JAGS-MAY 1991-VOL 39, NO. 5
1 gram im every 24 hours and metronidazole 500 mg every 6 hours via nasogastric tube were started for presumed peritonitis. The patient's condition stabilized on this regimen. Enteral feeding via nasogastric tube was restarted within 1 week. The antibiotics were discontinued after 21 days. A barium series performed via the PEG on November 22 confirmed the clinical diagnosis of gastrocolic fistula. An upper gastrointestinalendoscopy on December 4 revealed migration of the intra-gastric bumper of the PEG submucosally, and a fistulous opening was seen in the anterior wall of the stomach. A new PEG was placed on January 8, 1990, and enteral feeding through it commenced uneventfully. The old PEG was capped off and left in place. A repeat gastrostomy-tube barium series done through the new PEG on March 3, 1990 showed almost complete healing of the gastrocolic fistula. The new PEG began to leak enteral feedings, and a repeat upper gastrointestinal endoscopy on June 27, 1990, again revealed migration of the intra-gastric bumper submucosally. A jejunal feeding tube was passed through the gastrostomy, and enteral feeding was resumed. The patient remained stable until July 11, 1990 when she developed vomiting and abdominal pain and expired suddenly. An autopsy showed duodenal perforation without ulcer. The perforation was thought to have arisen secondary to the more recently placed jejunal feeding tube. There was no evidence of her previous gastrocolic fistula. To the best of our knowledge, this is the first reported case of delayed gastrocolic fistula following PEG placement successfully managed by conservative means in a nursing home. In addition we have documented complete healing using this approach alone.
LElTERS TO THE EDITOR
533
absorptiometry (mean Z-score 2.9) with only slight increases determined by quantitative computed tomography (mean Zscore 1.1). The authors hypothesize that this difference is related to a greater effect of hypoparathyroidism on cortical than trabecular bone. I am writing to propose an additional explanation for this discrepancy. Stutzman et a1 reviewed 600 cases of dual photon absorptiometry to identify casues of artifacts.' They stated that potential sources of upward error include osteophytes, pancreatic and aortic calcifications, renal stones, gall stones, contrast agents, and ingested calcium tablets. I would request that Shukla et a1 review the lateral lumbar films that were obtained on the seven patients with hypoparathyroidism and let the readers know if any of these overlying sources of increased density were identified. In addition, the seven patients with hypoparathyroidism who were presented were being treated with exceptionally large doses of calcium carbonate, up to 18 @day. Since these subjects had low PTH levels and perhaps low active Vitamin D status, they may have malabsorbed the orally administered calaum. The Lunar DP-4 scans out to approximately3-4 a n on either side of the vertebral bodies to establish a soft tissue baseline. The average total bone mineral content in lumbar vertebrae 2-4 in women aged 50-60 years old is approximately 42 grams (38%calcium) (personal communication-LunarCorporation). If the daily dose of calcium carbonate is 18 gm (40% calcium), gastrointestinal transit time is 3 days, calcium output in the urine 200 mg/24 hour, insensible calcium loss 100 mg/24 hours, one can estimate that approximately 20 gm of calcium would be floating in the intestine. I would appreciate if the authors could comment on the possibility of overlying calcium in the intestine causing an elevation in recorded dual photon absorptiometry of the lumbar spine.
SEAN MURPHY MB, MRCPI, MRCP (UK)
THOMAS J. PULW, MD JE"IFER LINDSAY, PA-C Francis Scott Key Medical Center Baltimore, MD
PAUL J. DRINKA, MD Wisconsin Veterans Home King,WI
REFERENCES REFERENCES 1 . Ditesheim JA, Richards W, Sharp K. Fatal and disastrous complications following percutaneous endoscopic gastrostomy. Am Surg 1989;55:92. 2. Larson DE, Burton DD, Schroeder KW et al. Percutaneous endoscopic gastrostomy: Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93:48. 3. Stroedel WE, Lemmer J, Eckhauser F et al. Early experiencewith endoscopicpercutaneous gastrostomy.Arch Surg 1983;118:449. 4. Saltzberg DM, Anand K, Juvan P et al. Colocutaneous fistula: An unusual complication of percutaneous endoscopic gastrostomy. JPEN 1987;11:86. 5. Van Gossum A, DesMarez 8, Cremer M. A colo-cutaneousgastric fistula: A silent and unusual complication of percutaneous endoscopic g a s b t o m y . Endoscopy 1988;20161. 6. Femandes ET, Hollabaugh R, Hixon SD et al. Late presentation of gastrocolic fistula after percutaneous gastrostomy. Gastrointest Endosc 1988;34:368.
The Skeleton in Hypoparathyroidism To the E d i t o r 4 am writing to comment on the paper by Shukla et a1 entitled, "The Effect of Hypoparathyroidism on the Aging Skeleton." The paper describes the results of lumbar mineral density determinationsin seven women with long-standing hypoparathyroidism. Large increases above normal were noted in lumbar mineral density by dual photon
1. Shukla S, Gillespy T, Thomas WC. The effect of hypoparathyroidism on the aging skeleton. J Am Geriatr Soc 1990;38:884-
888. 2. Stutzman ME,Yester MV, Dubovsky EV. Technical aspects of dual-photon absorptiometry of the spine. Technique 1987; 15(4):177-181.
Hypoparathyroidism and Cortical BMD To the Editor:-A manuscript published in a recent JAGS issue by Shukla et a1 concluded that "long-standing" hypoparathyroidism contributes to increased cortical bone mineral density (BMD).' In this study, trabecular bone mass was determined by quantitative computed tomography (QCT) measurements and trabecular as well as cortical bone mass was measured by dual photon absorptiometry (DPA). In addition, cortical density of the second metacarpal was evaluated by examining posterior-anterior view radiographs. Selective measurement of the trabecular ComDartment within the vertebrae avoids inclusion of extra-skel&al calcification.' Conversely, DPA measures the entire lumbar spine which allows inclusion not only of cortical bone, but also of osteophytic and aortic calcification. Orwoll et a1 attributed sigruficant increases in BMD values to inclusion of osteophytic calcification in men aged 35-91 (mean = 65 f 13) when using DPA to measure bone mass in the lumbar spine.3The presence of aortic calcification also may influence BMD of
1 gram im every 24 hours and metronidazole 500 mg every 6 hours via nasogastric tube were started for presumed peritonitis. The patient's condition stabilized on this regimen. Enteral feeding via nasogastric tube was restarted within 1 week. The antibiotics were discontinued after 21 days. A barium series performed via the PEG on November 22 confirmed the clinical diagnosis of gastrocolic fistula. An upper gastrointestinalendoscopy on December 4 revealed migration of the intra-gastric bumper of the PEG submucosally, and a fistulous opening was seen in the anterior wall of the stomach. A new PEG was placed on January 8, 1990, and enteral feeding through it commenced uneventfully. The old PEG was capped off and left in place. A repeat gastrostomy-tube barium series done through the new PEG on March 3, 1990 showed almost complete healing of the gastrocolic fistula. The new PEG began to leak enteral feedings, and a repeat upper gastrointestinal endoscopy on June 27, 1990, again revealed migration of the intra-gastric bumper submucosally. A jejunal feeding tube was passed through the gastrostomy, and enteral feeding was resumed. The patient remained stable until July 11, 1990 when she developed vomiting and abdominal pain and expired suddenly. An autopsy showed duodenal perforation without ulcer. The perforation was thought to have arisen secondary to the more recently placed jejunal feeding tube. There was no evidence of her previous gastrocolic fistula. To the best of our knowledge, this is the first reported case of delayed gastrocolic fistula following PEG placement successfully managed by conservative means in a nursing home. In addition we have documented complete healing using this approach alone.
LElTERS TO THE EDITOR
533
absorptiometry (mean Z-score 2.9) with only slight increases determined by quantitative computed tomography (mean Zscore 1.1). The authors hypothesize that this difference is related to a greater effect of hypoparathyroidism on cortical than trabecular bone. I am writing to propose an additional explanation for this discrepancy. Stutzman et a1 reviewed 600 cases of dual photon absorptiometry to identify casues of artifacts.' They stated that potential sources of upward error include osteophytes, pancreatic and aortic calcifications, renal stones, gall stones, contrast agents, and ingested calcium tablets. I would request that Shukla et a1 review the lateral lumbar films that were obtained on the seven patients with hypoparathyroidism and let the readers know if any of these overlying sources of increased density were identified. In addition, the seven patients with hypoparathyroidism who were presented were being treated with exceptionally large doses of calcium carbonate, up to 18 @day. Since these subjects had low PTH levels and perhaps low active Vitamin D status, they may have malabsorbed the orally administered calaum. The Lunar DP-4 scans out to approximately3-4 a n on either side of the vertebral bodies to establish a soft tissue baseline. The average total bone mineral content in lumbar vertebrae 2-4 in women aged 50-60 years old is approximately 42 grams (38%calcium) (personal communication-LunarCorporation). If the daily dose of calcium carbonate is 18 gm (40% calcium), gastrointestinal transit time is 3 days, calcium output in the urine 200 mg/24 hour, insensible calcium loss 100 mg/24 hours, one can estimate that approximately 20 gm of calcium would be floating in the intestine. I would appreciate if the authors could comment on the possibility of overlying calcium in the intestine causing an elevation in recorded dual photon absorptiometry of the lumbar spine.
SEAN MURPHY MB, MRCPI, MRCP (UK)
THOMAS J. PULW, MD JE"IFER LINDSAY, PA-C Francis Scott Key Medical Center Baltimore, MD
PAUL J. DRINKA, MD Wisconsin Veterans Home King,WI
REFERENCES REFERENCES 1 . Ditesheim JA, Richards W, Sharp K. Fatal and disastrous complications following percutaneous endoscopic gastrostomy. Am Surg 1989;55:92. 2. Larson DE, Burton DD, Schroeder KW et al. Percutaneous endoscopic gastrostomy: Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93:48. 3. Stroedel WE, Lemmer J, Eckhauser F et al. Early experiencewith endoscopicpercutaneous gastrostomy.Arch Surg 1983;118:449. 4. Saltzberg DM, Anand K, Juvan P et al. Colocutaneous fistula: An unusual complication of percutaneous endoscopic gastrostomy. JPEN 1987;11:86. 5. Van Gossum A, DesMarez 8, Cremer M. A colo-cutaneousgastric fistula: A silent and unusual complication of percutaneous endoscopic g a s b t o m y . Endoscopy 1988;20161. 6. Femandes ET, Hollabaugh R, Hixon SD et al. Late presentation of gastrocolic fistula after percutaneous gastrostomy. Gastrointest Endosc 1988;34:368.
The Skeleton in Hypoparathyroidism To the E d i t o r 4 am writing to comment on the paper by Shukla et a1 entitled, "The Effect of Hypoparathyroidism on the Aging Skeleton." The paper describes the results of lumbar mineral density determinationsin seven women with long-standing hypoparathyroidism. Large increases above normal were noted in lumbar mineral density by dual photon
1. Shukla S, Gillespy T, Thomas WC. The effect of hypoparathyroidism on the aging skeleton. J Am Geriatr Soc 1990;38:884-
888. 2. Stutzman ME,Yester MV, Dubovsky EV. Technical aspects of dual-photon absorptiometry of the spine. Technique 1987; 15(4):177-181.
Hypoparathyroidism and Cortical BMD To the Editor:-A manuscript published in a recent JAGS issue by Shukla et a1 concluded that "long-standing" hypoparathyroidism contributes to increased cortical bone mineral density (BMD).' In this study, trabecular bone mass was determined by quantitative computed tomography (QCT) measurements and trabecular as well as cortical bone mass was measured by dual photon absorptiometry (DPA). In addition, cortical density of the second metacarpal was evaluated by examining posterior-anterior view radiographs. Selective measurement of the trabecular ComDartment within the vertebrae avoids inclusion of extra-skel&al calcification.' Conversely, DPA measures the entire lumbar spine which allows inclusion not only of cortical bone, but also of osteophytic and aortic calcification. Orwoll et a1 attributed sigruficant increases in BMD values to inclusion of osteophytic calcification in men aged 35-91 (mean = 65 f 13) when using DPA to measure bone mass in the lumbar spine.3The presence of aortic calcification also may influence BMD of
