The use of the "cut-and-push" technique for percutaneous endoscopic gastrostomy (PEG) removal has been recognized since 1991. This technique is used in patients who are thought to have no risk of distal adhesions or strictures. Its use in selected patients is supported by current British Society of Gastorenterology guidelines. However, the risk of complications has long been debated. This report describes a patient who developed complications as a result of PEG removal using the cut-and-push technique. The patient had undergone previous abdominal surgery, and removal of the PEG endoscopically was not possible. A barium follow-through was performed in light of the history, and it excluded any mechanical blockage. Follow-up x-ray showed passage of the remnant beyond the pylorus. Despite this, the remnant became lodged in the small bowel, eventually resulting in perforation and death. This case highlights the fact that impaction of the remnant can occur in patients without evidence of mechanical obstruction on investigation. This raises a question about the need for serial x-rays to ensure passage of the remnant if the patient cannot confirm this visually.
Drug induced pancreatitis (DIP) is a serious adverse effect of many commonly used drugs. Pegylated interferon (peg- IFN) and ribavirin used for treatment of chronic hepatitis C (CHC) infection and various protease inhibitors (PIs) such as indinavir, nelfinavir, ritonavir and saquinavir used for HIV infection have been reported to cause DIP; although the mechanism of pancreatitis is not well known. Recently, telaprevir and boceprevir are introduced for treatment of HCV genotype 1 infection along with peg-IFN and ribavirin. There are no reports of acute pancreatitis due to telaprevir and boceprevir in liver transplant setting. We managed two such cases; both were male with HCV genotype 1 infection, had living donor liver transplantation for hepatocellular cancer few years ago and stable on cyclosporine. Both developed AP a month after adding one of PI to their combination therapy. First patient had past history of partial response with peg-IFN and ribavirin and retreated with addition of telaprevir to combination therapy. Second patient received peg-IFN and ribavirin for 4 months and then boceprevir was added. Patients were managed conservatively, the culprit PI was stopped and they recovered. We used the Naranjo Probability Scale for Adverse Drug Events to estimate the probability that a drug was the cause of the acute pancreatitis. A score of 7 was calculated in both patients, indicating a probable adverse drug reaction. The algorithm devised by Trivedi et al to diagnose drug-induced pancreatitis was also used and confirmed that this was likely to be a drug reaction. There is adequate circumstantial evidence pointing to telaprevir and boceprevir as the cause of their acute pancreatitis. Further evidence is needed but in the meantime we would recommend routine monitoring of amylase levels for all patients on triple therapy and advise patients of potential symptoms for which they should seek medical advice.
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