case, the use of a larger-bore puncture needle (19-gauge) Correspondence: Shinji Nishiwaki, Department of Internal Medicine, Nishimino Kosei Hospital, 986 Oshikoshi, Yoro-cho, Yoro-gun, Gifu 5031394, Japan. Email: wakky@nishimino.gfkosei.or.jp

A Case of Duodenal Crohn's Disease Associated with Ampullar Insufficiency and Cholangitis

Abstract: A 67‐year‐old Japanese woman with duodenal Crohns disease developed cholangitis. Radiographic and endoscopic examinations revealed a marked stenosis of the third portion and a dilatation of the second portion of the duodenum. The endoscopic and histopathological observations showed this disease affected the Vaters papilla. Duodenoscopic manometry indicated a reduced pressure of the phasic sphincter of Oddi, indicating ampullar insufficiency. E. coli was found in the bile culture as the infecting organism. The authors suggest that the cholangitis in this patient was caused by the reflux of duodenal contents into the biliary tract.