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Esophageal casts: unusual finding on removal of a nasogastric tube
apparent complications from free stent fragments. We hope this technique will prove useful in adjusting the length of wire stents. Ronald Schwartz, MD Richard Zera, MD Oliver Cass, MD
to be restarted if stent insertion fails because of disruption of the coaxial system or if bowing of the stent in the duodenum occurs. We recommend that an attempt to advance the stent up the bile duct be made using a polypectomy snare as described. Douglas Simon, MD Steve Landau, MD
Hennepin County Medical Center Minneapolis, Minnesota
Division of Gastroenterology Albert Einstein College of Medicine Bronx, New York
REFERENCES 1. Domschke W, Foerster E. Endoscopic implantation oflarge bore self-expanding biliary mesh stent. Gastrointest Endose 1990;
36:55-7.
Use of a polypectomy snare to salvage a faulted stent placement To the Editor: Endoscopic biliary stent placement is an important technique to palliate common bile duct obstruction. Stent placement is difficult and requires close coordination between the endoscopist and endoscopic technician. A critical component of stent placement is preventing the stent from bowing in the duodenum. If this occurs, stent placement can fail, requiring the stent to be removed and the procedure replicated. We describe a case where the endoscopic technician accidentally removed the inner guiding catheter and wire before the stent was completely placed, but the stent was still able to be successfully placed by using a polypectomy snare in a creative way. An 81-year-old woman presented with painless jaundice and pruritus. Her bilirubin was 24 mg/dl, and abdominal CAT scan showed a mass in the head and tail of the pancreas with dilation of the pancreatic duct, the gallbladder, and biliary tract. An ERCP showed a common bile duct with a diameter of 2 cm and an approximate 5-cm stricture distally. A small sphincterotomy was performed to facilitate stent insertion. The guide wire and the inner guiding catheter were then placed into the common hepatic duct. A lOF, 9-cm stent was advanced through the endoscope channel. The endoscopic technician maintained tension on the inner guide catheter as the stent was advanced to facilitate stent insertion. After 2 cm of the stent was advanced through the ampulla of Vater, the technician accidently pulled too hard on the inner guide catheter and wire, and these became disconnected from the stent. At this point approximately 7 cm of the stent was protruding from the ampulla of Vater. We decided to remove the stent with a polypectomy snare and begin again. A standard polypectomy snare was positioned and tightened around the stent, approximately 2 cm below the ampulla of Vater. By lifting the endoscope elevator and angling up the tip of the endoscope, the stent advanced up the bile duct by approximately 2 cm. The snare was loosened, moved down the stent by 2 cm, tightened, and again advanced up the bile duct by a combination of elevator elevation and endoscope tip angling. This was repeated until the stent was in proper position and bile was seen flowing from the stent. The bilirubin decreased to 10 mg/dl 3 days later and the pruritus resolved. This case is an example of how the procedure may not have 736
Esophageal casts: unusual finding on removal of a nasogastric tube To the Editor: We have recently encountered an unusual finding on removal of a nasogastric tube before evaluation for gastrointestinal bleeding. A 41-year-old woman who had received a cadaveric kidney transplant for end-stage renal disease secondary to glomerulosclerosis was admitted to the hospital for suspected transplant rejection. While the patient was receiving immunosuppressive therapy, multi-organ failure developed, suspected to be caused by dissemi· nated cytomegalovirus, including disseminated intravascular coagulopathy resistant to replacement therapy, respiratory failure, and pneumonia requiring endotracheal intubation, anuria requiring hemodialysis, and gastrointestinal bleeding manifested as bloody drainage from the nasogastric tube and melena. She had a nasogastric tube placed for decompression of gastrointestinal gas several days before our evaluation. Gastrointestinal bleeding began approximately 12 hours before endoscopic evaluation. .At that time she had already been scheduled to undergo exploratory laparotomy for removal of the rejected kidney. Physical examination before esophagogastroduodenoscopy revealed a sedated patient, intubated, with a nasogastric tube draining fresh blood, and an abdomen that was distended and tympanitic, with hypoactive bowel sounds. Abdominal radiographs showed an ileus pattern. The nasogastric tube was removed without any difficulty immediately before the endoscopy. The distal portion of the nasogastric tube was tightly and circumferentially wrapped with what appeared to be yellow-tan tissue (Fig. 1). Because endoscopic information could provide valuable information immediately before surgery, an esophagogastroscopy was performed. It revealed a normal proximal and mid-esophagus. In the third portion of the esophagus, a tubular structure was seen
Figure 1. Tip of the nasogastric tube after removal showing a tight circumferential yellow-tan tissue wrapped around it.
GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic view of the distal portion of the esophagus showing a tubular structure within the lumen.
Figure 1. High-power micrograph of colonoscopic biopsy specimen from right-sided colonic ulcer demonstrating viral intranuclear inclusions (arrows) compatible with HSV.
within the lumen, with walls that collapsed easily on touch with the endoscope (Fig. 2). The endoscope could not be advanced beyond this area. The patient underwent laparotomy immediately after endoscopy. No evidence of a viscus perforation was seen. The esophageal tubular structure was easily identified and removed. Pathologic findings of the material around the nasogastric tube showed fibrin and blood clot. The source of gastrointestinal bleeding was a diffuse, nonerosive gastritis. The patient died several days later. No post-mortem study was performed. Our case represents a very unusual (and disconcerting) finding on withdrawal of a nasogastric tube. Initially, we considered it to be a complication of the nasogastric tube, possibly associated with esophageal perforation. 1-3 We have not found a case similar to ours described in the English literature.
appears uniquely suited to cause most disease. The ubiquitous distribution and inherent latency of these infections in the normal host provide a great potential for reactivation disease with the initiation of immunosuppression. 2 Herpes simplex virus (HSV) disease appears to be common after kidney transplantation. 3, 4 The manifestation of these HSV infections are variable and site specific. Severe colitis attributable to HSV and treated successfully with acyclovir has been reported. 5 A case of HSV colitis with hemorrhage treated endoscopically is described here. A 47-year-old man with chronic kidney failure underwent cadaveric kidney transplantation. Post-operatively, the patient's graft exhibited acute rejection, requiring increased immunosuppression with cyclosporine, prednisone, and azathioprine. He developed increasing abdominal distention, with decreased stool output and flatus. An abdominal radiograph on post-operative day 7 revealed a dilated transverse colon. A decompressive colonoscopy was completed on postoperative day 8 and showed scattered submucosal hemorrhage involving the right and transverse colon without ulceration. Abdominal CT scan revealed a thickened colonic wall without masses or abscess. On post-operative day 10, the patient began spiking fevers. Initial blood cultures grew coagulase-negative Staphylococcus. Vancomycin was begun and all vascular access changed. Fevers persisted, and hematochezia developed on postoperative day 15. Stool cultures for Salmonella, Shigella, Campylobacter, and Clostridium difficile toxin assay were negative. Colonoscopy on post-operative day 16 revealed multiple discreet, deep ulcerations localized to the right colon and extending distally to the mid-transverse colon. Areas of normal-appearing mucosa were present between the ulcerations. The left colon appeared normal. Multiple biopsy specimens were obtained from the ulcers and demonstrated viral intranuclear inclusions compatible with HSV (Figure 1). This same day, vesicular oral lesions developed consistent with HSV infection. A urine culture taken at this time subsequently grew HSV type 1. The patient was placed on intravenous acyclovir and became afebrile. However, intermittent hematochezia continued, requiring transfusions totaling 12 units of red cells during the next 6 days. Because of persistent bleeding, colonoscopy was repeated on post-
Isaac Raijman, MD Joseph H. Sellin, MD Division of Gastroenterology The University of Texas Medical School at Houston Houston, Texas
REFERENCES Tiller HJ, Rhea WG, Jr. Iatrogenic perforation of the esophagus by a nasogastric tube. Am J Surg 1984;147:423-5. 2. Lewandrowski KB, Southern JF, Medeiros LJ, Jacobs M. Aortoesophageal fistula arising as a complication of prolonged nasogastric tube placement. Hum Pathol 1989;20:709-11. 3. Merchant FJ, Nichols RL, Bombeck CT. Unusual complication of nasogastric esophageal intubation: erosion into an aberrant right subclavian artery. J Cardiovasc Surg 1977;18:147-50. 1.
Colonoscopy and endoscopic therapy of hemorrhage from viral colitis To the Editor: The advent of transplantation and the attendant immunosuppression has resulted in growing recognition of viral infections in the susceptible host. 1 The herpes virus family VOLUME 39, NO.5, 1993
737
to be restarted if stent insertion fails because of disruption of the coaxial system or if bowing of the stent in the duodenum occurs. We recommend that an attempt to advance the stent up the bile duct be made using a polypectomy snare as described. Douglas Simon, MD Steve Landau, MD
Hennepin County Medical Center Minneapolis, Minnesota
Division of Gastroenterology Albert Einstein College of Medicine Bronx, New York
REFERENCES 1. Domschke W, Foerster E. Endoscopic implantation oflarge bore self-expanding biliary mesh stent. Gastrointest Endose 1990;
36:55-7.
Use of a polypectomy snare to salvage a faulted stent placement To the Editor: Endoscopic biliary stent placement is an important technique to palliate common bile duct obstruction. Stent placement is difficult and requires close coordination between the endoscopist and endoscopic technician. A critical component of stent placement is preventing the stent from bowing in the duodenum. If this occurs, stent placement can fail, requiring the stent to be removed and the procedure replicated. We describe a case where the endoscopic technician accidentally removed the inner guiding catheter and wire before the stent was completely placed, but the stent was still able to be successfully placed by using a polypectomy snare in a creative way. An 81-year-old woman presented with painless jaundice and pruritus. Her bilirubin was 24 mg/dl, and abdominal CAT scan showed a mass in the head and tail of the pancreas with dilation of the pancreatic duct, the gallbladder, and biliary tract. An ERCP showed a common bile duct with a diameter of 2 cm and an approximate 5-cm stricture distally. A small sphincterotomy was performed to facilitate stent insertion. The guide wire and the inner guiding catheter were then placed into the common hepatic duct. A lOF, 9-cm stent was advanced through the endoscope channel. The endoscopic technician maintained tension on the inner guide catheter as the stent was advanced to facilitate stent insertion. After 2 cm of the stent was advanced through the ampulla of Vater, the technician accidently pulled too hard on the inner guide catheter and wire, and these became disconnected from the stent. At this point approximately 7 cm of the stent was protruding from the ampulla of Vater. We decided to remove the stent with a polypectomy snare and begin again. A standard polypectomy snare was positioned and tightened around the stent, approximately 2 cm below the ampulla of Vater. By lifting the endoscope elevator and angling up the tip of the endoscope, the stent advanced up the bile duct by approximately 2 cm. The snare was loosened, moved down the stent by 2 cm, tightened, and again advanced up the bile duct by a combination of elevator elevation and endoscope tip angling. This was repeated until the stent was in proper position and bile was seen flowing from the stent. The bilirubin decreased to 10 mg/dl 3 days later and the pruritus resolved. This case is an example of how the procedure may not have 736
Esophageal casts: unusual finding on removal of a nasogastric tube To the Editor: We have recently encountered an unusual finding on removal of a nasogastric tube before evaluation for gastrointestinal bleeding. A 41-year-old woman who had received a cadaveric kidney transplant for end-stage renal disease secondary to glomerulosclerosis was admitted to the hospital for suspected transplant rejection. While the patient was receiving immunosuppressive therapy, multi-organ failure developed, suspected to be caused by dissemi· nated cytomegalovirus, including disseminated intravascular coagulopathy resistant to replacement therapy, respiratory failure, and pneumonia requiring endotracheal intubation, anuria requiring hemodialysis, and gastrointestinal bleeding manifested as bloody drainage from the nasogastric tube and melena. She had a nasogastric tube placed for decompression of gastrointestinal gas several days before our evaluation. Gastrointestinal bleeding began approximately 12 hours before endoscopic evaluation. .At that time she had already been scheduled to undergo exploratory laparotomy for removal of the rejected kidney. Physical examination before esophagogastroduodenoscopy revealed a sedated patient, intubated, with a nasogastric tube draining fresh blood, and an abdomen that was distended and tympanitic, with hypoactive bowel sounds. Abdominal radiographs showed an ileus pattern. The nasogastric tube was removed without any difficulty immediately before the endoscopy. The distal portion of the nasogastric tube was tightly and circumferentially wrapped with what appeared to be yellow-tan tissue (Fig. 1). Because endoscopic information could provide valuable information immediately before surgery, an esophagogastroscopy was performed. It revealed a normal proximal and mid-esophagus. In the third portion of the esophagus, a tubular structure was seen
Figure 1. Tip of the nasogastric tube after removal showing a tight circumferential yellow-tan tissue wrapped around it.
GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic view of the distal portion of the esophagus showing a tubular structure within the lumen.
Figure 1. High-power micrograph of colonoscopic biopsy specimen from right-sided colonic ulcer demonstrating viral intranuclear inclusions (arrows) compatible with HSV.
within the lumen, with walls that collapsed easily on touch with the endoscope (Fig. 2). The endoscope could not be advanced beyond this area. The patient underwent laparotomy immediately after endoscopy. No evidence of a viscus perforation was seen. The esophageal tubular structure was easily identified and removed. Pathologic findings of the material around the nasogastric tube showed fibrin and blood clot. The source of gastrointestinal bleeding was a diffuse, nonerosive gastritis. The patient died several days later. No post-mortem study was performed. Our case represents a very unusual (and disconcerting) finding on withdrawal of a nasogastric tube. Initially, we considered it to be a complication of the nasogastric tube, possibly associated with esophageal perforation. 1-3 We have not found a case similar to ours described in the English literature.
appears uniquely suited to cause most disease. The ubiquitous distribution and inherent latency of these infections in the normal host provide a great potential for reactivation disease with the initiation of immunosuppression. 2 Herpes simplex virus (HSV) disease appears to be common after kidney transplantation. 3, 4 The manifestation of these HSV infections are variable and site specific. Severe colitis attributable to HSV and treated successfully with acyclovir has been reported. 5 A case of HSV colitis with hemorrhage treated endoscopically is described here. A 47-year-old man with chronic kidney failure underwent cadaveric kidney transplantation. Post-operatively, the patient's graft exhibited acute rejection, requiring increased immunosuppression with cyclosporine, prednisone, and azathioprine. He developed increasing abdominal distention, with decreased stool output and flatus. An abdominal radiograph on post-operative day 7 revealed a dilated transverse colon. A decompressive colonoscopy was completed on postoperative day 8 and showed scattered submucosal hemorrhage involving the right and transverse colon without ulceration. Abdominal CT scan revealed a thickened colonic wall without masses or abscess. On post-operative day 10, the patient began spiking fevers. Initial blood cultures grew coagulase-negative Staphylococcus. Vancomycin was begun and all vascular access changed. Fevers persisted, and hematochezia developed on postoperative day 15. Stool cultures for Salmonella, Shigella, Campylobacter, and Clostridium difficile toxin assay were negative. Colonoscopy on post-operative day 16 revealed multiple discreet, deep ulcerations localized to the right colon and extending distally to the mid-transverse colon. Areas of normal-appearing mucosa were present between the ulcerations. The left colon appeared normal. Multiple biopsy specimens were obtained from the ulcers and demonstrated viral intranuclear inclusions compatible with HSV (Figure 1). This same day, vesicular oral lesions developed consistent with HSV infection. A urine culture taken at this time subsequently grew HSV type 1. The patient was placed on intravenous acyclovir and became afebrile. However, intermittent hematochezia continued, requiring transfusions totaling 12 units of red cells during the next 6 days. Because of persistent bleeding, colonoscopy was repeated on post-
Isaac Raijman, MD Joseph H. Sellin, MD Division of Gastroenterology The University of Texas Medical School at Houston Houston, Texas
REFERENCES Tiller HJ, Rhea WG, Jr. Iatrogenic perforation of the esophagus by a nasogastric tube. Am J Surg 1984;147:423-5. 2. Lewandrowski KB, Southern JF, Medeiros LJ, Jacobs M. Aortoesophageal fistula arising as a complication of prolonged nasogastric tube placement. Hum Pathol 1989;20:709-11. 3. Merchant FJ, Nichols RL, Bombeck CT. Unusual complication of nasogastric esophageal intubation: erosion into an aberrant right subclavian artery. J Cardiovasc Surg 1977;18:147-50. 1.
Colonoscopy and endoscopic therapy of hemorrhage from viral colitis To the Editor: The advent of transplantation and the attendant immunosuppression has resulted in growing recognition of viral infections in the susceptible host. 1 The herpes virus family VOLUME 39, NO.5, 1993
737