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A case of portal vein thrombosis caused by ingestion of a foreign body
Brief Reports
Aspiration pneumonia developed in patient 3 after secretin administration. The patient was observed vomiting immediately before her episode of oxygen desaturation. Moreover, the left-sided distribution of the pneumonia is suggestive of aspiration because the patient was in a left-lateral decubitus position during the procedure. A copious amount of pancreatic fluid was visualized from the ampulla after secretin stimulation (Video 1, available online at www.giejournal.org). In our experience, a rapid squirting of pancreatic fluid from the papilla is often observed in patients with a normal pancreas. This can reflux through the pylorus and increase the risk of aspiration. Although this may be an isolated incident, preventive measures such as elevating the head of the bed should be implemented. The stomach should be aggressively suctioned before secretin injection and monitored throughout the procedure. Secretin was previously thought to be a benign agent with minimal concern for adverse events. Given the outcomes of the cases reported here, endoscopists using this secretagogue should be aware of potential adverse outcomes. Consideration of ePFT in patients with no discernable features of chronic pancreatitis on EUS should be carefully scrutinized regarding the potential risks and benefits, along with the pretest probability for minimal change chronic pancreatitis. DISCLOSURE The following authors disclosed financial relationships relevant to this publication: Dr. Stevens: research support
from ChiRhoClin, Inc and Solvay Pharmaceuticals and consultant to Boston Scientific; Dr. Vargo: consultant to Olympus America. The other author disclosed no financial relationships relevant to this publication. Abbreviation: ePFT, endoscopic pancreatic function test.
REFERENCES 1. Stevens T, Dumot JA, Parsi MA, et al. Combined endoscopic ultrasound and secretin endoscopic pancreatic function test in the evaluation of chronic pancreatitis. Dig Dis Sci 2010;55:2681-7. 2. Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101:2379-400. 3. Niederau C, Liddle RA, Ferrell LD, et al. Beneficial effects of cholecystokininreceptor blockade and inhibition of proteolytic enzyme activity in experimental acute hemorrhagic pancreatitis in mice: evidence for cholecystokinin as a major factor in the development of acute pancreatitis. J Clin Invest 1986;78:1056-63. 4. Jensen RT, Charlton CG, Adachi H, et al. Use of 125I-secretin to identify and characterize high-affinity secretin receptors on pancreatic acini. Am J Physiol 1983;245:G186-95.
Department of Hospital Medicine (R.J.L.), Digestive Disease Institute (J.J.V., T.S.), Cleveland Clinic, Cleveland, Ohio, USA. Reprint requests: Tyler Stevens, MD, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A31, Cleveland, OH 44195. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.11.018
A case of portal vein thrombosis caused by ingestion of a foreign body Daniel A. Milner, BA, Avijit Chatterjee, MD Ottawa, Ontario, Canada
The most common etiologies of portal vein thrombosis include infectious, inflammatory, or malignant causes.1 We present a unique case of portal vein thrombosis precipitated by the ingestion of a foreign body and Staphylococcus aureus septicemia.
CASE REPORT A 51-year-old man presented at a hospital with a 3-week history of fever, chills, night sweats, right upper quadrant abdominal pain, nausea and vomiting, and weight loss (7.5 kg over 3 weeks). The patient had quit smoking before presentation despite a 20-pack-year history because of associated exacerbation of abdominal 1168 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
symptoms. The patient denied a significant alcohol history. The clinical examination revealed pallor, diaphoresis, and malaise. His abdomen was slightly distended with mild right upper quadrant and epigastric tenderness. The liver and spleen were not enlarged. He had no stigmata of chronic liver disease. Laboratory investigations showed an elevated serum creatinine level of 141 mol/L (normal 70-120 mol/L), an alanine transferase level of 116 U/L (normal 3-36 U/L), a gamma-glutamyl transferase level of 575 U/L (normal 10-35 U/L), an alkaline phosphatase level of 233 U/L (normal 35-100 U/L), and a normal bilirubin level of 14 mol/L (normal 3-17 mol/L). CT of the abdomen showed portal vein thrombosis (PVT) extending www.giejournal.org
Brief Reports
Figure 3. Foreign object causing SMV thrombosis, PVT, and an ulcerated lesion in the third part of the duodenum.
Figure 1. Abdominal CT showing extensive PVT (arrow).
Figure 4. Foreign object successfully retrieved endoscopically. The object was a metal wire measuring 2.5 cm.
Figure 2. Abdominal CT showing a linear opacity (arrow) in the third part of the duodenum and extending into the SMV, suspicious for a foreign body.
to the superior mesenteric vein (SMV) (Fig. 1). The identified cause of the clot was a linear opacity seen extending from the lumen of the third portion of the duodenum into the SMV (Fig. 2). There was no sign of fluid collection or free air. Blood cultures revealed methicillin-susceptible Staphylococcus aureus. Findings of laboratory investigations for a hypercoagulable state were negative. An echocardiogram revealed no evidence of endocarditis. The patient was treated with intravenous cloxacillin and anticoagulated with low-molecular weight heparin and referred to gastroenterology to assess for endoscopic retrieval of the foreign object. After consultation with surgery, informed consent was obtained from the patient, and a gastroscopy was performed to the second part of the duodenum: no esophageal varices were present and no lesion was visualized. The procedure was repeated with an enteroscope, and an ulcerated lesion www.giejournal.org
with a black linear object protruding into the lumen was identified (Figs. 3 and 4). The foreign object was removed with biopsy forceps without complications. The patient underwent oral anticoagulation for 6 months because of the extent of the PVT, and this treatment was followed by hematology and gastroenterology.
DISCUSSION PVT is not an uncommon condition seen by internists.1 To our knowledge, this is the first report of an ingested metal object perforating the duodenum and causing SMV thrombosis and PVT. Of note, S aureus was cultured from the patient’s blood and likely contributed to the development of PVT (septic thrombophlebitis). Peters et al2 and others3,4 have reported cases of septic thrombophlebitis (or suppurative pylephlebitis) secondary to toothpick ingestion–related injuries. These reports have documented significant associated morbidity and mortality. It is unclear how the metal wire was ingested in this case. The patient did not recollect accidental ingestion. He did, however, perform rewiring work at home and often used his teeth to assist with wire stripping. No comparable wire samples from home were identified. Volume 74, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1169
Brief Reports
Management of pylephlebitis is primarily based on intravenous broad-spectrum antibiotics and removal of the foreign object.5 Although early surgery intervention is often required,6 we describe the successful endoscopic removal of the foreign body.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Abbreviations: PVT, portal vein thrombosis; SMV, superior mesenteric vein.
2. Peters TG, Locke JR, Weight GR. Suppurative pylephlebitis caused by toothpick perforation. South Med J 1988;81:414-5. 3. Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-7. 4. Block DB. Venturesome toothpick. A continuing source of pyogenic hepatic abscess. JAMA 1984;252:797-8. 5. Paraskeva KD, Bury RW, Isaacs P. Streptococcus milleri liver abscesses: an unusual complication after colonoscopic removal of an infected fish bone. Gastrointest Endosc 2000;51:357-8. 6. Santos SA, Alberto SC, Cruz E, et al. Hepatic abscess induced by foreign body: case report and literature review. World J Gastroenterol 2007;13: 1466-70. Department of Medicine (D.A.M.), University of Ottawa, Ottawa, Ontario, Canada, Department of Gastroenterology (A.C.), The Ottawa Hospital, Ottawa, Ontario, Canada. Reprint requests: Daniel Milner, BA, Department of Medicine, University of Ottawa, 123 Hopewell Avenue, Ottawa, Ontario K1S 2Z2, Canada.
REFERENCES 1. Parikh S, Shah R, Kapoor P. Portal vein thrombosis. Am J Med 2010;123: 111-9.
Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.11.043
Clear water filling and puncture: sufficient for endoscopic diagnosis of pneumatosis cystoides intestinalis? (with video) Yong Gil Kim, MD, Kyung-Jo Kim, MD, Se Hui Noh, MD, Dong Hoon Yang, MD, Kee Wook Jung, MD, Byong Duk Ye, MD, Jeong-Sik Byeon, MD, Seung-Jae Myung, MD, Suk-Kyun Yang, MD Seoul, Korea
Pneumatosis cystoides intestinalis (PCI) is a rare but important condition in which air-filled cysts develop within the colon wall.1 PCI can have a polypoid appearance and can therefore be difficult to diagnose endoscopically. The present report describes the case of a 40-year-old woman referred to our department because of nonspecific abdominal pain. She was diagnosed with PCI at colonoscopy, after clear water filling in the colon and a needle puncture.
CASE REPORT A 40-year-old woman underwent a colonoscopy for nonspecific abdominal pain and mucoid stools after an informed consent was obtained for the colonoscopy. She was not taking any medication, and her medical history was unremarkable. Colonoscopy revealed small, sessile, ball-shaped subepithelial nodules that were clustered in streaks. Some subepithelial nodules in the sigmoid colon were covered with a swollen and reddish mucosa, but otherwise the subepithelial nodules were covered with normal mucosa. Several gas bubbles emerged from the cystic lesion after puncturing with a needle (Video 1, available online at www.giejournal.org). After this treatment, the patient was symptom free, and no underlying 1170 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
disease was found on chest and abdominopelvic CT. The patient was diagnosed with primary PCI.
DISCUSSION The etiology of pneumatosis has yet to be fully elucidated. Pneumatosis is currently classified as primary (or idiopathic) or secondary. Primary pneumatosis accounts for about 15% of cases. Secondary pneumatosis accounts for about 85% of cases and can be attributed to a number of underlying conditions such as bowel obstruction, necrotizing enterocolitis, mucosal inflammation (eg, inflammatory bowel disease), ischemic colitis, collagen vascular disease (eg, scleroderma, systemic lupus erythematosus, dermatomyositis), malignancies, trauma (eg, surgery, endoscopy), and pulmonary disease (eg, chronic obstructive pulmonary disease, asthma).2,3 Difficulties in diagnosing PCI mainly arise from the failure of the clinician to suspect this rare entity, rather than a shortage of effective techniques. Reported diagnostic techniques include simple puncture, puncture with aspiration cytology,4 a “biopsy-on-biopsy” technique to rupture the cyst, probe EUS examination,5 and CT.3 By standard (not underwater) puncture technique, the colwww.giejournal.org
Aspiration pneumonia developed in patient 3 after secretin administration. The patient was observed vomiting immediately before her episode of oxygen desaturation. Moreover, the left-sided distribution of the pneumonia is suggestive of aspiration because the patient was in a left-lateral decubitus position during the procedure. A copious amount of pancreatic fluid was visualized from the ampulla after secretin stimulation (Video 1, available online at www.giejournal.org). In our experience, a rapid squirting of pancreatic fluid from the papilla is often observed in patients with a normal pancreas. This can reflux through the pylorus and increase the risk of aspiration. Although this may be an isolated incident, preventive measures such as elevating the head of the bed should be implemented. The stomach should be aggressively suctioned before secretin injection and monitored throughout the procedure. Secretin was previously thought to be a benign agent with minimal concern for adverse events. Given the outcomes of the cases reported here, endoscopists using this secretagogue should be aware of potential adverse outcomes. Consideration of ePFT in patients with no discernable features of chronic pancreatitis on EUS should be carefully scrutinized regarding the potential risks and benefits, along with the pretest probability for minimal change chronic pancreatitis. DISCLOSURE The following authors disclosed financial relationships relevant to this publication: Dr. Stevens: research support
from ChiRhoClin, Inc and Solvay Pharmaceuticals and consultant to Boston Scientific; Dr. Vargo: consultant to Olympus America. The other author disclosed no financial relationships relevant to this publication. Abbreviation: ePFT, endoscopic pancreatic function test.
REFERENCES 1. Stevens T, Dumot JA, Parsi MA, et al. Combined endoscopic ultrasound and secretin endoscopic pancreatic function test in the evaluation of chronic pancreatitis. Dig Dis Sci 2010;55:2681-7. 2. Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101:2379-400. 3. Niederau C, Liddle RA, Ferrell LD, et al. Beneficial effects of cholecystokininreceptor blockade and inhibition of proteolytic enzyme activity in experimental acute hemorrhagic pancreatitis in mice: evidence for cholecystokinin as a major factor in the development of acute pancreatitis. J Clin Invest 1986;78:1056-63. 4. Jensen RT, Charlton CG, Adachi H, et al. Use of 125I-secretin to identify and characterize high-affinity secretin receptors on pancreatic acini. Am J Physiol 1983;245:G186-95.
Department of Hospital Medicine (R.J.L.), Digestive Disease Institute (J.J.V., T.S.), Cleveland Clinic, Cleveland, Ohio, USA. Reprint requests: Tyler Stevens, MD, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A31, Cleveland, OH 44195. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.11.018
A case of portal vein thrombosis caused by ingestion of a foreign body Daniel A. Milner, BA, Avijit Chatterjee, MD Ottawa, Ontario, Canada
The most common etiologies of portal vein thrombosis include infectious, inflammatory, or malignant causes.1 We present a unique case of portal vein thrombosis precipitated by the ingestion of a foreign body and Staphylococcus aureus septicemia.
CASE REPORT A 51-year-old man presented at a hospital with a 3-week history of fever, chills, night sweats, right upper quadrant abdominal pain, nausea and vomiting, and weight loss (7.5 kg over 3 weeks). The patient had quit smoking before presentation despite a 20-pack-year history because of associated exacerbation of abdominal 1168 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
symptoms. The patient denied a significant alcohol history. The clinical examination revealed pallor, diaphoresis, and malaise. His abdomen was slightly distended with mild right upper quadrant and epigastric tenderness. The liver and spleen were not enlarged. He had no stigmata of chronic liver disease. Laboratory investigations showed an elevated serum creatinine level of 141 mol/L (normal 70-120 mol/L), an alanine transferase level of 116 U/L (normal 3-36 U/L), a gamma-glutamyl transferase level of 575 U/L (normal 10-35 U/L), an alkaline phosphatase level of 233 U/L (normal 35-100 U/L), and a normal bilirubin level of 14 mol/L (normal 3-17 mol/L). CT of the abdomen showed portal vein thrombosis (PVT) extending www.giejournal.org
Brief Reports
Figure 3. Foreign object causing SMV thrombosis, PVT, and an ulcerated lesion in the third part of the duodenum.
Figure 1. Abdominal CT showing extensive PVT (arrow).
Figure 4. Foreign object successfully retrieved endoscopically. The object was a metal wire measuring 2.5 cm.
Figure 2. Abdominal CT showing a linear opacity (arrow) in the third part of the duodenum and extending into the SMV, suspicious for a foreign body.
to the superior mesenteric vein (SMV) (Fig. 1). The identified cause of the clot was a linear opacity seen extending from the lumen of the third portion of the duodenum into the SMV (Fig. 2). There was no sign of fluid collection or free air. Blood cultures revealed methicillin-susceptible Staphylococcus aureus. Findings of laboratory investigations for a hypercoagulable state were negative. An echocardiogram revealed no evidence of endocarditis. The patient was treated with intravenous cloxacillin and anticoagulated with low-molecular weight heparin and referred to gastroenterology to assess for endoscopic retrieval of the foreign object. After consultation with surgery, informed consent was obtained from the patient, and a gastroscopy was performed to the second part of the duodenum: no esophageal varices were present and no lesion was visualized. The procedure was repeated with an enteroscope, and an ulcerated lesion www.giejournal.org
with a black linear object protruding into the lumen was identified (Figs. 3 and 4). The foreign object was removed with biopsy forceps without complications. The patient underwent oral anticoagulation for 6 months because of the extent of the PVT, and this treatment was followed by hematology and gastroenterology.
DISCUSSION PVT is not an uncommon condition seen by internists.1 To our knowledge, this is the first report of an ingested metal object perforating the duodenum and causing SMV thrombosis and PVT. Of note, S aureus was cultured from the patient’s blood and likely contributed to the development of PVT (septic thrombophlebitis). Peters et al2 and others3,4 have reported cases of septic thrombophlebitis (or suppurative pylephlebitis) secondary to toothpick ingestion–related injuries. These reports have documented significant associated morbidity and mortality. It is unclear how the metal wire was ingested in this case. The patient did not recollect accidental ingestion. He did, however, perform rewiring work at home and often used his teeth to assist with wire stripping. No comparable wire samples from home were identified. Volume 74, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1169
Brief Reports
Management of pylephlebitis is primarily based on intravenous broad-spectrum antibiotics and removal of the foreign object.5 Although early surgery intervention is often required,6 we describe the successful endoscopic removal of the foreign body.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Abbreviations: PVT, portal vein thrombosis; SMV, superior mesenteric vein.
2. Peters TG, Locke JR, Weight GR. Suppurative pylephlebitis caused by toothpick perforation. South Med J 1988;81:414-5. 3. Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-7. 4. Block DB. Venturesome toothpick. A continuing source of pyogenic hepatic abscess. JAMA 1984;252:797-8. 5. Paraskeva KD, Bury RW, Isaacs P. Streptococcus milleri liver abscesses: an unusual complication after colonoscopic removal of an infected fish bone. Gastrointest Endosc 2000;51:357-8. 6. Santos SA, Alberto SC, Cruz E, et al. Hepatic abscess induced by foreign body: case report and literature review. World J Gastroenterol 2007;13: 1466-70. Department of Medicine (D.A.M.), University of Ottawa, Ottawa, Ontario, Canada, Department of Gastroenterology (A.C.), The Ottawa Hospital, Ottawa, Ontario, Canada. Reprint requests: Daniel Milner, BA, Department of Medicine, University of Ottawa, 123 Hopewell Avenue, Ottawa, Ontario K1S 2Z2, Canada.
REFERENCES 1. Parikh S, Shah R, Kapoor P. Portal vein thrombosis. Am J Med 2010;123: 111-9.
Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.11.043
Clear water filling and puncture: sufficient for endoscopic diagnosis of pneumatosis cystoides intestinalis? (with video) Yong Gil Kim, MD, Kyung-Jo Kim, MD, Se Hui Noh, MD, Dong Hoon Yang, MD, Kee Wook Jung, MD, Byong Duk Ye, MD, Jeong-Sik Byeon, MD, Seung-Jae Myung, MD, Suk-Kyun Yang, MD Seoul, Korea
Pneumatosis cystoides intestinalis (PCI) is a rare but important condition in which air-filled cysts develop within the colon wall.1 PCI can have a polypoid appearance and can therefore be difficult to diagnose endoscopically. The present report describes the case of a 40-year-old woman referred to our department because of nonspecific abdominal pain. She was diagnosed with PCI at colonoscopy, after clear water filling in the colon and a needle puncture.
CASE REPORT A 40-year-old woman underwent a colonoscopy for nonspecific abdominal pain and mucoid stools after an informed consent was obtained for the colonoscopy. She was not taking any medication, and her medical history was unremarkable. Colonoscopy revealed small, sessile, ball-shaped subepithelial nodules that were clustered in streaks. Some subepithelial nodules in the sigmoid colon were covered with a swollen and reddish mucosa, but otherwise the subepithelial nodules were covered with normal mucosa. Several gas bubbles emerged from the cystic lesion after puncturing with a needle (Video 1, available online at www.giejournal.org). After this treatment, the patient was symptom free, and no underlying 1170 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
disease was found on chest and abdominopelvic CT. The patient was diagnosed with primary PCI.
DISCUSSION The etiology of pneumatosis has yet to be fully elucidated. Pneumatosis is currently classified as primary (or idiopathic) or secondary. Primary pneumatosis accounts for about 15% of cases. Secondary pneumatosis accounts for about 85% of cases and can be attributed to a number of underlying conditions such as bowel obstruction, necrotizing enterocolitis, mucosal inflammation (eg, inflammatory bowel disease), ischemic colitis, collagen vascular disease (eg, scleroderma, systemic lupus erythematosus, dermatomyositis), malignancies, trauma (eg, surgery, endoscopy), and pulmonary disease (eg, chronic obstructive pulmonary disease, asthma).2,3 Difficulties in diagnosing PCI mainly arise from the failure of the clinician to suspect this rare entity, rather than a shortage of effective techniques. Reported diagnostic techniques include simple puncture, puncture with aspiration cytology,4 a “biopsy-on-biopsy” technique to rupture the cyst, probe EUS examination,5 and CT.3 By standard (not underwater) puncture technique, the colwww.giejournal.org