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Stomal polyps—further considerations
Since 1982 we have performed endoscopic positioning of enteral feeding tubes in our hospital, with more than five tubes placed per month and with a total of 285 tubes in four years. We performed only five endoscopic gastrostomies, probably because we do not have neurological patients who need long-term nutritional support. We do not need more than 60.days of tube placement for our patients. Endoscopic positioning of nasoenteral feeding tubes could be done in cases in which endoscopic gastrostomy is contraindicated, such as ascites, morbid obesity, esophagogastric varices, history of gastric surgery, active peptic disease, gastric cancer, and peritoneal carcinomatosis. The only possible disadvantage is that our procedure does not allow for gastric drainage. We have not had any complications with positioning or the use of these tubes if nutrition is properly done. Santiago Gallo, MD Inst. N. Nutrition Vasco de Quiroga, Mexico
REFERENCES 1. Van Steigmann G, Pearlman NW. Simplified endoscopic place-
ment of nasoenteral feeding tubes. Gastrointest Endosc 1986;32:349-50. 2. Gallo S, Ramirez A, Elizondo J. Endoscopic placement of enteral feeding tubes. J Parent Ent Nutr 1985;9:747-9.
Medications for use in patients with enteral feeding tubes To the Editor: Although medications have been given for years through large bore nasogastric tubes and surgical gastrostomies, the newer feeding tubes are of a smaller caliber. Giving crushed medications through these devices is fraught with difficulty. Over the 15 months prior to April 1, 1986, we placed 76 percutaneous endoscopic gastrostomy (PEG) tubes. Of the 22 patients still living and using their tubes, 12 tubes had been pulled and replaced with Foley catheters. Follow-up of these patients revealed that the original tubes had been replaced in most cases because they had gradually become obstructed. Although "liquid medications only" had been recommended, information obtained from records and telephone calls revealed that the majority of these patients had received crushed medications dissolved in water. With careful crushing of the tablets and meticulous flushing of the tubes, plugging can be avoided or delayed. At present, there is no readily accessible listing of liquid medications available to referring physicians and nursing homes. We have, therefore, compiled such a list of the most commonly used medications, based on medications used in our patient population. We will be happy to provide this list of liquid oral dosage forms to your readers upon request. If a medication is available in an oral liquid form, this would be the preferred oral dosage form to use. Flushing the gastrostomy tube should be diluted, shaken well, and injected through the tube and the tube flushed with water. (Address for list: Jack D. Welsh, MD, Oklahoma Memorial Hospital, P.O. Box 26307, Oklahoma City, Oklahoma 73126.) VOLUME 33, NO.2, 1987
Joe C. Zuerker, MD J. Chris Bradberry, PharmD Charles F. Seifert, PharmD Jack D. Welsh, MD Robert A. Rankin, MD Digestive Diseases and Nutrition Section Department of Medicine, College of Medicine Section of Pharmacy Practice, College of Pharmacy The University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma
Stomal polyps-further considerations To the Editor: Delpre et aI., in a previous letter in this journal,I suggested that polyps at a gastroenterostomy stoma, the so-called "gastritis cystica polyposa," have been reported in only eight cases. We wish to point out that in 1985 we reported 20 such polyps occurring in 18 subjects. 2 We have since collected 16 further such polyps in 12 patients. The 36 polyps occurred mainly at a gastroenterostomy site after a Billroth II surgical procedure but also was noted after Billroth I partial gastrectomy and simple gastroenterostomy without gastric resection, although less frequently. Gastritis cystica polyposa may show two different histological patterns: (1) gastritis cystica superficialis (with cystic glands limited to the mucosal layer), and (2) gastritis cystica profunda (with cystic glands spreading into the submucosa).3 These stomal polyps likely represent a reactive, regenerative phenomenon. However, we agree with Delpre et al.I in considering gastritis cystica polyposa as a possible precancerous lesion due to the high frequency of dysplastic changes. 2• 3 Giuseppe Franzin, MD Renata Musola, MD SeNizio di Endoscopia Istituti Ospitalieri Verona, Italy
REFERENCES 1. Delpre G, Kadish V, Avidor I. Postgrastrectomy polyps and
polyps at site of anastomosis-further considerations. Gastrointest Endosc 1986;32:247. 2. Franzin G, Musola R, Zamboni G, Manfrini C. Gastritis cystica polyposa-a possible precancerous lesion. Tumori 1985;71:13. 3. Franzin G, Novelli P. Gastritis cystica profunda. Histopathology 1981;5:535.
Duodenal ulcer complicating intraarterial chemotherapy To the Editor: Hepatic artery infusion chemotherapy, either via a surgically placed or percutaneous catheter, is an established method for treating hepatic metastases and yields response rates of 30% to 83% with a median survival of up to 25 months from the time of diagnosis.l-3 Gastrointestinal complications have been reported in up to 50% of the patients treated with this modality.4-6 We present a patient subjected 127
REFERENCES 1. Van Steigmann G, Pearlman NW. Simplified endoscopic place-
ment of nasoenteral feeding tubes. Gastrointest Endosc 1986;32:349-50. 2. Gallo S, Ramirez A, Elizondo J. Endoscopic placement of enteral feeding tubes. J Parent Ent Nutr 1985;9:747-9.
Medications for use in patients with enteral feeding tubes To the Editor: Although medications have been given for years through large bore nasogastric tubes and surgical gastrostomies, the newer feeding tubes are of a smaller caliber. Giving crushed medications through these devices is fraught with difficulty. Over the 15 months prior to April 1, 1986, we placed 76 percutaneous endoscopic gastrostomy (PEG) tubes. Of the 22 patients still living and using their tubes, 12 tubes had been pulled and replaced with Foley catheters. Follow-up of these patients revealed that the original tubes had been replaced in most cases because they had gradually become obstructed. Although "liquid medications only" had been recommended, information obtained from records and telephone calls revealed that the majority of these patients had received crushed medications dissolved in water. With careful crushing of the tablets and meticulous flushing of the tubes, plugging can be avoided or delayed. At present, there is no readily accessible listing of liquid medications available to referring physicians and nursing homes. We have, therefore, compiled such a list of the most commonly used medications, based on medications used in our patient population. We will be happy to provide this list of liquid oral dosage forms to your readers upon request. If a medication is available in an oral liquid form, this would be the preferred oral dosage form to use. Flushing the gastrostomy tube should be diluted, shaken well, and injected through the tube and the tube flushed with water. (Address for list: Jack D. Welsh, MD, Oklahoma Memorial Hospital, P.O. Box 26307, Oklahoma City, Oklahoma 73126.) VOLUME 33, NO.2, 1987
Joe C. Zuerker, MD J. Chris Bradberry, PharmD Charles F. Seifert, PharmD Jack D. Welsh, MD Robert A. Rankin, MD Digestive Diseases and Nutrition Section Department of Medicine, College of Medicine Section of Pharmacy Practice, College of Pharmacy The University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma
Stomal polyps-further considerations To the Editor: Delpre et aI., in a previous letter in this journal,I suggested that polyps at a gastroenterostomy stoma, the so-called "gastritis cystica polyposa," have been reported in only eight cases. We wish to point out that in 1985 we reported 20 such polyps occurring in 18 subjects. 2 We have since collected 16 further such polyps in 12 patients. The 36 polyps occurred mainly at a gastroenterostomy site after a Billroth II surgical procedure but also was noted after Billroth I partial gastrectomy and simple gastroenterostomy without gastric resection, although less frequently. Gastritis cystica polyposa may show two different histological patterns: (1) gastritis cystica superficialis (with cystic glands limited to the mucosal layer), and (2) gastritis cystica profunda (with cystic glands spreading into the submucosa).3 These stomal polyps likely represent a reactive, regenerative phenomenon. However, we agree with Delpre et al.I in considering gastritis cystica polyposa as a possible precancerous lesion due to the high frequency of dysplastic changes. 2• 3 Giuseppe Franzin, MD Renata Musola, MD SeNizio di Endoscopia Istituti Ospitalieri Verona, Italy
REFERENCES 1. Delpre G, Kadish V, Avidor I. Postgrastrectomy polyps and
polyps at site of anastomosis-further considerations. Gastrointest Endosc 1986;32:247. 2. Franzin G, Musola R, Zamboni G, Manfrini C. Gastritis cystica polyposa-a possible precancerous lesion. Tumori 1985;71:13. 3. Franzin G, Novelli P. Gastritis cystica profunda. Histopathology 1981;5:535.
Duodenal ulcer complicating intraarterial chemotherapy To the Editor: Hepatic artery infusion chemotherapy, either via a surgically placed or percutaneous catheter, is an established method for treating hepatic metastases and yields response rates of 30% to 83% with a median survival of up to 25 months from the time of diagnosis.l-3 Gastrointestinal complications have been reported in up to 50% of the patients treated with this modality.4-6 We present a patient subjected 127