A68 DISTAL MIGRATION OF A PERCUTANEOUS GASTROJEJUNAL DUODOPA INFUSION TUBE DUE TO BEZOAR FORMATION AT THE JEJUNAL TUBE TIP

Background Continuous intestinal infusion of levodopa/carbidopa intestinal gel (LCIG) for the treatment of advanced Parkinson’s Disease (PD) leads to less variability in plasma drug levels and improved symptom control. Percutaneous Gastrojejunostomy (PEG-J) tube placement has a high placement success rate; however, delayed tube malfunctions occur in approximately 58% of cases within two years. A rare complication is bezoar formation at the jejunal tube tip. Aims To present a case of bezoar formation at the jejunal tip of a PEG-J tube that caused distal migration of the tube with gastroduodenal ulceration and required surgical extraction. Methods Full chart review was conducted including clinical notes, laboratory results, radiographic imaging, endoscopy reports, and surgical reports. A relevant literature review was conducted. Results A 57-year-old male with severe PD underwent endoscopic guided PEG-J tube insertion for continuous infusion of LCIG; intestinal administration was effective for symptom control. Two years later, he noted that the gastric tube had retracted approximately 15 cm into the stoma without external manipulation of the apparatus. Attempts to externally pull the tube back into position were unsuccessful. The patient underwent Gastroscopy (EGD) with fluoroscopy. Contrast was used to confirm placement of the jejunal tip within the jejunum, but also showed migration of the gastric tip into the duodenum. A gastroscope was used to reposition the gastric tube in the stomach; the jejunal tube was visualized to be under traction. The bumper on the apparatus was re-positioned and external tape was used to further secure the apparatus and prevent migration. A month later the tube had migrated again; repeat EGD showed the jejunal tube to be under traction with some resultant ulceration of the pyloric channel and duodenal bulb where the tube had been pressing against the mucosa. The jejunal tube could not be pulled back and appeared to be fixed distally. A CT scan was obtained to assess for complications and a coiled tip was seen in the proximal jejunum. Surgical extraction of the malfunctioning tube was required. At laparotomy, the coiled tip of the feeding tube was successfully removed via enterotomy. The tube tip had coiled around itself and was encased with food materials, creating a large bezoar that was being pulled distally by peristalsis. The patient subsequently underwent insertion of a new GJ tube for ongoing administration of LCIG and has been doing well since. Conclusions Bezoar formation at the jejunal tip of LCIG PEG-J tubes is a rare complication and can lead to distal migration and traction related gastroduodenal ulceration. Surgical removal may be required. Funding Agencies None

Prospective observational study of the use of omeprazole and maropitant citrate in veterinary specialist care

The proton pump inhibitor omeprazole is administered to dogs with gastroduodenal ulceration or oesophagitis, whereas the neurokinin-1 receptor antagonist maropitant citrate is licensed as an antiemetic drug. In people, omeprazole is overprescribed in hospitals, increasing the risk of adverse effects and imposing unnecessary costs in healthcare. To investigate the use of omeprazole and maropitant in our veterinary specialist hospital, we conducted a prospective observational study in its Medicine and Surgery wards, recording patient data and obtaining contemporaneous information from clinicians about their reasons for administering either drug. In doing so, we find omeprazole and maropitant are administered to a large proportion of dogs, including to many of those with no presenting signs suggestive of gastrointestinal disease. We find prescribing clinicians consider both drugs safe but often underestimate their financial cost. We find the stated reasons and objective predictors of administration of both drugs vary according to clinical setting but that these modalities yield concordant results. Reviewing the manner of administration and stated indications for use of both drugs, we find omeprazole is often administered outside dosing recommendations, and both drugs are frequently administered for aims that are unlikely to be achieved when considering their known biological effects in dogs. In conclusion, our work reveals probable overprescribing of omeprazole and maropitant citrate in hospitalised dogs, highlighting a need for initiatives to decrease inappropriate prescribing.

Gastroduodenal Ulceration in Small Animals: Part 2. Proton Pump Inhibitors and Histamine-2 Receptor Antagonists

ABSTRACT In the first part of this review, we discussed the pathophysiology and epidemiology of gastric acid secretion and the epidemiology of gastroduodenal ulceration in dogs and cats. In this section, we discuss the pharmacology and evidence-based clinical use of histamine-2 receptor antagonists and proton pump inhibitors.

Gastroduodenal Ulceration in Small Animals: Part 1. Pathophysiology and Epidemiology

ABSTRACT Gastroduodenal ulceration in small animals is a complex and important comorbidity that occurs when the physiological homeostasis of the gastrointestinal tract is disrupted secondary to administration of medications or the presence of local or systemic diseases. The aim of this article is to provide a comprehensive review of the veterinary literature regarding the pathophysiology, epidemiology, and risk factors associated with gastroduodenal ulceration in small animals. Pertinent concepts from the human literature will be integrated into the discussion. This article serves as an introduction to the second part of this series, which will review current evidence regarding the use of H2-receptor antagonists and proton pump inhibitors in small animals.

Celecoxib and Diclofenac Plus Omeprazole are Similarly Effective in the Treatment of Arthritis in Patients at High GI Risk in the CONDOR Trial§

Objective: Compare effectiveness of celecoxib versus diclofenac plus omeprazole in improving arthritis signs and symptoms in patients at high gastrointestinal (GI) risk who were enrolled in the CONDOR (Celecoxib vs Omeprazole and Diclofenac in Patients With Osteoarthritis and Rheumatoid Arthritis) trial. Methods: CONDOR was a 6-month, prospective, double-blind, triple-dummy, parallel-group, randomized, multicenter trial comparing celecoxib 200 mg twice daily versus diclofenac slow release (SR) 75 mg twice daily plus omeprazole 20 mg daily. Patients were Helicobacter pylori negative, had osteoarthritis (OA) or rheumatoid arthritis (RA), were aged ≥60 years, were with or without a history of gastroduodenal ulceration, or were ≥18 years with previous gastroduodenal ulceration. Patients’ Global Assessment of Arthritis was determined at each study visit. Results: A total of 4484 patients were randomized to treatment (2238 celecoxib, 2246 diclofenac SR) and included in the intention-to-treat analyses. Least squares mean (LSM) (standard error [SE]) for Patients’ Global Assessment of Arthritis was 3.219 (0.017) and 3.221 (0.017) at baseline for celecoxib and diclofenac SR (p=0.90). Improvement in both groups was similar in months 2, 4, and 6; at month 1 the LSM (SE) was 2.647 (0.017) and 2.586 (0.017) for celecoxib and diclofenac (p=0.0025). LSM difference (SE) from baseline to final visit demonstrated an improvement of 0.75 (0.02) in celecoxib-treated patients and 0.77 (0.02) in diclofenac SR-treated patients (p=0.42). Conclusions: Celecoxib and diclofenac plus omeprazole were shown to have similar efficacy in patients with OA and/or RA at increased GI risk who were enrolled in the CONDOR trial. Trial Registry: Trial was registered under ClinicalTrials.gov identifier NCT00141102.