Letters to the Editor
Management of gastric ascariasis is based on two simple principles: (1) extraction of the offending worms and (2) institution of effective anthelmintic therapy so that worms downstream in the jejunum do not travel upstream. All our patients had effective relief of symptoms and pointed to the parasite as the cause of symptoms. Dyspepsia is a common symptom in the community. As a significant percentage of dyspeptic patients had gastric ascariasis, this entity should be considered as a differential diagnosis of dyspepsia in endemic regions. CONFLICT OF INTEREST
The authors declare no conflict of interest. All financial help/support has been received from funds from the Digestive Diseases Centre, Dr Khuroo’s Medical Clinic.
for determining visceral adiposity in the recent paper by Kang et al. (1). Although it is an important measure in terms of research, we think this can no longer be ethically justified. A cohort of more than 4,000 adults undergoing screening colonoscopy were exposed to the radiation of a CT scan for purposes of a research study. In recent months there has been growing awareness of the risks associated with diagnostic imaging (2,3), with CT scans being among the biggest culprits. We doubt that our institutional review board would approve such a study and suggest that due consideration be given to the safety aspects. Magnetic resonance imaging, although more expensive, may have been an alternative in this case. CONFLICT OF INTEREST
REFERENCES 1. Khuroo MS. Nematodes: Ascariasis. Gastroenterol Clin North Am 1996;25:553–78. 2. Choudhuri G, Saha SS, Tandon RK. Gastric ascariasis. Am J Gastroenterol 1986;81:788–90. 3. Astrozhnikov Iuv. Case of obstruction of the anastomosis with Ascaris following gastric resection. Sov Med 1954;18:34. 4. Mor R, Pitlik S, Rosenfeld JB. Ascariasis--an unusual case of pyloric obstruction. Harefuah 1980;98:163–4. 5. IHamed AD, Akinola O. Intestinal ascariasis in the differential diagnosis of peptic ulcer disease. Trop Geogr Med 1990;42:37–40. 6. Bhasin DK, Chhina RS. Hematemesis in gastric ascariasis. Am J Gastroenterol 1989;84:1585–6. 1 Digestive Diseases Centre, Dr Khuroo’s Medical Clinic, Srinagar, Kashmir, India; 2Department of Pathology, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. Correspondence: Mohammad Sultan Khuroo, MD, Digestive Diseases Centre, Dr Khuroo’s Medical Clinic, Sector 1, Sher-e-Kashmir Colony, Qamarwari, Srinagar, Kashmir 190010, India. E-mail:
[email protected]
Computed Tomography for Assessment of Visceral Adiposity Gabriel Duek, MD1, Alon Basevitz, MD1, Yoram Menahem, MD1 and Stephen Malnick, MA (Oxon), MSc, MBBS (Lond)1 doi:10.1038/ajg.2010.113
To the Editor: We wish to comment on the use of computed tomography (CT) scans © 2010 by the American College of Gastroenterology
The authors declare no conflict of interest. REFERENCES 1. Kang HW, Kim D, Kim HJ et al. Visceral obesity and insulin resistance as risk factors for colorectal adenoma: a cross-sectional, case-control study. Am J Gastroenterol 2010;105:178–87. 2. Fazel R, Krumholz HM, Wang Y et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 2009;361:849–57. 3. De Gonzales AB, Mahesh M, Kim K-P et al. Projected cancer risks from computed tomographic scans performed in the United States. Arch Intern Med 2009;169:2071–7. 1
Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel. Correspondence: Gabriel Duek, MD, Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel. E-mail:
[email protected]
ages, but it is rarely caused by foreign bodies, including medical materials (1). This report presents a case wherein an endoluminal clip used for polypectomy detached and dropped into the appendix and caused appendicitis after a long interval. A 66-year-old woman presented with right iliac fossa pain. A plain abdominal radiograph showed an endoluminal clip in the right iliac fossa. The patient had undergone endoscopic polypectomy for an ascending colon polyp 7 years earlier at another hospital and seven endoluminal clips had been used for that procedure. She was thereafter referred to this hospital for further investigation. She had mild abdominal pain in the right lower quadrant with no fever. Physical examination revealed that the abdomen was soft with normal bowel sounds. Her blood profile indicated a white blood cell count of 9.300/l and the C-reactive protein level was elevated to 8.0 mg/l. An abdominal scan showed the presence of the clip (Figure 1). Computed tomography showed the features of appendicitis with a mass forming and confirmed a clip in the lumen of the appendix (Figure 2). She was hospitalized. After admission she underwent colonoscopy, which showed external compression of the cecum wall, possibly due to appendicular mass. A laparotomy was performed and a hard appendicular mass was found with firm adhesion to the
Appendicitis Caused by an Endoluminal Clip Isamu Hoshino, MD, PhD1, Yuji Sugamoto, MD, PhD1, Toru Fukunaga, MD, PhD1, Syunsuke Imanishi, MD1, Yuka Isozaki, MD1, Masayuki Kimura, MD, PhD1, Masatoshi Iino, MD, PhD1 and Hisahiro Matsubara, MD, PhD2 doi:10.1038/ajg.2010.129
To the Editor: Appendicitis is a very common digestive inflammatory disease in all
Figure 1. Plain abdominal radiograph showing a radio-opaque object in the right iliac fossa (arrow).
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Letters to the Editor
Figure 2. Axial view on computed tomography showing a foreign body in the inflamed appendix (arrow).
cecum. There was no peritoneal contamination with turbid fluid. Consequently she underwent an appendectomy with partial cecal resection. The appendix was opened, and an open endoluminal clip was found in the lumen. There were no postoperative complications and she was discharged a week later. A histopathological examination showed acute and chronic appendicitis with transmural suppurative inflammation and granulation tissue. The inflammation spread from the mesentery of the appendix to the cecum wall. The first report of appendicitis due to a foreign body was reported in the eighteenth century. Klingler et al. (1) reviewed previous reports and described that most
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common cases were caused by hand-sewing and eating of wild game containing lead shot. Collins (2) reported that the incidence of appendicitis caused by a foreign body was 3% and noted items including stones, shells, solder, glass, enamel, coal, wood, nails, hair, mercury batteries, and the mercury end of a thermometer. According to these studies, appendicitis caused by medical instruments is exceedingly uncommon. Indeed, only a few cases have been reported. Only Tzovaras et al. (3) and Schwab et al. (4) reported appendicitis caused by entrapment of a migrated biliary stent into the appendiceal lumen. There have so far been no reports of appendicitis caused by an endoluminal clip. The endoluminal clip is designed for placement within the gastrointestinal tract for the purpose of endoscopic marking or hemostasis. Once the clip is deployed, it should not be able to re-open. However, occasionally a clip becomes detached from the wall of the bowel. After becoming detached from the intestinal wall, the clip should pass through the gastrointestinal tract without settling there like other foreign bodies. In contrast, 1–12% of foreign bodies require surgical removal because of their causing complications such as appendicitis (5). Appendicitis caused by the entrapment of a migrated endoluminal clip is extremely
rare and this is the first case reported in the literature. Although this case is an unusual example, it might occasionally cause appendicitis, as endoluminal clips are widely used for many purposes. CONFLICT OF INTEREST The authors declare no conflict of interest.
REFERENCES 1. Klingler PJ, Smith SL, Abendstein BJ et al. Management of ingested foreign bodies within the appendix: a case report with review of the literature. Am J Gastroenterol 1997;92:2295–8. 2. Collins DC. 71 000 Human appendix specimens. A final report, summarizing forty years′ study. Am J Protocol 1963;14:265–81. 3. Tzovaras G, Liakou P, Makryiannis E et al. Acute appendicitis due to appendiceal obstruction from a migrated biliary stent. Am J Gastroenterol 2007;102:195–6. 4. Schwab D, Baum U, Hahn EG. Colonoscopic treatment of obstructive appendicitis caused by dislocation of a biliary stent. Endoscopy 2005;37:606. 5. Velitchkov NG, Grigorov GI, Losanoff JE et al. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg 1996;20:1001–5. 1
Department of Surgery, Numazu City Hospital, Numazu, Japan; 2Department of Frontier Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan. Correspondence: Isamu Hoshino, MD, PhD, Department of Surgery, Numazu City Hospital, Higashi Shiji 550, Numazu, Shizuoka, 410-0302, Japan. E-mail:
[email protected]
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