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 21 October 2017

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Classical Case Studies

GastroenterologyNutrition

Parenteral nutrition

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A Patrick Goiter as a complication of TPN
A Patrick, 18 September 2003
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Summary

TPN use is becoming more widespread for a variety of indications. It is generally well tolerated and safe when given via a PICC line. It can enable patients to continue treatment at home. However one must be alert for the common complications of line migration, sepsis, leakage and thrombosis.

Pain or swelling of a limb or the face in patients’ receiving TPN should alert the physician to the possible presence of venous thrombosis. In such patients with PICC lines there should be a high index of suspicion of line migration.

Low dose warfarin has been suggested to help prevent thrombosis [6].

We report an unusual cause of goiter in a 30-year-old lady with Crohn’s disease on home TPN.


Case report

History

Our patient was diagnosed with Crohn’s disease in 1984. She had a right hemicolectomy at age 13, and a proctocolectomy with a left iliac fossa ileostomy in 1990. She presented to us with symptomatic recurrent Crohn's disease of the neo-terminal ileum, which initially responded well to oral Prednisone, but on dose reduction she developed recurrent colicky abdominal pain, a left iliac fossa mass and 10kg weight loss.

She was referred for surgical treatment. At laparotomy a Crohn’s inflammatory mass, together with 16cm of the neo-terminal ileum, was resected. Initial post-operative recovery was uneventful and she was commenced on Azathioprine at 2mg/kg and Prednisone tapered.

One month later she presented acutely with pelvic abscesses. These were drained percutaneously and the patient was commenced on triple antibiotic therapy.

Her BMI was 15 and she was commenced on high calorie and protein oral feed, but her ileostomy flux increased despite use of Codeine Phosphate, Omeprazole and St Mark's rehydration mix. An examination under anaesthetic showed 2 communicating cavities and a Pigtail drain was inserted. A sinogram demonstrated retrograde filling of the ileum.

The fistula was treated conservatively with complete bowel rest and total parenteral nutrition (TPN) was commenced via a right antecubital fossa peripherally inserted central catheter (PICC). Further small bowel contrast studies 20 days after admission showed a persistent fistula and so she was discharged home on TPN (1500 KCal non-protein calories, osmolality 1390 mosmol/l).

Four days after discharge she re-presented with a gradual onset of face and neck swelling.

Investigation

Chest X-ray demonstrated that the PICC line had migrated distally, with the tip resting at the junction of the brachiocephalic and right internal jugular veins. An ultrasound found bilateral internal jugular and thyroid vein thromboses (Figure 1).

Management

The PICC line was withdrawn to the axillary vein and TPN was changed to a Peripheral Parenteral Nutrition formulae (osmolality 868 mosmol/l). Anticoagulation with subcutaneous fractionated heparin and warfarin was commenced.

Outcome

Her facial swelling settled over 72 hours and she continued PPN and warfarin without further adverse events. The fistula closed successfully and PPN was stopped on the 77th day.

Warfarin was discontinued after 3 months and a subsequent thrombophilia screen showed normal Antithrombin 3, Protein C and S activity and no Lupus or Anticardiolipin antibodies.

Discussion

Complete bowel rest by parenteral nutrition can encourage closure of enteric fistulae. TPN via a peripherally inserted catheter (PICC) is a safe and now widely used entity due to improvements in catheter technology and care.

Compared to centrally inserted catheters PICC lines have similar rates of thrombosis and sepsis but greater rates of local complications such as malposition, phlebitis and leakage [1].

This case illustrates an unusual presentation of a common complication. Accepted rates of thrombosis secondary to indwelling venous catheters are between 1 and 4% [2]. Thrombosis of the thyroid vein has not been described before.

Migration of the PICC line from a position distal to the superior vena cava increases the chance of associated thrombosis [3]. Our patient had a major migration of the catheter tip whilst she was out of hospital and this was probably the main factor in the subsequent clot formation.

Underlying Crohn’s disease [4] and the high osmolality of the feed [5] into a vein with lower blood flow would also have contributed.

Prophylactic low-dose warfarin has been advocated for patients on home TPN to avoid such complications, with one study documenting a ten fold reduction in the relative risk of thrombosis [6].

Figure 1
Ultrasound demonstrating thrombosis in the left internal jugular and thyroid veins.

Authors

Dr Alasdair Patrick MBChB
Dr Russell Walmsley MRCP, MD
Department of Gastroenterology, North Shore Hospital, Takapuna, Auckland, New Zealand

Contact information

Dr Alasdair Patrick
Registrar, Auckland Hospital, Auckland, New Zealand
alasdairp@adhb.govt.nz

This article was first published on GastroHep.com on 18 September 2003.

References

  1. Duerksen DR, Papineau N, Siemens J, Yaffe C. Peripherally inserted central catheters for parenteral nutrition: A comparison with centrally inserted catheters. J Parenter Enteral Nutr 1999; 23: 85-9.
  2. Allen AW, Megargell JL, Brown DB, Lynch FC, Singh H, Singh Y, Waybill PN. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11(10): 1309-14.
  3. Bargan IA, Barker NW. Extensive arterial and venous thrombosis complicating chronic ulcerative colitis. Arch Intern Med 1936; 58: 17-31.
  4. Koksoy C, Kazu A, Erden I, Akkaya A. The risk factors in central venous catheter related thrombosis. Aust NZ J Surg 1995; 65(11): 796-8.
  5. Kearns PJ, Coleman S, Wehner JH. Complications of long arm-catheters: A randomized trial of central vs peripheral tip location. J Parenter Enteral Nutr 1996; 20: 20-4.
  6. Veerabagu MP, Tuttle-Newhall J, Maliakkal R, Champagne C, & Mascioli EA. Warfarin and reduced central venous thrombosis in home total parenteral nutrition patients. Nutrition 1995; 11: 142-4.


 
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