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Duodenal perforation after removal of swallowed tooth
aware that potential esophageal injury, including frank perforation, can occur with the use of PEG-ELS preparations. Matthew A. McBride, MD Arvydas Vanagunas, MD Northwestern University Medical School Section of Gastroenterology Chicago. Illinois
REFERENCES 1. Reynolds JEF. Martindale: the extra pharmacopeia. 29th ed. London: Pharmaceutical Press, 1989:1130. 2. Brullet E, Moron A, Calvet X, Frias C, Sola J. Urticarial reaction to oral polyethylene glycol electrolyte lavage solution. Gastrointest Endosc 1992;38:400-1. 3. Schuman E, Balsam PE. Probable anaphylactic reaction to polyethylene glycol lavage solution. Gastrointest Endosc 1991; 37:411. 4. Foutch PG, Fleischer D. Lavage-induced pill malabsorption [Letter]. Gastrointest Endosc 1984;30:116. 5. Yantis PL. Lavage-induced cardiac asystole [Letter]. Gastrointest Endosc 1984;30:117. 6. Brinberg DE, Stein J. Mallory-Weiss tear with colonic lavage. Ann Intern Med 1986;104:894-5. 7. Raymond PL. Mallory-Weiss tear associated with polyethylene glycol electrolyte lavage solution [Letter]. Gastrointest Endosc 1991;37:410-1.
Figure 1. An unused PEG tube dilating catheter (top) compared to the first (middle) and second (bottom) dilating catheters used in the first patient.
patients because they had very muscular abdominal walls. We recommend that additional care be taken in adult patients with muscular abdominal walls requiring gastrostomy. In particular, the dilating catheter should always be grasped as far away from its end as possible to maximize the strength of the tube. Richard Zera, MD Oliver Cass, MD
Stretching of PEG dilation catheters To the Editor: We wish to report a vexing problem with the Seldinger technique of PEG placement. A 17-year-old female in a persistent vegetative state after closed head injury was referred for gastrostomy placement. A 20F over-the-wire set was used (no. 000331, Bard Interventional Products, Tewksbury, Mass.). The procedure was unremarkable until the dilating catheter was pulled through the abdominal wall. Pulling on the dilating catheter an inch from its end resulted in stretching of the dilating catheter without emergence of the gastrostomy tube through the abdominal wall (Fig. 1, middle). Attempts to pull and push the catheter through the abdominal wall only made the situation worse. The dilating catheter-gastrostomy tube assembly was retrieved through the mouth, the skin incision was enlarged slightly, and a fresh tube was passed over the wire. After it emerged from the abdominal wall, the second catheter was grasped about 2 inches from the end. It also stretched (Fig. 1, bottom). A third dilating catheter was successfully passed through the abdominal wall after grasping it 2.5 inches from the end. The rest of the procedure was unremarkable. The same phenomenon occurred in a 38-year-old man who had difficulty swallowing after a stab wound to the brainstem. The dilating tube stretched slightly while exiting the abdominal wall. However, in this patient, the procedure was completed by grasping the dilating catheter at the site of the stretching as close to the PEG site as possible. We believe that the dilating catheter stretched in these
VOLUME 39, NO.6, 1993
Departments of Surgery and Medicine Hennepin County Medical Center Minneapolis, Minnesota
Duodenal perforation after removal of swallowed tooth To the Editor: Despite the strict choice of indications for UGI endoscopy and performance by an experienced physician, serious complications sometimes still remain unavoidable. Recently, we encountered a complication after a therapeutic upper endoscopy that may be of interest to your readers. A 64-year-old man was admitted to our hospital for epigastric pain of more than 2 weeks. UGI endoscopy (GIF 1T20 Olympus, Olympus Corp., Tokyo, Japan) revealed an ulcer in the anterior wall of the duodenal bulb. The size of the ulcer was approximately 1 x 2 em with a depth of 0.5 cm. Moreover, a molar tooth lay in the crater (afterwards the patient admitted he swallowed a tooth about 20 days previously). The foreign body was grasped with a snare and pulled out together with the endoscope. Shortly after the procedure, the patient had severe abdominal pain. Physical examination demonstrated diffuse abdominal tenderness with rebound pain, and roentgenography confirmed a perforation. Emergency operation was performed, and a perforation of the anterior duodenal bulb was found. The patient's condition deteriorated, and he died 1 week after the endoscopy.
857
Endoscopic perforation of the gut occurs most commonly as a result of excessive operator force or blind maneuvers. Perforations are most often seen in diseased or distorted areas. 1,2 In this case, the duodenal lesion was probably aggravated by the friction of the foreign body, resulting in deeper penetration of the ulcer crater. With increased tension in the duodenal bulb with inflated air, perforation occurred.
lin left on biopsy forceps does not affect the sensitivity of the CLO test. If duodenal biopsy specimens are to be taken on a patient, this can be performed before re-positioning the gastroscope in the antrum for CLO test biopsy specimens without affecting the sensitivity of the test.
Liu Zunchang Qin Chengyong
Taburn Medical Centre Victoria, Australia
Department of Internal Medicine ShanDong Provincial Hospital JiNan, China
1. Marshall BJ, McGechie DB, Rogers PAR, Glancy RG. Pyloric
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. London: Blackwell Scientific Publications, 1982. 2. Shinya H. Colonoscopy: diagnosis and treatment of colonoscopic disease. New York: Igaku-Shoin Medical Publishers, 1982.
Luke Crantock, MBBS, FRACP Ian Willett, MBBS, FRACP
REFERENCES Campylabacter infection and gastroduodenal disease. Med J Aust 1985;149:439-44.
Latex seal for leaky endoscope valve Sensitivity of CLO test not affected by pre-immersion of biopsy forceps in formalin To the Editor: Helicobacter pylori has been shown to cause chronic gastritis and is implicated in the cause of gastric and duodenal ulcers and some cases of non-ulcer dyspepsia.l Methods for its detection include biopsy with demonstration of urease activity, microscopy, or culture. Serologic and breath tests are alternative means for its detection. For patients undergoing gastroscopy the easiest of these by far is biopsy of the gastric antrum and subsequent demonstration of urease activity using the CLO test (Delta West Ltd., Bently, W. Australia). Frequently, multiple sampling of the UGI tract during gastroscopy is important, including biopsy for Helicobacter pylori. This report determines whether CLO biopsy specimens must be taken first by testing the sensitivity of CLO test before and after immersion of biopsy forceps in formalin. Forty-three patients with gastroduodenitis or duodenal ulcer disease were tested for Helicobacter pylori by taking an antral biopsy sample and embedding this in the medium of the CLO test. Subsequently, the same forceps were immersed in standard 10% buffered formalin and, without rinsing in saline, were used to obtain a further antral biopsy sample from adjacent mucosa for a second CLO test. A total of25 patients tested positive for Helicobacter pylori after 24 hours of incubation at room temperature, and in all of these a positive reaction was similarly recorded for the postimmersion biopsy specimen. No cases occurred in which a positive reaction was found only in the pre-immersion test. Time to positivity was similar for pre-immersion and postimmersion biopsy specimens where Helicobacter pylori was found. Additionally, two drops of 10 % buffered formalin were added to 10 CLO test mediums and the result checked after 24 hours. No false positives were seen. From this we can conclude that a small amount of forma858
To the Editor: Insufflation of air through the endoscope is necessary to allow proper luminal visualization. This requires that the endoscope, which has two or three channels running through it, has intact valves to maintain air pressure in the lumen. The biopsy channel has a rubber valve that allows the introduction of instruments into the endoscope while maintaining a tight air seal by virtue of the "memory" of the rubber and pressure it applies around the instrument. When this valve is overstretched through prolonged use or the introduction of oversized instruments (i.e., lOF stents) air leaks occur. We use a cheap solution to air leaks for times when a replacement valve is not readily available. A latex glove is cut into squares about 2 em on each side. One of these squares is inserted into the leaky valve and sealed as shown (Fig. 1). The instrument is inserted through the valve and punctures the latex to create a new, tighter opening (Fig. 2).
Figure 1. A latex square is inserted into the open valve. GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Reynolds JEF. Martindale: the extra pharmacopeia. 29th ed. London: Pharmaceutical Press, 1989:1130. 2. Brullet E, Moron A, Calvet X, Frias C, Sola J. Urticarial reaction to oral polyethylene glycol electrolyte lavage solution. Gastrointest Endosc 1992;38:400-1. 3. Schuman E, Balsam PE. Probable anaphylactic reaction to polyethylene glycol lavage solution. Gastrointest Endosc 1991; 37:411. 4. Foutch PG, Fleischer D. Lavage-induced pill malabsorption [Letter]. Gastrointest Endosc 1984;30:116. 5. Yantis PL. Lavage-induced cardiac asystole [Letter]. Gastrointest Endosc 1984;30:117. 6. Brinberg DE, Stein J. Mallory-Weiss tear with colonic lavage. Ann Intern Med 1986;104:894-5. 7. Raymond PL. Mallory-Weiss tear associated with polyethylene glycol electrolyte lavage solution [Letter]. Gastrointest Endosc 1991;37:410-1.
Figure 1. An unused PEG tube dilating catheter (top) compared to the first (middle) and second (bottom) dilating catheters used in the first patient.
patients because they had very muscular abdominal walls. We recommend that additional care be taken in adult patients with muscular abdominal walls requiring gastrostomy. In particular, the dilating catheter should always be grasped as far away from its end as possible to maximize the strength of the tube. Richard Zera, MD Oliver Cass, MD
Stretching of PEG dilation catheters To the Editor: We wish to report a vexing problem with the Seldinger technique of PEG placement. A 17-year-old female in a persistent vegetative state after closed head injury was referred for gastrostomy placement. A 20F over-the-wire set was used (no. 000331, Bard Interventional Products, Tewksbury, Mass.). The procedure was unremarkable until the dilating catheter was pulled through the abdominal wall. Pulling on the dilating catheter an inch from its end resulted in stretching of the dilating catheter without emergence of the gastrostomy tube through the abdominal wall (Fig. 1, middle). Attempts to pull and push the catheter through the abdominal wall only made the situation worse. The dilating catheter-gastrostomy tube assembly was retrieved through the mouth, the skin incision was enlarged slightly, and a fresh tube was passed over the wire. After it emerged from the abdominal wall, the second catheter was grasped about 2 inches from the end. It also stretched (Fig. 1, bottom). A third dilating catheter was successfully passed through the abdominal wall after grasping it 2.5 inches from the end. The rest of the procedure was unremarkable. The same phenomenon occurred in a 38-year-old man who had difficulty swallowing after a stab wound to the brainstem. The dilating tube stretched slightly while exiting the abdominal wall. However, in this patient, the procedure was completed by grasping the dilating catheter at the site of the stretching as close to the PEG site as possible. We believe that the dilating catheter stretched in these
VOLUME 39, NO.6, 1993
Departments of Surgery and Medicine Hennepin County Medical Center Minneapolis, Minnesota
Duodenal perforation after removal of swallowed tooth To the Editor: Despite the strict choice of indications for UGI endoscopy and performance by an experienced physician, serious complications sometimes still remain unavoidable. Recently, we encountered a complication after a therapeutic upper endoscopy that may be of interest to your readers. A 64-year-old man was admitted to our hospital for epigastric pain of more than 2 weeks. UGI endoscopy (GIF 1T20 Olympus, Olympus Corp., Tokyo, Japan) revealed an ulcer in the anterior wall of the duodenal bulb. The size of the ulcer was approximately 1 x 2 em with a depth of 0.5 cm. Moreover, a molar tooth lay in the crater (afterwards the patient admitted he swallowed a tooth about 20 days previously). The foreign body was grasped with a snare and pulled out together with the endoscope. Shortly after the procedure, the patient had severe abdominal pain. Physical examination demonstrated diffuse abdominal tenderness with rebound pain, and roentgenography confirmed a perforation. Emergency operation was performed, and a perforation of the anterior duodenal bulb was found. The patient's condition deteriorated, and he died 1 week after the endoscopy.
857
Endoscopic perforation of the gut occurs most commonly as a result of excessive operator force or blind maneuvers. Perforations are most often seen in diseased or distorted areas. 1,2 In this case, the duodenal lesion was probably aggravated by the friction of the foreign body, resulting in deeper penetration of the ulcer crater. With increased tension in the duodenal bulb with inflated air, perforation occurred.
lin left on biopsy forceps does not affect the sensitivity of the CLO test. If duodenal biopsy specimens are to be taken on a patient, this can be performed before re-positioning the gastroscope in the antrum for CLO test biopsy specimens without affecting the sensitivity of the test.
Liu Zunchang Qin Chengyong
Taburn Medical Centre Victoria, Australia
Department of Internal Medicine ShanDong Provincial Hospital JiNan, China
1. Marshall BJ, McGechie DB, Rogers PAR, Glancy RG. Pyloric
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. London: Blackwell Scientific Publications, 1982. 2. Shinya H. Colonoscopy: diagnosis and treatment of colonoscopic disease. New York: Igaku-Shoin Medical Publishers, 1982.
Luke Crantock, MBBS, FRACP Ian Willett, MBBS, FRACP
REFERENCES Campylabacter infection and gastroduodenal disease. Med J Aust 1985;149:439-44.
Latex seal for leaky endoscope valve Sensitivity of CLO test not affected by pre-immersion of biopsy forceps in formalin To the Editor: Helicobacter pylori has been shown to cause chronic gastritis and is implicated in the cause of gastric and duodenal ulcers and some cases of non-ulcer dyspepsia.l Methods for its detection include biopsy with demonstration of urease activity, microscopy, or culture. Serologic and breath tests are alternative means for its detection. For patients undergoing gastroscopy the easiest of these by far is biopsy of the gastric antrum and subsequent demonstration of urease activity using the CLO test (Delta West Ltd., Bently, W. Australia). Frequently, multiple sampling of the UGI tract during gastroscopy is important, including biopsy for Helicobacter pylori. This report determines whether CLO biopsy specimens must be taken first by testing the sensitivity of CLO test before and after immersion of biopsy forceps in formalin. Forty-three patients with gastroduodenitis or duodenal ulcer disease were tested for Helicobacter pylori by taking an antral biopsy sample and embedding this in the medium of the CLO test. Subsequently, the same forceps were immersed in standard 10% buffered formalin and, without rinsing in saline, were used to obtain a further antral biopsy sample from adjacent mucosa for a second CLO test. A total of25 patients tested positive for Helicobacter pylori after 24 hours of incubation at room temperature, and in all of these a positive reaction was similarly recorded for the postimmersion biopsy specimen. No cases occurred in which a positive reaction was found only in the pre-immersion test. Time to positivity was similar for pre-immersion and postimmersion biopsy specimens where Helicobacter pylori was found. Additionally, two drops of 10 % buffered formalin were added to 10 CLO test mediums and the result checked after 24 hours. No false positives were seen. From this we can conclude that a small amount of forma858
To the Editor: Insufflation of air through the endoscope is necessary to allow proper luminal visualization. This requires that the endoscope, which has two or three channels running through it, has intact valves to maintain air pressure in the lumen. The biopsy channel has a rubber valve that allows the introduction of instruments into the endoscope while maintaining a tight air seal by virtue of the "memory" of the rubber and pressure it applies around the instrument. When this valve is overstretched through prolonged use or the introduction of oversized instruments (i.e., lOF stents) air leaks occur. We use a cheap solution to air leaks for times when a replacement valve is not readily available. A latex glove is cut into squares about 2 em on each side. One of these squares is inserted into the leaky valve and sealed as shown (Fig. 1). The instrument is inserted through the valve and punctures the latex to create a new, tighter opening (Fig. 2).
Figure 1. A latex square is inserted into the open valve. GASTROINTESTINAL ENDOSCOPY