Successful endoscopic closure with endoscopic clips for endoscopic ultrasound related large duodenal perforation.

Objectives: Duodenal perforation as a complication of endoscopic ultrasound-guided fine needle aspiration may progress to acute peritonitis and septic shock. Open surgery, the standard treatment, can be avoided by performing closure during endoscopy using endoscopic clips. Patient: A 77-year-old woman was referred to our hospital with salivary gland swelling. She had elevated hepatobiliary enzymes and jaundice. Computed tomography (CT) revealed pancreatic head swelling and bile duct dilation. Endoscopic ultrasonography revealed a hypoechoic mass in the pancreatic head. The pancreatic head mass was punctured twice using a 22-gauge Franchine-type puncture needle at the duodenal bulb. The endoscope was advanced to the descending part of the duodenum, and part of the superior duodenal angle was perforated (diameter approximately 15 mm) with the endoscope. The duodenal mucosa around the perforation was immediately closed using endoscopic clips. Results: Abdominal CT showed gas in the peritoneal and retroperitoneal spaces. The patient experienced abdominal pain and fever and was treated with fasting and antibiotics. The gas gradually decreased, symptoms improved, and she was discharged 18 days after the perforation. Histopathologically, the pancreatic tissue was consistent as autoimmune pancreatitis. Conclusion: Endoscopic closure using endoscopic clips may be a better therapeutic option for duodenal perforation caused by endoscopy.

[A study on cases developed pulmonary tuberculosis after receiving gastrectomy].

OBJECTIVE: Patients who had undergone gastric resection are considered to be high risk of developing tuberculosis. We investigated the factors leading to pulmonary tuberculosis after gastrectomy. MATERIALS AND METHODS: We retrospectively examined 654 pulmonary tuberculosis patients discharged from Chiba-East National Hospital from January 1999 to December 2001. RESULTS: Fifty-five patients (31-84 years old, mean 63.5 +/- 12.5 years, 48 males and 7 females) had the history of gastric resection. The proportion of patients receiving gastrectomy among patients with pulmonary tuberculosis was 8.4 percent. The mean age of patients received gastric resection was 50.2 +/- 16.6 years, and the mean interval from gastrectomy to the development of pulmonary tuberculosis was 13.6 +/- 11.0 years. On admission to our hospital, 34 out of 55 cases were smear positive by sputum examination for acid-fast bacilli and 39 cases had cavitary lesions on chest X-ray. Gastrectomy was done due to carcinoma of the stomach in 31 cases, peptic ulcer in 21 cases, adenomatous polyp in two cases, and accidental injury in one case. Out of total 55 cases, 52 patients improved, but three cases died of pulmonary tuberculosis. None had the recurrence of carcinoma of the stomach. Body weight, Body mass index, Prognostic nutritional index (PNI; 10 x serum albumin concentration + 0.005 x peripheral lymphocyte count) which was proposed by Onodera, serum albumin level and serum total cholesterol level were lower in the gastrectomy group than in the non-gastrectomy group. The odds ratio of developing tuberculosis among gastrectomy patients compared with the appropriate controls in 30 to 59 year-old-men was 3.8. CONCLUSION: This study confirms that gastrectomy is one of the risk factors of developing tuberculosis in 30 to 59 year-old-men. However, whether gastrectomy in itself is a risk factor or whether it is secondarily associated with another risk factor such as underweight status and/or inadequate nutrition following surgery remains unclear.

[A study on pulmonary tuberculosis retreatment cases].

OBJECTIVE: To investigate the factors leading to the retreatment for tuberculosis. MATERIALS: Forty-seven retreatment cases with pulmonary tuberculosis, who were discharged from the National Chiba Higashi Hospital from 2000 to 2002. METHODS: Data on all retreatment cases were studied as to the condition of the original treatment and factors leading to the retreatment. RESULTS: Of the 47 cases, 33 cases received the original treatment in our hospital. Of the 33 cases, 24 cases were relapsed cases and 9 cases were defaulters. Most relapsed cases were male aged 50s and 12 cases (50%) were jobless. As the factors leading to retreatment, the delay in the negative conversion of sputum culture accounted for 11 cases (45.8%) out of 24 cases. No specific factors were found in three cases (12.5%). Among the defaulters, no bias was seen as to age and occupation of cases, but all the cases were male, and they defaulted during the maintenance phase of treatment at the out-patient department. CONSIDERATION: The delay in the negative conversion of sputum culture was the main factor relating to the relapse. Diabetes mellitus (DM) is one of the factors leading to the relapse, but many factors were observed in DM patients. Male cases aged 50s had many factors leading to the relapse. An intensive management for out-patients and involvement of welfare department aiming at the completion of treatment for the socially vulnerable groups might be necessary as the measure to prevent defaulting. CONCLUSION: The delay in the negative conversion of sputum culture was the main factor leading to relapse, and intensive management for out-patients aiming at the completion of treatment is necessary to prevent the defaulting.