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Complete Clogging by Fungus Ball: A Rare Complication of Gastrostomy
IMAGE OF THE MONTH Complete Clogging by Fungus Ball: A Rare Complication of Gastrostomy Shunsuke Yamamoto, Masato Komori, and Harumasa Yoshihara Department of Gastroenterology, Osaka Rosai Hospital, Osaka, Japan
63-year-old man was referred to our Gastroenterology Department for insertion of a gastrostomy catheter, owing to repeated aspiration pneumonia after chemoradiation therapy for hypopharyngeal cancer 3 months earlier. His nutritional status was normal. He had been taking prednisolone for interstitial pneumonia beginning 10 days before and also after gastrostomy placement. The course of the pneumonia was stable. Before performing the gastrostomy, we confirmed the safety of placement by computed tomography and esophagogastroduodenoscopy. A percutaneous endoscopic gastrostomy (PEG) was placed at the anterior wall of the middle body of the stomach without complications using an endoscopyassisted method. We administered ampicillin-sulbactam (3 g/d) for 2 days to avoid bacterial infection. The day after PEG placement, we began to infuse a liquid food formula through the PEG. At first, the infusion proceeded without any problems. A few days later, however, infusion became more difficult, and 7 days later even clear liquids could not be infused. The patient had no abdominal pain or fever. We found no causal abnormalities through computed tomography and radiographic examination. On day 14, we performed an esophagogastroduodenoscopy that showed a hard yellowish mass with a red granular surface inside the bottom part of the gastrostomy tube (Figure A). We completely removed it with a grasp forceps (Figure B). After removal, infusion through the PEG proceeded
A
normally. Pathologic findings included only packed Candida spores and hyphae with no other entities, suggesting that the entire mass was a fungus ball (Figure C). After removing the ball, there was no recurrence of complications. Infection around the gastrostomy and PEG clogging are known complications after gastrostomy placement.1 Infection occurs in 18% of patients without preprocedural antibiotics.1 An appropriate antibiotic regimen can prevent this complication. In our case, there were no clinical findings of bacterial infection. Clogging of the tube occurs in 45% of patients owing to thick enteral feedings and medications without water flush.1 We did not infuse these agents and found no reports showing clogging of the tube in such a short time as in this case. Based on the clinical and pathologic findings, we considered that the PEG tube was clogged by the fungus ball alone, without preceding clogging by food or agents. Gottlieb et al2 reported that oral Candida could colonize in gastrostomy tubes.3 They also reported that colonization of fungi in a gastrostomy tube could occur in as little as 1 week after placement. Fungus balls are reported to form a solid mass in vivo.4 The mechanism of the present case is uncertain, but it is conceivable that the immunosuppressive state promoted the fungus colonization and the growth, and resulted in complete PEG clogging.
Clinical Gastroenterology and Hepatology 2014;12:xxix–xxx
IMAGE OF THE MONTH, continued References 1.
2.
3.
xxx
Schrag SJ, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointest Liver Dis 2007;16:407–418. Gottlieb K, Iber FK, Livak A, et al. Oral Candida colonizes the stomach and gastrostomy feeding tubes. J Parenter Enteral Nutr 1994;18:264–267. Gottlieb K, Leya J, Kruss DM, et al. Intraluminal fungal colonization of gastrostomy tubes. Gastrointest Endosc 1993;39: 413–415.
4.
Niall FD, Lisa GS, Elizabeth M, et al. Ureteric obstruction due to fungus-ball in a chronically immunosuppressed patient. Can Urol Assoc J 2013;7:355–358.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.01.017
63-year-old man was referred to our Gastroenterology Department for insertion of a gastrostomy catheter, owing to repeated aspiration pneumonia after chemoradiation therapy for hypopharyngeal cancer 3 months earlier. His nutritional status was normal. He had been taking prednisolone for interstitial pneumonia beginning 10 days before and also after gastrostomy placement. The course of the pneumonia was stable. Before performing the gastrostomy, we confirmed the safety of placement by computed tomography and esophagogastroduodenoscopy. A percutaneous endoscopic gastrostomy (PEG) was placed at the anterior wall of the middle body of the stomach without complications using an endoscopyassisted method. We administered ampicillin-sulbactam (3 g/d) for 2 days to avoid bacterial infection. The day after PEG placement, we began to infuse a liquid food formula through the PEG. At first, the infusion proceeded without any problems. A few days later, however, infusion became more difficult, and 7 days later even clear liquids could not be infused. The patient had no abdominal pain or fever. We found no causal abnormalities through computed tomography and radiographic examination. On day 14, we performed an esophagogastroduodenoscopy that showed a hard yellowish mass with a red granular surface inside the bottom part of the gastrostomy tube (Figure A). We completely removed it with a grasp forceps (Figure B). After removal, infusion through the PEG proceeded
A
normally. Pathologic findings included only packed Candida spores and hyphae with no other entities, suggesting that the entire mass was a fungus ball (Figure C). After removing the ball, there was no recurrence of complications. Infection around the gastrostomy and PEG clogging are known complications after gastrostomy placement.1 Infection occurs in 18% of patients without preprocedural antibiotics.1 An appropriate antibiotic regimen can prevent this complication. In our case, there were no clinical findings of bacterial infection. Clogging of the tube occurs in 45% of patients owing to thick enteral feedings and medications without water flush.1 We did not infuse these agents and found no reports showing clogging of the tube in such a short time as in this case. Based on the clinical and pathologic findings, we considered that the PEG tube was clogged by the fungus ball alone, without preceding clogging by food or agents. Gottlieb et al2 reported that oral Candida could colonize in gastrostomy tubes.3 They also reported that colonization of fungi in a gastrostomy tube could occur in as little as 1 week after placement. Fungus balls are reported to form a solid mass in vivo.4 The mechanism of the present case is uncertain, but it is conceivable that the immunosuppressive state promoted the fungus colonization and the growth, and resulted in complete PEG clogging.
Clinical Gastroenterology and Hepatology 2014;12:xxix–xxx
IMAGE OF THE MONTH, continued References 1.
2.
3.
xxx
Schrag SJ, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointest Liver Dis 2007;16:407–418. Gottlieb K, Iber FK, Livak A, et al. Oral Candida colonizes the stomach and gastrostomy feeding tubes. J Parenter Enteral Nutr 1994;18:264–267. Gottlieb K, Leya J, Kruss DM, et al. Intraluminal fungal colonization of gastrostomy tubes. Gastrointest Endosc 1993;39: 413–415.
4.
Niall FD, Lisa GS, Elizabeth M, et al. Ureteric obstruction due to fungus-ball in a chronically immunosuppressed patient. Can Urol Assoc J 2013;7:355–358.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.01.017