Is early endoscopy after percutaneous endoscopic gastrostomy placement dangerous?
Figure 3. A, Small lie lesion with minimal endoscopic findings. B, Dye endoscopy showing details of lesion.
area carefully with air insufflation, which will expand the gastric body. The lesion was endoscopically treated by EGMR. In Japan, routine endoscopy using a slender forwardviewing scope called "panendoscopy" is in wide use. Tsuchiya et al. 9 reported that the accuracy of panendoscopy for early detection of gastric cancer was 77.4 %. Thus, early gastric cancers can be overlooked by panendoscopy. We make use of a slender oblique-viewing scope and a mucous-removing technique6 for routine endoscopy. Our method has resulted in a high rate of detection of small gastric lesions; fundic gland polyps 7,8 and small early cancers amenable to EGMR.4 Our method does not exclude a coexisting lesion. We also detected a small IIc-type gastric cancer, which was overlooked in an initial endoscopy, adjacent to an adenoma. lO In ongoing work, we are studying the patterns in which coexisting lesions with small cancer escape detection by the endoscopist. We hope GI endoscopists will find our method accurate and cost-effective. Keishi Takechi, MD Koji Koda, MD Kizawa Memorial Hospital Minokamo, Japan
REFERENCES 1. Oguro Y. Endoscopic treatment of early gastric cancer. Dig Endose 1991;3:3-15. 2. Takemoto T, Tada M, Yanai H, et al. Significance of strip biopsy with particular reference to endoscopic mucosectomy. Dig Endosc 1989;1:4-9. 3. Salmon PRo Endoscopic treatment of gastro-intestinal tumours: can surgery be avoided? Endoscopy 1992;24:229-31. 4. Takechi K, Mihara M, Saito Y, et al. A modified technique for endoscopic mucosal resection of small early gastric carcinomas. Endoscopy 1992;24:215-7. 5. Misumi A, Misumi K, Murakami A, et al. Endoscopic diagnosis of minute, small and flat early gastric cancers. Endoscopy 1989; 21:159-64. 6. Ida K, Hashimoto Y, Takeda S, et al. Endoscopic diagnosis of gastric cancer with dye scattering. Am J GastroenteroI1975;63: 316-20. 7. Takechi K, Endo J, Furuhashi K et al. Endoscopic characteristics of gastric polyps and their background mucosa on the gastric body. Dig Endosc 1992;4:134-8. 8. Endo J, Takechi K, Saito Y, et al. Endoscopic view of fundic gland polyp [in Japanese]. Endosc Dig 1991;3:786-7. 9. Tsuchiya H, Takasu S, Kitamura A, et al. Accuracy of pan endoscopy as the routine screening method for early gastric cancer [in Japanese]. Stomach Intest 1985;20:955-60. 10. Takechi K, Furuhashi K, Usui T, et al. A case of gastric adenoma combined with lIe type early gastric cancer [in Japanese]. Endose Dig 1991;3:111-4.
To the Editor: PEG has recently become the preferred method of access for long-term enteral nutrition. After PEG placement, the junction between gastric serosa and anterior abdominal wall is important in preventing peritonitis from leakage of gastric contents. Formation of a fibrous gastrocutaneous tract requires at least 1 to 2 weeks! and may be delayed in patients receiving steroids or immunosuppressive therapy or in patients with poor wound healing from malnutrition. 2 Currently, no guidelines exist as to the safe interval between PEG placement and repeat UGI endoscopy. In this report we present a case of fatal peritonitis after repeat gastrointestinal endoscopy 3 days after PEG placement. A 30-year-old woman underwent PEG placement without difficulty 2 weeks after surgical evacuation of a subarachnoid hemorrhage. At the time of PEG placement, a small pyloric channel ulcer was noted but considered inconsequential. Enteral feedings, which were instituted 24 hours later, were well tolerated, and follow-up abdominal examinations were benign. Three days after PEG placement, hematemesis and melena developed. UGI endoscopy at that time showed bleeding from the pyloric channel ulcer, and good hemostasis was achieved with heater probe cautery. Three hours after the endoscopy, the patient showed physical signs consistent with peritonitis. An emergency laparotomy demonstrated approximately 1 to 2 L of gastric contents in the peritoneal cavity, but the PEG tube and bumper were in good position. No evidence of gastric ulcer perforation was seen. The patient subsequently succumbed to complications of peritonitis. The overall procedure-related morbidity from PEG placement is 9.5 %. Mortality in the first 30 days after PEG placement ranges from 9 % to 15 % and is often related to underlying disease. 3 Although peritonitis is a known complication of PEG placement, it has never been reported after repeat endoscopy within 2 weeks of uncomplicated PEG placement. It can be speculated that manipulation of a PEG tube before the formation of an adequate fibrous gastrocutaneous tract was responsible for peritonitis in our patient. A recent report has described a method of placing two U-shaped through-and-through sutures alongside the gastrostomy tube that prevents separation of the parietal surfaces and retards contamination of the peritoneal cavity.4 Hopefully, this recommendation will alleviate future complications within the first 2 weeks of PEG placement, but until more information is available, early UGI endoscopy after PEG placement may cause peritonitis and should be deferred for at least 2 weeks after PEG placement. Michael J. Santoro, MD Yang K. Chen, MD Martin J. Collen, MD Lorna Linda University Medical Center Lorna Linda, California
REFERENCES 1. Galat SA, Gerig KD, Porter JA, Slezak FA. Management of
premature removal of the percutaneous gastrostomy. Am Surg 1990;56:733-6.
2. Ditesheim JA, Richards W, Sharp K. Fatal and disastrous com-
plications following percutaneous endoscopic gastrostomy. Am Surg 1989;51:92-6. 3. Mamel JJ. Percutaneous endoscopic gastrostomy. Am J Gastroenterol 1989;84:703-9. 4. Rogers BRG, Kaminski MV, All J. Stabilizing sutures for percutaneous endoscopic gastrostomy. Gastrointest Endosc 1989; 35:241-3.
Colonoscopic diagnosis of mucocele of the appendix Figure 1. Colonoscopic view of the base of the cecum with
To the Editor: The pre-operative diagnosis of appendiceal mucocele is difficult. Abdominal ultrasonography, barium enema examination, abdominal CT, and colonoscopy are all important examinations in patients with appendiceal mucocele.l- 4 Hamilton and Stormont5 reported colonoscopic findings of two cases of appendiceal mucocele as a "volcano" sign in 1989. Our report describes a case of this disease where colonoscopy contributed to its recognition and successful treatment. A 40-year-old man was admitted to the Toshima Chuo Hospital in Tokyo· with a 7-day history of a right lower quadrant abdominal pain. Physical examination was unremarkable except for a right lower abdominal mass. A plain abdominal X-ray examination revealed no calcification. A barium enema revealed irregularities of the cecal wall and stenosis of the cecum, with extrinsic compression of the inferomedial side. The Olympus 200HS colonoscope (Olympus Corp., Tokyo, Japan) was passed to the cecum. The colonoscopic findings showed a tumor-like protrusion of the cecal mucosa around the orifice of the appendix, with whitish liquid material issuing from it (Fig. 1). Biopsy specimens ofthis protrusion indicated inflammatory changes in the cecal mucosa. An abdominal sonogram revealed a 4 X 5 em purely cystic mass with a prominent distal acoustic shadow. An abdominal CT scan demonstrated a well-defined rounded mass of near water density in the right lower quadrant medial to the cecum. The primary pre-operative diagnosis was mucocele of the appendix. At laparotomy a 15 X 10 X 8 em yellowish mucus cyst of the appendix was found. A right hemicolectomy was performed. The opened appendix was found to contain clear yellowish thick mucin (45 ml) (Fig. 2). No other mucus cysts were found after careful abdominal examination. The final pathologic diagnosis was mucocele of the appendix. An uneventful post-operative recovery ensued. Mucocele of the appendix is uncommon, and pre-operative diagnosis is rarely made. Diagnosis is important because some of these lesions are malignant, and early identification may reduce the incidence of pseudomyxoma peritonei. Barium enema examination has been the usual diagnostic technique used in the evaluation of right iliac fossa masses. Newer imaging methods, including sonography and CT, have been shown to be valuable in the diagnosis of mucocele. 1- 2 VOLUME 39, NO.5, 1993
a tumor-like protrusion of the cecal mucosa around the orifice of the appendix with whitish liquid material (arrows) issuing from the orifice of the appendix.
Figure 2. The opened appendix was found to contain a clear yellow-white thick mucus.
Sonography showed the mucocele to be largely hypoechoic, with an irregular inner wall caused by mucinous debris and varying degrees of epithelial hyperplasia. Sonography is valuable also in demonstrating any pseudomyxoma peritonei when peritoneal scalloping of the hepatic outline or septate ascites may be found. 2 In previously reported cases, the CT appearance was that of a well-encapsulated large cystic mass, round or slightly oval in shape. A similar appearance was present in our case. Using sonography and CT, a correct pre-operative diagnosis of appendiceal mucocele can be made in most cases. Because mucocele of the appendix is a submucosal lesion with a soft consistency, it may be confused endoscopically with a lipoma and other benign submucosal lesions of the colon. 6 Its appearance may present as a submucosal tumor with the appearance of a volcano. 5 In our case, an outpouring of inflammatory exudate into the cecum from the orifice of the appendiceal mucocele was seen. The combined findings of a low-density mass at CT and a through-transmitting mass with echogenic foci at sonography in the correct location in a patient who has not had an appendectomy are typ733