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Hookworm infestation diagnosed by capsule endoscopy (with video)
At the Focal Point
A 62-year-old woman with hepatitis C cirrhosis was seen for severe right upper quadrant pain similar to prior episodes of biliary colic. She had a complicated cholecystectomy in 1971 with biliary-enteric anastomosis and blood transfusion causing hepatitis C. A feeding tube was recently placed at an outside hospital for severe malnutrition before liver transplantation. After initiation of feeding, severe pain ensued. On examination, exquisite right upper quadrant tenderness was appreciated. Admission radiography revealed abnormal positioning of the tube in the right upper quadrant (A). Computed tomographic scan confirmed placement of tube within the biliary-enteric anastomosis (B). Examination under fluoroscopy revealed side-to-side choledochoduodenostomy anatomy (C, black arrow) and distal end of tube in the common bile duct. The tube was
reduced under direct fluoroscopic guidance into the stomach (C, white arrow). The patient had immediate resolution of pain. She then tolerated tube feeding well.
DISCLOSURE The authors have nothing to disclose. Jeremias C. Tan, MD, Fredric D. Gordon, MD, Department of Gastroenterology, Lahey Clinic Medical Center, Burlington, Massachusetts, USA doi:10.1016/j.gie.2006.01.043
Commentary Biliary-enteric anastomoses are best used as a conduit for bile to flow into the duodenum, not for duodenal contents or nutrients to flow retrograde into the pancreaticobiliary system. Retrograde passage is seen with a closed duodenal loop and may include foreign bodies such as enteroliths, ingested nematodes or trematodes, and now this interesting nutritional infusate. Whether the pain was true biliary colic, which is not colic at all, or if it resulted from stimulation of stretch and chemical receptors in the biliary epithelium is not clear and with luck will not be seen more frequently than other medical anecdotes. Lawrence J. Brandt, MD Associate Editor for Focal Points
Hookworm infestation diagnosed by capsule endoscopy (with video)
www.giejournal.org
Volume 64, No. 2 : 2006 GASTROINTESTINAL ENDOSCOPY 277
At the Focal Point
tium-labeled red blood cell scan had negative results. Capsule endoscopy (PillCam SB capsule, Given Imaging, Yoqneam, Israel) disclosed numerous rhabditiform worms from the third portion of the duodenum to the jejunum (A, B) (Video 1; available online at www.giejournal. org). Concentrated stool examination demonstrated the hookworm ova (C; merthiolate-iodine formaldehyde, orig. mag. 400). Mebendazole 100 mg twice daily was administered for 3 days. No more melena occurred. The follow-up course was uneventful, and serial stool evaluations did not find any ova. DISCLOSURE The authors have no disclosure. An 88-year-old farmer was seen in the hospital with a 1-month history of intermittent melena. Laboratory tests revealed hemoglobin 6.9 g/dL (normal: 13-17 g/dL), platelet count 375,000/mm3 (normal: 150,000-400,000 mm3), and white blood cell count 6930/mm3 (PMNs 82.7%, lymphocytes 8.8%, and eosinophils 2.3%) (normal: 4000-11,000 mm3, 40%-75%, 20%-45%, 1%-6%). Esophagogastroduodenoscopy (EGD) and colonoscopy did not find any bleeding site. Initial stool tests showed no ova or parasites. A techne-
Tan-Hsia Chen, MD, Tzy-Yen Chen, MD, Division of Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; LingYuh Shyu, MD, Department of Parasitology, Chung Shan Medical University, Taichung, Taiwan; Chen-Kun Lin, MD, Chun-Che Lin, MD, PhD, Division of Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan doi:10.1016/j.gie.2006.01.039
Commentary It is estimated that 1 billion people are infected with hookworm, mostly Necator americanus and Ancylostoma duodenale. After the third-stage larvae penetrate the skin and migrate to the lungs, they eventually penetrate alveoli and are swallowed, passing into the small bowel, where they mature. Mature worms mate and lay eggs: N americanus w10,000 per day and A duodenale w20,000 per day for more than 10 years! Hookworms graze on the mucosa, feeding on host blood. Blood consumption is estimated at up to 0.04 mL per day for N americanus and up to 0.3 mL per day for A duodenale; some hookworm species (Ancyclostoma caninum) also may cause eosinophilic enteritis and aphthae. In this case, the cause of the melena is unclear, especially because it wasn’t noted on the capsule endoscopy. I will look with interest for future evaluations of the small bowel in hookworm infection. Lawrence J. Brandt, MD Associate Editor for Focal Points
278 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 2 : 2006
www.giejournal.org
A 62-year-old woman with hepatitis C cirrhosis was seen for severe right upper quadrant pain similar to prior episodes of biliary colic. She had a complicated cholecystectomy in 1971 with biliary-enteric anastomosis and blood transfusion causing hepatitis C. A feeding tube was recently placed at an outside hospital for severe malnutrition before liver transplantation. After initiation of feeding, severe pain ensued. On examination, exquisite right upper quadrant tenderness was appreciated. Admission radiography revealed abnormal positioning of the tube in the right upper quadrant (A). Computed tomographic scan confirmed placement of tube within the biliary-enteric anastomosis (B). Examination under fluoroscopy revealed side-to-side choledochoduodenostomy anatomy (C, black arrow) and distal end of tube in the common bile duct. The tube was
reduced under direct fluoroscopic guidance into the stomach (C, white arrow). The patient had immediate resolution of pain. She then tolerated tube feeding well.
DISCLOSURE The authors have nothing to disclose. Jeremias C. Tan, MD, Fredric D. Gordon, MD, Department of Gastroenterology, Lahey Clinic Medical Center, Burlington, Massachusetts, USA doi:10.1016/j.gie.2006.01.043
Commentary Biliary-enteric anastomoses are best used as a conduit for bile to flow into the duodenum, not for duodenal contents or nutrients to flow retrograde into the pancreaticobiliary system. Retrograde passage is seen with a closed duodenal loop and may include foreign bodies such as enteroliths, ingested nematodes or trematodes, and now this interesting nutritional infusate. Whether the pain was true biliary colic, which is not colic at all, or if it resulted from stimulation of stretch and chemical receptors in the biliary epithelium is not clear and with luck will not be seen more frequently than other medical anecdotes. Lawrence J. Brandt, MD Associate Editor for Focal Points
Hookworm infestation diagnosed by capsule endoscopy (with video)
www.giejournal.org
Volume 64, No. 2 : 2006 GASTROINTESTINAL ENDOSCOPY 277
At the Focal Point
tium-labeled red blood cell scan had negative results. Capsule endoscopy (PillCam SB capsule, Given Imaging, Yoqneam, Israel) disclosed numerous rhabditiform worms from the third portion of the duodenum to the jejunum (A, B) (Video 1; available online at www.giejournal. org). Concentrated stool examination demonstrated the hookworm ova (C; merthiolate-iodine formaldehyde, orig. mag. 400). Mebendazole 100 mg twice daily was administered for 3 days. No more melena occurred. The follow-up course was uneventful, and serial stool evaluations did not find any ova. DISCLOSURE The authors have no disclosure. An 88-year-old farmer was seen in the hospital with a 1-month history of intermittent melena. Laboratory tests revealed hemoglobin 6.9 g/dL (normal: 13-17 g/dL), platelet count 375,000/mm3 (normal: 150,000-400,000 mm3), and white blood cell count 6930/mm3 (PMNs 82.7%, lymphocytes 8.8%, and eosinophils 2.3%) (normal: 4000-11,000 mm3, 40%-75%, 20%-45%, 1%-6%). Esophagogastroduodenoscopy (EGD) and colonoscopy did not find any bleeding site. Initial stool tests showed no ova or parasites. A techne-
Tan-Hsia Chen, MD, Tzy-Yen Chen, MD, Division of Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; LingYuh Shyu, MD, Department of Parasitology, Chung Shan Medical University, Taichung, Taiwan; Chen-Kun Lin, MD, Chun-Che Lin, MD, PhD, Division of Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan doi:10.1016/j.gie.2006.01.039
Commentary It is estimated that 1 billion people are infected with hookworm, mostly Necator americanus and Ancylostoma duodenale. After the third-stage larvae penetrate the skin and migrate to the lungs, they eventually penetrate alveoli and are swallowed, passing into the small bowel, where they mature. Mature worms mate and lay eggs: N americanus w10,000 per day and A duodenale w20,000 per day for more than 10 years! Hookworms graze on the mucosa, feeding on host blood. Blood consumption is estimated at up to 0.04 mL per day for N americanus and up to 0.3 mL per day for A duodenale; some hookworm species (Ancyclostoma caninum) also may cause eosinophilic enteritis and aphthae. In this case, the cause of the melena is unclear, especially because it wasn’t noted on the capsule endoscopy. I will look with interest for future evaluations of the small bowel in hookworm infection. Lawrence J. Brandt, MD Associate Editor for Focal Points
278 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 2 : 2006
www.giejournal.org