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Asparagus and jejunal-through-PEG: An unhappy encounter in intrajejunal levodopa infusion therapy
Parkinsonism and Related Disorders 17 (2011) 67–69
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Asparagus and jejunal-through-PEG: An unhappy encounter in intrajejunal levodopa infusion therapyq Keywords: Phytobezoar Parkinson's disease Jet-PEG PEG-J Duodopa Complications Intrajejunal levodopa infusion
Dear Sir, Continuous intrajejunal infusion of a levodopa gel (DuodopaÒ) is a novel and effective treatment of motor fluctuations in advanced idiopathic Parkinson’s disease (IPD) [1]. The levodopa gel is applied through a percutaneous gastrostomy (PEG) tube with a jejunal extension (J-tube). The end of the J-tube is positioned 15–35 cm below the ligament of Treitz and has a pigtail ending to prevent retrograde dislocation [1]. Technical problems with this device (PEG-J) may occur in 57–69% of the patients [1,2] and include tube dislocation, occlusion by crystallized gel, kinking or knotting, or tube erosion. We would like to report a very peculiar complication associated with the J-tube. 1. Case 1 A 71 year old gentleman with a 19 year history of fluctuating IPD and no previous gastrointestinal tract (GIT) surgery was started on DuodopaÒ therapy (3840 mg total levodopa dose per day) with excellent results. 3 months later the J-tube had to be reinserted after an inadvertent removal by the patient. 8 weeks later – in spring – the patient had recurrent episodes of epigastric pain occurring without any relation to meals. Another 6 weeks later he suddenly developed additional nausea, and the DuodopaÒ pump rose high pressure alarm indicating a clotted catheter. On admission, the J-tube could not be flushed suggesting kinking, knotting, or obstruction. Lab tests showed mild anemia (Hb 12.3 g/dl) and mild pancreatitis (lipase 259 U/l) but otherwise normal results. Gastroscopy revealed that the J-tube had eroded into the gastric mucosa (Fig. 1a) and undigested fibres of asparagus had got entangled in the pigtail-shaped tip of the J-tube forming a phytobezoar (Fig. 2). After endoscopic removal of the J-tube a pressure ulcer (Fig. 1b) was found. A new jejunal extension was inserted two q The review of this paper was entirely handled by the Co-Editor-in-Chief, Ronald Pfeiffer. 1353-8020/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.parkreldis.2010.09.004
weeks later after the pressure ulcer had healed. In retrospect the patient disclosed that his dentures had broken several weeks before and chewing therefore was inefficacious. 2. Case 2 A 69 years old gentleman with a 13 years history of fluctuating IPD and no previous GIT surgery was started on DuodopaÒ therapy (2320 mg total levodopa dose per day) with excellent benefit. 7 weeks after the insertion of the J-tube – in the high season for asparagus – he experienced sudden epigastric pain and nausea several hours after his last meal. The DuodopaÒ pump worked normally, and the J-tube could be flushed easily. Laboratory investigations revealed mild anemia (Hb 12.5 g/dl) and pancreatitis (lipase 891 U/l). Abdominal CT showed a dilated stomach despite fasting for 24 h and a dislocated bumper of the gastric tube. After endoscopic clearing of the stomach the bumper was still dislocated (Fig. 1c). Further advancing the endoscope revealed an extensively stretched J-tube and multiple pyloric and jejunal ulcera. At the tip of the J-tube there was an obstruction composed of undigested asparagus fibres. Endoscopic removal of the J-tube failed due to an accidental tube cut. The following day, however, enemas removed the J-tube per viam naturalem where a phytobezoar consisting of asparagus fibres and a knot at the tip of the tube were found. A J-tube replacement was performed immediately without any complications. Both patients recovered without sequelae and safely returned on DuodopaÒ. 3. Discussion A bezoar is a mass found trapped in the gastrointestinal system. Four types can be distinguished: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars, of which phytobezoars are the most common [3]. They are composed of vegetable matter (especially celery, pumpkin, asparagus, salsify, skin of citrus fruits or of grape, prune, and persimmons) that contain a large amount of non-digestible fibres (cellulose, hemicellulose, lignin, and fruit tannins) [3]. Normally found in the stomach, bezoars may pass through the small bowel, but rarely cause obstruction. Primary small bowel bezoars are very seldom and normally form in patients with an underlying small bowel disease like diverticula or strictures (e.g. by Crohn’s disease, tuberculosis, previous surgery, or tumours). PEG tubes normally do not predispose to phytobezoars, since they usually are used to feed patients who cannot eat solid food and who moreover suffer from disturbed gastric emptying and/or reflux. When using PEG-J-tubes for intrajejunal levodopa infusion,
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Letter to the Editor / Parkinsonism and Related Disorders 17 (2011) 67–69
Fig. 1. Endoscopic views. Patient 1, upper row: jejunal extension eroding into the mucosa of the stomach (a); after removal of the jejunal extension a white pressure ulcer remains (b). Patient 2, lower row: peristalsis had propelled the phytobezoar thereby building up tension on the J-tube resulting in a dislocated bumper (c); when advancing into the jejunum asparagus fibres from the bezoar were found (d).
though, patients retain their normal eating habits. It comes as no surprise that food with a large portion of indigestible fibres such as asparagus may chronically (as in patient 1) or even acutely (as in patient 2) form phytobezoars and thereby lead to intestinal obstructions at the pigtail of the J-tube. Subsequently, peristaltic movements propel the bezoar, and as the J-tube is fixed to the abdominal wall, the J-tube may be stretched tightly, carve in the mucosa, and cause pressure ulcera. The obstruction of the GIT may also hinder the secretion of bile and pancreatic enzymes which
may lead to pancreatitis. The foods with the highest risks of phytobezoar formation in Europe probably are celery, citrus fruits, grape, prune, salsify, and asparagus. Of these, especially white asparagus is very popular in Germany. It is harvested in a period of a few weeks between May and June, and true connoisseurs (as our IPD patients) enjoy it many times during each season. Of the 25 patients on DuodopaÒ we follow up on a regular basis since 2005, 2 had obstruction due to a phytobezoar, thus it may not be an extremely rare complication. It is astounding,
Fig. 2. Phytobezoar of patient 1: a compact oval convolute entangled the pigtail tip of the J-tube. Insertion: tip of the J-tube after removal of the bezoar.
Letter to the Editor / Parkinsonism and Related Disorders 17 (2011) 67–69
however, that this potential complication has not been reported yet. The probably best way to prevent this complication might be to stick to a low-fibre diet. We recommend informing patients on DuodopaÒ and their relatives or carers about this potential complication and to advise them to chew as thoroughly as possible and to avoid big morsels of fibrous foods. In patients on DuodopaÒ with sudden or insidious onset of epigastric pain, a history of eating habits may be useful, and a bezoar should be ruled out. To do so, in our cases intestinoscopy was superior to abdominal CT. A bezoar does not necessarily cause pressure alert even if the pigtail tip forms a knot. Disclosures CS is a consultant to Abbott (formerly Solvay Pharmaceuticals) and received honoraria for teaching courses on intrajejunal levodopa infusion therapy. SB, JW, DD, and TJW have nothing to disclose with regards to this work. References [1] Nyholm D, Lewander T, Johansson A, Lewitt PA, Lundqvist C, Aquilonius SM. Enteral levodopa/carbidopa infusion in advanced Parkinson disease: longterm exposure. Clin Neuropharmacol 2008 Mar–Apr;31(2):63–73.
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[2] Devos D, French DUODOPA Study Group. Patient profile, indications, efficacy and safety of duodenal levodopa infusion in advanced Parkinson’s disease. Mov Disord 2009 May 15;24(7):993–1000. [3] Andrus CH, Ponsky JL. Bezoars: classification, pathophysiology, and treatment. Am J Gastroenterol 1988 May;83(5):476–8.
C. Schrader*, S. Böselt Movement Disorders Section, Department of Neurology, Hannover Medical School, D-30623 Hannover, Germany * Corresponding author. Tel.: þ49 511 532 3111; fax: þ49 511 532 3115. E-mail address: [email protected] (C. Schrader) J. Wedemeyer Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany D. Dressler Movement Disorders Section, Department of Neurology, Hannover Medical School, D-30623 Hannover, Germany T.J. Weismüller Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany 19 July 2010
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Asparagus and jejunal-through-PEG: An unhappy encounter in intrajejunal levodopa infusion therapyq Keywords: Phytobezoar Parkinson's disease Jet-PEG PEG-J Duodopa Complications Intrajejunal levodopa infusion
Dear Sir, Continuous intrajejunal infusion of a levodopa gel (DuodopaÒ) is a novel and effective treatment of motor fluctuations in advanced idiopathic Parkinson’s disease (IPD) [1]. The levodopa gel is applied through a percutaneous gastrostomy (PEG) tube with a jejunal extension (J-tube). The end of the J-tube is positioned 15–35 cm below the ligament of Treitz and has a pigtail ending to prevent retrograde dislocation [1]. Technical problems with this device (PEG-J) may occur in 57–69% of the patients [1,2] and include tube dislocation, occlusion by crystallized gel, kinking or knotting, or tube erosion. We would like to report a very peculiar complication associated with the J-tube. 1. Case 1 A 71 year old gentleman with a 19 year history of fluctuating IPD and no previous gastrointestinal tract (GIT) surgery was started on DuodopaÒ therapy (3840 mg total levodopa dose per day) with excellent results. 3 months later the J-tube had to be reinserted after an inadvertent removal by the patient. 8 weeks later – in spring – the patient had recurrent episodes of epigastric pain occurring without any relation to meals. Another 6 weeks later he suddenly developed additional nausea, and the DuodopaÒ pump rose high pressure alarm indicating a clotted catheter. On admission, the J-tube could not be flushed suggesting kinking, knotting, or obstruction. Lab tests showed mild anemia (Hb 12.3 g/dl) and mild pancreatitis (lipase 259 U/l) but otherwise normal results. Gastroscopy revealed that the J-tube had eroded into the gastric mucosa (Fig. 1a) and undigested fibres of asparagus had got entangled in the pigtail-shaped tip of the J-tube forming a phytobezoar (Fig. 2). After endoscopic removal of the J-tube a pressure ulcer (Fig. 1b) was found. A new jejunal extension was inserted two q The review of this paper was entirely handled by the Co-Editor-in-Chief, Ronald Pfeiffer. 1353-8020/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.parkreldis.2010.09.004
weeks later after the pressure ulcer had healed. In retrospect the patient disclosed that his dentures had broken several weeks before and chewing therefore was inefficacious. 2. Case 2 A 69 years old gentleman with a 13 years history of fluctuating IPD and no previous GIT surgery was started on DuodopaÒ therapy (2320 mg total levodopa dose per day) with excellent benefit. 7 weeks after the insertion of the J-tube – in the high season for asparagus – he experienced sudden epigastric pain and nausea several hours after his last meal. The DuodopaÒ pump worked normally, and the J-tube could be flushed easily. Laboratory investigations revealed mild anemia (Hb 12.5 g/dl) and pancreatitis (lipase 891 U/l). Abdominal CT showed a dilated stomach despite fasting for 24 h and a dislocated bumper of the gastric tube. After endoscopic clearing of the stomach the bumper was still dislocated (Fig. 1c). Further advancing the endoscope revealed an extensively stretched J-tube and multiple pyloric and jejunal ulcera. At the tip of the J-tube there was an obstruction composed of undigested asparagus fibres. Endoscopic removal of the J-tube failed due to an accidental tube cut. The following day, however, enemas removed the J-tube per viam naturalem where a phytobezoar consisting of asparagus fibres and a knot at the tip of the tube were found. A J-tube replacement was performed immediately without any complications. Both patients recovered without sequelae and safely returned on DuodopaÒ. 3. Discussion A bezoar is a mass found trapped in the gastrointestinal system. Four types can be distinguished: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars, of which phytobezoars are the most common [3]. They are composed of vegetable matter (especially celery, pumpkin, asparagus, salsify, skin of citrus fruits or of grape, prune, and persimmons) that contain a large amount of non-digestible fibres (cellulose, hemicellulose, lignin, and fruit tannins) [3]. Normally found in the stomach, bezoars may pass through the small bowel, but rarely cause obstruction. Primary small bowel bezoars are very seldom and normally form in patients with an underlying small bowel disease like diverticula or strictures (e.g. by Crohn’s disease, tuberculosis, previous surgery, or tumours). PEG tubes normally do not predispose to phytobezoars, since they usually are used to feed patients who cannot eat solid food and who moreover suffer from disturbed gastric emptying and/or reflux. When using PEG-J-tubes for intrajejunal levodopa infusion,
68
Letter to the Editor / Parkinsonism and Related Disorders 17 (2011) 67–69
Fig. 1. Endoscopic views. Patient 1, upper row: jejunal extension eroding into the mucosa of the stomach (a); after removal of the jejunal extension a white pressure ulcer remains (b). Patient 2, lower row: peristalsis had propelled the phytobezoar thereby building up tension on the J-tube resulting in a dislocated bumper (c); when advancing into the jejunum asparagus fibres from the bezoar were found (d).
though, patients retain their normal eating habits. It comes as no surprise that food with a large portion of indigestible fibres such as asparagus may chronically (as in patient 1) or even acutely (as in patient 2) form phytobezoars and thereby lead to intestinal obstructions at the pigtail of the J-tube. Subsequently, peristaltic movements propel the bezoar, and as the J-tube is fixed to the abdominal wall, the J-tube may be stretched tightly, carve in the mucosa, and cause pressure ulcera. The obstruction of the GIT may also hinder the secretion of bile and pancreatic enzymes which
may lead to pancreatitis. The foods with the highest risks of phytobezoar formation in Europe probably are celery, citrus fruits, grape, prune, salsify, and asparagus. Of these, especially white asparagus is very popular in Germany. It is harvested in a period of a few weeks between May and June, and true connoisseurs (as our IPD patients) enjoy it many times during each season. Of the 25 patients on DuodopaÒ we follow up on a regular basis since 2005, 2 had obstruction due to a phytobezoar, thus it may not be an extremely rare complication. It is astounding,
Fig. 2. Phytobezoar of patient 1: a compact oval convolute entangled the pigtail tip of the J-tube. Insertion: tip of the J-tube after removal of the bezoar.
Letter to the Editor / Parkinsonism and Related Disorders 17 (2011) 67–69
however, that this potential complication has not been reported yet. The probably best way to prevent this complication might be to stick to a low-fibre diet. We recommend informing patients on DuodopaÒ and their relatives or carers about this potential complication and to advise them to chew as thoroughly as possible and to avoid big morsels of fibrous foods. In patients on DuodopaÒ with sudden or insidious onset of epigastric pain, a history of eating habits may be useful, and a bezoar should be ruled out. To do so, in our cases intestinoscopy was superior to abdominal CT. A bezoar does not necessarily cause pressure alert even if the pigtail tip forms a knot. Disclosures CS is a consultant to Abbott (formerly Solvay Pharmaceuticals) and received honoraria for teaching courses on intrajejunal levodopa infusion therapy. SB, JW, DD, and TJW have nothing to disclose with regards to this work. References [1] Nyholm D, Lewander T, Johansson A, Lewitt PA, Lundqvist C, Aquilonius SM. Enteral levodopa/carbidopa infusion in advanced Parkinson disease: longterm exposure. Clin Neuropharmacol 2008 Mar–Apr;31(2):63–73.
69
[2] Devos D, French DUODOPA Study Group. Patient profile, indications, efficacy and safety of duodenal levodopa infusion in advanced Parkinson’s disease. Mov Disord 2009 May 15;24(7):993–1000. [3] Andrus CH, Ponsky JL. Bezoars: classification, pathophysiology, and treatment. Am J Gastroenterol 1988 May;83(5):476–8.
C. Schrader*, S. Böselt Movement Disorders Section, Department of Neurology, Hannover Medical School, D-30623 Hannover, Germany * Corresponding author. Tel.: þ49 511 532 3111; fax: þ49 511 532 3115. E-mail address: [email protected] (C. Schrader) J. Wedemeyer Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany D. Dressler Movement Disorders Section, Department of Neurology, Hannover Medical School, D-30623 Hannover, Germany T.J. Weismüller Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany 19 July 2010