Holy Foley: Iatrogenic Duodenal Obstruction From a Make-Shift Gastrostomy Tube

Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Acute motor and sensory axonal neuropathy in a patient with undiagnosed mixed connective tissue disease

Case Report: Acute motor and sensory axonal neuropathy (AMSAN) syndrome is a rare subtype of Guillain-Barre syndrome (GBS) with poor recovery [1]. While respiratory and gastrointestinal infections may precipitate AMSAN, an underlying autoimmune disorder is seldom reported in literature. We herein report the complex case of a patient with undiagnosed, asymptomatic mixed connective tissue disease (MCTD) who developed AMSAN syndrome. Case: A 44-year-old Asian male without medical history presented with progressively worsening weakness of both upper and lower extremities and inability to perform daily activities. His symptoms started 12 weeks prior with difficulty standing from a seated position. He felt subjectively better for some time until a week prior, when he became bedbound. He had diarrhea 6 months ago, with 5-6 loose bowel movements a day for a few weeks. Vital signs on admission was normal. On neurological examination, he was alert and oriented, with bilateral upper and lower extremity flaccid paralysis, diffuse muscle atrophy, bilateral hand and foot drop, negative Hoover sign, diffuse areflexia, and intact sensation. Cerebrospinal fluid (CSF) analysis showed WBC 0 and protein level 136. MRI cervical, thoracic, and lumbar spine were normal. EMG revealed sensory involvement with positive sharp waves in proximal muscles along with fibrillations. Intravenous immunoglobulin (IVIG) was initiated at 0.4 mg/kg for 5 days. Infectious workup for COVID-19, stool culture, HIV, TB, RPR and campylobacter jejuni antibody (Ab), was negative. ANA was positive in a speckled pattern with titres 1:1280, with a positive RNP Ab, SS-A, and RF IgM, IgG and IgA. Rest of the autoimmune workup (anti-dsDNA, anti-CCP, SS-B, aldolase, anti-Jo-1, anti-Scl-70, p-ANCA, c-ANCA, anti-GM1, anti-GQ1b, and anti-GD1a ganglioside Ab) was negative. The myositis specific 11 Ab panel was negative. Despite IVIG therapy, he developed dysphagia, respiratory distress, with a negative inspiratory force of -0, requiring intubation. He had a tracheostomy and PEG tube placed and remains quadraplegic nearly 120 days later. Discussion(s): The authors report a unique case of a patient who became progressively weak over 3 months, leading to complete quadriplegia. Interestingly, this is more consistent with chronic inflammatory demyelinating poly-neuropathy (CIDP), as AMSAN typically develops over a short period of 2 to 4 weeks [2]. Despite having negative anti-GM1 and anti-GD1a Ab (in which positive Ab are pathognomonic but not always present in AMSAN syndrome), the patient had weakness that began in the lower extremities, progressing to paralysis, along with albuminocytological dissociation on CSF analysis, pointing to a GBS diagnosis [3]. He had sensory involvement in the EMG, thus making the diagnosis as AMSAN. He had an undiagnosed, asymptomatic autoimmune process most consistent with MCTD. Whether the two disease processes are related to each other is a concept that has not yet been investigated. Pediatric Clinical Case Reports Concurrent Session Saturday February 4, 2023 1:00 PM Copyright © 2023 Southern Society for Clinical Investigation.

LARGE ISCHEMIC STROKE AS A COMPLICATION OF COVID-19

CASE: Patient is a 67-year-old white male who is from Ohio who has a past medical history significant for diabetes mellitus type 2, essential hypertension and hyperlipidemia. He presented to the emergency department with complaints of generalized weakness and shortness of breath. He was vaccinated against COVID about 3-4 months ago. Dyspnea has been progressive over several days. Initial laboratory values and vital signs in the emergency department were pertinent for a heart rate 92/min, blood oxygen saturation of 93% on 5 L nasal cannula, ESR 40, CRP 22.9, D-dimer 21.1, positive for COVID-19 on PCR. Chest x-ray showed developing multifocal infiltrates consistent with COVID-19 pneumonia. Patient was started on dexamethasone, remdesivir, ceftriaxone, azithromycin and was placed on low molecular weight heparin for DVT prophylaxis regimen during the first few hours of admission. We continued standard therapies but the patient's oxygen requirements increased. During this hospitalization patient became acutely unresponsive and was noticed that he was not moving his right side. A stroke work-up was undertaken MRI brain/head without contrast showed large left MCA territory infarction, no acute hemorrhage has been identified, loss of flow void within the left intracranial ICA, suggesting obstruction versus high-grade stenosis. Echo showed normal LV systolic function. MRA of the head and neck showed occluded left ICA and left MCA. Unfortunately due to the size of the infarction the patient was not a candidate for full dose anticoagulation.Eventually patient was not following commands, remained unresponsive and had persistent dysphagia for which he had PEG tube placement. Family has been updated on his clinical status and overall prognosis is poor. IMPACT/DISCUSSION: The incidence of stroke has been reported in 5.7% of patients with severe COVID-19 and in 0.8% of patients with nonsevere infection.The frequency of stroke detected in hospitalized COVID-19 patients was 1.1% associated with older age and stroke risk factors.Early-onset cerebrovascular disease is more common in COVID- 19 patients with underlying cerebrovascular risk factors including older age (>65 years).The significant increase in D- dimer levels like our patient suggests that COVID-19 can induce an inflammatory response and trigger a hypercoagulable state causing an acute ischemic stroke .The hypercoagulable state in patients with COVID-19 supports the formation of small and/or large blood clots in many organs such as the brain, which have the potential to cause cerebrovascular disease.Increased D-dimer levels confirm the theories of endothelial activation and hypercoagulability. CONCLUSION: Our case report highlights the fact that COVID-19 is a risk factor for acute ischemic stroke along with other underlying cerebrovascular risk factors such as diabetes, hypertension and hyperlipidemia like in our patient. We should be aware of these neurological symptoms and act promptly in the evaluation of stroke in COVID-19 patients.

SAFETY AND EFFICACY OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) PLACEMENT IN PATIENTS WITH SARS-COV-2 INFECTION

Introduction: Coronavirus Disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a worldwide pandemic. It is primarily a pulmonary disease which can lead to respiratory distress syndrome;some go on to develop ventilator dependent chronic respiratory failure. In these patients, enteral feeding is critical and initially provided by nasogastric (NG) or orogastric (OG) tubes. However, feeding tubes are associated with local complications such as nasopharyngeal/oropharyngeal erosions and esophageal/gastric cardia ulceration. Percutaneous endoscopic gastrostomy (PEG) tube placement facilitates longer-term enteral access. Minimal data exists on the safety and efficacy of PEG tube placement in patients with SARS-CoV-2 infection. Methods: A retrospective chart review was performed to collect data for patients who underwent PEG tube placement between January 2020 to January 2021 at Houston Methodist Hospital. Inclusion criteria included patients who had endoscopic PEG tube placement during this time interval. Exclusion criteria included patients who underwent PEG placement via interventional radiology or surgically. Approval for study was obtained from the Institutional Review Board at Houston Methodist Hospital. Success was defined as PEG placement and use to provide enteral nutrition with no complications over a 4-week period after placement. Results: 36 patients with (mean age 63.6 years;38.8% females) and 104 patients without COVID-19 infection (mean age 64.9 years, 44.2% females) were included in the study. 25 patients were excluded who had missing data, had PEG-J tube placed, or had it placed by interventional radiology initially and exchanged endoscopically during the study period. Table 1 summarizes the main demographic and clinical characteristics of participants. COVID-19 patients were more likely to be obese, be on anticoagulants and have a tracheostomy in place. 11.1% of the patients with COVID-19 developed PEG-related complications compared to 16.3% patients without COVID-19 χ2 with Yate's correction (1, N=140) = 0.23, p=0.65. The success rates of PEG placement in patients with and without COVID -19 were similar at 97.2% and 90.3%, respectively,, χ2(1, N=140) =1.7, p=0.18. Conclusion: This is, to our knowledge, the first study to assess the safety and efficacy of PEG tube placement in patients with SARSCoV- 2 infection. The study demonstrates that despite high BMI and rate of anticoagulant therapy, PEG placement was universally successful, and complication rates no different from those of age- and gender-matched non-COVID-19 patients. PEG tube placement offers a safe and effective means of providing longer term access for enteral nutrition in COVID- 19 patients. (Table Presented)

Long-term results of hypofractionated radiotherapy in locally advanced laryngeal cancer: Single institution experience

Introduction: Hypofractionated radiotherapy (HF-RT) has been used in the UK as a non-surgical treatment for locally advanced laryngeal cancer (LALC) in the past. HF-RT has been readopted in some departments during the COVID-19 pandemic due to having a shorter overall treatment time and fewer attendances. This study explores the outcomes of a cohort of patients treated from 2003 to 2012 at Aberdeen Royal Infirmary (Scotland, UK). Materials and Methods: 36 patients received HF-RT (55 Gy in 20 fractions) through 2D or 3D conformal radiotherapy, 7 of them received concurrent cisplatin (CRT). Overall survival (OS), locoregional recurrence free survival (LRFS), progression free survival (PFS), laryngectomy free survival (LFS), disease specific survival (DSS) and late toxicity data were analysed in patients treated with HF-RT at 1-year (1Y), 2-year (2Y) and 5-year (5Y). The same outcomes were measured between the RT and CRT group for any differences. Results: The mean follow-up durationwas 43.0 months. OS at 1Y, 2Y and 5Y was 69.4%, 52.8% and 30.6%. LRFS at 1Y, 2Y and 5Y was 63.9%, 47.2% and 25.0%. PFS at 1Y, 2Y and 5Y was 63.9%, 44.4% and 25.0%. LFS at 1Y, 2Y and 5Y was 69.4%, 50.0% and 27.8%. DSS at 1Y, 2Y and 5Y was 63.9%, 52.8% and 30.6%. During the period of treatment and up to 5Y follow up, 41.7% of patients required an NG tube for feeding and 25% required a PEG tube at any point. 22.2% of patients required long term enteral feeding via PEG tube beyond 5Y. No significant differences were found in the survival outcomes or alternative feeding route outcomes between patients treated by RT alone or CRT. Conclusions: HF-RT constitutes an alternative for the treatment of LALC with acceptable local control and toxicity. Further investigation is needed in the comparison of this regime with standard fractionation and its application with modern radiotherapy techniques

Methods for a Seamless Transition From Tracheostomy to Spontaneous Breathing in Patients With COVID-19.

The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. The majority of reports thus far have focused on the epidemiology, clinical factors, and acute care of these patients, with less attention given to the recovery phase and care of those patients requiring extended time on mechanical ventilation. In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.