[A case of cerebral salt wasting syndrome caused by minor head injury].

An 80-year-old woman who was hospitalized due to small subarachnoid hemorrhaging caused by a bruise in the left temporal region of the brain. Nausea/vomiting and malaise appeared after dinner on the fourth day of the illness. Head computed tomography showed that the post-traumatic status was almost normal; however, the sodium ion (Na+) level was 114 mEq/L, indicating severe hyponatremia. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) following a head injury was initially suspected, and water restriction and saline fluid replacement were initiated. However, the Na+ level did not improve, and signs of dehydration emerged. On the seventh day of the illness, drinking water restriction was discontinued, and 3% sodium chloride fluid replacement was initiated. The patient subsequently followed a favorable course, and the Na+ level remained normal even after fluid replacement was discontinued. It is important to differentiate between SIADH and cerebral salt wasting syndrome (CSWS), as the treatment of the two are diametrically opposite. However, distinguishing between these two diseases at an early onset can be difficult, as they have very similar laboratory findings. CSWS can occur in patients with minor head injury, as in the present case, so we should bear this disease in mind as a differential diagnosis, even when imperceptible graduations are recognized in patients.

[Eight cases of Percutaneous Endoscopic Gastrostomy (PEG) in patients taking oral anticoagulants].

Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on antiplatelet therapy. There is a potential risk of infarction if these medications are discontinued.The guidelines of the Japan Gastroenterological Endoscopy Society, classify PEG as an operation associated with a high risk of bleeding; however, it is known that surgery can be performed without interruption when patients are treated with low-dose aspirin alone. Nevertheless, we experienced the case of severe bleeding at the incision site, which was accompanied by massive hematemesis and hemorrhagic shock the night after PEG using the modified introducer method in an 87-year-old male patient. The patient was being treated with Bayer aspirin (100 mg/day, oral). The patient's platelet count, PT, and APTT were within the normal levels. Thus, we decided to investigate the pull method as the effective method for pressure hemostasis comparing with the modified introducer method, to reduce the risks associated with bleeding after surgery when patients are being treated with antiplatelet drugs.PEG was performed by the pull method on eight patients who were being treated with oral antiplatelet drugs (including four patients receiving dual antiplatelet therapy [DAPT]). All patients had previously suffered strokes, and they all presented with normal platelet counts, PT, and APTT values.Only slight bleeding was observed in one out of eight patients (bleeding had stopped by the following day using an alginate patch on the abdominal wall at the incision site, along with direct pressure using a stationary plate). None of the patients showed infection at the incision site.Although the study population was small, the present study showed that PEG using the pull method is safe while patients are being treated with oral antiplatelet drugs.

[A case of gastric endocrine cell carcinoma which was significantly reduced in size by radiotherapy].

In 2010, the World Health Organization classified gastric neuroendocrine tumors (NETs) into three types: NET grade (G) 1, NET G2 and neuroendocrine carcinoma (NEC). NECs are associated with a very poor prognosis. The patient was an 84-year-old female who was initially diagnosed by gastrointestinal endoscope with type 3 advanced gastric cancer with stenosis of the gastric cardia. Her overall status and performance status did not allow for operations or intensive chemotherapy. Palliative radiotherapy was performed and resulted in a significant reduction in the size of the tumor as well as the improvement of the obstructive symptoms. She died 9 months after radiotherapy. An autopsy provided a definitive diagnosis of gastric endocrine cell carcinoma, and the effectiveness of radiotherapy was pathologically-confirmed. Palliative radiotherapy may be a useful treatment option for providing symptom relief, especially for old patients with unresectable advanced gastric neuroendocrine carcinoma.