Risk of bleeding after percutaneous endoscopic gastrostomy (PEG).

BACKGROUND: Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited. AIMS: To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG. METHODS: A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011. RESULTS: A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively. CONCLUSION: Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

Acute esophageal necrosis: a case series of five patients presenting with "Black esophagus".

Acute esophageal necrosis (AEN), also known as "Black esophagus", is a rare condition that typically presents as upper gastrointestinal hemorrhage. A retrospective chart analysis was conducted at two tertiary care hospitals over a three-year period (2005-2007) using a computerized inpatient database. Out of 9,179 upper endoscopies performed, five patients (0.05% prevalence) were found to have black esophagus. Their mean age was 44 years and the most common presentation was upper gastrointestinal bleeding. All five patients had comorbid conditions, most commonly coronary artery disease, diabetes mellitus, and renal insufficiency. Two patients died, but the cause of death was not related to AEN in either. In conclusion, AEN is usually seen in critically ill elderly patients with multiple comorbid conditions, particularly vascular disease, diabetes mellitus and azotemia.

Jejunoileal bypass: a surgery of the past and a review of its complications.

Jejunoileal bypass (JIB), popular in the 1960s and 1970s, had remarkable success in achieving weight loss by creating a surgical short bowel syndrome. Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery. Later, it was recognized that he had a JIB in the 1970s, which was also responsible for the gamut of his illnesses. Patients with JIB are often not recognized, as they died of complications, or underwent reversal of their surgery or a liver-kidney transplant. Early identification with prompt reversal, and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.