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Detection of esophagitis by technetium 99m tetrofosmin chest SPECT
1950
Letters to the Editor
hemoglobin drops significantly the doses of ribavirin should be reduced (1). In some cases blood transfusion may also be necessary (5). In this case, the patient remained symptom free, his activity was such that he did not need transfusions, and treatment was completed successfully without transfusions. This case illustrates that it is possible to treat chronic hepatitis C successfully in a patient with pre-existing hemolytic anemia and transfusion may not be required, although close monitoring is necessary. Nasir Khokhar, M.D. Division of Gastroenterology Department of Medicine Shifa International Hospital and Shifa College of Medicine Islamabad, Pakistan
REFERENCES 1. McHutchison JG, Gordon SC, Schiff ER, et al. Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis “C”. N Engl J Med 1998;339:1485– 92. 2. Shivatori Y, Imazeki F, Moriyama M, et al. Histologic improvement of fibrosis in patients with hepatitis “C” who have sustained response to interferon therapy. Ann Intern Med 2000; 132:517–24. 3. Linker CA. Anemias. In: Tierney LM, Mcphee SJ, Papadakis MA, eds. Current medical diagnosis and treatment. Stamford, CT: Appleton & Lange, 1998:489 –90. 4. Dimarco V, Iacono OL, Capra M, et al. Alpha interferon treatment of chronic hepatitis “C” in B-thalassemia. Gut 1993; (suppl):S142–3. 5. Telfer PT, Garson JA, Whitley K, et al. Combination therapy with interferon alpha and ribavirin for chronic hepatitis “C” virus infection in thalassemic patients. Br J Haematol 1997;98: 850 –5.
AJG – Vol. 96, No. 6, 2001
tecting malignant lesions of the esophagus (2), with good results. Forty gastroesophageal reflux disease patients who underwent endoscopy for diagnosis and grading of esophagitis according to the Savary-Miller system (3) were included in this study. On the morning after endoscopy, patients were scheduled for Tc-TF chest SPECT to detect and grade esophagitis. The chest SPECT was performed 15 to 30 min after an i.v. injection of 740 MBq of Tc-TF. The sagittal slices of SPECT were interpreted as negative (no uptake in the esophagus) or positive. Based on the endoscopic findings, the sensitivity, specificity, and accuracy rates of Tc-TF chest SPECT in detecting esophagitis were 100%, 77%, and 95%, respectively. The correlation between the endoscopic and Tc-TF chest SPECT findings was good (r ⫽ 0.913, p ⬍ 0.05). Mitochondrial/plasma membrane potentials, the cellular mitochondrial content of the esophageal mucosa, and inflammatory cells could all play significant roles in esophageal uptake of Tc-TF (4), or the uptake may be caused by indirect phenomena such as locally increased blood flow and capillary permeability from inflammation. Therefore, the hypothesis underlying this study was that increased blood flow and capillary permeability associated with esophageal erosions/inflammation could be detected by Tc-TF chest SPECT imaging. Although this pilot study population was small, Tc-TF chest SPECT appeared to have high sensitivity and accuracy in detecting esophagitis among gastroesophageal reflux disease patients. We concluded that the use of Tc-TF chest SPECT is excellent for the exclusion of coronary artery disease when chest pain is encountered. If uptake in the esophagus can be seen in early postexercise or rest studies, the next examination should be endoscopy to rule out esophagitis. Chia-Hung Kao Sheng-Ping ChangLai Jong-Kang Lee Department of Nuclear Medicine Taichung Veterans General Hospital Department of Nuclear Medicine Chung-Shan Medical and Dental Hospital Department of Nuclear Medicine China Medical College Hospital Taichung, Taiwan
Reprint requests and correspondence: Nasir Khokhar, M.D., Division of Gastroenterology, Shifa International Hospital, Shifa College of Medicine, Islamabad, 44000, Pakistan. Received Dec. 21, 2000; accepted Jan. 8, 2001.
Detection of Esophagitis by Technetium 99m Tetrofosmin Chest SPECT TO THE EDITOR: A review of the literature showed that Tl 201 imaging had a high sensitivity for detecting esophagitis when compared with the endoscopic findings (1). However, poor emission characteristics for single photon emission CT (SPECT) imaging and availability problems related to cyclotron production are significant disadvantages of Tl 201. Tc 99m tetrofosmin (Tc-TF) (Myoview, Amersham International, Arlington Heights, IL), competing with Tl 201, has been used as a new radiopharmaceutical for myocardial imaging. In addition, Tc-TF imaging has been tried in de-
REFERENCES 1. De Gregorio BT, Fennerty MB, Wilson RA. Noninvasive diagnosis of gastroesophageal inflammation using dipyridamole thallium-201 tomography. Am J Gastroenterol 1998;93: 1255–9. 2. Watanabe N, Hirano T, Fukushima Y, et al. Esophageal cancer detection with Tc-99m tetrofosmin SPECT. Clin Nucl Med 1997;22:431–3. 3. Savary M, Miller G. The esophagus. In: Savary M, Miller G, eds. Handbook and atlas of endoscopy. Switzerland: Verlag Gassman, 1978:119 –295.
AJG – June, 2001
4. Chiu ML, Kronauge JF, Piwnica-Worms D. Effect of mitochondrial and plasma membrane potentials on accumulation of hexakis (2-methoxyiso-butylisonitrile) technetium (I) in cultured mouse fibroblast. J Nucl Med 1990;31:1646 –53. Reprint requests and correspondence: Chia-Hung Kao, M.D., Department of Nuclear Medicine, Taichung Veterans General Hospital, 160 Taichung Harbor Road, Section 3, Taichung 407, Taiwan. Received Apr. 14, 2000; accepted Jan. 12, 2001.
The Relevance of Systemic Complications and the Different Outcomes of Subgroups After Percutaneous Endoscopic Gastrostomy (PEG) TO THE EDITOR: The usefulness of routine antibiotic prophylaxis before percutaneous endoscopic gastrostomy (PEG) to prevent peristomal infections is supported by the recently published meta-analysis by Sharma and Howden (1) and an article by Ku¨lling et al. (2). In the articles, the authors state that individual investigators judged only a few local infections in various patient groups to be clinically serious. In both clinical trials and the practical setting, local infections after PEG mostly occur as minor complications and rarely necessitate treatment with antibiotics. Infection is controlled in nearly all cases by intensive local treatment. The reduction of peristomal infection rates should not be the only reason to initiate routine antibiotic prophylaxis in all patient groups (3). Systemic infections and, more particularly, postintervention pneumonia are also a serious problem. They are not always evaluated during prospective PEG trials, and this may be why they are frequently underestimated. These infections more often require the use of antibiotics, and sometimes result in a prolonged hospital stay and poorer survival rates (3). To demonstrate the efficacy of antibiotic prophylaxis before PEG, the outcome of subgroups needs to be considered in relation to the underlying disease (e.g., cancer or neurological disease) and the presence of local and systemic infections needs to be taken into account and integrated into a meta-analysis. Severe systemic complications, in contrast to peristomal infections, generally occur in patients with neurological disease (3). One reason for this could be the high risk of aspiration, which is sometimes caused by a feeding protocol using large boluses (4). In the final analysis of our randomized multicenter PEG trial with 216 patients (106 of them given ceftriaxone 1 ⫻ 1 g i.v. prophylactically) undergoing a standardized PEG intervention including care before (including prior antiseptic mouthwash) and after the intervention, 67.2% of the patients had a neurological disease (5). Patients with tumors were scored positive for local infection without (31.0%) and with (3.7%) antibiotic prophylaxis (p ⬍ 0.05). They derived
Letters to the Editor
1951
greater benefit from antibiotic prophylaxis in terms of local infection rates than patients with neurological disease (local infection rate 20.3% vs 11.4%, p ⬎ 0.05). Of the 18.5% of patients scoring positive for peristomal infection, only 2.7% (all without preintervention prophylaxis) received antibiotic therapy for this reason during the 10-day follow-up period. This demonstrates the low grade nature of the infection. The total rate of systemic infections was 11.8% without and 1.9% with antibiotic prophylaxis (p ⬍ 0.05). It was predominantly patients with underlying neurological disease who suffered from postintervention pneumonia (9.5% without and 1.9% with prophylaxis, p ⬍ 0.05). Only one tumor patient (1.4%) not given prophylaxis developed post-PEG pneumonia. All cases of pneumonia occurred in the periinterventional period during the first 96 h after PEG. In conclusion, we believe that different underlying diseases in patients undergoing PEG give rise to different problems and outcomes. Patients with tumors may be at greater risk of peristomal infection because of the passage of the internal bumper through the necrosis and the associated contamination encountered in the widely used pull-through technique. The risk can be reduced significantly by singleshot antibiotic prophylaxis using various regimens. The usefulness of a routine mouthwash in this setting is not clear. Patients with underlying neurological disease are at high risk for costly systemic complications. Antibiotic prophylaxis can significantly reduce the incidence of severe systemic infections in these patients in a way similar to that of other patient groups, but the available data for PEG are sparse (6). Long-acting antibiotic substances may be more effective in preventing systemic complications of this type (3, 6). These aspects should be considered in future trials and meta-analyses so as to demonstrate the efficacy of different antibiotic regimens in different patient groups. A. J. Dormann, M.D. H. Huchzermeyer, M.D. H. Lippert, M.D. Medical Clinic Klinikum Minden Minden, Germany Department of Surgery Otto von Guericke University Magdeburg, Germany
REFERENCES 1. Sharma VK, Howden CW. Meta-analysis of randomised controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol 2000;95:3133– 6. 2. Ku¨lling D, Sonnenberg A, Fried M, Bauerfeind P. Cost analysis of antibiotic prophylaxis for PEG. Gastrointest Endosc 2000; 51:152– 6. 3. Dormann AJ, Wigginghaus B, Risius H, et al. A single dose of
Letters to the Editor
hemoglobin drops significantly the doses of ribavirin should be reduced (1). In some cases blood transfusion may also be necessary (5). In this case, the patient remained symptom free, his activity was such that he did not need transfusions, and treatment was completed successfully without transfusions. This case illustrates that it is possible to treat chronic hepatitis C successfully in a patient with pre-existing hemolytic anemia and transfusion may not be required, although close monitoring is necessary. Nasir Khokhar, M.D. Division of Gastroenterology Department of Medicine Shifa International Hospital and Shifa College of Medicine Islamabad, Pakistan
REFERENCES 1. McHutchison JG, Gordon SC, Schiff ER, et al. Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis “C”. N Engl J Med 1998;339:1485– 92. 2. Shivatori Y, Imazeki F, Moriyama M, et al. Histologic improvement of fibrosis in patients with hepatitis “C” who have sustained response to interferon therapy. Ann Intern Med 2000; 132:517–24. 3. Linker CA. Anemias. In: Tierney LM, Mcphee SJ, Papadakis MA, eds. Current medical diagnosis and treatment. Stamford, CT: Appleton & Lange, 1998:489 –90. 4. Dimarco V, Iacono OL, Capra M, et al. Alpha interferon treatment of chronic hepatitis “C” in B-thalassemia. Gut 1993; (suppl):S142–3. 5. Telfer PT, Garson JA, Whitley K, et al. Combination therapy with interferon alpha and ribavirin for chronic hepatitis “C” virus infection in thalassemic patients. Br J Haematol 1997;98: 850 –5.
AJG – Vol. 96, No. 6, 2001
tecting malignant lesions of the esophagus (2), with good results. Forty gastroesophageal reflux disease patients who underwent endoscopy for diagnosis and grading of esophagitis according to the Savary-Miller system (3) were included in this study. On the morning after endoscopy, patients were scheduled for Tc-TF chest SPECT to detect and grade esophagitis. The chest SPECT was performed 15 to 30 min after an i.v. injection of 740 MBq of Tc-TF. The sagittal slices of SPECT were interpreted as negative (no uptake in the esophagus) or positive. Based on the endoscopic findings, the sensitivity, specificity, and accuracy rates of Tc-TF chest SPECT in detecting esophagitis were 100%, 77%, and 95%, respectively. The correlation between the endoscopic and Tc-TF chest SPECT findings was good (r ⫽ 0.913, p ⬍ 0.05). Mitochondrial/plasma membrane potentials, the cellular mitochondrial content of the esophageal mucosa, and inflammatory cells could all play significant roles in esophageal uptake of Tc-TF (4), or the uptake may be caused by indirect phenomena such as locally increased blood flow and capillary permeability from inflammation. Therefore, the hypothesis underlying this study was that increased blood flow and capillary permeability associated with esophageal erosions/inflammation could be detected by Tc-TF chest SPECT imaging. Although this pilot study population was small, Tc-TF chest SPECT appeared to have high sensitivity and accuracy in detecting esophagitis among gastroesophageal reflux disease patients. We concluded that the use of Tc-TF chest SPECT is excellent for the exclusion of coronary artery disease when chest pain is encountered. If uptake in the esophagus can be seen in early postexercise or rest studies, the next examination should be endoscopy to rule out esophagitis. Chia-Hung Kao Sheng-Ping ChangLai Jong-Kang Lee Department of Nuclear Medicine Taichung Veterans General Hospital Department of Nuclear Medicine Chung-Shan Medical and Dental Hospital Department of Nuclear Medicine China Medical College Hospital Taichung, Taiwan
Reprint requests and correspondence: Nasir Khokhar, M.D., Division of Gastroenterology, Shifa International Hospital, Shifa College of Medicine, Islamabad, 44000, Pakistan. Received Dec. 21, 2000; accepted Jan. 8, 2001.
Detection of Esophagitis by Technetium 99m Tetrofosmin Chest SPECT TO THE EDITOR: A review of the literature showed that Tl 201 imaging had a high sensitivity for detecting esophagitis when compared with the endoscopic findings (1). However, poor emission characteristics for single photon emission CT (SPECT) imaging and availability problems related to cyclotron production are significant disadvantages of Tl 201. Tc 99m tetrofosmin (Tc-TF) (Myoview, Amersham International, Arlington Heights, IL), competing with Tl 201, has been used as a new radiopharmaceutical for myocardial imaging. In addition, Tc-TF imaging has been tried in de-
REFERENCES 1. De Gregorio BT, Fennerty MB, Wilson RA. Noninvasive diagnosis of gastroesophageal inflammation using dipyridamole thallium-201 tomography. Am J Gastroenterol 1998;93: 1255–9. 2. Watanabe N, Hirano T, Fukushima Y, et al. Esophageal cancer detection with Tc-99m tetrofosmin SPECT. Clin Nucl Med 1997;22:431–3. 3. Savary M, Miller G. The esophagus. In: Savary M, Miller G, eds. Handbook and atlas of endoscopy. Switzerland: Verlag Gassman, 1978:119 –295.
AJG – June, 2001
4. Chiu ML, Kronauge JF, Piwnica-Worms D. Effect of mitochondrial and plasma membrane potentials on accumulation of hexakis (2-methoxyiso-butylisonitrile) technetium (I) in cultured mouse fibroblast. J Nucl Med 1990;31:1646 –53. Reprint requests and correspondence: Chia-Hung Kao, M.D., Department of Nuclear Medicine, Taichung Veterans General Hospital, 160 Taichung Harbor Road, Section 3, Taichung 407, Taiwan. Received Apr. 14, 2000; accepted Jan. 12, 2001.
The Relevance of Systemic Complications and the Different Outcomes of Subgroups After Percutaneous Endoscopic Gastrostomy (PEG) TO THE EDITOR: The usefulness of routine antibiotic prophylaxis before percutaneous endoscopic gastrostomy (PEG) to prevent peristomal infections is supported by the recently published meta-analysis by Sharma and Howden (1) and an article by Ku¨lling et al. (2). In the articles, the authors state that individual investigators judged only a few local infections in various patient groups to be clinically serious. In both clinical trials and the practical setting, local infections after PEG mostly occur as minor complications and rarely necessitate treatment with antibiotics. Infection is controlled in nearly all cases by intensive local treatment. The reduction of peristomal infection rates should not be the only reason to initiate routine antibiotic prophylaxis in all patient groups (3). Systemic infections and, more particularly, postintervention pneumonia are also a serious problem. They are not always evaluated during prospective PEG trials, and this may be why they are frequently underestimated. These infections more often require the use of antibiotics, and sometimes result in a prolonged hospital stay and poorer survival rates (3). To demonstrate the efficacy of antibiotic prophylaxis before PEG, the outcome of subgroups needs to be considered in relation to the underlying disease (e.g., cancer or neurological disease) and the presence of local and systemic infections needs to be taken into account and integrated into a meta-analysis. Severe systemic complications, in contrast to peristomal infections, generally occur in patients with neurological disease (3). One reason for this could be the high risk of aspiration, which is sometimes caused by a feeding protocol using large boluses (4). In the final analysis of our randomized multicenter PEG trial with 216 patients (106 of them given ceftriaxone 1 ⫻ 1 g i.v. prophylactically) undergoing a standardized PEG intervention including care before (including prior antiseptic mouthwash) and after the intervention, 67.2% of the patients had a neurological disease (5). Patients with tumors were scored positive for local infection without (31.0%) and with (3.7%) antibiotic prophylaxis (p ⬍ 0.05). They derived
Letters to the Editor
1951
greater benefit from antibiotic prophylaxis in terms of local infection rates than patients with neurological disease (local infection rate 20.3% vs 11.4%, p ⬎ 0.05). Of the 18.5% of patients scoring positive for peristomal infection, only 2.7% (all without preintervention prophylaxis) received antibiotic therapy for this reason during the 10-day follow-up period. This demonstrates the low grade nature of the infection. The total rate of systemic infections was 11.8% without and 1.9% with antibiotic prophylaxis (p ⬍ 0.05). It was predominantly patients with underlying neurological disease who suffered from postintervention pneumonia (9.5% without and 1.9% with prophylaxis, p ⬍ 0.05). Only one tumor patient (1.4%) not given prophylaxis developed post-PEG pneumonia. All cases of pneumonia occurred in the periinterventional period during the first 96 h after PEG. In conclusion, we believe that different underlying diseases in patients undergoing PEG give rise to different problems and outcomes. Patients with tumors may be at greater risk of peristomal infection because of the passage of the internal bumper through the necrosis and the associated contamination encountered in the widely used pull-through technique. The risk can be reduced significantly by singleshot antibiotic prophylaxis using various regimens. The usefulness of a routine mouthwash in this setting is not clear. Patients with underlying neurological disease are at high risk for costly systemic complications. Antibiotic prophylaxis can significantly reduce the incidence of severe systemic infections in these patients in a way similar to that of other patient groups, but the available data for PEG are sparse (6). Long-acting antibiotic substances may be more effective in preventing systemic complications of this type (3, 6). These aspects should be considered in future trials and meta-analyses so as to demonstrate the efficacy of different antibiotic regimens in different patient groups. A. J. Dormann, M.D. H. Huchzermeyer, M.D. H. Lippert, M.D. Medical Clinic Klinikum Minden Minden, Germany Department of Surgery Otto von Guericke University Magdeburg, Germany
REFERENCES 1. Sharma VK, Howden CW. Meta-analysis of randomised controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol 2000;95:3133– 6. 2. Ku¨lling D, Sonnenberg A, Fried M, Bauerfeind P. Cost analysis of antibiotic prophylaxis for PEG. Gastrointest Endosc 2000; 51:152– 6. 3. Dormann AJ, Wigginghaus B, Risius H, et al. A single dose of