Risk factors for aspiration pneumonia after percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is generally used for long-term enteral nutrition. Patients who require PEG placement are often very sick, and postoperative complications, especially aspiration pneumonia, can be fatal. OBJECTIVE: In this study we investigated the risk factors for aspiration pneumonia after PEG using a simple two-step swallowing provocation test (S-SPT), as reported in 1999 by Teramoto et al. METHODS: The study included 29 patients (10 men, 19 women; mean age 84.6 years) who underwent S-SPT before PEG. We evaluated the presence of reflux esophagitis (RE) and esophageal hiatal hernia (EHH) with PEG. According to the S-SPT results, a normal response to the 1st step S-SPT was given a score of 0, a normal response to the 2nd step S-SPT was given a score of 1, and an abnormal response to the 2nd step S-SPT was given a score of 3. In addition to S-SPT, the presence of RE was given a score of 3, the absence of RE was given a score of 0, the presence of EHH was given a score of 2, and the absence of EHH was given a score of 0. We evaluated the association between the presence of aspiration pneumonia, as an early and critical complication, up to 1 month after PEG and determined the total risk score (score of S-SPT+ score of RE+ score of EHH). RESULTS: The group with an abnormal response to the 2nd step S-SPT and the group with RE both exhibited aspiration pneumonia. The patients with aspiration pneumonia all achieved total scores > or =3, and 8 of 13 patients without aspiration pneumonia achieved scores < or =2. CONCLUSIONS: S-SPT is particularly useful in PEG patients. The scores provided by S-SPT and endoscopic examination can be very useful for aspiration pneumonia after PEG. The patients with scores < or =2 appear to be at very low risk for aspiration pneumonia, and patients with the scores > or =3 should be carefully followed up.

Henoch-Schönlein purpura after postoperative Staphylococcus aureus infection with hepatic IgA nephropathy.

A 66-year-old man with a two-year history of hepatitis C viral liver cirrhosis, was diagnosed as having ascending colon cancer. Right hemicolectomy was performed, and a drain was fed down to the anastomosis. On post-operative day (POD) 9, and methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from both drains. After POD 12, relapsing persistent diarrhea with some blood occurred. On POD 20, the temperature increased to 39 degrees C, with symmetrical purpura and swelling in the femurs, and knee arthralgia developed. HSP was suspected. Clinical follow-up showed slight spontaneous reduction of diarrhea and purpura on POD 26. However, despite the negative drain culture, the high fever was maintained on POD 27. Therefore, intravenous steroid pulse therapy was performed. The purpura subsequently disappeared, except for a slight pigmentation and the temperature returned to normal. A renal biopsy was performed 26 days after the appearance of purpura. Pathological views demonstrated acute focal segmental glomerulonephritis-like nephropathy in addition to cirrhotic nephropathy with a membranoproliferative glomerulonephritis (MPGN)-like pattern and the mesangial proliferative glomerulonephritis type. We describe a case of Henoch-Schönlein purpura (HSP) after postoperative Staphylococcus aureus infection of the intra-abdominal drain with IgA nephropathy associated with hepatitis C virus liver cirrhosis.

Recovery from idiopathic thrombocytopenic purpura (ITP) following right hemicolectomy for mucocele of appendix.

A 61-year-old woman with a 2-year medication-free history of idiopathic thrombocytopenic purpura was referred to our hospital complaining of right lower abdominal pain. The platelet count was about 3-4x10(4)/mm3. This patient was diagnosed with mucocele of the appendix on computed tomography and colonoscopy. We performed only right hemicolectomy without splenectomy. The pathological diagnosis was mucinous cystadenoma of the appendix. The platelet count increased to 18.1x10(4)/mm3 on postoperative-day 7, and remained stable, at 20-24x10(4)/mm3, for 14 months after the operation. Platelet-associated immunoglobulin G decreased remarkably after the operation, to 30.2 ng/10(7) cells, from 240 ng/10(7) cells preoperatively. We describe the first case of recovery from idiopathic thrombocytopenic purpura following right hemicolectomy performed for mucocele of the appendix. Considering our patients clinical course, it is possible that mucinous cystadenoma of the appendix may have influenced the thrombocytopenia. Findings in this patient suggest that mucocele of the appendix may be associated with a new diagnosis and idiopathic thrombocytopenic purpura treatment.

Hepatic venous stenosis-related reduction of cyclosporin clearance in a pediatric patient after liver transplantation.

A 20-month-old girl with Alagille syndrome developed stenosis of hepatic venous anastomosis after living related-donor liver transplantation. Cyclosporin (a microemulsion formulation) was given orally at a dose of 50 mg twice daily, and the trough blood concentration was relatively stable. Before balloon angioplasty of the hepatic vein, trough cyclosporin blood concentrations became elevated and consequently, the dosage was reduced to 15 mg twice daily. On the day of angioplasty, the calculated elimination rate constant of cyclosporin was 0.036 hr(-1), while its apparent basal value was 0.078 hr(-1). The cyclosporin trough concentration to dosage (C/D) ratio gradually increased reaching the maximum on the day after angioplasty. Thereafter, the C/D ratio promptly decreased. Thus, it is speculated that the increase in cyclosporine C/D ratio was mainly dependent on reduction of hepatic clearance of cyclosporin due to hepatic congestion caused by the stenosis of the hepatic venous anastomosis.