Mechanism of the development of gastric ulcer after percutaneous endoscopic gastrostomy

BACKGROUND AND STUDY AIMS

The present study was carried out in order to elucidate the mechanism of the development of gastric ulcer, one of the serious complications of PEG tube placement.

PATIENTS AND METHODS

This retrospective study included 92 patients who underwent gastric endoscopy after PEG tube placement. Gastric ulcers detected at gastroscopy were examined in relation to the length of the protrusion from the PEG tubes intragastric bumper and the use of histamine H 2 -receptor antagonists.

RESULTS

Gastric ulcers were found in nine of the 92 patients, and in all nine the ulcer was found on the posterior wall of the gastric body, where the tip of the PEG tube was attached. Seven of the 21 patients (33.3 %) who had a PEG tube with a long protrusion from the intragastric bumper developed gastric ulcer. By contrast, only two of the 71 patients (2.8 %) who had a PEG tube with a short protrusion developed gastric ulcer. The use of H 2 -blockers had no significant impact on the development of gastric ulcer.

CONCLUSIONS

The occurrence of gastric ulcer after PEG placement was attributable to the shape of the PEG tube within the intragastric space, and not to the use of H 2 -blockers, suggesting that appropriate placement of the PEG tube is an important factor in preventing gastric ulcer.

[Complications of percutaneous endoscopic gastrostomy in the elderly: local skin infection and respiratory infection]

We investigated post-operative management of acute complications of percutaneous endoscopic gastrostomy (PEG) which often caused respiratory infections and local skin infections. The subjects were a total of 341 patients (male 131, female 210, and the mean age was 80.3), they were classified into six groups by method of feeding and use of antibiotics. Patients were divided into three groups based on the time that feeding was started. In Group I, enteral feeding was not started within the first five days. In Group II, sterilized enteral feeding (lactated Ringer's solution for intravenous infusion) using sterilized intravenous infusion kit started within 24 hours after the procedure, and in Group III, feeding of the usual enteral formula started within 24 hours after the procedure. And as for the using of antibiotics, they were also divided into two groups, antibiotics administered[AB (+)] and no antibiotics administered[AB (-)]. Thus, the patients were divided into six groups according to the time of starting nutrition and the use of antibiotics. The rates of incidence of acute respiratory infections and local skin infections in the six groups were compared by the chi-square test and differences in the rates of incidence of complication were also compared between two PEG methods; the Pull/Push method and the Introducer method. The frequency of local skin infection in Group III was significantly higher than in Group I and Group II. As for the PEG methods, the frequency of local skin infection in the Pull/Push method was significantly higher than Introducer methods. Acute respiratory infections occurred significantly less in the AB (+) group than in the AB (-) group. Postoperative administration of antibiotics would seem to be appropriate for prophylaxis of respiratory infection in elderly patients after PEG. On the other hand, local skin infections are not related to administration of antibiotics, and are highly related to the method of feeding. We concluded that nutrition of sterilized enteral feeding immediately after operation using a sterilized intravenous infusion kit and administration of antibiotics are advisable to prevent major complications in elderly patients.

[Usefulness and problems of percutaneous endoscopic gastrostomy in a geriatric hospital]

Usefulness and problems of percutaneous endoscopic gastrostomy (PEG) placement in a geriatric hospital where most patients were severely demented or bed-ridden were evaluated. The variables examined were acute complications, chronic complications, restraint of patients before and after PEG placement, change in physical activity, and ability of oral intake. Results showed that both acute and chronic complications were not rare, but these problems are not peculiar to geriatric hospitals. Quality of life (QOL) was clearly improved. Restraint could be reduced or stopped in 65.2% of restrained patients after PEG tube placement, activity was improved in 55.5% of patients, and oral intake became possible in 14.0% of patients. There were also some improvements in the management of PEG, as the incidence of self-extubation decreased, and tube exchange became easier. In conclusion, it is possible to insert and manage the PEG tubes even in geriatric hospitals, and PEG tubes are quite useful in managing patients with chronic disease and in improving QOL.

[Gastro-esophageal reflux successfully treated with transgastrostomal jejunal tube feeding]

An 82-year-old man suffered from recurrent melena due to reflux esophagitis and aspiration pneumonia, which were caused by severe gastroesophageal reflux. We constructed a gastric stoma by percutaneous endoscopic gastrostomy (PEG) and fixed a transgastrostomal jejunal tube (TGJ tube) in the jejunum through the stoma. Direct administration of fluid into the jejunum was followed by a significant reduction in gastro-esophageal reflux. The reflux esophagitis and aspiration pneumonia did not recur. There was no vomiting, self-extubation, or restlessness that might have been caused by dementia, and the patient was could discharged cared for at into home.

[The effect of soluble fiber dietary supplement on constipation in 3 patients with dysphagia who suffered from cerebral infarction with special reference to serum diamine oxidase activity]

Dietary supplement with soluble fibers was given to 3 patients with stroke and dysphagia and obtained improved defecation condition. These clinical effects of soluble fibers should reduce the burden of the patients and families. Long-term inaction of the gastrointestinal tract or continuation of supplementary diet without fibers will induce atrophic intestinal mucosa and abnormal intestinal function. The addition of dietary soluble fibers into supplementary diet can improve the atrophy of the intestinal mucosa and the decline in function of the intestine, constipation and meteorism. The serum diamine oxidase activity, which is regarded as a parameter of intestinal mucosal atrophy, increased with the improvement of constipation and meteorism after addition of dietary soluble fibers. We think that dietary soluble fibers are necessary, especially for the patients who have low diamine oxidase activity. The measurement of serum diamine oxidase activity should be an effective method to evaluate intestinal mucosal atrophy and estimate dietary fibers. We selected a supplementary diet, Enrich-SF, which contains Fibaron, a kind of soluble fiber, galactomannan purified from guar, because this canned supplementary diet has only one kind of soluble fiber. Some consider that soluble fibers are fermented to short-chain fatty acids in the intestinal tract, and improve the disordered bacterial flora in the intestine, resulting in more regular intestinal function. Attention should be paid to dietary fibers in cases of long-term tube feeding.

Congenital radio-ulnar synostosis

Thirty-three patients with congenital radio-ulnar synostosis were examined. There was one familial predisposition. Chromosomal patterns were examined in seventeen patients and were normal. Bone maturation appeared normal. The radial deviation angle, in the patients whose distal radial epiphysis had closed, was elevated (Madelung's deformity). However, in the patients whose distal epiphysis maturation score was 8, it was not elevated. On the other hand, elongation of the ulna (plus variant) and/or dorsal dislocation of the distal end of the ulna was seen in early life. In terms of treatment, all attempts to divide the two bones failed. It was found that derotation of the nonwriting hand by an osteotomy through the proximal fusion mass was a useful procedure.