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Argon laser treatment of radiation proctitis
the stomach and duodenum following ingestion of chloroquine phosphate. Over a period of 1 year, four patients with malaria presented to us with upper gastrointestinal symptoms following ingestion of chloroquine phosphate. These patients had taken four tablets of chloroquine phosphate (600-mg base) with food. All of them developed nausea, vomiting, and epigastric pain 24 to 36 hours after taking the drug. Endoscopy revealed, in all four cases, a normal esophagus, multiple hemorrhagic gastric erosions of varying shapes and sizes, and multiple duodenal erosions. Patients were treated with ranitidine, 150 mg twice daily. A repeat endoscopy 1 week later revealed normal mucosa. Deepak K. Bhasin, MD, OM Rajoo Singh, MD Department of Gastroenterology and Internal Medicine Postgraduate Institute of Medical Education & Research Chandigarh 160012, India
Argon laser treatment of radiation proctitis To the Editor: Radiation therapy for malignant gynecologic disease and prostatic cancer has resulted in increased survival and cure rate. This modality has unfortunately produced debilitating radiation proctitis. The bleeding that results from the proctitis can and does produce severe anemia that often requires replacement blood therapy. Recently, three patients were seen with continuous rectal bleeding secondary to radiation disease of the rectum. Two were women treated for cervical carcinoma and one was a man with prostatic cancer. These patients were refractory to steroid retention enemas, iron therapy, and 5-ASA enema therapy. All three patients were endoscoped to ascertain the linear extent of the proctitis. Disease in all three was confined to the distal 30 cm of the colorectum. Treatment was accomplished using an argon laser with a 300-lLm fiber passed via flexible sigmoidoscope. The most proximal mass areas were treated first. One and one-half watts at 0.5-sec pulses were used. Up to 50 pulses were delivered per therapy session. The fiber is placed in contact with the lesion and circumferentially for 0.5 em surrounding each suspected area. Bleeding stopped in the two women after two session and in the man after four sessions. They were treated as outpatients without the need for hospitalization and did not require analegesics. The patients have remained free of bleeding for 3 months without the use of medication. The Argon laser is well suited for this type of procedure. The vessels are superficial requiring 1 to 3 mm depths of coagulation and are usually small. Using telangiectasia as a model where the argon laser therapy is most effective, radiation proctitis should have a similar result. These three cases appear to add proof to this premise at least in short-term follow-up. John J. O'Connor, MD, FACS Katherine I. Strickland, RN, GIA Debra Burleson Spring Valley Endoscopy and Laser Center Washington, D.C.
VOLUME 34, NO.6, 1988
Appendicitis complicating colonoscopv To the Editor: Perforation and hemorrhage are well known complications of colonoscopy, having an incidence of 0.1 and 1%, respectively.' Splenic rupture,2 toxic megacolon," and the development of hepatic portal vein gas 3 have also been reported. We report the first case of appendicitis immediately following colonoscopy. A 35-year-old man with a year's history of intermittent lower abdominal pain and constipation was referred for colonoscopy. The colonoscope CF LB3R passed to the cecum without difficulty. The examination was normal and no biopsy was performed. He was well when discharged 2 hours later. Six hours following discharge he was readmitted with generalized lower abdominal pain and guarding maximal in the suprapubic and right iliac fossa regions. Abdominal xray and a limited gastrografin enema showed no evidence of colonic perforation. His pain and signs localized to the right iliac fossa and 30 hours after admission a grossly inflamed appendix was removed. His recovery was unremarkable. Histology revealed fecal matter impacted in the appendicular lumen with acute inflammation. Appendicitis rarely follows barium enema examination, the so-called barium appendicitis: but has not previously been reported following colonoscopy. It presumably occurs due to impaction of fecal matter present in the appendicular lumen into a more distal position. This results in luminal obstruction and acute appendicitis. We suggest that this will be a more common complication in the future and may indeed be more common now than the literature would suggest. A. Houghton, FRCS N. Aston, FRCS Department of Surgery Guys Hospital London, England
REFERENCES 1. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy:
a report on the complications of 5000 diagnostic and therapeutic colonoscopies. Gut 1983;24:374-83. 2. Castelli M. Splenic rupture-an unusual late complication of colonscopy. Can Med Assoc J 1986;134:916-7. 3. Huycke A, Moeller DO. Hepatic portal venous gas after colonoscopy in granulomatous colitis. Am J Gastroenterol 1985;80:637-8. 4. Sisley JF, Wagner CWo Barium appendicitis. South Med J 1982;75:498-9.
Lactulose-induced megacolon To the Editor: I enjoyed reading the article by Harig et aI., but do not agree with the conclusions stated therein. If the patients presenting with nontoxic megacolon were not randomized to avoid treatment bias, no particular conclusion can be derived from the data presented. A randomized trial looking at alternate treatment modalities in this group of heterogenous patients is warranted. 489
Argon laser treatment of radiation proctitis To the Editor: Radiation therapy for malignant gynecologic disease and prostatic cancer has resulted in increased survival and cure rate. This modality has unfortunately produced debilitating radiation proctitis. The bleeding that results from the proctitis can and does produce severe anemia that often requires replacement blood therapy. Recently, three patients were seen with continuous rectal bleeding secondary to radiation disease of the rectum. Two were women treated for cervical carcinoma and one was a man with prostatic cancer. These patients were refractory to steroid retention enemas, iron therapy, and 5-ASA enema therapy. All three patients were endoscoped to ascertain the linear extent of the proctitis. Disease in all three was confined to the distal 30 cm of the colorectum. Treatment was accomplished using an argon laser with a 300-lLm fiber passed via flexible sigmoidoscope. The most proximal mass areas were treated first. One and one-half watts at 0.5-sec pulses were used. Up to 50 pulses were delivered per therapy session. The fiber is placed in contact with the lesion and circumferentially for 0.5 em surrounding each suspected area. Bleeding stopped in the two women after two session and in the man after four sessions. They were treated as outpatients without the need for hospitalization and did not require analegesics. The patients have remained free of bleeding for 3 months without the use of medication. The Argon laser is well suited for this type of procedure. The vessels are superficial requiring 1 to 3 mm depths of coagulation and are usually small. Using telangiectasia as a model where the argon laser therapy is most effective, radiation proctitis should have a similar result. These three cases appear to add proof to this premise at least in short-term follow-up. John J. O'Connor, MD, FACS Katherine I. Strickland, RN, GIA Debra Burleson Spring Valley Endoscopy and Laser Center Washington, D.C.
VOLUME 34, NO.6, 1988
Appendicitis complicating colonoscopv To the Editor: Perforation and hemorrhage are well known complications of colonoscopy, having an incidence of 0.1 and 1%, respectively.' Splenic rupture,2 toxic megacolon," and the development of hepatic portal vein gas 3 have also been reported. We report the first case of appendicitis immediately following colonoscopy. A 35-year-old man with a year's history of intermittent lower abdominal pain and constipation was referred for colonoscopy. The colonoscope CF LB3R passed to the cecum without difficulty. The examination was normal and no biopsy was performed. He was well when discharged 2 hours later. Six hours following discharge he was readmitted with generalized lower abdominal pain and guarding maximal in the suprapubic and right iliac fossa regions. Abdominal xray and a limited gastrografin enema showed no evidence of colonic perforation. His pain and signs localized to the right iliac fossa and 30 hours after admission a grossly inflamed appendix was removed. His recovery was unremarkable. Histology revealed fecal matter impacted in the appendicular lumen with acute inflammation. Appendicitis rarely follows barium enema examination, the so-called barium appendicitis: but has not previously been reported following colonoscopy. It presumably occurs due to impaction of fecal matter present in the appendicular lumen into a more distal position. This results in luminal obstruction and acute appendicitis. We suggest that this will be a more common complication in the future and may indeed be more common now than the literature would suggest. A. Houghton, FRCS N. Aston, FRCS Department of Surgery Guys Hospital London, England
REFERENCES 1. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy:
a report on the complications of 5000 diagnostic and therapeutic colonoscopies. Gut 1983;24:374-83. 2. Castelli M. Splenic rupture-an unusual late complication of colonscopy. Can Med Assoc J 1986;134:916-7. 3. Huycke A, Moeller DO. Hepatic portal venous gas after colonoscopy in granulomatous colitis. Am J Gastroenterol 1985;80:637-8. 4. Sisley JF, Wagner CWo Barium appendicitis. South Med J 1982;75:498-9.
Lactulose-induced megacolon To the Editor: I enjoyed reading the article by Harig et aI., but do not agree with the conclusions stated therein. If the patients presenting with nontoxic megacolon were not randomized to avoid treatment bias, no particular conclusion can be derived from the data presented. A randomized trial looking at alternate treatment modalities in this group of heterogenous patients is warranted. 489