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Small bowel obstruction secondary to distal migration of the intestinal probe in a patient with an endoscopic gastrostomy for continuous carbidopa-levodopa infusion
Obstrucción de intestino delgado secundaria a migración distal de la sonda intestinal en una paciente con gastrostomía endoscópica para la infusión continua de carbidopa-levodopa
Arantxa Díaz Gómeza, Raquel Díaz Ruiza,
Corresponding author
diaz.ruiz.r@gmail.com

Corresponding author.
, Óscar Nogalesa, Beatriz de la Casab, Carmen Fernández Alvárezc, Cecilia González Asanzaa
a Department of Gastroenterology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Department of Neurology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Department of Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Levodopa is the gold standard treatment for Parkinson&#39;s disease &#40;PD&#41;&#46; However&#44; due to its short plasma half-life&#44; requiring repeated doses&#44; long-term levodopa use &#40;usually within 5&#8211;10 years after initiating treatment&#41; is associated with motor fluctuations and dyskinesias&#46; Impaired gastric emptying is also common in PD patients and leads to unpredictable responses to oral medication&#46; These facts induce disability and lower quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Therapeutic alternatives for patients with advanced PD include deep brain stimulation&#44; continuous subcutaneous apomorphine infusion and intrajejunal levodopa-carbidopa infusion&#46; Continuous intraduodenal&#47;intrajejeunal infusion of a levodopa-carbidopa &#40;L-C&#41; gel &#40;Duodopa&#174;&#44; Abbvie&#41; &#8211; which contains levodopa 20<span class="elsevierStyleHsp" style=""></span>mg&#47;ml plus carbidopa 5<span class="elsevierStyleHsp" style=""></span>mg&#47;ml &#8211; improves motor fluctuations<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> &#40;<span class="elsevierStyleItalic">off</span> time and severity and dyskinesia&#41;&#44; non-motor symptoms&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> autonomy for basic activities<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> This therapy is performed by placing a specific percutaneous endoscopic gastrostomy &#40;PEG&#41; kit &#40;Frecka&#174; PEG gastric set&#41; that contains inside a 9Fr duodenal pigtail &#40;Freka&#174; CH9 intestinal tube&#41; probe&#46; This technique requires cooperation between the neurologist that sets the indication for this treatment and does a close surveillance of the patient&#44; and the Gastroenterologist&#47;Endoscopist that places the PEG probe and performs the surveillance and replacements of the device&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 76 year-old woman with advanced PD complicated with motor fluctuations required Duodopa&#174; administration to control her motor symptoms&#46; Therefore&#44; a PEG-Duodopa was placed&#44; with Propofol sedation&#44; after informing the patient and her family about the benefits and the possible risks related to the procedure&#46; Thirty minutes before the PEG-duodopa allocation&#44; the patient received antibiotic prophylaxis with Cefazolin 2<span class="elsevierStyleHsp" style=""></span>g&#46; It was performed without any immediate complications and lack of complications was verified by immediate endoscopic control&#44; as usual&#46; The patient was discharged from hospital 2 days after the procedure&#44; with marked improvement of the motor symptoms&#44; since PEG-duodopa was used for the first time 24<span class="elsevierStyleHsp" style=""></span>h after its allocation&#46; After eleven days&#44; the patient was admitted to the emergency room because of abdominal distension with pain and vomiting&#44; which was highly suggestive of an intestinal obstruction&#46; Plain abdominal X-ray showed the duodenal probe tip of the Freka&#174; CH9 Intestinal Tube projected in right iliac fossa and absence of pneumoperitoneum&#46; Severe abdominal pain persisted despite administration of analgesics&#44; so an urgent abdominal CT was indicated to discard any other complication&#46; It confirmed the presence of the pigtail probe coiled in the ileum due to distal migration&#44; conditioning severe retrograde small bowel dilation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Since the patient had no response to conservative treatment&#44; emergency surgery was indicated&#44; performing an ileostomy&#44; extraction of the probe and primary suture without associated complications&#46; Ten days after surgery&#44; after discussing the case between surgeons&#44; endoscopists and neurologists&#44; and with the agreement of the patient&#44; placement of a new duodenal pigtail type probe was carried out without further complications&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Continuous L-C gel infusion is a highly effective and well accepted alternative for the treatment of advanced PD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a> Duodenal infusion avoids problems related to delayed stomach transit&#46; It has a similar safety profile to oral medication providing better control of motor and non motor symptoms in those cases&#46; However&#44; specific complications related to probe placement cannot be overlooked&#46; They include complications related to&#58; &#40;a&#41; the stoma&#44; like infection&#44; granuloma development&#44; etc&#46;&#44; &#40;b&#41; the gastrostomy probe&#44; like buried bumper syndrome&#59; and &#40;c&#41; the pigtail probe&#58; distal migration&#44; bending&#44; or probe break&#46; Events that involve the probe are very frequent &#40;a study<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> described that more than 60&#37; of the patients had at least 1 event with duodenal probe after one year with continuous L-C infusion&#41;&#46; Distal migration is generally asymptomatic&#44; with spontaneous anal expulsion&#46; Perforation or intestinal obstruction<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> secondary to probe migration as in the case exposed is exceptional&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos