Most authors accept that mesenteric lipodystrophy, MP and sclerosing mesenteritis are part of the spectrum of one disease - usually one feature predominates, whose etiology remains obscure. Mesenteric panniculitis has been associated with a number of autoimmune conditions, with clinical response to immunomodulatory medications including corticosteroids, azathioprine and cyclophosphamide. Dual-phase abdominal CT is the most sensitive imaging modality for detecting MP. This is the first reported case seen of MP caused secondary to cryoglobulenemia that responded well to steroids and had other features of rare cryoglobulemia manifestations of low rheumatoid factor level with no manifestations and LV. Probable etiology would be vasculitis of the mesenteric vessels.
Abstract:
Amir Butt, MD*, Malvinder Singh, MD, Siddarth Mathur, MD, Niket Sonpal, NA, Sushil Duddempudi, MD, Mukul Arya, MD. Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, Division of Gastroenterolgy, Wyckoff Heights Medical Center, Brooklyn, NY.
Purpose: A 71 year-old male present to the emergency room with a chief complaint of epigastric pain for two weeks. He mentioned this was associated with post-prandial, non-bilious vomiting. He described having loose dark stools for the same interval. He denied unintentional weight loss. His past history was significant for a sub-total colectomy for hematochezia more than twenty years ago. Physical exam was remarkable for epigastric tenderness and fullness, with a healed midline scar. Bowel sounds were normal. Gastric lavage was negative. CT of the abdomen with oral contrast revealed a distended stomach with thickening of the distal antrum and pylorus. Upper endoscopy revealed a narrow pylorus with friable and erythematous mucosa. Multiple biopsies were taken from this region. In the duodenum, multiple large sessile and pedunculated polyps were noted. A large polyp was clipped at the pedicle and snared from above. Colonoscopy revealed an intact ileo-rectal anastamosis with polyps similar to the ones found in the duodenum. Biopsies from the pyloric channel revealed moderately differentiated invasive adenocarcinoma. Histology of the polyp revealed tree-like arborization, consistent with a hamartomatous polyp. Peutz-Jeghers Syndrome is a rare autosomal dominant disorder characterized by mucocutaneous pigmentation and harmtomatous polyps throughout the gastrointestinal tract. It is associated with an elevated risk of development of gastrointestinal and extra-intestinal malignancy. During the second and third decades of life, patients may present with abdominal pain, hematochezia and obstruction. Prior to this hospital admission, our patient never had an upper endoscopy. We recommend that patients presenting with hematochezia, despite a negative gastric lavage, should undergo an upper endoscopy to ensure such rare diagnosis are not missed.
Abstract:
Amir Butt, MD*, Shikha Doomra, MD, Frederick Fallick, MD. Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, Department of Gastroenterology, St. Barnabas Hospital, Bronx, NY.
Purpose: We report a case of a 21-year-old African male who was referred to the emergency room for noticeable abdominal distention. The patient described it as abdominal 'fullness' without symptoms. He also mentioned having constipation since for the past one month and a change in stool consistency, with stools alternating between diarrhea and constipation. He denied any pain in the abdomen, weight loss, nausea, vomiting, or fever. The patient was not on any medication and denied used of performance enhancing medication. Family history was significant for resection of ovarian teratoma in his mother and niece at ages of 19 and 11 respectively. Physical examination was significant for a soft non-tender distended abdomen. A central mass was palpable with unclear margins. A small lymph node was palpable in the right groin. Laboratory data revealed hemoglobin of 13 gm/dL with a normal MCV. His liver function tests showed mildly elevated transaminases (ALT/AST 56/46). An abdominal CT scan was ordered which revealed a large heterogeneous non-calcified, non-fat containing intra-peritoneal mass occupying the majority of the abdomen with displacement of bowel loops and compression of the recto-sigmoid colon. A small amount of ascities was also noted. Markers for malignancy CEA, CA 19-9, HCG were negative. An MRI of the abdomen revealed the same large midline intra-abdominal mass, which appeared to arise just inferior to the level of the pancreas with maximum dimensions of 16 cm by 8 cm by approximately 15 cm wide. The mass did not involve the abdominal wall or the bladder. Markers for malignancy CEA, CA 19-9, HCG were negative. The mass was subsequently biopsied on day three. Core-needle biopsy revealed small, blue cells with hyperchromatic nuclei and scant cytoplasm. Tissue staining was positive for the marker CD 99, consistent with Ewing's sarcoma. In summary, although rare, Ewing's sarcoma should be a part of the differential diagnosis in patients presenting with an abdominal mass. Furthermore, because of the rarity of this tumor, patients diagnosed with Ewing's sarcoma should be referred to centers that have experience with the disease.
Abstract:
Jitendrakumar Patel, MD*, Kashyapkumar Patel, MD, Kelly Cervellione, MA, Avani Patel, MD. Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY.
Purpose: Granulomatous appendicitis (GA) is a rare condition occurring in 0.1% to 2% of all appendectomies. Possible etiologies of GA include Crohn's disease (CD), sarcoidosis, foreign body reaction, obstruction caused by fecalith, mucocele or tumor and infectious agents such as mycobacterium, fungi and parasites. Idiopathic granulomatous appendicitis (IGA) is an extremely rare condition with unknown etiology.
Methods: A 29-year-old male presented with complain of right lower quadrant (RLQ) pain for 6 months. In addition, patient had nausea, vomiting, diarrhea, fever and chills.
Results: On abdominal examination, localized tenderness present in the RLQ with positive rebound. On laboratory investigation, patient had leukocytosis with normal hemoglobin, amylase and lipase. Patient was admitted for same episodic complaint 6 months and 4 months prior; perforated appendix with peritonitis was diagnosed at those times, but patient refused surgery. He was treated with oral antibiotics and advised to follow-up in surgery clinic. The patient now presented with same complain. Intravenous antibiotics were started; CT scan revealed phlegmon in RLQ. Patient underwent laparoscopic appendectomy. On laproscopy, there were local chronic inflammatory process with fibrosis and adhesion on the lateral wall, which complicated the procedure. Therefore, open laprotomy was attempted. Appendix and cecum was inflamed so appendectomy was completed along with right hemicolectomy and terminal ileactomy. Biopsy of appendix revealed focal ulceration, mucosal necrosis, transmural acute and chronic inflammation with crypt abscess, and multiple small non-necrotizing granulomas with multinucleated giant cells in lamina propria, submucosa and muscularis mucosa. Stain for fungal, acid fast bacilli and Yersinia organisms were negative. Histopathology of right colon and terminal ileum revealed scattered inflammatory cell infiltrate without evidence of cryptitis, crypt abscess or granuloma. Mesenteric lymph nodes showed benign acute and chronic inflammatory infiltrate. Patient was discharged without further episodes.
Conclusion: IGA is an extremely rare condition with unknown etiology, though it is theorized that it may be associated with recurrent and subacute appendicitis. Recurrent appendicitis produces granulomatous reaction secondary to inflammation. Use of temporary treatment, such as antibiotics, delays the need for appendectomy, but may inclrease chances of developing IGA. IGA was initially thought to be part of the Crohns Disease spectrum, but recent studies show that IGA has different histopathological features than CD and that only 5 to 10% of IGA patients eventually developed CD. IGA should be considered in cases that mimic the illness course described here.
Abstract:
Shivangi Kothari, MD*, Chintan Mody, MD, Robert Spira, MD, Joseph DePasquale, MD. Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ, Gastroenterology and Hepatology, Internal Medicine, St. Michael's Medical Center, Newark, NJ.
Purpose: Giant sigmoid diverticulum is a rare air-filled cystic cavity greater than 3-4 cm. Giant pseudodiverticulum of sigmoid colon is one of the two types of sigmoid diverticulum. It is a very rare presentation of diverticular disease. It has a typical radiological and histological finding, which is helpful in making the diagnosis.
Methods: A 72-year old female with hypertension presented with complaints of abdominal distention, decreased appetite and weight loss for 2 weeks. The patient denied fever, abdominal pain, vomiting or constipation. On physical exam abdomen was distended, soft, non tender with presence of normal bowel sounds. Labs revealed leukocytosis of 38.2 with 21% bands, normal liver functions, amylase and lipase. Patient was started on antibiotics and IV fluids. Abdominal CT showed an air fluid level with a large 10 cm dilated loop of sigmoid colon. Patient was presumed to have volvulus and colonoscopy was performed. The scope was advanced into a narrowed area in the recto-sigmoid region and it entered into a large air filled cavity lined by blackish appearing serosa. The cavity lacked the lining by normal colonic mucosa. Upon continuous suctioning of the air in the cavity it completely collapsed resolving abdominal distention. Patient was referred to surgery for possible sigmoid pseudodiverticulum versus colonic perforation. Patient underwent exploratory laparotomy with left hemicolectomy, rectal Hartman's pouch and colostomy. The pathology report showed sigmoid pseudodiverticulum with focal acute and chronic inflammation. Post surgical hospital course was uneventful and patient was discharged.
Results: -
Conclusion: Giant Colonic diverticulum (GCD) was first described by Bonvin and Bonte in 1946. GCD has been divided into Type I and Type II. Type I is a pseudodiverticulum with the cyst wall lacking the smooth muscle and consisting mostly of fibrous tissue and chronic inflammatory cells. Type II is a true diverticulum, congenital in origin with the wall consisting of distinct smooth muscular layer and all the layers of normal bowel wall. Type I and Type II account for 87% and 17% cases respectively. Some of the proposed theories of formation are unidirectional ball valve mechanism, gas forming organisms or differences in the intracolonic and GCD pressure through the communicating ostium. Gender distribution is equal in Type I while Type II has male predominance. The common symptom is the abdominal pain with distension in 70% of the patients. Diagnosis is made with plain abdominal films, abdominal CT scan, and colonoscopy. Treatment is based on the type of GCD, for type I - segmental resection is recommended. For type II, diverticulectomy is suggested. Prognosis is usually good after surgical intervention.
Abstract:
Lakshminarayan Sooraj T K, MD, MPH*, Mary Atten, MD, Bashar Attar, MD, PhD, FACG, Victoria Angelova, MD, Benjamin Go, MD. Gastroenterology and Hepatology, Cook County-John H. Stroger Hospital, Rush University, Chicago, IL.
Purpose: NA
Methods: Introduction: Iron overload occurs in patients with chronic hepatitis C infection (HCV), however it is usually mild. Iron is hepatotoxic, hinders therapeutic response to interferon/ribavirin, and accelerates progression to liver fibrosis while also increasing the risk of hepatocellular carcinoma. Hereditary hemochromatosis, an autosomal recessive disease, independently causes iron overload in the homozygous state. H63D mutation accounts for a minority of hereditary hemochromatosis cases, and does not cause iron overload in the heterozygous carrier state. Here we present a patient with heterozygous H63D mutation and HCV infection with significant iron overload. Case presentation: A 45-year-old female was referred for management of HCV genotype 1 infection. She had normal liver enzymes, coagulation profile, leukocyte count, platelet count, low hemoglobin of 11.8 gm/dl, and hematocrit of 34.1%. She had elevated ferritin of 639.9, and transferrin saturation of 81%. DNA analysis showed heterozygous H63D mutation. Liver biopsy showed mild fibrosis (stage 1-2/6), moderate inflammation (MHAI score 6/18), and increased iron deposition in hepatocytes on iron stain (Grade 3/4). She is currently undergoing therapeutic phlebotomy prior to starting HCV therapy. Discussion: The carrier state for hemochromatosis mutations, though not associated with phenotypic hemochromatosis in otherwise normal individuals, assumes clinical importance when it occurs with HCV infection. These patients develop increased hepatic iron deposition and fibrosis. Significant iron overload in a patient with HCV, such as our patient, should raise suspicion for hemochromatosis mutations. If present these patients may benefit from phlebotomy prior to antiviral therapy.
Abstract:
Mohamad Erfani, MD*, Touraj Zolfaghari, MD, Hilary Hertan, MD, FACG. Gastroenterology, Our Lady of Mercy Medical Center, Bronx, NY.
Purpose: Approximately 120,000 percutanaeus endoscopic gastrostomy (PEG) procedures are performed in U.S. annually. Although PEG placement is generally safe, 16 to 70% complication rate is reported. Minor complications include wound infection, tube dysfunction, gastric outlet obstruction, peristomal leakage, bleeding, cutaneous or gastric ulceration, pneumoperitoneum and temporary ileus. Major complications include necrotizing fasciitis, esophageal or gastric perforation, buried bumper syndrome, and inadvertent PEG removal. Here we present another complication of GT migration into the duodenum. This complication has been under-recognized and rarely reported.
Methods: This is a case series study. Five nursing home patients with PEG who were admitted with obstructive symptoms, elevated serum amylase and lipase and normal liver enzymes were reviewed. In all cases the physical and radiological examination (Fig. 1), revealed migration of the GT into the duodenum. Symptoms were resolved after GT replacement or retraction. Serum amylase and lipase were also normalized within 2 to 3 days. No other causes for acute pancreatitis were identified. In one case the patient was re-admitted several times with migrated GT and similar findings. Pancreatic enzymes were normalized after GT replacement in every occasion.
Results: In all cases, there was evidence of migrated GT balloon compressing periampullary area with increased amylase and lipase, which normalized when the balloon was deflated and moved away from the ampullary region. This condition was associated with balloon-type internal bolster, replaceable GT.
Conclusion: In elderly patients with PEG, abdominal pain, vomiting and hyperamylasemia, a migrated GT to the periampullary region should be looked for and the GT should be repositioned.
Abstract:
Shivangi Kothari, MD*, Chintan Mody, MD, Robert Spira, MD, Joseph DePasquale, MD, Gunwant Guron, MD. Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ, Internal Medicine, Gastroenterology, St Michaels Medical Center, Newark, NJ, Oncology, St. Michael's Medical Center, Newark, NJ.
Purpose: Hairy Cell Leukemia (HCL) is a form of chronic lymphoproliferative disorder. Leukemic involvement of the gastrointestinal (GI) tract must be considered in any patient with acute or chronic leukemia who presents with unusual GI symptoms. We report a patient with HCL presenting with fever, abdominal pain and was found to have hairy cell (HC) infiltration on random biopsies of endoscopically normal appearing duodenum.
Methods: Our patient is a 48 year old Hispanic male with history of HCL who presented with fever for two days after one cycle of cladribine (2-CdA). Patient had temperature of 101.4 and right abdominal tenderness with no rebound, guarding or rigidity. Labs showed WBC 0.4, ANC 0.2, Hb 8.9, platelet 23, ALP 137, ALT 42, AST 32. He was started on Imipenem, Vancomycin, Diflucan and Neupogen. Extensive septic work-up was negative. HIDA scan was negative. Bone marrow biopsy done for persistent spiking of high grade fever was negative for any pathogens. Abdominal CT showed circumferential thickening of 2nd and 3rd portion of duodenum. EGD revealed a completely normal esophagus and duodenum. Random biopsies of the duodenum revealed chronic inflammatory infiltrate chiefly composed of atypical lymphocytes and plasma cells. Immunohistochemical stains of paraffin sections of biopsy revealed atypical lymphocytes positive for TRAP (tartrate resistant acid phophatase), consistent with hairy cell leukemic infiltrate of duodenum. Patient's WBC subsequently improved on Neupogen and he was discharged.
Results:
Conclusion: Extramedullary involvement of the GI tract with leukemia is very rare and usually involvement of lymphoreticular organs, brain, testes and ovaries is seen. The reported autopsy incidence of GI involvement by leukemia ranges from 5.7% to 13% and reaches upto 20% in cases of acute lymphocytic leukemia. Leukemic involvement of the GI tract can be from mouth to anus with duodenum and distal colon being least commonly affected. Macroscopically, GI tract involvement can assume a variety of forms, including necrosis, hemorrhage, ulceration, inflammation or polypoid lesions. We did not find any case in literature with duodenal infiltration by hairy cell leukemia having a normal endoscopic appearance. Acute presentations may include necrotizing enteritis, perforation and abscesses. Radiographic studies may show thickening of bowel wall or ulcerations. Differential should include any underlying infectious etiology. Recurrent GI symptoms in a patient with known leukemic involvement of the GI tract should raise suspicion for leukemic relapse or progression. If index of suspicion is high, random biopsies should be taken regardless of the gross mucosal appearance, as a normal appearing mucosa does not rule out underlying pathology.
Abstract:
Kumaravel Perumalsamy, MD*, Alejandra Borensztein, MS, Natalia Segal, MS, Kadirawel Iswara, MD, Jianjun Li, MD, Scott Tenner, MD. Maimonides Medical Center, Brooklyn, NY.
Purpose: Colitis Cystica Profunda (CCP) is a rare, benign condition that can often provoke a diagnostic dilemma. CCP was shown in study to be confused with adenocarcinoma in up to 25% of cases. CCP is most commonly found in the distal colon. Isolated right colonic CCP is rare and we report a case of CCP of the right colon referred for further management of colonic polyposis.
Methods: 50 year-old woman with no prior PMHx underwent screening colonoscopy. She was found to have multiple sessile growths in the right colon. She was referred for further mangement of right colonic polyposis. During repeat Colonoscopy numerous sessile and polyploid lesions with smooth and tense mucosal surface consistent with submucosal cystic lesions seen in the right colon. These lesions were mainly grouped together in clusters and measured between 0.5 cm and 1 cm in diameter. On needle inspection, these lesions were found to have a liquid, mucinous content and the cystic structures collapsed.
Results: CCP is characterized by the presence of mucin-filled cysts confined to the submucosa most frequently seen in the distal colon. CCP is most often seen in the 3rd and 4th decades of life and has equal predilection for men and women. It is often found in association with solitary rectal ulcers and rectal prolapse as well as defecation disorders. CCP has also been seen in patients with chronic inflammation or trauma such as Crohn's disease, ulcerative colitis and radiation colitis. While several theories have been proposed, it is believed that trauma or chronic inflammation most likely leads to the production of these cysts. The cysts can appear as ulcerated (57%), polyploidy (25%), or flat (18%). The majority of lesions are found in the distal colon, often between 5 and 12 cm from the anal margin on the anterior wall. However, the cysts can be found through the colon and even, rarely, in the small intestine and the stomach. It can also have a segmental distribution or, least frequently, it can present as pancolitis. The lesions seen in CCP have often been mistaken for adenomatous polyps and even adenocarcinoma. Histopathologic analysis can demonstrate mucin pools with flattened epithelial lining within the submucosa. In patients with minimal symptoms, conservative treatment is indicated. The treatment is aimed at reducing straining during defecation by retraining habits, as well as high fiber diets and bulk laxatives. These measures have been demonstrated to cause complete regression within a 6-12 month period in various studies. When rectal prolapse is the cause, surgical correction is indicated to correct the problem.
Conclusion: Isolated right colon CCP is rare and should be considered in the differential diagnosis of multiple polyposis syndrome.
Abstract:
Shivangi Kothari, MD*, Chintan Mody, MD, Robert Spira, MD, Joseph DePasquale, MD. Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ, Internal Medicine, Gastroenterology, St. Michael's Medical Center, Newark, NJ.
Purpose: Malignant melanoma is one of the most common malignancies to metastasize to the gastrointestinal (GI) tract. Metastases to GI tract can present at time of primary diagnosis or decades later as first sign of recurrence. Metastatic melanoma to GI tract is found during diagnostic workup in 1%-4% of patients with cutaneous primary and up to 60% of melanoma patients in autopsy.
Methods: Our patient is a 45 year old white male with history of primary non-pigmented urinary bladder melanoma who presented with complaint of dyspepsia for 2 months. Patient had received full course of chemotherapy with Tamodar for 5 months with good response. He denied any nausea, vomiting, dysphagia or bleeding. He had no primary skin lesion found on extensive detailed physical exam. Whole body PET scan showed markedly thickened stomach walls with multiple omental lesions in the perigastric region. Upper endoscopy revealed two large, non-pigmented ulcerating masses in body of stomach on the greater curvature. These masses had "volcano appearance" with heaped up edges and central crater. Multiple biopsies were taken which were consistent with non pigmented metastatic melanoma confirmed by immunohistochemical stains. Patient was subsequently started on carboplatin and has had mild improvement in symptoms.
Results:
Conclusion: Gastrointestinal invasion by melanoma is a rare condition and is often associated with invasion of other visceral organs. The endoscopic classification of the gastric metastases comprises three main types: (a) melanotic nodules, often ulcerated at the tip; most common (b) submucosal mass, melanotic or not, elevated and ulcerated at apex; typical aspect of "bull's eye" lesion and (c) mass lesions with varying incidence of necrosis and melanosis. Gastric metastases may appear even as a simple ulcer. Majority of gastric metastases are reported to occur in body and fundus, most often on the greater curvature. Most frequent sites of melanoma metastases include small bowel, stomach, colon, and anorectum in decreasing order. Symptoms may include abdominal pain, dysphagia, small bowel obstruction and GI bleed. Diagnosis requires careful inspection of mucosa and biopsy with special immunohistochemical stains. Management may include surgical resection, chemotherapy, immunotherapy, observation, or enrollment in clinical trials. Surgery seems to be of limited value and should be performed in carefully selected patients and in patients with complications. Prognosis is poor, with median survival time in patients presenting with GI invasion being less than 1 year. Endoscopic "Volcano ulcers" in the stomach have been reported in many secondary neoplasms of the stomach and their presence should always raise suspicion for an underlying malignancy.
Abstract:
Bilal Hameed, MD*, Saqib Razzaque, MD, Ahmad Abdulkarim, MD, Nadeem Chaudhary, MD. Gastroenterology, University of Minnesota, Minneapolis, MN, Gastroenterology, Regions Hospital, St. Paul, MN.
Purpose: Common sites of metastasis for the breast cancer are bones, lungs, central nervous system and liver. Colon is the rarest site of metastasis for breast cancer. 84 year old female with history of stage III infiltrating lobular carcinoma of the breast presented with abdominal discomfort and diarrhea. Extensive work up was negative. Colonoscopy showed three polyps (2-6 mm) in the cecum and ascending colon and about 10 mm polyp at the hepatic flexure. No masses or other lesions seen on colonoscopy. Pathology of hepatic flexure polyp showed sessile serrated adenoma and cells positive for CKAE1/AE3 and ER positive staining consistent with metastatic lobular carcinoma. Similarly biopsy specimen from ascending and cecum showed tubular adenoma and metastatic carcinoma of breast (confirmed with CKAE1/AE3 and ER positive staining, PR and CD68 was negative). Histological comparison was also done from her breast cancer which revealed similar tumor. Patient is currently on systemic chemotherapy (faslodex) and doing well. There are about <30 cases in the literature of breast cancer with metastasis to colon in alive individuals. Most of these tumors were lobular carcinoma. Our patient is unique as there is no other case report of breast cancer with metastasis to colon polyps in an alive patient. Diagnosis of colon metastasis from breast is difficult because of non specific symptoms, variable imaging presentations and its rarity. Patients with history of breast cancer presenting with abdominal pain, diarrhea or obstruction should be examined for possible colon metastasis.
Abstract:
Nelson Lim, MD*, Mia Perez, MD, Donald Rankin, MD, Michael Lim, BS, Manoj Shah, MD. Department of Pediatric Gastroenterology, Department of Pathology, Department of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA.
Purpose: To report this rare finding.
Methods: Case: A 15 y/o Caucasian male presents with fever of unknown origin. He has a h/o cardiac transplant in 1992 for Hypoplastic left heart syndrome. His cough symptoms did not improve with a course of azithromycin. The patient had a four-week visit with relatives in Michigan and Illinois approximately 3 months prior to the appearance of these symptoms. He now develops nausea, some vomiting, and slightly increased loose stool while hospitalized. A test for urine Histoplasma Ag was positive. A chest CT and sputum cultures showed no evidence of a fungal infection. An EGD showed several several duodenal bulb erosions. During colonoscopy, there was extensive erythema seen with superficial to deep ulcerations scattered from the cecum to sigmoid colon. Multiple pseudopolyps and inflammatory nodules were seen in the cecum. Biopsies were taken throughout which were significant for non-necrotizing granulomas. Giemsa and PAS special stains were also positive for numerous intracellular small yeast forms with focal narrow-based budding and rare hyphal forms. Duodenal biopsies were similar. These were morphologically consistent with Histoplasma capsulatum.
Results: Histoplasma Capsulatum is a dimorphic fungus and found worldwide.1 In North America it is endemic in the major river valleys (Mississippi and Ohio) of the southern and central United States.2 Once the acute infection is spread hematogenously from the lungs to other organs it is generally classified as systemic. In addition to this, findings of positive blood cultures, or positive urine or serum Histoplasma antigens changes its classification to disseminated.2 Most infections are self-limited, but 1 in 2000 infections result in progressive dissemination especially in immunocompromised hosts.4 The symptoms of disseminated histoplasmosis include fever, malaise, anorexia, and weight loss. The gastrointestinal tract is commonly involved (70-90%) during disseminated infection as determined by autopsy studies.4,8 The colon is usually the most involved organ of the gastrointestinal tract followed by the small bowel. Serious gastrointestinal complications include malabsorption from severe diarrhea, ulcerations, strictures, bowel obstruction, gastrointestinal hemorrhage and perforations.7,8
Conclusion: Our case is a unique example of an immunosuppressed patient with recent travel to an endemic area which may have predisposed the duodenum and colon to a Histoplasma Capsulatum infection. Laboratory evidence of dissemination warrants endoscopic exam even when asymptomatic because the gastrointestinal tract is commonly involved. Prompt diagnosis and treatment may reduce the incidence of serious gastrointestinal complications.
Abstract:
Nissrin Ezmerli, MD*, Naveen Gupta, MD, Nadim Haddad, MD. Georgetown University Hospital, Washington, DC.
Purpose: Squamous cell cancer of the esophagus (ESCC) has been decreasing in incidence in the United States (U.S.) however 5 year mortality remains high with survival ranging from 10 to 13 percent. Multiple risk factors have been identified including geographic (highest in China), dietary/lifestyle (alcohol, smoking, and betel nut ingestion) and other risk factors (achalasia and lye ingestion). The role of viral infections has been evaluated and remains controversial. In particular the role of human papilloma virus (HPV)(subtypes 16 and 18) has received the most scrutiny. Prior studies have been questioned as they have been performed in high risk geographical areas. In low risk areas such as the U.S. retrospective pathology reviews reveal no association between the virus and cancer. However, in high risk areas (China), there is appears to be a 6-fold increase risk of ESCC in patients with HPV-16 seropositivity. There also remains a question as to whether this represents a causative factor or a facilitative factor to the development of ESCC. To our best knowledge, outside of pathology reviews, there has been only one case report in North America of an HPV associated ESCC. We present a case of a 48 year old Caucasian female with an HPV-16 associated ESCC. A 48 year old Caucasian female presented for upper endoscopy for evaluation of progressive dysphagia over 2 week duration. Endoscopy revealed an area of salmon colored mucosa with two associated white plaques at 20 cm from the incisors. Biopsies revealed severe dyplasia bordering on squamous cell cancer in situ with koilocytic atypia. PCR revealed the presence of HPV-16. Follow up endoscopy and endoscopic ultrasound revealed intact esophageal wall layers and endoscopy with Lugol staining revealed no further lesions. Endoscopic mucosal resection was performed with final pathology of clear margins with carcinoma in situ without evidence of invasive malignancy. To our knowledge this represent the second reported cause of HPV associated ESCC. The current standard for further HPV evaluation is based on histiologic findings including koilocytosis, giant or multi-nucleated cells, dyskeratosis, hyperkeratosis and acanthosis. Considering the remaining question for an association, the growing body of evidence of the involvement of HPV in the pathogenesis of neoplasia and the availability of vaccination against oncogenic strains of HPV, perhaps further evaluation into the utility for routine testing for the virus is indicated.
Abstract:
Homayoon Mahjoob, MD*, John Carroll, MD, Reena Jha, MD, Elisabeth Kramer, BS, Firas Al-Kawas, MD. Medicine, Georgetown University Medical Center, Washington, DC.
Purpose: Introduction: Ansa Pancreatica is a type of pancreatic ductal variation. The significance of this type of pancreatic duct anomaly and its relationship to the development of pancreatitis is unclear. Case Report: We report the case of a 51-year-old male who presented with 10 episodes of acute pancreatitis and a 30 Lb weight loss over the course of a year. CT scan and MRI findings were consistent with acute pancreatitis. An ERCP was performed, revealing a loop of the pancreatic duct in the head with a branch that directed towards the minor papilla consistent with Ansa Pancreatica. A prophylactic 5F 3 cm stent was placed into the pancreatic duct via major papilla. Sphincterotomy was not performed. EUS revealed a tortuous pancreatic duct with a circular course, located in the pancreatic head. The duct was of normal caliber, at 1.7 mm. Acute inflammatory changes were noted in the parenchyma of the tail of the pancreas. The patient was discharged and shortly after readmitted with another episode of pancreatitis. ERCP was again performed and the pancreatic duct was cannulated and anomaly of pancreatic duct was identified. Despite multiple attempts, it was not possible to cannulate the minor papilla to establish its patency. Pancreatic sphincterotomy was performed via the major papilla. A prophylactic 4 F 3 cm single pig tail stent was placed into the pancreatic duct, and a sphincterotomy was extended over the stent. The patient has been asymptomatic for last six months and gained 20 lbs after discharge. Conclusion: It is presumed that the drainage of pancreatic juice can be impaired by Ansa Pancreatica ductal variation. Such patients are vulnerable to the development of pancreatitis. Pancreatic sphincterotomy via major papilla and/or minor papilla may be considered as a treatment modality in symptomatic patients with this type of anomaly.
Abstract:
Lia Kaufman, BS*, Jennifer Dorfmeister, MD, Sherri Yong, MD, Khondker Islam, MD. Loyola University Medical Center, Maywood, IL.
Purpose: This is a 75 year old male with history of adenocarcinoma of the sigmoid colon status post resection and chemotherapy. Four years after diagnosis the patient was found to be anemic with a hemoglobin of 4.9 gm/dL, and a negative stool guaiac. Subsequent EGD and colonoscopy failed to reveal a clear source of bleeding. Capsule endoscopy (CE) was then performed. Four days after ingestion of the capsule, the patient developed abdominal pain and emesis. A KUB confirmed a retained capsule. The patient refused surgical intervention and decided to follow-up weekly with serial x-rays. KUB at nine weeks showed no change in capsule position. The patient consented to have laparoscopic exploration which revealed a circumferential jejunal mass at the site of capsule retention with extensive lymphadenopathy and carcinomatosis. Subsequent pathology confirmed the jejunal mass as metastatic adenocarcinoma, consistent with a colonic primary. Discussion The most common locations for colorectal adenocarcinoma metastasis include the regional lymph nodes followed by the liver and lung. Primary colorectal cancer metastasis to the small bowel is an unusual occurrence; it has been mentioned in case reports but definitive numbers describing its incidence is lacking. Capsule retention is an infrequent but significant complication of CE. The average reported incidence of capsule retention is 1-3%. Although those patients who are asymptomatic can be managed medically at first, up to 95% of them eventually require surgical intervention. The most common causes of retained capsule include Crohn's disease, NSAID-induced enteropathy or stricture and less commonly malignant tumors. CE can detect small bowel neoplasms that are often missed by traditional examinations. In our patient the CE images did not reveal the pathology likely to be responsible for his chronic anemia. CE was ultimately successful in its diagnostic aim in the manifestation of its one major complication, retention. It was the retention of the capsule that alerted the presence of pathology in our patient. This observation has been made before, acknowledging CE's role in identifying new obstructing lesions when retention has occurred and prompting interventions that otherwise would not have been considered. Conclusion Retention of the capsule endoscope is relatively rare, and most likely represents small bowel pathology. It is difficult to predict in which patients retention will occur. In a patient with a history of intestinal malignancy and surgical resection, a presentation of new iron deficiency anemia may represent recurrence of malignancy or metastatic disease.
Abstract:
Sarah DeNucci, MD*, Omar Hyder, MD, Daniel Quirk, MD, MPH. Internal Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
Purpose: A glucagonoma, a glucagon secreting tumor of the pancreas, can be a devastating diagnosis resulting in metastasis and thromboemoblism. Typical presentation includes dermatitis, diabetes and weight loss. Prior GI diagnosis and non-specific symptoms may delay identification and treatment. To alert clinicians to its spectrum and potential for misdiagnosis, we report a case of glucagonoma presenting as isolated diarrhea in a patient with irritable bowel syndrome (IBS) and diverticulosis. Case Report: A 50 y.o. Male with known IBS, diverticulosis and remote parathyroidectomy presents with alternating diarrhea and constipation for several months. Physical exam: Unremarkable. Chem-7, CBC, LFT, Amylase, Lipase, INR: within normal limits (wnl). Infectious stool workup: negative. Colonoscopy: Diverticular disease in the left colon, no masses, no polyps. Initial CT scan: normal pancreas, known diverticulosis. History of likely hyperparathyroidism raised concern of islet cell tumor. Octreotide scan was scheduled but patient did not follow through. Patient returns one year later with worsened symptoms. Repeat CT scan: 10 mm hypodensity of pancreatic tail. Octreotide Scan: increased uptake in pancreatic tail. CEA 19-9, Gastrin, Chromogranin A, pancreatic polypeptide, somatostatin, VIP, 5HIAA: wnl. Insulin = 28 uIU/mL. Glucagon = 76 pg/mL. Endoscopic US: 1.1 x 1.5 cm round, isoechoic pancreatic tail mass. Patient underwent distal pancreatectomy and splenectomy. Surgical pathology revealed a well-differentiated pancreatic neuroendocrine tumor, positive for glucagon by immunohistochemistry. Discussion: Glucagonoma is a functional pancreatic endocrine tumor (PET) of low incidence, commonly associated with a triad of migratory necrolytic dermatitis, glucose intolerance, and weight loss. Nonspecific symptoms such as anemia, diarrhea, and thromboembolism may also occur. Consistent with other functional PET, symptoms are secondary to hormone-excess, and rarely caused by anatomical effects of the tumor itself, i.e. abdominal pain. Typical work-up is positive for increased plasma glucagon levels and corresponding CT findings, most often in the pancreatic tail. Surgical resection is curative; however disease is frequently metastatic at presentation. Our patient lacked typical features of presentation and only complained of chronic diarrhea. Gastrointestinal complaints in patients with known IBS are often attributed to their pre-existing diagnosis. Especially in patients with IBS and prior endocrine disease, rare but fatal causes of chronic diarrhea, such as glucagonoma, must not be excluded.
Abstract:
Ronald Concha, MD*, Ali Azarm, MD, Adam Goodman, MD, Frank Gress, MD. Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY.
Purpose: To report a unique case of abdominal aortitis associated with Crohn's disease. Case: A 47 year old African Caribbean female with a history of colonic Crohn's disease and uveitis (diagnosed 3 years earlier) was admitted for increased bowel movements (up to10 stools/day), abdominal pain, and fever (39[degrees]C). Physical examination was normal except for fever. Leukocyte count was normal (10,700 x 10.sup.9/L) and ESR was elevated (74 mm/1st hr). The remaining hematologic parameters were normal. Empirical antibiotic treatment was initially started while awaiting for blood, urine, and stool cultures results, which were all negative. An abdominal CT scan ruled out intra-abdominal abscess but showed an increased wall thickness of the abdominal aorta up to 1 cm in the thickest region (Fig. 1). This thickness extended inferior to the celiac axis to the suprarenal aorta. ANA, anti DS-DNA, AMA, and ASMA were negative. Serology for syphilis was also negative. IV Methylprednisolone was started for suspected autoimmune aortitis. Patient improved clinically and was discharged on escalating doses of azathioprine and prednisone tapering doses. A control CT scan confirmed the normalization of the aorta wall thickness. Discussion: Crohn's disease is considered to be a systemic disease since it is often associated with extra intestinal manifestations. Takayasu Arteritis is an extremely unusual extra-intestinal manifestation of Crohn's disease. In the literature only 21 cases of this unusual association have been reported. The diagnosis of aortitis is based on the occurrence of compatible clinical manifestations together with an imaging study demonstrating vascular wall abnormalities or compatible histologic changes in biopsies. When histology is not available, blood cultures and serology for syphilis must be performed in order to exclude bacterial and fungal infectious aortitis. The development of granulomas and granulomatous vasculitis seen in both Crohn's disease and Takayasu arteritis may suggest a common physiopathologic mechanism.
Abstract:
Tetsuhiro Yoshino, MD*, Shigenari Hozawa, MD, Tokuhiro Kimura, MD, Masahiro Jinzaki, MD, Yuji Yamada, MD, Yoshiyuki Yamagishi, MD, Hideaki Kanamori, MD, Yasunori Okada, MD, Toshifumi Hibi, MD. Department of Radiology, Department of Pathology, Division of Gastroenterology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
Purpose: Immunohistological and electron microscopic examinations at autopsy were performed to confirm a diagnosis of a patient, who was clinically diagnosed as poorly differentiated adenocarcinoma by percutaneous biopsy of thickening part of peritoneum.
Methods: Enhanced CT scan showed distended stomach and rectum, broad intestinal wall thickening, thickening peritoneum, enlarged mesenteric lymph nodes, small amount of ascites, mild hydronephrosis and thrombosis of innominate and jugular vein. The echo-guided biopsy of the thickening part in the peritoneum was performed, and the lesion was diagnosed as poorly-differentiated adenocarcinoma. However, immunohistological analysis and additional imaging studies could not determine a primary lesion. At autopsy, immunohistochemical studies were performed using primary antibodies for pancytokeratin, epithelial membrane antigen, carcinoembryonic antigen, CA125, neuron-specific enolase, calretinin, D2-40, WT1, cytokeratin 7, cytokeratin 20, BerEP4, LeuM1, CA19-9, chromogranin, synaptophysin, and thyroglobulin. Electron microscopic examination was further performed.
Results: Histological examination revealed invasive growth of neoplastic cuboidal or columnar cells with eccentric nuclei forming papillary and glandular structures. Psammoma bodies were found. These microscopic features were highly reminiscent of ovarian/peritoneal serous adenocarcinoma of women. Tumor invasion was observed in subcutaneous tissue of the abdominal wall. The tumor also invaded the right ureter, resulting in hydronephrosis of the right kidney. No tumor was found in paratesticular regions. Metastasis of the tumor was found in lymph nodes (mesenteric, paraaortic, and paratracheal), left adrenal gland, and bilateral lungs. The lungs showed marked lymphangitis carcinomatosa and tumor emboli in the pulmonary artery branches. Venous thrombi containing metastatic tumor cells filled the lumina of the left jugular vein and left renal vein. No primary tumor was found in the visceral organs. The tumor cells were positive for pancytokeratin, EMA, monoclonal CEA, CA125, and NSE. They were negative for calretinin, D2-40, WT1, cytokeratin 7, cytokeratin 20, BerEP4, LeuM1 (CD15), CA19-9, chromogranin, synaptophysin, and thyroglobulin. In electron microscopic examination of the tumor cells, no apparent microvillus was found, although a small number of irregular short cytoplasmic processes were observed. Bundles of intermediate filaments were not seen in these cells. These findings indicated that the tumor was papillary serous adenocarcinoma of the peritoneum in a man. The diagnosis of peritoneal malignant mesothelioma was unlikely.
Conclusion: This report is the third case of PSCP in male.
Abstract:
Lea Ann Chen, MD*, Elliot Ellis, MD, Hyosun Han, MD, Sita Chokhavatia, MD. Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, New York, NY.
Purpose: A 54 year old man with diabetes, hypertension, hyperlipidemia, and hypothyroidism presented for evaluation of a painless right neck mass incidentally noticed during shaving. A carcinoid tumor of unknown primary, presenting as a left neck mass, had been treated twelve years ago with radiation and chemotherapy at an outside hospital. A recurrence ten years later was successfully treated, and CT scan after chemotherapy showed no residual tumor. The patient denied diarrhea, palpitations, skin changes, shortness of breath, wheezing, or weight loss. On examination, a non-tender 3 cm by 3 cm mass in the right cervical region and right submandibular lymphadenopathy were palpated. Surgical scars were noted on the left neck consistent with previous carcinoid resection. Labs, including chromogranin A level, were normal. A PET scan showed increased uptake in the right cervical region and the rectosigmoid area, and an octreotide scan did not show any increased uptake. Colonoscopy to the terminal ileum and an upper endoscopy to the third portion of the duodenum revealed normal mucosa, and no submucosal lesions were seen. Carcinoid tumors are rare neuroendocrine neoplasms with approximately 100,000 cases reported in the U.S. Sixty-four percent of all carcinoids originate in the GI tract and twenty eight percent first develop in the lungs or bronchi. Isolated primary cervical carcinoid is exceedingly rare and may be due to a primary in the foregut or rectum. Our patient had 2 recurrences of cervical carcinoid with no diagnosed primary site, suggesting an as yet undiagnosed pulmonary or GI carcinoid metastasizing to the cervical region. Both GI and non-GI neuroendocrine tumors should be considered in patients presenting with a cervical mass.
Abstract:
Sohail Asfandiyar, MD*, Ann Silverman, MD, FACG, Stuart Gordon, MD, FACG. Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI.
Purpose: BACKGROUND: Although celiac disease (CD) is associated with various autoimmune disorders and is a cause of nonspecific liver enzyme abnormalities, this entity is not commonly recognized in the setting of end stage liver disease (ESLD). We report three patients who presented over a 6 month timeframe with ESLD for transplant evaluation who were all found to have untreated or refractory CD. CASE REPORTS: Patient A: A 60 year old woman with a history of refractory CD presented with ascites unresponsive to medical management; laboratory and imaging studies were consistent with cirrhosis. She was listed for OLT but expired from sepsis prior to transplant. Patient B: A 71 year old man with esophageal varices and a cirrhotic liver and portal hypertension at CT who presented with chronic diarrhea and a 50 lb weight loss. Small biopsy showed subtotal villous atrophy and crypt hyperplasia. His diarrhea resolved on a gluten free diet. He experienced sudden death secondary to myocardial infarction. Patient C: A 41 year old man with a two year history of liver enzyme abnormalities, and previous documentation of steatohepatitis, presented with progressive jaundice and coagulopathy. Physical exam showed stigmata of cirrhosis and a BMI of 41.5. His daughter had documented CD and the patient acknowledged longstanding diarrhea. Additional evaluation showed positive anti-endomysial IgA antibody and small bowel biopsy with total villous atrophy. His is currently listed for OLT. In each case other causes of liver disease, including metabolic, viral, alcohol and autoimmune were excluded. Patient C was presumed to have underlying NASH as the etiology for his cirrhosis, and patients A and B had presumed cryptogenic liver disease. Patients B and C had been previously evaluated by gastroenterologists for their liver disease but the diagnosis of CD was not entertained.
Conclusion: The mechanism of CD mediated liver injury is unexplained. We speculate that longstanding untreated hepatic dysfunction from CD may lead to cirrhosis, or that CD may act as a cofactor in other underlying liver disorders. In the setting of ESLD, especially NASH or cryptogenic, the entity of CD should be considered, including appropriate serologies or small bowel biopsies.
Abstract:
Ketul Patel, MD*, Jiwanjot Chhatwal, MD, Robbie Taha, DO, Nahid Elyas, MD. Internal Medicine, Providence hospital, Southfield, MI.
Purpose: Introduction Approximately 4.1 million Americans have been infected with Hepatitis C virus, of which 3.2 million are chronically infected. However, Hepatitis C is estimated to account for only 20% of all cases of acute viral hepatitis in the United States. A unique case of a patient who was recently diagnosed with Hepatitis C presented to us in the acute state with the additional findings of fulminant liver disease. Case Report A 59 year old African American male with end-stage renal disease on hemodialisis and diabetes mellitus presented with 3 week duration of nausea, vomiting, diarrhea, jaundice, and severe pruritus. He was noted to have right upper and lower quadrant abdominal pain with increased serum aminotranferases. Laboratory studies were significant for HCV RNA by PCR being positive with quantitative HCV RNA of 26,731,000 international units. Serology was negative for Hepatitis A and B. His alpha fetoprotein tumor marker was elevated at 14.0 and ferritin was also elevated at 6,451. During the course of his admission the patient's serum aminotranferases worsened along with further deterioration of his coagulation studies. Due to these abnormal lab studies with the patient's presentation of symptoms a computed temography guided liver biopsy was performed. The final diagnosis of the biopsy was severe active Hepatitis with acute hepatocellular injury which was consistent with acute viral Hepatitis C. The decision was made to transfer the patient to a liver center for a possible transplant. Upon transfer of the patient, follow up serum aminotransferases improved and he was advised for outpatient therapy with interferon. Due to his history of end-stage renal disease he was not a candidate for ribaviron. Discussion Fulminant Hepatitis C is rare and incidence is unknown. The center for disease control estimated that new acute Hepatitis C virus infections in the United States fell from 240,000 cases per year in the 1980's to 19,000 cases per year in 2006. Most cases of acute Hepatitis C are anicteric and asymptomatic. Transfusion associated cases are now less than 1 per 2 million transfused units of blood. Most cases are due to injection drug users. In fulminant hepatitis the fluctuation of aminotransferases is common after an acute infection of Hepatitis C with symptoms such as nausea, malaise, right upper quadrant pain and jaundice in less than 25% of cases. These acute symptoms are apparent in approximately 2-12 weeks. Fulminant hepatic failure is defined as the rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who had a normal or a well compensated liver.
Abstract:
Raymond Duggan, DO*, Timothy Pfanner, MD. Gastroenterology, Texas A&M Health Science Center - Scott & White Memorial Hospital, Temple, TX.
Purpose: We present a case of a 61 y/o male staus post chemoradiation for squamous cell carcinoma of the base of the tongue. He developed a radiation stricture and outside attmepts at dilation resulted in perforation. The patient had a prolonged recovery requiring placement of a PEG tube for nutrition. An esphagopharyngeal stricturoplasty resulted in relief for 2 month but was followed by reocclusion of the stricture. Subsequently a combined GI/ENT/Thoracic/Vascular Surgery procedure was performed. The stricture was punctured from a retrograde approach with an EUS FNA needle and a 0.018 mm biliary guidewire was placed across it. Next an excimer laser from the antegrade end was used to ablate the scar tissue. Ballon dilation was perfomred to 9 mm and a nasogastric feeding tube left in place. Two days later he was dilated to 10 mm. After that a series of dilations began with an initial interval of 3-5 days for the first month. He was dilated weekly for the next 2 months. Then he underwent dilation every 2 weeks for several months until his PEG tube was removed and he was tolerating a regular diet. Over the course of his multitude of dilations he did receive directed Kennalog steroid injections twice. Now he undergoes surveillance EGD every 2 months with dilation of any hint of a stricture.
Abstract:
Daniel Blachman, MD*, Kiron Das, MD, Naomi Schlesinger, MD. Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ.
Purpose: Our patient is a 44-year-old African American male who has a 30-year history of Hidradenitis Suppurativa (HS) and Acne Conglobata (AC). HS and AC are part of the follicular occlusion (FO) triad (HS, AC and Perifolliculitis Capitis Abscedens et Suffodiens). He has a 10-year history of a spondyloarthropathy. He has clinical and radiological evidence of ankylosis of bilateral sacroiliac joints and cervical spine ankylosis. Recently he developed high fevers and Pyoderma Gangrenosum (PG) on both his lower extremities, which was resistant to local wound care and systemic corticosteroid treatment. Our purpose is to demonstrate a trial of an anti-tumor necrosis factor (TNF) agent for PG resistant to steroid treatment in a patient with associated HS, AC and Spondyloarthropathy.
Methods: Our patient was treated with a retinoid and antibiotics as needed for his AC and HS. An NSAID has been prescribed for his arthritis as well as sulfasalazine for the spondyloarthropathy. He received aggressive physical therapy for his spondyloarthropathy. Therapy with infliximab in a dosage of 5 mg/kg/d I.V. (three doses at 0, 2 and 6 weeks) was started when he presented with the severe bilateral PG on both legs.
Results: A dramatic improvement was seen after treatment with infliximab for pyoderma as well as the HS, AC and the spondyloarthropathy. After the first dose, the pyoderma lesions on both lower extremities improved significantly. Six months later, the patient is in remission from the skin lesions and his spondyloarthropathy is much improved. He continues treatment with Infliximab and Sulfasalazine.
Conclusion: A triad of HS, AC and spondyloarthropathy is a rare syndrome described only in a few case reports in the literature. PG has been associated with Acne Conglobata in rare cases and has been described extensively in Crohn's disease, which the patient developed one year prior to admission. The exact role of anti-tumor-necrosis-factor antibodies in this syndrome is unclear. Further evaluation is needed to assess the role of anti-TNF as a therapeutic choice for this rare syndrome.
Abstract:
Laxmi Thummalakunta, MD, MPH*, Naishadh Raghuwanshi, MD, MBA, Frank Burton, MD, Richa Gupta, MD. Internal Medicine, St. Luke's Hospital, St. Louis, MO, Gasteroenterology, St. Louis University, St. Louis, MO.
Purpose: A 50 year old obese female with a previous history of cholelithiasis status post cholecystectomy presented with complaints of epigastric pain for the past one week. The pain was moderate to severe in intensity and was radiating straight through to her back. It started after consumption of fatty food. It was associated with nausea and vomiting. She also had a 10 pound weight loss in the last 2 months. She did not have jaundice. On initial presentation a clinical diagnosis of acute pancreatitis was made. The patient subsequently underwent two endoscopic retrograde cholangiopancreatographys (ERCPs) at outside hospitals with failed biliary cannulation. An endoscopic ultrasound (EUS) was then performed which showed a small pancreatic lesion. A fine needle aspiration (FNA) was performed and cytology was negative for malignancy. The CBD was successfully cannulated on the third ERCP attempt and the findings revealed a stricture at the distal third of the CBD and a pancreatic duct stricture at neck of ventral pancreatic duct. A biliary stent was then placed. The patient was discharged home but continued to have nausea, vomiting and abdominal pain for the next 6 weeks. The patient suddenly spiked a high fever along with recurrence of the abdominal pain requiring readmission. An ERCP was performed which demonstrated a CBD stricture suspicious for extrinsic compressive effect from pancreas. Possible filling defects vs. air bubbles above stricture were noted. A biliary balloon dilatation of stricture was performed and a biliary stent was placed. A Computed tomography scan of the abdomen revealed the presence of an enlarged pancreatic head without the presence of a definite mass. The laboratory studies including an amylase, lipase and alkaline phosphatase were normal. The abdominal pain did improve, so the patient was discharged with a plan for repeat ERCP and EUS on an outpatient basis. A distal CBD stricture with proximal dilatation was again evident. The EUS again revealed a discrete lesion within the head of the pancreas. The FNA specimen was diagnosed as adenocarcinoma. Given the above findings, the patient was referred for a pancreaticoduodenectomy. The histological analysis revealed lymphoplasmacytic infiltrate surrounding the ducts and lobular with parenchyma fibrosis consistent with autoimmune pancreatitis. During the work up to discern the etiology of her recurrent acute exacerbation of chronic pancreatitis, the antinuclear antibodies (ANA), anti-smooth muscle antibody (ASMA) and IgG4 serologies were normal. Her IgG4 level was 19 mg/dl with the normal range being between 7 and 89 mg/dl. Our specimen was sent for IgG4 immunohistochemical staining by Mayo Clinic which was positive.
Abstract:
Ahmed Morales, MD*, Praveen Nallapareddy, MD, Shivani Jain, DO, Michael Klamut, MD, Sherri Yong, MD, Khondker Islam, MD. Loyola University Medical Center, Maywood, IL.
Purpose: Clinical Presentation A 23 y/o African American female with history of uncontrolled type I Diabetes with gastroparesis, presents with abdominal pain, which is sharp, diffuse and non-radiating. She denies melena, hematochezia, hematemesis, fever or chills. Her pain is controlled with narcotics or NSAID's. Episodes of alternating diarrhea and constipation are associated with nausea and vomiting. She describes intermittent arthralgias, mostly in her knees and has a history of an intermittent rash primarily involving her legs. Her medications include insulin and NSAID's. Her family history is remarkable for her mother having surgery for a "gastrointestinal problem". She smokes 1-2 cigarettes a day and denies alcohol. Work up includes: a. EGD: small ulcerations in the fundus and proximal body. Biopsies revealed non caseating granulomas, h pylori negative. b. Colonoscopy to the terminal ileum: normal mucosa, biopsies of right colon with non caseating granulomas. -CMP, IBD panel normal. Elevated ESR, ACE level pending -inguinal lymph node biopsy in 2005: positive for non caseating granulomas, neg for AFB and fungal organisms. -gastric emptying study in 2005 with 25% emptying at 90 minutes. Discussion Interesting case of a young woman with uncontrolled diabetes and chronic abdominal pain and vomiting with altered bowel habits. The abdominal pain has been presumed to be related to diabetic gastroparesis, but her endoscopic biopsies revealed non caseating granulomas. The differential diagnosis for gastrointestinal granulomas include inflammatory conditions (Crohn's, Sarcoidosis, vasculitis), infectious (TB, histoplasmosis, H. pylori, Whipple's), drug induced or idiopathic. In her case, the clinical picture is suggestive for a diagnosis of sarcoidosis. The gastrointestinal manifestations occur in approximately 0.1-0.9% of patients with sarcoidosis, and are usually related either to peptic ulcer disease or to narrowing of the gastric lumen due to granulomatous inflammation and associated fibrosis of the gastric wall; in the latter case diminished peristalsis often results. Peripheral lymphadenopathy can occur in up to 40% of the patients. The stomach is the organ most commonly involved. Endoscopy may reveal nodular changes, gastritis, thickened mucosa, greater or lesser curvature deformities, or ulcers. Segmental mucosal thickening and nondistensibility that mimics linitis plastica are the most common abnormalities on upper GI series. Conclusion Gastrointestinal sarcoidosis is a rare cause of abdominal pain and gastroparesis. High index of suspicion is necessary for diagnosis which requires multiple gastrointestinal biopsies, particularly for patients that present with multi-systemic symptoms.
Abstract:
Saba Ansari, MD*, Lourdes Merlo, MD, Avani Patel, MD, Asit Mehta, MD. Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY.
Purpose: Amyloidosis is a syndrome that occurs when there is a deposition of abnormally configured proteins inside human cells. These proteins interrupt the normal functioning of the cells, leading to serious disease process than can affect multiple organ systems and can prove to be fatal if left untreated. The gastrointestinal tract is often affected by this syndrome. The typical features of GI tract involvement include anorexia, malabsorption, weight loss, diarrhea and/or black stools. We present a rare case with isolated involvement of the stomach presenting only as recurrent hematemesis.
Methods: A 58-year-old male with past medical history of nephrolithiasis) and hypertension presented to the emergency room with complaints of vomiting fresh blood 5-6 times associated with belly pain. He denied any other symptoms. Patient had a similar episode 4 years prior and endoscopy showed gastritis. At that time, colonoscopy was completed and was determined to be normal. He was currently taking spironolactone and verapamil hypertension.
Results: On physical exam patient had mucosal pallor, the belly was benign and stool guaic test was negative. Lab tests revealed anemia with microcytoses, leukocytosis and acute/chronic renal insufficiency. He was started on broad spectrum intravenous antibiotics. Endoscopy showed erythematous, nodular and friable gastric mucosa resembling tumor. Biopsy with Congo red staining revealed amyloid deposits. The patient signed out against medical advise and was lost follow-up. Upon discharge he was afebrile and his white cell count was normal. He was discharged on augmentin and prevacid.
Conclusion: The incidence of gastrointestinal amyloidosis is variable depending on the type. Patients with certain disorders, like multiple myeloma, rheumatoid arthritis and chronic renal insufficiency, are at higher risk for developing amyloidosis. Definitive diagnosis can be obtained using biopsy of the affected organ tissue. Rectal biopsy is more sensitive than fat biopsy. Gastrointestinal involvement is associated with high morbidity, but relatively low mortality. Cause of death in patients with gastrointestinal amyloidosis is usually renal failure, restrictive cardiomyopathy or ischemic heart disease. Treatment is usually directed towards the symptomatic management of gastrointestinal symptoms and treating the underlying cause of amyloidosis. As illustrated by the case presented here, amyloidosis should be considered as one of the differential diagnoses in patients presenting with hematemesis.
Abstract:
Nancy Gundersen, MD*, Robert Kraichely, MD. Internal Medicine, Mayo Clinic Rochester, Rochester, MN, Gastroenterology, Mayo Clinic, Rochester, MN.
Purpose: We present the case of a 71 year old female of Japanese descent who presented with five months of chronic, watery diarrhea of up to 20 bowel movements daily. Her diarrhea was large volume without cramping, pain, or fevers, and persisted during the night and despite fasting. She also had a 20 pound weight loss and dehydration requiring eight hospitalizations for intravenous fluid administration and symptom control. Her past medical history was significant for human T-lymphotropic virus type I-associated adult T cell leukemia/lymphoma (HTLV-1 ATLL) diagnosed two years prior to admission. At that time, she also was diagnosed with Strongyloides stercoralis infection via small bowel biopsies. Though the parasite was successfully eradicated with ivermectin, strongyloides recurred four months prior to presentation, requiring further ivermectin treatment in addition to lifelong suppressive therapy. Past history also was remarkable for Clostridium difficile infection detected six months prior to presentation, successfully treated with a combination of oral metronidazole and vancomycin. A 72 hour stool collection confirmed large volume diarrhea of greater than 5000 grams. Investigation of the diarrhea was largely unremarkable, including evaluation of infectious (negative Clostridium difficile and enteric pathogen cultures, hepatitis serologies, strongyloides culture, ova and parasite studies, and small bowel aspirate), neuroendocrine (normal vasoactive intestinal peptide, thyroid studies, pancreatic polypeptide, calcitonin, 24 hour urine collection of 5-HIAA and histamine, gastrin and gastric pH level), anatomic (normal endoscopies, abdominal CT and MRI scans), and autoimmune (normal TTG, ANA, AMA, serum IgG/IgA levels, SPEP and UPEP) causes. She had little improvement with loperamide, octreotide, cholestyramine, or tincture of opium. Duodenal biopsy revealed intraepithelial lymphocytosis and an atypical CD4 positive T cell infiltrate, consistent with HTLV-1/ATLL infiltration of the small bowel. Chemotherapeutic treatment with alemtuzumab was recommended. HTLV-1 infection is endemic in many parts of the world, including southern Japan. It is a risk factor for strongyloides infection, which can present with diarrhea. Any patient with HTLV-1 infection and chronic diarrhea should be evaluated for strongyloides infection. Though there are few examples describing HTLV-1 lymphomatous infiltration of the small bowel, our case demonstrates it does occur. Refractory diarrhea in patients with HTLV-1 lymphoma requires extensive evaluation, and may even be an indication for chemotherapeutic treatment of ATLL, as in this case.
Abstract:
Ronald Concha, MD*, Ayse Aytaman, MD, Mujtaba Butt, MD, Rosemary Wieczorek, MD, Fidelina Desoto-Lapaix, MD, Gerald Fruchter, MD. Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY, Pathology, Gastroenterology, VA New York Harbor Health Care System, Brooklyn, NY.
Purpose: To support the possible role of H. pylori infection in the development of granulomatous gastritis. Case 1: A 25 year old male with no prior medical history presented with epigastric pain. EGD showed diffuse antral erythema with a beefy red appearance of the mucosa. Representative biopsies revealed severe chronic inflammation with scattered non-caseating granulomas. H. pylori organisms were identified. Stains for acid-fast bacilli and fungi were negative. PPD was negative. ESR was normal. CT chest was negative for hilar adenopathy. Patient was given clarithromycin based triple therapy for 14 days and his epigastric pain resolved. EGD repeated 6 weeks later demonstrated severe antral erythema with a nodular appearance. Biopsies revealed a single non-caseating granuloma, chronic inflammation and no H. pylori seen. Case 2: 64 year old male presented with upper GI bleed. EGD was performed and showed nodular antral mucosa with multiple shallow ulcerated lesions. Biopsies showed marked chronic active gastritis and non-caseating granuloma. H. pylori organisms were identified. Stains for acid-fast bacilli and fungi were negative. CRP, C-ANCA, and ACE-1 levels in serum were normal. CXR was normal. Patient received clarithromycin based triple therapy for 14 days. EGD repeated 6 weeks later revealed complete healing of the antral ulcerations. Biopsies revealed a single non-caseating granuloma, chronic inflammation, and no H. pylori infection seen. Discussion: Isolated granulomatous gastritis (IGG) is a very rare entity. It refers to an idiopathic chronic granulomatous reaction limited to the stomach. The diagnosis of IGG is made by the exclusion of other granulomatous diseases, such as Crohn's disease, sarcoidosis, infections (e.g., tuberculosis, histoplasmosis, syphilis), foreign bodies, malignancy, or vasculitis. Miyamoto et al. recently described a possible association of IGG with H. pylori since the granulomatous gastritis resolved in two patients one year after successful eradication of H. pylori. In our cases we observed clinical improvement with H. pylori eradication. However, incomplete resolution of granulomas was noted, possibly due to the short term endoscopic follow up after H. pylori eradication. The natural history and the optimal therapy of IGG have not been yet established.
Abstract:
Erin Karandish, MD*, Charlene Prather, MD, MPH. Gastroenterology and Hepatology, St. Louis University, St. Louis, MO.
Purpose: A 52 year-old healthy Caucasian female presented with two weeks of abdominal pain, vomiting, and fevers. She had lost 40 pounds over eight months. She denied diarrhea or family history of gastrointestinal disorders. Physical examination revealed a temperature of 38.2 degrees Celsius. Upper abdomen was tender to palpation. There was no peripheral lymphadenopathy. White blood cell count was 24.7 thousand/mL. Hemoglobin was 9.3 g/dL with MCV 78. Albumin was 2.7 g/dL. Computed tomography of the abdomen and pelvis revealed retroperitoneal and mesenteric lymphadenopathy as well as omental thickening. Excisional omental lymph node resection was performed, yielding architectureal effacement, histiocytic infiltrate, and fatty cysts. On flow cytometry, an aberrant B-cell population was identified, but cytogenetic and molecular testing were normal, as was bone marrow biopsy. Upper endoscopy revealed thickened, boggy folds and white plaques in the duodenum. Distal duodenal biopsies showed thickened, clubbed villi and histiocytic infiltration with a positive periodic acid-schiff (PAS) stain. Electron microscopy was performed, allowing the identification of bacillary organisms with a trilamellar wall. Whipple's disease is a systemic disease caused by Tropheryma whipplei, a gram-positive bacillus closely related to Actinobacter. It is more common in men than women. While any system may be affected, it classically presents with weight loss, chronic diarrhea, and migratory arthralgias. Fever, anemia and lymphadenopathy are also common, which may initially lead to efforts toward diagnosing lymphoma. Neurologic involvement may be isolated from other symptoms and can be irreversible, causing higher morbidity and mortality despite treatment. Diagnosis is secured by distal duodenal biopsy, which reveals thickening or clubbing of the villous architecture and histiocytic infiltration. PAS stain is positive, and electron microscopy reveals the bacillus with the typical trilamellar wall. Polymerase chain reaction is confirmatory but not routinely performed. Treatment with antibiotics is imperative, although the ideal regimen and duration has not been clearly established. A two week course of a third-generation cephalosporin followed by one to two years of trimethoprim/sulfamethoxazole has been generally recommended. This case illustrates both classic and unusual features of Whipple's disease and highlights the necessity of having a high index of suspicion for this rare disease, even when faced with common symptoms.
Methods: N/A
Results: N/A
Conclusion: N/A
Abstract:
Deborah Anghesom, MD*, Kendrick Che, DO, Ronald Griffin, MD, Christian Jackson, MD. Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, Division of Gastroenterology, Loma Linda VA Medical Center, Loma Linda, CA.
Purpose: A 64-year-old man with diabetes, atrial fibrillation, hypertension, hepatitis C, and stage 5 chronic kidney disease not on dialysis was admitted with a 4 day history of weakness, black tarry stools and supratherapeutic INR on coumadin. His hemoglobin had dropped from 11 to 5.3. His current medications include metoprolol, amlodipine, furosemide, hydralazine, and metolazone for hypertension. He had also been taking ferrous sulfate 325 mg twice daily supplementation for the past two years. EGD revealed a normal appearing esophagus, small plaque-like lesions in the stomach, and multiple black pigmented spots distributed diffusely throughout the entire duodenum. A colonoscopy done the same day was entirely normal. As no active source of bleeding was found, a capsule endoscopy was performed the next day. This revealed multiple black pigmented lesions beginning in the first portion of the duodenum consistent with previous visualization on EGD but extended to the proximal jejunum. Biopsies revealed scattered pigment-laden macrophages within the intestinal villi and lamina propria which showed hemosiderin deposition with a positive Prussian blue stain consistent with pseudomelanosis. Discussion: Pseudomelanosis involving the jejunum had been described 3 times previously in the literature. Banai et al reported a case in 1997 involving the proximal jejunum in a patient with ulcerative colitis. Weinstock et al reported another case in 2003 involving the stomach, duodenum, and jejunum in a woman with chronic kidney disease also on long term ferrous sulfate medication. Moore et al described a case in 2007 involving the jejunum and ileum diagnosed using capsule endoscopy. Mechanisms of iron deposition on the intestinal walls are unknown. There appears to be a strong association with the use of iron supplementation, kidney disease, and hypertensive medications, namely furosemide and hydralazine, and the incidence of pseudomelanosis. Hemosiderin deposition may also be indicative of chronic, long standing gastrointestinal bleeding, seen in our patient as well as others in previous case studies, possibly secondary to vascular ectasias. Our case is the second described using capsule endoscopy and supports the association of oral iron therapy and hemosiderin deposition causing pseudomelanosis of the proximal small bowel.
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Abstract:
Paul Panzarella, MD*. Winthrop University Hospital, Mineola, NY.
Purpose: Gastroesophageal reflux disease (GERD) is a frequently occurring problem in patients with Cerebral Palsy (CP), often diagnosed at an advanced stage. The prevalence is about 50% in those with an IQ <50, with about 70% having endoscopic evidence of reflux esophagitis. Diagnosis may be difficult in CP patients due to atypical presentations such as frequent pulmonary infections, dental erosions, rumination and hematemesis. Though proton-pump inhibitors (PPI's) are effective, a percentage of CP patients do not respond to medical management. Success of Nissen fundoplication in CP patients is often cited in the pediatric literature but limited data is available in the adult population. We present a case of a 26 year old female with CP who presented to our institution with a history of chronic GERD refractory to PPI's. The patient reported worsening regurgitation with intermittent solid food dysphagia, significant nausea, abdominal pain and a 10 lb weight loss over a 3 month period. Upper endoscopy showed a small sliding hiatal hernia but was essentially normal. A BRAVO pH study revealed multiple episodes of acid reflux, while on high dose PPI. Impedance pH monitoring (on BID PPI) revealed 208 reflux events (normal <73) with evidence of proximal reflux as well. A gastric emptying study was normal. An initial esophageal manometry study at an outside institution showed findings suggestive of scleroderma esophagus with a low LES pressure and aperistalsis. However, serologic workup for scleroderma was negative. A manometry study was repeated in our institution, which revealed normal peristalsis and a normal mean LES pressure of 21 mmHg. Due to the refractory GERD and normal repeat manometry study, the patient was referred for laparoscopic Nissan fundoplication. The patient underwent Nissen fundoplication with complete resolution of her chronic reflux symptoms. One year post operatively, she continues to be asymptomatic and has regained her weight. To our knowledge, this is the first case of successful surgical management of GERD in an adult patient with CP and emphasizes the importance of this modality of treatment in patients with GERD refractory to medical management who are otherwise good surgical candidates.
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Abstract:
Neil Sharma, MD*, Vesna Vrcelj, MD, Prasad Kulkarni, MD. Department of Gastroenterology, University of South Florida, Tampa, FL, Department of Pathology, James A Haley Veterans' Administration Hospital, Tampa, FL.
Purpose: Primary melanoma of the esophagus is an extremely rare diagnosis. Bulky esophageal melanomas are even rarer. We report a case of Malignant Melanoma involving the esophagus in a patient with no prior history of the disease who presented with complaints of dysphagia. Case Report: 79 yo male with a history of prostate cancer, CAD with CABG, and CVA comes to the hospital with complaints of progressive solid food dysphagia and weight loss for 2 months. The patient had no history of Melanoma. A heterogeneously hyperpigmented bulky lesion was seen on EGD from 25 cm to 35 cm in the mid esophagus. The mass was friable and involved 2/3 of the lumen. A small, 3 mm, dark, hyperpigmented lesion was also seen in the gastric body. Biopsies confirmed Melanoma on s100 staining at both sites. Pt was note to have metastatic disease to the liver, and multiple lung nodules on staging CT. The primary Internal Medicine team did not note any evidence of Melanoma on skin exam. Eye exam done by Ophthalmology also did not find any evidence of Melanoma. In view of advanced disease, only palliation was sought. A gastric feeding tube was placed by interventional radiology. Pt was started on Temodar by Oncology, and sent with Hospice follow up. Discussion: Primary Esophageal Melanoma of the esophagus is rare diagnosis with less then 250 cases reported in the world literature to date. Esophageal Melanoma is a very aggressive tumor which carries a poor overall prognosis. There is limited data, primarily in the form of case reports, about potential surgical cures for very early stage disease. Treatment is evolving. Once metastatic, the prognosis for the disease is poor and palliative care should be considered.
Abstract:
Neil Sharma, MD*, Jonathan Keshishian, BS, Jean Johnson, MD, Jeffery Kooper, MD, Adel Daas, MD, Donald Amodeo, MD. Department of Gastroenterology, University of South Florida, Tampa, FL, Department of Pathology, Department of Gastroenterology, Internal Medicine, James A Haley Veterans' Administration Hospital, Tampa, FL, School of Medicine, University of South Florida, Tampa, FL.
Purpose: We report a case of anemia initially attributed to arteriovenous malformations and duodenitis. Further evaluation of the friable mucosa with endoscopy and biopsies revealed the true underlying diagnosis to be AL (Lambda) type Amyloidosis. Case Report: A 59 yo male with DM, CAD, and CKD presented to his PCP with a complaint of fatigue. He denied any gastroenterological complaints and was found to have a Hgb of 6.1 (g/dL) and was FOBT positive. On initial EGD, mild gastritis with a 2 or 3 AVMs were noted in the stomach along with a "friable" appearing duodenitis. The colonoscopy showed a few scattered submucosal hemorrhagic vessels. Since these limited findings did not explain the patient's degree of anemia, a capsule endoscopy was performed which showed angioectasias with limited active bleeding in the proximal jejunum and friable mucosa. Enteroscopy with biopsy of the distal duodenum and proximal jejunum was performed. There was significant oozing of the friable mucosa noted post biopsy. The biopsies were positive for Amyloidosis on Congo Red staining showing classic apple green birefringence. Fat pad biopsy was subsequently done and positive as well, with further staining confirming AL type. Renal and bone marrow biopsies were negative for Amyloidosis. The patient was referred to Oncology and was started on oral melphalan with high dose dexamethasone. Discussion: AL type Amyloidosis has an estimated incidence of 1 in 100,000 in Westernized countries, and its diagnosis upon biopsy from the gastrointestinal tract is even rarer. The presentation of acute on chronic anemia with no gastrointestinal complaints makes this case clinically unique.
Abstract:
Kenneth Reed, DO*, Ketul Patel, MD, Serge Sorser, MD, Robbie Taha, DO, Julia Greer, MD. Providence Hospital, Southfield, MI.
Purpose: Introduction Intussusception is a rare disorder in which the intestine prolapses into an immediately adjacent portion of the intestine forming a telescoping effect. This can often lead to obstruction. Intussusception is the most common cause of intestinal obstruction among children and its etiology is often idiopathic, while a small portion of cases are brought on by a viral infection. Intussusception in adults is a rare phenomenon. Most cases of adult intussusception are the result of an underlying organic cause. Case Presentation A 60-year-old African American male with a history of peptic ulcer disease presented to the emergency room complaining of intermittent abdominal pain associated with progressively worsening constipation of two weeks duration, as well as an unintentional 15 pound weight loss over the prior 2 months. Initial work up included computed tomography (CT) of the abdomen, which showed a large left renal mass, diffuse wall thickening in the descending colon associated with intussusception. Note was also made of a probable colonic mass and multiple pulmonary nodules. A colonoscopy was performed and findings were consistent with an intussusception and an obstructive lesion at 60 centimeters. Biopsies of the lesion were obtained and the area was tattooed with India ink. Necrotic tissue fragments and acutely inflamed benign colonic mucosa were identified on histologic examination. The patient underwent exploratory laparotomy with left partial colectomy and primary anastomosis. A left radical nephrectomy was also attempted, but the tumor was deemed unresectable. The pathology obtained from the partial colectomy was consistent with metastatic renal cell carcinoma. Discussion Renal cell carcinoma is rare, accounting for only 3% of all adult malignancies. Approximately 30% of the cases present with metastatic disease, with a 5-year survival of less than 5%. Intussusceptions account for only 3% of obstructions in adults and of these 90% have an identifiable pathologic lead point. The majority of intussusceptions are either enteric or ileocolic cases, with only one third of adult intussusceptions being colocolic or colorectal in nature. Approximately two thirds of colonic cases have a malignant basis compared to one quarter of enteric types. Debate has centered on whether to perform endoscopic reduction before surgical resection. However, recent trends have favored surgical resection without prior reduction in order to prevent tumor seeding.
Abstract:
Bryan Kavanaugh, MD*, Bridget Seymour, MD, Patricia Kozuch, MD. Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA.
Purpose: A previously healthy 62-year-old male from Eastern Pennsylvania was admitted to the hospital with 10 weeks of "band-like" upper abdominal pain associated with nausea, constipation, post-prandial bloating, early satiety and a 30-lb weight loss. These symptoms were preceded by an ovoid, non-pruritic, non-vesicular rash on his right gluteus maximus that spontaneously resolved in 2 weeks. A prior extensive workup including upper and lower endoscopy, abdominopelvic CT, and MRI/MRA, small bowel series, and abdominal ultrasound was unrevealing. Supportive medications included tramadol, hydromorphone, colace, polyethylene glycol, and zolpidem. Physical exam on admission was significant for mild epigastric abdominal tenderness. Laboratory testing revealed an elevated ALT of 53 IU/L (normal <45) and CRP of 1.4 mg/dL (normal <0.80). A gastric emptying scan was performed with an emptying half time of 490 minutes (significantly delayed). On hospital day 2, the patient developed a left-sided facial droop. Brain MRI was normal. Lumbar puncture revealed a lymphocytosis, elevated protein, and elevated Lyme IgG titers. Elevated serum Lyme antibody was confirmed by Western blot. The patient was diagnosed with early-disseminated Lyme disease, complicated by cranial nerve VII palsy and gastroparesis. Ceftriaxone was initiated and continued for 4 weeks at home; a gastroparesis diet and metoclopramide were started. At follow-up 3 weeks later, the patient's symptoms were markedly diminished, and he had gained 5 lbs. Two months after discharge, the patient was asymptomatic except for a slight left-sided facial droop; a repeat gastric emptying scan was normal. Gastroparesis is a chronic disorder of delayed gastric emptying without mechanical obstruction. The most common etiologies are diabetes, post-surgical and idiopathic; a subset of the latter category may be associated with post-viral infections. Lyme disease is the most common tick-borne disease in the U.S. and is caused by the spirochete Borrelia burgdorferi, which can elicit a multisystem inflammatory response and is often accompanied by the hallmark rash, erythema migrans. The most common gastrointestinal symptom of Lyme disease is subclinical hepatitis, although dysmotility syndromes including gastroparesis and intestinal pseudo-obstruction have been reported. While the pathogenesis is not completely understood, gastroparesis secondary to Lyme disease may result from an inflammatory neuropathy of the enteric nervous system by direct invasion of B. burgdorferi or an indirect, cell-mediated inflammatory response. This case highlights an unusual presentation of a relatively common (regional) disease.
Abstract:
Nayantara Coelho-Prabhu, MD*, William Sanchez, MD. Gastroenterology, Mayo Clinic Rochester, Rochester, MN.
Purpose: Mirizzi Syndrome is characterized by biliary obstruction caused by a gallstone impacted in the cystic duct or gallbladder neck creating extrinsic compression and inflammation of the common bile duct. XGC is a rare chronic inflammatory condition of the gallbladder that can involve adjacent structures and thereby mimics gallbladder carcinoma.
Methods: N/A
Results: A 68 year old Caucasian male was evaluated due to a two month history of intermittent nausea, abdominal discomfort, elevated transaminases and hyperbilirubinemia. Medical history was significant for recurrent melanomatous skin cancer resections. He had consumed 2 alcoholic drinks per day for 25 years but had no risk factors for viral hepatitides. On initial assessment, serologic studies for viral hepatitis and autoimmune hepatitis were negative. Initial abdominal ultrasonography showed cholelithiasis but was otherwise unrevealing. Upon recurrence of symptoms, cholelithiasis without choledocholithiasis or dilated ducts was seen on repeat ultrasonography. A liver biopsy was performed which revealed portal inflammation, bile ductular proliferation and periportal fibrosis. MRI of the liver with MRCP showed intrahepatic ductal dilation, an extrinsic-appearing stricture of the proximal hepatic duct and irregular enhancement of the gallbladder wall, concerning for malignancy. ERCP confirmed the stricture at the proximal hepatic duct with a thin irregular wall. Brushings obtained were negative for malignant cytology, FISH was positive, and a serum CA19-9 was mildly elevated. The patient then underwent open cholecystectomy. Examination of the gallbladder was negative for malignancy, but instead revealed acute and chronic cholecystitis with cholelithiasis, peri-gallbladder inflammation, fibrosis and abscess formation with xanthogranulomatous inflammation.
Conclusion: We present a case of recurrent cholestatic hepatitis secondary to Mirizzi syndrome associated with xanthogranulomatous cholecystitis. While Mirizzi syndrome is seen in approximately 1% of all cholecystectomies, to our knowledge, only 4 cases associated with XGC have been reported previously in the literature. Because gallbladder carcinoma is a more common cause of Mirizzi syndrome, and XGC can be diagnosed only on pathologic examination of the resected gallbladder, cholecystectomy remains the treatment of choice if this association is suspected.
Abstract:
Brandon Craft, MD*, Marcelo Vela, MD. Digestive Disease Center, Department of Medicine, Medical University of South Carolina, Charleston, SC.
Purpose: Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in the United States and are generally safe with few side effects. We report a case of recurrent symptomatic hypocalcemia associated with PPI use. A 33 year old female with a history of papillary thyroid cancer resection and subsequent diminished PTH activity requiring oral calcium carbonate to maintain normocalcemia presented with postprandial heartburn. She was started on omeprazole/sodium bicarbonate 40 mg once daily for GERD. After one week of therapy she developed cramping, tetany, and perioral numbness and tingling; serum calcium levels revealed a decrease in calcium levels from a baseline 9.0 to 6.5 mg/dL despite her oral calcium supplementation. Upon discontinuation of omeprazole/sodium bicarbonate, her calcium levels normalized and the symptoms of hypocalcemia resolved. Symptoms of GERD persisted and Esomeprazole 20 mg once daily was begun. After one week of therapy, the symptoms of hypocalcemia returned and serum calcium levels decreased to 7.3 mg/dL. Because esomeprazole 20 mg failed to control her heartburn, the dose was increased to 40 mg once per day without an increase in her calcium supplementation. This resulted in yet another episode of symptomatic hypocalcemia and a drop in calcium levels to 6.3 mg/dL. Her calcium supplementation was changed from calcium carbonate to calcium citrate, resulting in normalization of serum calcium levels; however, calcium carbonate caused significant dyspepsia. Eventually the dose of calcium citrate was titrated so that normocalcemia could be acheived with only minimal dyspepsia with esomeprazole 40 mg per day. The acidic environment in the stomach increases calcium solubility by releasing ionized calcium salts from its insoluble forms. Calcium malabsorption secondary to acid suppression by PPI therapy appears to have caused symptomatic hypocalcemia in this patient with parathyroid insufficiency. Gastrectomy and pernicious anemia have been shown to increase the risk of osteopenia and fracture, and recent studies suggest that chronic acid suppression therapy may lead to an increased risk of hip fractures possibly related to decreased calcium absorption. Symptomatic hypocalcemia due to PPIs is rarely seen in patients with normal parathyroid function. The case we report should alert clinicians about this possible complication of PPIs in patients with hypoparathyroidism, and should also be a reminder about the potential for asymptomatic hypocalcemia in other patients. Compared to calcium carbonate, calcium citrate appears to be better absorbed in the setting of pharmacological acid suppression and should be the supplementation of choice in these patients.
Abstract:
Zeeshan Perveze, MD*, Nasser Saffarian, MD, Ayaz Chaudhary, MD, FACG. Gastroenterology, Internal Medicine, Medical College of Georgia, Augusta, GA, Internal Medicine, Trinity Hospital, Minot, ND.
Purpose: Intro: There are numerous reports of acute hemolysis during hemodialysis over the past two decades. Etiology of hemolysis in hemodialysis patients is usually related to problems with dialysate, which include overheating; hypotonicity; contamination with formaldehyde, bleach, chloramine or nitrates from water supply; and copper from copper tubing. Red cell fragmentation can also occur due to pump malocclusion, inappropriate single needle dialysis ie high flow, or collapse of arterial line. Immune factors as with mismatched transfusion, drugs or hemoglobin abnormality can also be the cause for hemolysis. We report kinking of arterial blood line which resulted in acute pancreatitis as a consequence of acute hemolysis in chronic hemodialysis patient. Case: A 79 year old male with history of end stage renal disease was admitted for dialyisis. Right after dialysis, the patient experienced nausea, vomiting and abdominal pain radiating to the back. Labs drawn at dialysis showed hemoglobin of 8.2 g/dl, which dropped from 10.2 g/dl. Other labs included amylase of 1415 U/L, LDH 3965 IU/L, haptoglobin of 64.9 mg/dl and total bilirubin of 6 mg/dl. Electrolytes, PT, PTT, AST, ALT, complement factors, vitamin B-12, folate and ceruloplasmin were within normal range. ANA, serum and urine electrophoresis were negative. Peripheral blood smear revealed target cell, ovalacytes, schistocytes, helmet and tear drop cells. CT scan of abdomen was done which showed pancreatitis. Imaging did not reveal any gallstones and all other etiologies of pancreatitis were ruled out. Workup for paroxysmal nocturnal hemoglobinuria, glucose-6- phosphate dehydrogenase deficiency and autoimmune hemolysis was negative. There was no contamination with formaldehyde, chloramine, nitrates, copper or hypotonicity of the dialysate. Mechanical hemolysis due to kinking of line was presumed to be the cause. The patient was kept NPO, intravenous fluids and pain management was initiated. After replacing a new line there were no further hemolytic episodes. His condition improved during the hospital stay and was discharged home after two weeks. Discussion: Acute hemolysis on hemodialysis has become rare in recent years. This makes it extremely difficult to link hemolysis with acute pancreatitis in patients on hemodialysis unless it is high on the list of differential. In this case, after excluding all known causes of pancreatitis by radiology, serology and drug screening we proposed hemolysis induced by kinked hemodialysis blood line as a cause of acute pancreatitis. By emphasizing such an unusual mechanism of hemolysis leading to acute pancreatitis, we want to highlight the principle of root cause analysis which eventually led us to the etiology.
Abstract:
Shilpa Madadi, MD*, Mark Versland, MD. Department of Medicine, Division of Gastroenterology, University of Connecticut, Farmington, CT, Department of Medicine, Division of Gastroenterology, The Hospital of Central Connecticut, New Britain, CT.
Purpose: Introduction: Cytomegalovirus (CMV), a DNA virus is a member of the herpes virus family. CMV infection may affect all parts of the gastrointestinal tract, most commonly the esophagus and the colon. It is most often seen in immunocompromised patients. Small bowel involvement is rare. We herein present a case of an immunocompetent woman with isolated CMV infection of the small bowel. Case Report: A 65 year old Chinese woman was hospitalized with profuse diarrhea, vomiting, abdominal pain, and fever. Her past history was significant for hypertension, depression, osteoarthritis, hysterectomy and breast cancer 8 yrs ago treated with lumpectomy and radiation. Her medications included Lotrel, Celebrex, Prozac, Neurontin and Xanax. She was a non smoker and denied any drug use. On physical examination, the patient appeared ill. Her temperature was 101[degrees]F, heart rate 142 beats/min and blood pressure 100/72 mmHg. Her abdominal exam was notable for diffuse tenderness with no rebound. Laboratory values on admission were notable for an elevated creatinine but otherwise normal. Her blood and stool cultures were negative. Abdominal computed tomography showed thickening of the mid to distal small bowel. A small bowel follow through showed mucosal edema and ulcerations in the same area. Colonoscopy with intubation of the terminal ileum was normal including random biopsies. HIV test was negative. Her symptoms persisted and she was then taken for laparoscopy where a segment of abnormal small bowel was resected. Histological examination showed atypical cells with intranuclear inclusions. Immunoperoxidase stain for CMV was strongly positive. A high titer of IgM antibodies to CMV confirmed the diagnosis. Antiviral therapy was initiated and the patient recovered. Discussion: CMV infection in immunocompetent individuals is usually asymptomatic, or may produce a mononucleosis-like illness. It generally resolves without treatment. Small bowel involvement is very rare in immunocompetent individuals. A Medline search produced only 7 cases of CMV enteritis in immunocompetent subjects. The ages ranged from 18 to 68 years. Diarrhea was present in all the patients, abdominal pain in 5 cases and fever in 3 cases. Most patients were treated conservatively and symptoms resolved. Four required surgery for intestinal perforation or strictures. The characteristic histological findings of CMV enteritis are cytomegalic inclusion bodies in the endothelial cells of the capillaries. Ganciclovir and foscarnet are the primary treatment agents for clinically significant CMV infection. In conclusion, CMV enteritis is rare in immunocompetent patients but should be considered in the differential diagnosis of acute enteritis.
Abstract:
Ritesh Jha, MD*, Bashar Attar, MD, PhD, Mary Atten, MD. Division of Gastroenterology and Hepatology, Cook County-John H. Stroger Hospital, Rush University, Chicago, IL.
Purpose: Introduction: Ascariasis results in substantial morbidity and mortality worldwide. The diagnosis is usually incidental when the host passes a worm in the stool or vomit. Stool samples for ova and parasites will also demonstrate Ascaris eggs. Ascariasis diagnosed via EGD is an unusual method of diagnosing this disease. We report the case of a patient who presented with vague abdominal pain and was diagnosed with Ascariasis when an adult Ascaris worm was found in the second portion of his duodenum during EGD. Case: A 73 year old Filipino male with a history of vague abdominal pain presented for an elective outpatient EGD. Physical exam was unremarkable. Laboratory tests revealed a white blood cell count of 9,500/[mu]L with 8.0% eosinophils. EGD revealed a single, superficial, erythematous ulcer in the antrum. The patient was started on Protonix 40 mg twice daily and advised to return in 8 weeks for a repeat EGD to evaluate ulcer healing. Upon returning 8 weeks later for a follow-up EGD the patient reported no change in the character of his abdominal pain. Repeat EGD revealed a well healed ulcer in the gastric antrum, and upon entering the second portion of the patient's duodenum an 18 cm worm was identified. The worm was extracted using rat-tooth forceps, placed in formalin, and sent for histopathology. Pathology results confirmed the worm to be Ascaris lumbricoides. The patient was treated with a single dose of albendazole 400 mg. The patient reported complete relief of symptoms upon follow-up 4 weeks later. Discussion: Ascaris lumbricoides is the largest human intestinal nematode and can reach 40 cm in length. Nearly a fourth of the world's population is infected and Ascaris causes 20,000 deaths a year worldwide. The adult worm in the upper small bowel usually causes no symptoms but may cause vague abdominal symptoms in the form of abdominal pain, distension, nausea and occasional diarrhea. This case demonstrates that patients with vague abdominal pain, who are from or have traveled to endemic areas, should be evaluated for parasitic infections, particularly Ascariasis.
Abstract:
Scott Leverage, MD*, Luis Pena, MD. University of Kentucky, Lexington, KY.
Purpose: A 47-year-old woman with history of GERD on chronic PPI and hyperplastic colon polyps presents to GI clinic with iron deficiency anemia of unknown etiology. She has a family history significant for a brother with a Schatzki's ring of the esophagus as well as Barrett's esophagus, a father with colon cancer detected at age 50, two paternal uncles with colonoscopies revealing less than 100 polyps, a paternal great-grandfather with colon cancer, and a maternal grandfather with gastric cancer. Patient's hemoglobin and hematocrit were 10.5 g/dL and 31.6%, respectively. Iron studies revealed an iron level of 25 ug/dL, TIBC of 488 ug/dL, ferritin of 6 ng/ml, transferrin of 390 mg/dL, and transferrin saturation of 5%. Colonoscopy revealed a sessile, 3 mm polyp in the ascending colon and a sessile, 4 mm polyp in the rectum both with biopsy results consistent with a hyperplastic polyp. EGD revealed a mild Schatzki ring in the lower third of the esophagus, a medium-sized hiatal hernia, and 30-50, 5 to 30 mm pedunculated and sessile polyps with no stigmata of recent bleeding in the gastric antrum and body of the stomach. The examined duodenum was normal. Histology confirmed these were fundic gland polyps. Video capsule endoscopy revealed multiple large pedunculated and sessile polyps with no bleeding or stigmata of recent bleeding in the gastric body, fundus and antrum. The patient was evaluated for genetic mutations of the APC or MYH genes because of the multiple, large fundic gland polyps and her family history of colon cancer. Genetic testing came back negative for any mutations in the APC or MYH genes. Ultimately, it was felt that the patient's multiple polyps were secondary to chronic PPI use and were not secondary to malignancy. Polyps are often incidentally discovered on endoscopy and should not simply be overlooked. They require a "double take". Biopsy is necessary for histological evaluation. When multiple gastric polyps are found, particularly to the degree in this case, further evaluation should be undertaken, regardless of histologic type. Assessing the possibility of genetic mutations that could predispose to GI malignancy is reasonable. APC or MYH gene mutations may be revealed which correlate highly with FAP. In addition, there is a clear correlation between fundic gland polyps and FAP. This could have serious implications for a patient leading to colon cancer. Suddenly, the incidental finding of a gastric polyp which may have been overlooked is very significant. In conclusion, gastric polyps need diagnostic evaluation beyond what is seen during endoscopy which is a change from the current practice during many endoscopies.
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Abstract:
Mayur Trivedi, MD*, Gerold Fruchter, MD, Andrew Seymour, MD. Gastroenterology, VA NY Harbor Healthcare System & SUNY Downstate Medical Center, Brooklyn, NY, Gastroenterology, VA NY Harbor Healthcare System, Brooklyn, NY.
Purpose: Case: 66 year old white male with history of long standing Crohn's disease presented for a surveillance colonoscopy. He was diagnosed in 1977 presenting with colo-vesicular fistula requiring a sigmoid resection. He subsequently developed peri-anal disease including fistulas and abscesses. Over the past several years the patient's disease was quiescent while receiving maintenance dosing of 6 mercaptopurine. He reported one to two formed, non-bloody bowel movements per day. His prior colonoscopy one year earlier revealed no evidence of active colitis and biopsies including the rectum did not show evidence of any dysplasia. A complete colonoscopy was performed which was normal with the exception of a uniform circumferential white-grayish discoloration extending 6 cm beyond the anal verge (Fig. 1). This finding simulated the appearance seen in Barrett's esophagus. Random biopsies were obtained every 10 cm from the colon using cold biopsy forceps. Other than the area in the rectum, the pathology revealed mild colonic inflammation. The proximal rectum revealed normal colonic mucosa, while pathology from the distal rectum revealed squamoglandular mucosa with focal acute cryptitis, without evidence of dysplasia or malignancy (Fig. 2). Discussion: The patient's findings reveals a rare case of squamous cell metaplasia in the rectum in a patient with long standing Crohn's disease. Review of literature revealed one such case in patient's with Crohn's disease, and two cases in patients with ulcerative colitis. The squamous cell metaplasia is likely due to chronic inflammation. This entity carries an increased risk for malignant transformation, however, due to the paucity of cases the magnitude of this risk is uncertain.
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Abstract:
John Kalarickal, MD*, David Victor, MD, Fredric Regenstein, MD, Sander Florman, MD. GI, Tulane University, New Orleans, LA, Surgery, Tulane University Health Sceinces Center, New Orleans, LA.
Purpose: Focal lesions of the liver are often encountered on abdominal imaging and frequently present as incidental findings on an imaging study typically done for other indications. These lesions range from simple cysts to more aggressive lesions such as hepatocellular carcinoma or metastatic disease. Advances in imaging technology allow the practitioner to diagnose the etiology of lesions often obviating the need for biopsy. However, this is not always the case. When the lesion is associated with aggressive features, there should be a lower threshold for further evaluation.
Methods: N/A.
Results: The present case is of an asymptomatic 76 year old female with no known history of underlying liver disease who was referred for evaluation of an incidentally discovered liver mass on abdominal computed tomography (CT). A 3 x 5 cm ovoid lesion demonstrating nodular enhancement was visualized in segment 5 of the liver. Magnetic resonance imaging demonstrated similar findings. A nuclear tagged red blood cell scan was negative for hemangioma. Subsequently the patient underwent a CT-guided biopsy that revealed no evidence of malignancy but was otherwise non-diagnostic. Serial abdominal CT scan revealed interval increase in the size of the lesion to 5 x 6 cm over the course of one year. The patient remained asymptomatic. There was no history of taking oral contraceptive or hormonal medications. Extensive laboratory evaluation was unremarkable. Given the rapid growth of this atypical enhancing lesion, it was felt the best approach would be resection with a formal right lobectomy. Intraoperatively the tumor was identified and was found to be enveloped within the liver. Upon dissection of the appropriate structures, it became apparent that the tumor and its vascular supply were originating from retroperitoneal tissue. Its growth had invaginated the surface of the liver without invading the liver capsule. The tumor was easily dissected from the surface of the liver and resected from its retroperitoneal origin, no hepatic resection was required. Histopathologic evaluation revealed a rare atypical spindle cell tumor likely of smooth muscle origin of uncertain biologic potential. Intraoperative liver biopsy was noteable only for mild steatohepatitis. The postoperative course was uneventful.
Conclusion: Surgical evaluation of atypical liver lesions should be considered if incidental lesions are large and possess aggressive features on serial imaging. Although liver biopsy findings may be specific, it does not obviate further evaluation if no diagnosis is made. This interesting case illustrates a rare spindle cell tumor of retroperitoneal origin mimicking a primary tumor of the liver.
Abstract:
Matthew Wyneski, MD*, Naim Alkhouri, MD, Lori Mahajan, MD. Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative condition of the skin that complicates about 2% of cases of IBD. While the exact pathogenesis remains unclear, it appears to be immune-mediated. The ulcers typically occur on the lower extremities. The clinical variant known as peristomal pyoderma gangrenosum (PPG) was first described in 1984. PPG has only been reported previously in 3 patients age 18 yrs and younger. We report the unusual development of PG at an ileostomy site that had been closed for over 7 years. Case: At 9 yrs of age, our female patient underwent total abdominal colectomy, loop ileostomy, and J pouch formation for treatment of fuminant colitis (presumed UC). She later underwent IPAA with closure of her ileostomy. Her diagnosis was subsequently changed to Crohn's disease (CD) due to mild chronic pouchitis and development of aphthous ulcers in her neo-terminal ileum proximal to her pouch. She was subsequently maintained on 5-ASA products with relatively good control. At the age of 16 yrs, however, she developed a significant exacerbation of her underlying CD with development of bloody diarrhea and recurrent emesis suggestive of a partial small bowel obstruction. Days prior to her admission, she had developed small erythematous pustules at the site of her prior ostomy. By the time she was admitted, the lesions had coalesced and a central area of ulceration and necrosis had developed. The lesion had serpiginous, violacious borders and measured approximately 4 cm in diameter. Lesion evaluation did not identify any fistulous tract or feculent drainage. She had rapid clinical improvement following initiation of IV corticosteroids, metronidazole and ciprofloxacin and was discharged after 7 days. She completed an approximate 8 week course of oral antibiotic therapy with complete resolution of her Crohn's symptoms as well as complete healing of the PG at her prior ostomy site. Conclusion: PG is an uncommon neutrophilic dermatosis characterized by small erythematous papules that rapidly spread, coalesce, and centrally ulcerate. It develops over lower extremities >70% of the time; however, any cutaneous or mucosal surface may be affected. There are only 3 prior reports of the peristomal variant occurring in a pediatric patient. In addition, there is a single case of PG at multiple incision sites in a child after colectomy. This is the first case of PG development in a child at a former ostomy site that had been healed for 7 years. As the diagnosis of PG is clinical and treatment is empiric, clinicians must have a high index of suspicion and low threshold for initiation of therapy.
Abstract:
Thomas Park, MD*, Asad Ullah, MD, Ashok Shah, MD, MACG. Gastroenterology, University of Rochester, Rochester, NY.
Purpose: Pneumatosis coli, also known as pneumatosis cystoides intestinalis (PCI), is a rare condition involving gas in the bowel wall. Primary, or idiopathic, PCI is an uncommon form, comprising 15% of all cases of PCI. We present a case where a patient with idiopathic, isolated PCI was misdiagnosed in the community and referred to our institution, where we made the diagnosis with endoscopic ultrasound.
Methods: N/A
Results: A 54 year-old Caucasian man underwent average-risk colon cancer screening colonoscopy at a community endoscopy center. Colonoscopy revealed a 10 mm submucosal lesion at the splenic flexure, and two much smaller similar-appearing lesions adjacent to it (see image). A few biopsies were taken with cold forceps. The remainder of the colon and distal terminal ileum appeared normal. Histologic analysis revealed benign mucosal tissue and mildly disordered glandular architecture. He was referred to our institution for evaluation with EUS for suspicion of lipoma versus submucosal nodules. The patient denied any GI or respiratory symptoms. His past medical history included hypertension and depression, for which he was taking antihypertensive and antidepressant medications. Two months later at our institution, the patient underwent a fiber-optic lower endoscopy to the transverse colon, which revealed a smooth, round, centimeter-sized submucosal lesion at the splenic flexure, with a few smaller similar-appearing lesions adjacent to it. These were soft when probed. EUS revealed anechoic areas in the submucosa with air shadows. A sclerotherapy needle was inserted into two of the masses, and air was aspirated from them.
Conclusion: Idiopathic pneumatosis coli can present as an isolated lesion in an asymptomatic patient. Endoscopists should be aware of the typical features of pneumatosis coli to avoid misdiagnosis and unnecessary treatment. EUS can be a useful diagnostic tool in diagnosing pneumatosis coli.
Abstract:
Jenny Smith, MD*, Richard Sterling, MD, A. Scott Mills, MD, R. Stravitz, MD, Velimir Luketic, MD, Michael Fuchs, MD, Arun Sanyal, MD, Mitchell Shiffman, MD. Pathology, Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA.
Purpose: Herpes simplex virus (HSV) is recognized as a cause of gastrointestinal infection in patients with underlying immunodeficiency with esophagus, perineum, and rectum as the most common sites of involvement, but diffuse colitis is rare. A 50 yo male with history significant for Crohn's disease and hepatitis B (HBV) and hepatitis D (HDV) cirrhosis presented with complaint of bloody stools. Patient (pt) was enrolled in NIH PEG-IFN for HDV trial, and mesalamine used for Crohn's maintenance therapy with flares previously controlled with antibiotics. IFN and mesalamine were stopped six months prior to presentation due to foot abscess. Pt was treated for presumed Crohn's flare two months prior to presentation, and IFN was subsequently restarted. Pt then developed progressive weakness, weight loss, abdominal pain, and rectal bleeding, and presented to outside hospital where he was again treated for presumed Crohn's flare prior to transfer. Vital signs normal and pt afebrile on admission. Physical examination negative for encephalopathy. The pt had temporal wasting, and abdomen notable for distention with right upper quadrant tenderness to palpation. Laboratories notable for sodium 134, AST 50, ALT 38, Alk Phos 291, albumin 2.0, WBC 11 with 91% neutrophils, hemoglobin 11, platelets 70, INR 1.5, CMV PCR negative. Pt initially placed on bowel rest and started TPN. Intravenous antibiotics, steroids and oral mesalamine were continued. Stool cultures were negative, and pt referred for endoscopic evaluation. The colon was diffusely erythematous, friable, and ulcerated with purulent exudate. CT scan showed diffuse contiguous bowel wall thickening extending from the ascending colon to the rectum. Biopsy specimens of the colon showed ulcerated mucosa with fibrinous necrosis. Herpes simplex viral inclusions, confirmed by immunostaining, were noted within the surface epithelium and within the ulcer bed. CMV and adenovirus immunostaining were negative. Colonic tissue viral culture was positive for HSV-2. Steroids were discontinued, and pt treated with antiviral therapy with cessation of abdominal pain and bloody stools. However, he developed progressive hepatic decompensation and subsequently expired. Treatment of Crohn's flare begins with exclusion of acute infection and atypical etiologies should be considered in those patients who fail to respond to therapy, especially those who are immunosuppressed. Diffuse colonic involvement with HSV is very rare and has been reported once in a Crohn's pt, and has not been reported in a patient with HBV/HDV cirrhosis. This case demonstrates the need to consider HSV in the diagnosis of refractory colitis in order to reduce the morbidity and mortality of this disease entity.
Abstract:
Melanie Harrison, MD*, Steven Epstein, MD, Kelly Crawford, MD. Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA.
Purpose: T-cell lymphomas of the gastrointestinal tract are rare and not well characterized. The principal subtype is enteropathy associated T-cell lymphoma, which tends to have an aggressive course and poor prognosis. In recent years, several case reports have emerged of CD4+ T-cell lymphomas of the gastrointestinal tract unrelated to celiac disease, which have an indolent course associated with an improved prognosis. We report a case of a 53 year old Caucasian male who presented to the gastroenterology clinic with a four month history of diarrhea and a 20 pound weight loss. He denied any nausea, vomiting, abdominal pain, recent travel, or sick contacts. He had empirically started a gluten-free diet, which did not alleviate his symptoms. He had a past medical history of colon polyps with a normal colonoscopy six months prior to presentation. His family history was significant for a maternal grandfather with colon cancer diagnosed in his 70s, and a niece with celiac disease. His physical exam revealed small scattered lymph nodes in his neck. On laboratory exam he had evidence of malabsorption manifested by a low albumin, B12, and VitD25 level. A tissue transglutaminase IgA was negative, and quantitative IgA levels were normal. An esophagogastroduodenoscopy was performed, which revealed a hypopharyngeal mass, and a nodular duodenum with diffuse villous blunting. Multiple biopsies of the duodenum were taken, which showed extensive T cell lymphocytic infiltrates in the lamina propria. Immunohistochemical studies were positive for CD3, CD4, CD45, CD8, and CD5. A computed tomography scan of the chest, abdomen, and pelvis revealed diffuse abdominal and pelvic lymphadenopathy, two areas of small bowel intussusception, wall thickening in the ileum, and splenomegaly. A PET scan showed multifocal lymphadenopathy in the mesentery, retroperitoneum, and bilateral inguinal regions with mild FDG uptake, but no uptake in the gastrointestinal tract. A bone marrow biopsy demonstrated a similar T cell receptor gene arrangement. The patient's clinical history, lack of evidence of celiac disease, and extensive infiltration of the lamina propria with CD4+ T cell lymphocytes suggests CD4+ T cell lymphoma of the gastrointestinal tract, which is rarely described in the literature. Only six other cases have been reported. It is important to distinguish this entity from enteropathy associated T cell lymphoma due to the differences in clinical, pathologic, and prognostic features.
Abstract:
Andrew Rackoff, MD*, Patrick Brady, MD. Division of Digestive Diseases, Univ of South Florida, Tampa, FL.
Purpose: Polycythemia vera (PCV) is a known cause of hypercoagulable states, however, isolated splenic vein thrombosis associated with PCV is only rarely reported. We report a case of the insidious onset of a splenic vein thrombosis presenting as an upper gastrointestinal bleed in a patient with PCV. Case: A 46 year old white female presented to the emergency room with complaints of melena for four days. She denied vomiting and abdominal pain associated with the melena. Her history was significant for polycythemia vera for which she had not seen a physician in years. She reported intermittent phlebotomy in the past. She denied non-steroidal anti-inflammatory use. Hemodynamics were significant for orthostasis, and presenting labs revealed a hemoglobin of 6.9 gm/dL. Abdominal examination was normal. After volume resuscitation, an esophagogastroduodenoscopy was performed. This revealed a normal esophagus and duodenum but multiple large, gastric varices with red marking signs in the gastric fundus. The finding of isolated gastric varices prompted an evaluation for a splenic vein thrombosis. An ultrasound Doppler exam revealed patent portal veins and a patent splenic vein at the level of the splenic hilum. As this did not exclude the possibility of a more central splenic vein occlusion, a CT venogram was ordered for confirmation. This revealed non-visualization of the splenic vein, suggesting a chronic splenic vein thrombosis. Extensive collateral formation was noted around the stomach and spleen. The patient underwent splenectomy with gastric devascularization and ligation of gastric and retroperitoneal varices as definitive treatment. The patient had a full recovery. This case highlights the importance of maintaining a high level of suspicion for the consequences of thrombosis in unusual locations in patients with hypercoagulable states. This case also demonstrates the relative lack of sensitivity of extracorporeal ultrasound for the diagnosis of splenic vein thrombosis.
Abstract:
Aman Ali, MD*, William Pullano, MD. Gastroenterology, Lenox Hill Hospital, New York, NY.
Purpose: Clostridium Difficile remains a significant cause of morbidity and mortality among hospitalized patients. In recent years C. Difficile infections were observed to be more frequent, more severe and more refractory to standard therapy. We describe our experience with nitazoxanide in two cases of severe, refractory C. Difficile colitis.
Methods: 71 year old female with hypertension, diverticulosis and hypothyroidism presented with diffuse abdominal pain, profuse non bloody diarrhea, fevers and vomiting. She quickly developed septic shock and respiratory distress requiring mechanical ventilation. Labs revealed metabolic acidosis, WBC count of 71K and CRP was 67 mg/L. Stool C. difficile assay for toxin A and B was positive. Despite receiving oral metronidazole, vancomycin, saccharomyces boulardii and cholestyramine, her clinical status remained unchanged. CT scan of Abdomen (Figure) revealed diffuse pancolitis and pericolonic fat stranding. Surgical intervention was contemplated, however, as a last resort, nitazoxanide 500 mg BID per NG tube was started. Over the course of several days, fevers resolved, WBC count improved significantly, she was extubated and continued to improve clinically. Nitazoxanide was continued for 10 days and then vancomycin PO was continued for another 2 weeks. A repeat CT scan revealed resolution of colitis and at 2 months follow up, she was doing well.
Results: The second case involves a 52 year old female with ESRD, Hypertension and Diabetes who presented with severe refractory C. Diff pancolitis and failed standard therapy. She received nitazoxanide for 10 days as add on therapy and had dramatic improvement in clinical and laboratory parameters and remains well at 2 months follow up.
Conclusion: Nitazoxanide should be considered as a rescue therapy for refractory C. Difficile colitis especially when standard treatment fails. In some patients colectomy can be avoided. Questions remain about the appropriate timing of nitazoxanide treatment in these patients. Also it is unclear whether nitazoxanide is effective as an add on therapy only or if it can work well as monotherapy.
Abstract:
Siddharth Mathur, MD*, Niket Sonpal, BS, William Thelmo, MD, Yashpal Arya, MD, Mukul Arya, MD. Wyckoff Heights Medical Center, Brooklyn, NY.
Purpose: Primary rectal lymphomas are a very uncommon disease and have not been extensively described in the literature. They compromise about 0.1-2% of primary lymphomas of the gastrointestinal tract, and .4-4% of the malignant neoplasms of the rectum. We present a case of a malignant primary large B cell rectal lymphoma and highlight the notable EUS characteristics.
Methods: A 95 year old male presented to the ED with complaints of bleeding per rectum for last five days. He had a history of abdominal pain for the past three months which had worsened in the last one month. The patient denied any history of fever, diarrhea, weight loss and loss of appetite. His PMH is significant for diverticulosis, COPD, DMII, BPH and CAD. Physical examination on admission was non contributory except for a tender palpable mass which was hard in consistency on rectal examination and yielded guiac positive stool. Other laboratory findings were non contributory and a colonoscopy was undertaken to evaluate for the blood loss. A suspicious malignant tumor in rectum was seen 8 cm in length, circumferential, fungating but not obstructing the lumen. Biopsy and subsequent immunhistochemical stain for CD 45 were strongly positive for immunoblastic type diffuse large B cell lymphoma.
Results: Radial EUS performed for staging demonstrated a large hypoechoic mass arising just above the anal verge extending to the serosal surface without penetration into the peri-rectal fat consistent with a T3 process. A second lesion measuring 3.5 x 1.5 cm was seen intramurally just proximal to the mucosal mass. This second lesion was sonograhically distinct from the lymphomatous process and appeared to be arising from the muscularis propria with extension into peri-rectal fat. This finding was corroborated by the initial CT of the abdomen showing a rectal mass with extensive extra luminal component. Echo features of the tumor were characterized by marked heterogeneity and small cystic spaces.
Conclusion: Modern diagnostic procedures with multiple biopsies and endoscopic ultrasound (EUS) for staging increase the percentage of early detection and more precise diagnoses without the need for invasive surgeries. Further fine need aspiration can be implemented to increase the yield in biopsies of local or lymph node metastasis. EUS has the ability to image colonic wall layers and peri-rectal lymph nodes and is therefore most accurate staging method for rectal cancer. However due to the rarity of a primary rectal lymphoma very little has been described in the current literature on the EUS findings in this disease process.
Abstract:
Juan Young, MD*, Ricardo Prieto, MD, Yasser Saloum, MD, FACG, Patrick Brady, MD, FACG. Internal Medicine, Digestive Diseases and Nutrition, University Of South Florida, Tampa, FL.
Purpose: Transesophageal echocardiography (TEE) is a widely used imaging modality for the evaluation of multiple cardiovascular conditions and its clinical applications are numerous. It is a moderately invasive study that uses a diamond-shaped probe typically inserted blindly without fluoroscopic guidance. This carries rare but potentially serious complications. Rare reports have addressed the risk of TEE-induced trauma to the gastrointestinal tract (hypopharynx, esophagus, and stomach), the commonly used therapies, and the natural history of this type of injury. We review a case of iatrogenic dissection of the cervical portion of the esophagus during a TEE that was performed to evaluate for infective endocarditis in a 39 year old male with gram-positive cocci bacteremia. After multiple attempts to advance the probe, the operator was able to advance it partially with moderate resistance but was unable to obtain any images so the procedure was terminated. Upon removal of the instrument, there was evidence of bright red blood on the probe, and the patient complained of dysphagia to solids and liquids. Gastroenterology Service was consulted and an esophagogastroduodenoscopy (EGD) was performed. On EGD, the patient appeared to have a mucosal tear in the proximal esophagus; however, the endoscope could not be advanced distal to this tear due to luminal stenosis. An esophagogram was performed immediately following the EGD to rule out a transmural esophageal perforation. This revealed a contained tear in the upper esophagus with extravasation of contrast material into the anterior wall of the esophagus (false lumen). The patient was treated conservatively with nothing by mouth and parenteral nutrition. A follow-up endoscopy two weeks later confirmed adequate healing of the lesion. These as well as other potential gastrointestinal complications of TEEs are briefly discussed.
Abstract:
Mouen Khashab, MD*, Spencer Wilson, MD, Won Kyoo Cho, MD. Medicine, Indiana University/Roudebush VAMC, Indianapolis, IN.
Purpose: Spirochete is implicated for its pathogenic role in invasive hepatic infection and hepatitis, and spirochetemia. However, its role in colonic injury is not well established. We report an unusual case of colonic spirochetosis causing colonic ulcer.
Methods: Clinical case presentation and review of English medical literature on intestinal spirochetosis.
Results: A 55 year-old homosexual male with HIV on HAART therapy presented for screening colonoscopy. He denied recent fevers, chills, weight loss, abdominal pain, blood in stool, constipation or diarrhea. Laboratory results were notable for a CD4 count of 237 cells/mL and HIV RNA by PCR < 50 copies/mL. A colonoscopy was normal except for a non-bleeding 4 mm ulcer in the cecum. Pathology of the ulcer biopsy specimens demonstrated mild acute cryptitis with a prominent luminal brush border. No viral inclusions were identified. A Warthin-Starry stain showed luminal spirochetes on the surface epithelium (Fig. 1). Intestinal spirochetosis was diagnosed and the patient was treated with metronidazole and remained asymptomatic over 6 months.
Conclusion: This is the first report of a patient with intestinal spirochetosis (IS) presenting with an asymptomatic colonic ulcer. Although IS has been described in homosexual men and patients with AIDS, colonoscopic exams often reveal a normal appearing mucosa or edematous and erythematous mucosal changes without ulceration. The cecal ulcer in our patient is likely a manifestation of invasive IS, presumably from pathogenic organisms or enteric commensal organisms due to other factors such as increased microorganism virulence and/or diminished host defense, leading to an inflammatory response. Diagnosis is usually made by histology noticing a 3-[mu]m basophilic fringe on the intestinal mucosal epithelium on hematoxylin and eosin (HE) sections, and often confirmed with a silver stain like Grocott or Warthin-Starry. Symptomatic or invasive IS patients can be treated after alternative causes have been excluded. The treatment of choice for IS is metronidazole. In asymptomatic IS patients, a conservative clinical follow up is often advised. However, our patient was treated with metronidazole given the mucosal damage with ulceration in the cecum.
Abstract:
Ritesh Jha, MD*, Bashar Attar, MD, PhD, Gijo Vettiankal, MD, Melchor Demetria, MD. Division of Gastroenterology and Hepatology, Cook County-John H. Stroger Hospital, Rush University, Chicago, IL.
Purpose: Introduction: Carcinoid tumors account for only 1-2% of gastrointestinal neoplasms. Carcinoid tumors within the gastrointestinal tract are usually located in the appendix, small intestine, rectum and stomach. Carcinoid tumors of the ampulla of Vater are extremely rare. We report the case of a patient who was incidentally found to have a carcinoid of the ampulla of Vater on a routine EGD. Case: A 68 year old African American female with a past medical history of hypertension, osteoarthritis, asthma and GERD presented for an elective outpatient EGD due to GERD symptoms despite compliance with PPI therapy. Physical examination and laboratory tests, including tests of liver function, were unremarkable. EGD revealed a normal esophagus, a non-obstructing Schatzki's ring at the gastroesophageal junction, diffuse gastritis in the antrum and body of the stomach, and a very prominent major papilla with irregular mucosa. Biopsies from the prominent major papilla revealed a well-differentiated neuroendocrine tumor which stained strongly with the neuroendocrine markers synaptophysin and chromogranin, consistent with carcinoid. An endoscopic ultrasound was subsequently performed which demonstrated an isoechoic lesion located on the major papilla measuring 3.2 cm X 1.4 cm without evidence of local lymph node spread. A CT of the abdomen/pelvis revealed an enhancing lesion in the second portion of the duodenum and no evidence of metastatic spread. Octreotide scan findings were consistent with a neuroendocrine tumor in the second portion of the duodenum without evidence of tumor metastases. The patient was subsequently taken to surgery and had a pancreatoduodenectomy performed. Discussion: Carcinoid tumors of the ampulla of Vater have been infrequently reported in the medical literature. The most common presenting symptoms reported in the literature are jaundice, followed by nonspecific upper abdominal discomfort and weight loss. Rarely, a patient may be incidentally found to have this disease as was demonstrated by our patient. This case demonstrates that successful staging for a carcinoid of the ampulla of Vater can be accomplished with a CT of the abdomen/pelvis, octreotide scan and a EUS.
Abstract:
Ronald Concha, MD*, Daniel Lindemberg, MD, Ayse Aytaman, MD, Andrew Seymour, MD, Gerald Fruchter, MD. Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY, Pathology, Gastroenterology, VA New York Harbor Health Care System, Brooklyn, NY.
Purpose: To report a unique case of esophageal squamous papilloma (ESP) in a patient with AIDS. Case: A 61 years old heterosexual male with HIV-1 infection (viral load < 75 copies/ml and CD4 count 75) on HAART therapy (efavirenz and emtricitabine/tenofovir) was referred to GI service for evaluation of iron deficiency anemia. Upper endoscopy was performed and revealed a 1 cm sessile lesion with fleshy, pinkish elevated edge in mid esophagus, at 30 cm from the incisors. Biopsy was obtained and revealed squamous papilloma with changes consistent with human papilloma virus (HPV) infection. Hypergranulosis, orthokeratosis, verruciform architecture as well as nuclear and cytoplasmic features were suggestive of viral cytopathic effect. Discussion: Squamous papilloma of the esophagus is a rare benign tumor; less than 200 cases have been reported in the literature. The prevalence of endoscopically diagnosed squamous papilloma of the esophagus have been reported in only a very few series and it varies from 0.01 to 0.43%. Two etiological factors for the development of esophageal squamous papillomas have been proposed. One is hyper-regenerative response of the mucosa to chemical and mechanical irritation such as GERD. The other is HPV infection. To what extent HPV infection contributes as an etiological factor of papillomas of the esophagus still remains undetermined. It may be underreported by the fact that more than 200 HPV genotypes have been characterized, but the majority of subtypes may be missed on current standard PCR, hybridization and immunohistochemical methods. HIV-1 infection causes the acquired immunodeficiency syndrome (AIDS) a chronic progressive illness characterized by progressive immune dysfunction. Rates of cervical and anal HPV infection and abnormal cytology are high in HIV-infected patients, as are rates of anal HPV infection and abnormal cytology in HIV-infected, homosexual men. Surprisingly, esophageal papillomas (HPV and non-HPV related) in HIV-infected patients have not been previously described in the English literature. To our knowledge this is the first report of esophageal papilloma in a patient with HIV infection. In view of such, the risk of malignant transformation can not be ascertained. The reason for the intriguing lack of the presence of esophageal papillomas in HIV patients remains unknown.
Abstract:
Andrew Rackoff, MD*, Prasad Kulkarni, MD. Division of Digestive Diseases, Univ of South Florida, Tampa, FL, Gastroenterology, James A Haley Veterans Hospital, Tampa, FL.
Purpose: Cap polyposis is a rare condition characterized by erythematous, inflammatory colonic polyps covered by a cap of fibropurulent mucous. Etiology is largely unknown, but may be related to abnormal colonic motility. Symptoms may include rectal bleeding and mucoid diarrhea. Optimal treatment has not yet been established. Case: A 66 year old male underwent a colonoscopy for intermittent painless hematochezia. He denied weight loss, diarrhea, abdominal pain, fevers, or family history of colon cancer. Past medical history was unremarkable. Lab tests revealed hemoglobin of 14 gm/dL. Abdominal exam was benign. Colonoscopy revealed several 10 to 25 mm sessile, friable recto-sigmoid polyps which appeared to have an overlying exudate. Several were removed with the initial pathology revealing hyperplastic polyps with ulceration and granulation tissue. From the appearance of the initial colonoscopy, malignancy was still entertained despite the benign findings on pathology. A repeat endoscopic examination revealed more coalesced polyps into a 7 cm fungating, friable appearing recto-sigmoid mass. Biopsies revealed fibropurulent exudate and benign inflammatory mucosal prolapse polyps. Continued concern for malignancy prompted endoscopic ultrasound examination which revealed these lesions to be T1. Pathology review and consensus diagnosis was Cap polyposis. Multiple courses of antibiotics, as recommended, were tried for treatment without regression on repeat endoscopy. Persistent rectal bleeding and concern for possible underlying malignancy led to the patient electing to undergo a low anterior resection of the involved area. Final pathologic diagnosis specimen revealed inflammatory polyps without dysplasia, consistent with Cap polyposis. The post-operative course was complicated, including an anastomotic leak and abscess formation leading to a prolonged hospitalization. Our case demonstrates the need to use caution in treating this rare but benign disease. Efficacy of current medical treatment is unclear. As surgical intervention may lead to unnecessary morbidity, a conservative approach with periodic endoscopy with biopsies and EUS may be adequate.
Abstract:
Joseph Manlolo, MD*, William Robinson, MD, Sumona Saha, MD, Baishali Bhattacharya, MD, Fadlallah Habr, MD. Pathology, Medicine, Brown University / Rhode Island Hospital, Providence, RI.
Purpose:Purpose: Vanishing Bile Duct Syndrome (VBDS) is an acquired disorder of cholestasis characterized by the destruction and ultimate disappearance of the intrahepatic bile ducts. The presentation of VBDS is highly variable due to its numerous underlying causes. Outcomes range from favorable with gradual regeneration and recovery to devastating with progressive and irreversible bile duct loss. We describe a case of an elderly male with jaundice following moxifloxacin exposure found to have VBDS on liver biopsy. Despite drug discontinuation cholestatic hepatitis persists. Case: An 82 year-old male with no significant past medical history was admitted to the hospital with empyema that was treated with intravenous antibiotics and drainage. On hospital day 21, he was discharged on a continuing course of oral moxifloxacin 400 mg daily. Eight days later he presented with jaundice and mild pruritis. He denied fevers, nausea, vomiting, abdominal pain, or change in stools. The exam was notable for marked jaundice and a palpable liver edge 3 cm below the costal margin. Laboratories revealed an alkaline phosphatase of 821 IU/L, ALT of 441 IU/L, total bilirubin of 15.3 mg/dl, and direct bilirubin of 9.2 mg/dl. Viral hepatitis and autoimmune serologies, iron studies, abdominal CT scan, right upper quadrant ultrasound with dopplers, MRCP, and ERCP produced inconclusive results. A liver biopsy was performed revealing cholestatic hepatitis with bile stasis and marked ductopenia. He was started on ursodiol (15 mg/kg) and cholestyramine (4 mg). At 3 months follow-up, the patient reported improved pruritis however liver chemistries remained markedly elevated with an alkaline phosphatase of 226 IU/L, ALT of 128 IU/L, total bilirubin of 25.8 mg/dl, and direct bilirubin of 14.5 mg/dl. Discussion: Cholestasis due to drug toxicity accounts for 2-5% of admissions for jaundice and up to 20% of cases of jaundice in the geriatric population. Moxifloxacin is a known hepatotoxin producing symptoms 3-10 days after drug ingestion and has been reported to cause fulminant hepatic failure and death. VBDS in association with flouroquinolone use is exceedingly rare with only one case reported in the literature. Most cases of VBDS resolve within 6 months, however VBDS can persist and lead to secondary biliary cirrhosis, liver failure, and death. The proposed mechanism of bile duct loss is T-cell toxicity and a dysregulation of apoptosis. Treatment requires recognition and prompt discontinuation of the inciting agent, although this does not uniformly lead to improvement. Corticosteroids, rifampicin, and opiate antagonists have been used for symptom management, however evidence regarding their efficacy is limited.
Abstract:
Jenny Sauk, MD, BA*, Sita Chokhavatia, MD, FACG. Division of Gastroenterology, Mount Sinai Hospital, New York, NY.
Purpose: A 78 year old active male with a history of gastroesophageal reflux and coronary artery disease presented with right lower extremity (RLE) swelling and rectal bleeding, described as four "raspberry red, " loose bowel movements per day for two weeks. He experienced no abdominal pain, nausea, vomiting or fever. Venous doppler study confirmed the presence of a right lower extremity deep vein thrombosis (DVT). Due to rectal bleeding, anticoagulation could not be initiated and an IVC filter was placed. He had lost thirty pounds within the last six months. He had not used NSAIDs, anticoagulants or fleets enemas. He had previously refused colonoscopic evaluation. He reported no recent travels or antibiotic use, no sick contacts or family history of inflammatory bowel disease and no addictions. Significant exam findings included a soft, nontender abdomen with no rebound or guarding, no masses or hepatosplenomegaly and no hemorrhoids or fissures. His rectal exam yielded bright red blood. He also had 2+ edema in the RLE. C. difficile toxin and thrombophilia workup were negative. Thickening of the bowel wall from the distal descending to the proximal sigmoid colon with diverticular disease mainly in the left colon was seen on abdominal CT scan. Colonoscopy revealed edematous and erythematous mucosa from the anal verge to the proximal sigmoid colon. Diverticula were noted throughout the colon. Biopsies from the left colon and the cecum revealed chronic active colitis suggestive of inflammatory bowel disease. The differential diagnosis included new-onset inflammatory bowel disease (IBD), ischemic colitis and segmental colitis associated with diverticulosis (SCAD). Intravenous fluids were continued and ciprofloxacin was discontinued two days after stool studies ruled out infectious colitis. As colonoscopy showed inflammation in the rectum, ischemic colitis was ruled out. Since active colitis was noted throughout the right and left colon and he presented with a DVT, diagnosis of new-onset IBD was considered. A 5-ASA was started and the patient experienced resolution of diarrhea and rectal bleeding a week later. The incidence of ulcerative colitis and Crohn's disease in the elderly (age >60) is 8 of 100,000 and 4 of 100,000 patients per year, respectively. Elderly patients are more likely to present with weight loss, bleeding and fever rather than abdominal pain and diarrhea. As 80% of elderly patients will ultimately respond to medical therapy, it is important to treat these patients expediently. Furthermore, disease activity is highly associated with increased thromboembolic risk. Specific thrombophilias have not been officially linked to this increased risk of thromboembolism in IBD patients.
Abstract:
Sadiya Sarij, MD*, Khondker Islam, MD. Gastroententerology, Hepatology and Nutrition, Loyola University Medical Center, Maywood, IL.
Purpose: Managing older patients with Inflammatory Bowel Disease (IBD) can be clinically challenging due to co-morbid illnesses, atypical presentation and varying response to therapy. Most therapies for IBD have not been studied specifically in the elderly. Current guidelines and principles of medical treatment are the same irrespective of age. With improved diagnostic modalities and increased treatment options, there is an aging population of IBD patients. Older patients currently represent at least 15% of newly diagnosed IBD. The clinician must apply caution when treating IBD in older patients, especially when monitoring for drug toxicity. We present a case of a 69-year-old female with Crohn's Colitis who developed elevated liver enzymes due to Azathioprine (AZA) therapy. This occurred despite thiopurine s-methyltransferase (TPMT) testing and appropriate dosing. This 69 year old female had a complicated course of Crohn's colitis. She initially underwent a left transverse loop colostomy for a bowel obstruction. She later developed strictures, requiring resection of the distal colon and proximal rectum. Maintained on Mesalamine, the patient presented five years later with hematochezia and abdominal pain, requiring a course of steroids. The patient had previously been tried on AZA, but it was stopped because of mild alopecia. She underwent TPMT enzyme testing, which revealed 35.2 Enzyme Units (normal activity). Her baseline liver enzyme and function tests were normal. One week after starting AZA, liver enzymes increased to more than three times the upper limit of normal. No other etiology of hepatoxicity was found. Lab values returned to normal after the AZA was discontinued. The Immunomodulators AZA and 6-mercaptopurine (6-MP) are widely used drugs in IBD. Current guidelines highlight the utility of dosing based upon TPMT activity and metabolite levels. Patients' enzyme activity determines dosing. Older patients with IBD are often treated in a similar fashion as younger patients. However, many factors make them more likely to experience adverse effects of medications. Increased hepatotoxicity in older patients is likely attributable to altered pharmacokinetics and pharmacodynamics. Our case report highlights the need for increased caution when treating IBD, with closer follow up and more frequent evaluations of liver enzymes. To conclude, there is a need for randomized studies to determine the optimal dosing method in older patients.
Abstract:
Stacie Vela, MD*, Joseph Romagnuolo, MD, FRCPC, MScEpi. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC.
Purpose: Background: Polyspenia is a rare congenital malformation rarely diagnosed in adults. Patients with this syndrome usually do not survive over the age of 5 due to associated cardiac anomalies. Adult polysplenia patients lack the cardiac defects and are usually diagnosed incidentally. Several intra-abdominal anomalies have been described in association with polysplenia, including malformation of the pancreas. We present a case of polysplenia, agenesis of the dorsal pancreas, enlarged liver, and duodenal narrowing referred to our center for endoscopic ultrasound (EUS) of a suspected pancreatic head mass. Case: 47-year-old woman with nausea, vomiting, epigastric pain, and 35 lb. weight loss over 1 year. Her past medical history included diabetes mellitus, hypertension and lung cancer that was cured with left pneumonectomy. She is no longer smoking, but is currently abusing alcohol. Physical examination was notable for absent breath sounds on the left, but was otherwise normal. Complete blood count and basic metabolic panel were normal. AST and ALT were elevated (112 IU/L and 60 IU/L respectively). Bilirubin and alkaline phosphatase were normal. Transabdominal ultrasound and CT scan of the abdomen done at an outside hospital to evaluate her symptoms were read as showing a head of pancreas mass with atrophic vs. absent body and tail of the pancreas. Furthermore, there was perisplenic lymphadenopathy vs. splenule. These results prompted referral to our center for EUS of the pancreatic head mass. On further review of the CT scan 3 splenules were present in the left upper quadrant, and the dorsal pancreas was absent. The liver was enlarged with an atrophic left lobe. EGD was first performed and at the junction of the duodenal bulb to D2 there was a sharp, unusual angulation/distortion. The endoscope was maneuvered upward and to the right to get into D2. There was a muscular web making the area difficult to traverse. EUS was performed and confirmed the absence of the body and tail of the pancreas beyond the portal confluence. There were 3 spenules noted in the usual location of the spleen. In the head and neck of the pancreas the parenchyma was lobular, with hyperechoic foci and strands. The MPD emerged from the papilla along with the CBD, and was of normal appearance and caliber. The portal confluence appeared dilated with an anomalous venous branch. Conclusion: Agenesis of the dorsal pancreas is a rare association with polysplenia. Our case demonstrates polysplenia and agenesis of the dorsal pancreas in addition to the malrotation of the duodenum and enlarged liver that can also occur in these patients.
Abstract:
Nissrin Ezmerli, MD*, Naveen Gupta, MD, Aline Charabaty, MD, Halim Charbel, MD. Division of Gastroenterology, Georgetown University Hospital, Washington, DC.
Purpose: Anal cancer (AC) is an uncommon cancer, comprising 1.6% of all GI tract cancers in the U.S. Risk factors include female gender, HPV infection, HIV infection and cigarette smoking. In general, the disease is often locoregional with metastasis being uncommon. The liver and the lung are the most common sites for distal metastasis. Prior experience of locoregional disease reveals that direct extension into the surrounding soft tissue and the rectum can occur. Metastatic lesions to the rectum have not been well described. Here we report two cases of AC metastatic to the rectum. The first case involves a 46 year old female who presented for colonoscopy with symptoms of blood per rectum and the development of a peri-anal mass. Ensuing colonoscopy demonstrated two distinct lesions, one at 5 cm from the anal verge and the other extending from the anal verge. Biopsies revealed rectal mucosa with squamous cell carcinoma (SCC) in situ. Follow up endoscopic ultrasound (EUS) revealed the proximal lesion arising from the muscularis propria. The EUS revealed this lesion to be much larger than seen endoscopically and distinct from the anal canal lesion. The distal lesion appeared to arise from the deep mucosa and was above the dentate line (nonkeratinized SCC). The second case is a 55 year female with development of constipation associated with blood per rectum. On exam an anal mass was palpated. Colonoscopy revealed an anal mass with biopsies consistent with SCC. Staging PET/CT revealed a hypermetabolic focus in the area of the anal mass as well as a second, distinct area of increased uptake in a soft tissue mass adjacent to the superior portion of the rectum. EUS imaging revealed the anal mass involving the puborectalis musculature. At 10 cm from the anal verge, a hypoechoic lesion that disrupted the rectal wall involving the muscularis propria was seen. This lesion was distinct from the anal mass and was not readily appreciated endoscopically. Fine needle aspiration was positive for metastatic AC. Both patients are currently undergoing combined modality chemotherapy/XRT. We present two cases of AC metastatic to the rectum. In our review of the literature, while direct extension has been noted, metastatic lesions in the rectum have not been well reported. This may in fact represent lesions having been attributed to direct extension when in fact they were metastatic lesions. Furthermore, these cases illustrate the utility of EUS to fully delineate the involvement of the primary anal lesion, lymph node involvement and to differentiate extension of anal cancer to the rectum versus metastatic lesions. This has important implications in regards to prognosis.
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Abstract:
Sohail Shaikh, MD*, Chintan Modi, MD, Hamid Shaaban, MD, Robert Spira, MD. Gastroenterology, Seton Hall University, South Orange, NJ.
Purpose: Introduction: Crohn's disease is a transmural chronic granulomatous inflammatory bowel disease typically classified as stricturing, penetrating, or inflammatory. Associated extra-intestinal manifestations (EIM) occur in 21-25% of patients, most commonly arthropathy, dermatological and ocular involvement. EIM may predate quiescent Crohn's disease in 10% of patients and co-diagnosed in 14% of patients. This case illustrates a rare presentation of EIM heralding Crohn's colitis. Case Report: A 38 year old male with intermittent uveitis and back pain presented with bilateral knee pain for 2 months; greater in the right knee with associated fever and swelling. Physical exam revealed a large right knee effusion with no evidence of trauma or cellulitis. He denied any bowel complaints or family history of colitis. Initial labs: Hemoglobin 11.3, MCV 90, WBC 10.7 (N-75%), ESR 137, CRP 16.2, HLA-B27 (+), PPD (-) Knee aspirate (100 cc): Glucose 61, WBC 42,111, RBC 3,333, Crystals and Gram Stain (-) Additional negative studies: ANA, p and c-ANCA, CCP, HIV, Lyme, and Urine Lumbar x-ray: sacroileitis NSAIDS, antibiotics and prednisone were given for presumed septic joint vs. seronegative spodyloarthropathy. Four days later the patient experienced hematochezia with no nausea, vomiting or pain. Physical exam: stable vital signs with scant blood in stool Hemoglobin remained unchanged and stool was negative for C. difficile toxin and culture; Wright stain was (+). CT: Proximal sigmoid and rectal and thickening Colonoscopy: 1+ descending colitis with no pseudomembranes; biopsies: acute and chronic transmural colitis, focal cryptitis, crypt abscesses, and prominent lymphoid aggregates Crohn's was diagnosed, azulfadine was started and steroids continued. Enteric symptoms and peripheral arthropathy improved, however axial arthropathy remained. For steroid sparing effect 6-MP was initiated. Conclusion: Inflammatory bowel disease (IBD) should be considered in patients with enteric symptoms and other organ involvement for a unifying diagnosis. Although Crohn's disease usually presents with enteric symptoms, 10% of patients may herald their disease with EIM, most commonly involving the eye, skin and joints. Initial presentation may resemble an autoimmune or seronegative arthropathy as in this case. Although Crohn's disease activity correlates with peripheral arthropathy and may improve with treatment, HLA B-27 associated sacroileitis and uveitis do not. Salicylates and immunomodulators are at the core of IBD therapy. In this case azulfadine was chosen for its rheumatologic and enteric effects. This case illustrates a rare occurrence of extra-intestinal manifestations predating the diagnosis of Crohn's disease.
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Conclusion: N/A
Abstract:
Matthew Wyneski, MD*, Orhan Atay, MD, Marsha Kay, MD, Vera Hupertz, MD. Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: Upper gastrointestinal hemorrhage in pediatrics can be associated with significant morbidity. Endoscopic hemoclipping, a well established technique in adults, can be technically difficult in pediatric patients. Limitations of this technique in pediatrics has not yet been established. We report a young patient who underwent successful hemoclipping of bleeding gastric lesions. The patient was a 14 month old white male with a neonatal history of truncus arteriosus and hemophagocytic lymphohistiocytosis, diagnosed at age 6 months. Umbilical cord blood transplant was done at age 11 months. EGD and colonoscopy with biopsies were done for evaluation of emesis, diarrhea and increased liver enzymes to rule out infection, graft vs. host disease (GVHD), or other causes of enteritis. The EGD demonstrated Grade I GVHD in the duodenum and stomach; colonoscopy was negative. Two days later, the patient developed melena and anemia. The patient was hospitalized and received multiple transfusions of packed red blood cells and platelets. Despite medical treatment, he had persistent melena and refractory anemia and underwent a repeat EGD. Endoscopy found multiple hematomas at the previous biopsy sites with persistent bleeding noted in two areas. Due to persistent bleeding, two endoclips were placed - one in the gastric antrum, and another in the gastric fundus at the site of the bleeding lesions. Post procedure, the patient did well with resolution of anemia and melena. He returned to outpatient clinic 15 weeks later, however, with issues of recurrent hematemesis. Repeat EGD demonstrated resolution of previous hematomas; the two previously deployed clips were present at their deployment sites. The mucosa adjacent to the fundic clip was actively oozing blood; this area was injected with epinephrine solution 1:10,000 with resolution of the bleeding. The patient has remained stable from a GI standpoint; the endoclips continue to be present on abdominal radiographs obtained for other indications 31 weeks after initial application. Initial reports have suggested that endoscopic clips typically dislodge between 1 to 3 weeks after deployment. In previous studies in animal subjects, they have been retained for periods up to and greater than 25 weeks. In our patient the clips have been retained for more than 31 weeks without apparent adverse sequelae. To date no studies have been done in the pediatric population on the durability of, or long term issues associated with retained endoscopic clips. Our case suggests that prolonged retention of endoscopically placed clips may occur in pediatric patients. In our patient, the prolonged retention appears to be benign but further long-term outcomes need to be determined.
Methods: NA
Results: NA
Conclusion: NA
Abstract:
John Carroll, MD*, Elisabeth Kramer, BS, Homayoon Mahjoob, MD. Medicine, Georgetown University Medical Center, Washington, DC.
Purpose: Introduction: Endoscopic mucosal resection (EMR) has become the standard of care for the endoscopic management of early neoplastic lesions of the GE-Junction. Lesions that are effectively removed with clear resection margins are uniformly felt to be endoscopic cures and are followed with surveillance endoscopies. The exact surveillance guidelines for following post-resection lesions are not well established. Case Report: A 52 y/o man with dyspepsia was found to have a GE-Junction nodule with high grade dsyplasia. EUS demonstrated that it was confined to the mucosa (T1 N0). EMR was done and the resected specimen showed carcinoma in situ with clear margins. Follow up endoscopies and biopsies were done at 2 and 5 months, and were normal without residual dysplasia. At that point, the patient was followed annually with surveillance EUS. At the 5 year surveillance EUS, the GE-Junction again appeared normal endoscopically with normal biopsies. EUS, however, revealed new local adenopathy, with a 1.3 cm perigastric LN, found to be adenocarcinoma by FNA. An oncologic evaluation showed no evidence of metastatic disease, or of a second primary. The patient underwent adjuvant chemotherapy, followed by an esophagectomy, with the pathology showing 8 of 23 LN's positive for disease, as well as a focus of adenocarcinoma in the peri-esophageal fat. Conclusion: The exact guidelines for following early GE-Junction neoplastic lesions which have been resected endoscopically are not well established. This case demonstrates that resected superficial T1 lesions can present with delayed local nodal spread in the absence of mucosal recurrence. This case suggests that resected neoplastic GE-Junction lesions should be followed for at least five years after endoscopic resection, and that EUS should be part of the surveillance to detect extraluminal recurrence.
Abstract:
Uzma Abbasi, MD*, Rishi Pawa, MD, Vishal Gupta, MD, PhD, Jay Cowan, MD. Gastroenterology, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, NY.
Purpose: Kaposi's sarcoma is an uncommon neoplasm that occasionally involves the gastrointestinal tract in immunosuppressed individuals. Although skin lesions are the usual presentations, visceral lesions are common in organ transplant recipients and involve the gastrointestinal tract. The gastrointestinal tract is involved in approximately 40 percent of patients with KS at initial diagnosis and in up to 80 percent at autopsy.
Methods: Chart review and review of the available literature using Medline and bibliographies of published articles.
Results: A 30-year-old man with medical history of HIV, not on HAART, presented with nodular, velvety skin lesions on face, arms and legs. Biopsy of the skin lesion was suggestive of AIDS-related Kaposi's sarcoma. A CT scan of the chest, abdomen and pelvis showed thickening of the stomach wall and the colon at the hepatic flexure. EGD performed subsequently revealed hemorrhagic confluent nodules in the body of the stomach, biopsies of which showed spindle cells with positive staining for human herpes virus 8, suggestive of gastric Kaposi's sarcoma. Colonoscopy was unremarkable. Patient was subsequently started on HAART therapy along with intralesional injection of skin lesions with vinblastine.
Conclusion: The gastrointestinal lesions in Kaposi's sarcoma may be asymptomatic as in our patient or cause one or more of the following symptoms: weight loss, abdominal pain, nausea/vomiting, upper or lower GI bleeding or diarrhea. Systemic cytotoxic chemotherapy should be administered in the presence of widespread skin involvement and symptomatic visceral involvement.
Abstract:
Tony Tseng, MD*, Igor Grosman, MD, David Bernstein, MD. North Shore University Hospital, Manhasset, NY.
Purpose: A 57-year-old man was seen after being sent by his physician for a syncopal episode in the shower. The patient had gone to visit his physician complaining of one month duration of sore throat, dysphagia, and decreased intake by mouth. The patient's past medical history consisted of hepatitis C with liver cirrhosis, hemachromatosis, and type II diabetes mellitus. He was on week 12 therapy of Peginterferon 2a/Ribavarin. On physical examination, he was well appearing and his HEENT exam revealed pharyngeal mucosal erythema with patent airway and no cervical lymphadenopathy or tenderness. Soon after admission, patient complained of worsening sore throat and dysphagia with muffled voice and noticed pain on the right side of his neck. CT of the neck revealed swelling of the epiglottis and aryepiglottic folds with retropharyngeal and retrolaryngeal swelling. Intravenous antibiotics and steroid treatment was initiated and ENT evaluation was called. Due to extensive epiglottic swelling, the patient underwent a tracheostomy and surgical swab of the epiglottis was taken which was positive for MRSA. Vancomycin was then added to the antibiotic regimen. Patient clinically improved and eventually discharged on antibiotics and steroid taper. Subsequently, the tracheostomy was removed. The advent of novel therapy using pegylated interferons along with ribavirin for hepatitis C has been associated with higher sustained viral response rates. However, these medications have side effects, with flu-like symptoms as the most common one. More serious complications are anemia, leucopenia, and thrombocytopenia all of which can be life threatening. The above patient had been on combination pegasys and ribavirin for 12 weeks. Our patient had leucopenia earlier in the course of therapy. But at the time of admission, he had normal WBC count which represented an alarming sign that was not recognized at time of admission. Therefore, evaluating physicians need to be aware that interferon therapy is immune modulating and severe infections must be considered. The common pathogens for epiglottitis are H. influenza, S. pneumonia, and S. pyogenes. Although MRSA induced epiglottitis is rare, community-acquired MRSA infections in general are emerging. Acute epiglottitis is now increasingly more recognized in adults. Still, only a few cases of MRSA induced adult epiglottitis have ever been reported in literature. We describe a case in which a patient was predisposed to such possible clinical scenario. Studies have shown that the rate of infection is not significantly increased in hepatitis C treated patients. However, caution and consideration must be taken with patients that are on interferon and ribavirin regimen.
Abstract:
Anand Gupta, MD*, Shruti Agnihotri, MBBS, Justin Lundbye, MD. Internal Medicine, University of Connecticut, farmington, CT, Cardiology, Hartford Hospital, Hartford, CT.
Purpose: Extrinsic left atrial compression is an uncommon source of hemodynamic compromise that can be caused by many mediastinal structures. To date, however, few cases of hemodynamically significant left atrial compression secondary to gastric compression have been reported. An 85-year-old woman with past medical history of GI bleed presented with hematemesis and malena, shortness of breath and palpitations. Physical examination was positive for rapid, irregularly irregular pulse, variable intensity heart sounds, bilateral basal crepitations and moderate epigastric tenderness. ECG revealed atrial fibrillation with rapid ventricular rate. Shortly after her arrival to the emergency department, the patient's respiratory distress worsened and she had to be intubated. Patient was admitted to the Cardiac Intensive Care Unit. Chest X-ray revealed bilateral pulmonary edema, bilateral pleural effusions and significant air fluid level. Echocardiography revealed severe extrinsic compression of the left atrium with maximum left atrial diameter of 1.28 cm. There were Doppler markers of tamponade physiology including respiratory variation in mitral inflow velocity (89 cm/sec and 123 cm/sec). In addition, the trans- mitral valve gradient was 4.63 mmHg suggestive of moderate mitral stenosis due to external compressing mass. There was mild MR with some chordal SAM without significant LVOT obstruction. CT chest confirmed the presence of a large hiatal hernia compressing the left atrium. Following this patient had a single contrast upper GI series, which revealed organoaxial gastric volvulus with evidence of obstruction. Initially patient was medically managed with diuretics and gastric decompression. Definitive surgical treatment was undertaken thereafter. This case illustrates an uncommon presentation and interesting mechanism of 'mitral stenosis' physiology (with structurally normal valves) produced by a large hiatal hernia due to compressive effects on the heart.
Abstract:
Prateek Wali, MD*, Janaki Gokhale, MD, Seema Khan, MD. Pediatric Gastroenterology & Nutrition, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE.
Purpose: To describe a presentation of neonatal cholestasis with marked elevation in alpha fetoprotein without severe liver dysfunction. Result: A 25 day old full term AA female presented with jaundice. Prenatal and birth history were unremarkable. She had a normal physical exam except jaundice. Initial lab data: AST 630 u/L, ALT 549 u/L, Alk phos 841 U/L, GGT 65 u/L, TB/DB 10.7/8.5 mg/dL, PT 12.8 secs and a high ferritin of 5564 ng/mL. AFP was also markedly elevated at 41463 ng/mL. Ultrasound of the abdomen was normal. HIDA scan showed hepatic dysfunction but good excretion in 4 hr. Iron studies showed a low transferrin level at 97 mg/dL, low TIBC at 146 mcg/dL and iron of 132 mcg/dL. MRI of the abdomen showed iron deposition in the liver but no deposition in the pancreas or spleen. A minor salivary gland biopsy was normal. Other pertinent tests: MM alpha 1-antitrypsin phenotype, negative TORCH titers, lactate, ammonia, pyruvate, urine succinylacetone; urine amino acids showed a generalized aminoaciduria. Urine and serum bile acid studies were consistent with cholestasis. At 34 days of age, AFP rose to 69475 ng/mL, with improving DB of 7.5 mg/L, and stable PT of 13.8 secs. She was feeding well with Pregestimil, had appropriate weight gain and was discharged on ursodiol, tocopherol, and ADEK. At 54 days of age, she had a peak level of AFP at 137229 ng/mL, ferritin of 1359 ng/mL, improving transaminases and cholestasis with a normal PT. A percutaneous liver biopsy done at 69 days of age demonstrated hepatocellular and canalicular cholestasis with giant cell transformation, no bile duct proliferation. Iron deposits were seen mainly in the macrophages, more consistent with hemosiderosis than NH. At follow up, at 10 mo of age she had appropriate growth and development with AFP of 62.1 ng/mL, ferritin of 28.5 ng/mL, and resolved cholestasis. Conclusion: Neonatal hemochromatosis is a rare disease associated with liver failure, often an indication for transplantation. Elevations in AFP and ferritin are marked with low aminotransferase concentrations. The diagnosis is made by findings of extrahepatic siderosis. This case presented with multiple features of NH in the absence of liver failure and extrahepatic siderosis. Cases of NH-like liver failure with favorable outcomes have been reported. This may represent a case of idiopathic neonatal hepatitis with a robust regenerative process accounting for marked elevation in AFP. This case adds to an understanding of NH-like presentations and high AFP with a benign clinical course.
Abstract:
Sohail Shaikh, MD*, Kavitha Tipirneni, DO, Joseph DePasquale, MD. Gastroenterology, Seton Hall University, South Orange, NJ.
Purpose: Introduction: Esophageal stents are used for benign and malignant conditions. Type of pathology, length of lesion, distance from the upper esophageal sphincter (UES) and lower esophageal sphincter (LES) are critical in stent selection. Patients with prior esophageal surgery present additional factors to consider, such as lack of an LES. 10-40% of stent complications require re-intervention with stent migration occurring 3-6% of the time. Esophageal stent deployment utilizes direct endoscopic visualization with fluoroscopic guidance. This case illustrates a novel approach to non-fluoroscopic stent replacement. Case Report: A 67 year old white female with esophageal adenocarcinoma, status post distal esophagectomy with gastric pull-up, radiotherapy and chemotherapy 5 years prior, presented with shortness of breath, and dry cough exacerbated by oral intake. CT Scan: Esophago-bronchial fistula with left lower lobe pneumonia EGD: Erosions spanning 21-25 cm from the incisors, with two fistulous openings immediately proximal to the gastric pull up A covered esophageal stent was placed (18 mm x 12 cm). One month later she experienced a recurrence of symptoms with distal stent migration into the stomach. Endoscopic manipulation showed the stent diameter to be more narrow than the esophagus, therefore it was removed. Using a marker-clip (from the initial stent) for precise placement, a wider stent (23 mm x 12 cm) was replaced under direct endoscopic visualization without fluoroscopic assistance. The patient's symptoms resolved and was discharged on antibiotics. Discussion: Multiple anatomical complexities in this case favored direct visual deployment. Post-surgical changes included a shortened, widened esophagus, no LES and fistulous openings immediately adjacent to a gastric pull-up. Lack of a distal anchoring point (LES) and proximity of the UES to the fistulas were critical considerations mandating a proximal-release. Although distal deployment is more common, proximal release with direct visualization (utilizing the previously placed marker-clip) allowed precise positioning of the bulbous deployment-end 2 cm below the UES (essential to avoid complications) generously covering the distal fistulas. For additional security, to mitigate possible migration, clips were used on the bulbous end anchoring the stent. Conclusion: Many factors must be taken into consideration for esophageal stent selection and placement. Additional measures may be needed to mitigate migration. This case, with a unique constellation of difficulties, illustrates an alternative method for stent placement with direct visualization to ensure precise positioning.
Abstract:
Harris Naina, MD*, Samar Harris, MD. Internal Medicine, Internal Medicine, Division of Oncology, Mayo Clinic, Rochester, MN.
Purpose: Gastrointestinal metastasis from the lung cancer is rare and when encountered the common site of metastasis is usually to the small bowel. The diagnosis of metastasis made either on imaging or during symptomatic presentation such as bleeding or intestinal obstruction. We report a case of asymptomatic metastatic lung cancer detected as a sessile polyp on a routine colon cancer screening. A 65 year old male was followed up by his primary care physician for hypertension and hyperlipidemia. His past history was notable for recurrent diverticulitis in the past requiring sigmoid resection and a rectal polyp (tubular adenoma, low grade dysplasia) discovered 8 years ago. He was on medications for his hypertension and hyperlipidemia. He had no prior history of smoking, or family history of cancer. He was asymptomatic during the clinical visit. He underwent colon age appropriate cancer screening and a 1 cm sessile poly was found in the distal transverse colon. The biopsy results of his sessile poly showed moderately differentiated adenocarcinoma. Immunohistochemical stains were performed using antibodies directed against synaptophysin, PSA, cytokeratin 20, chromogranin, cytokeratin 7, S100, and TTF-1. The neoplastic cells showed strong cytoplasmic positive staining for cytokeratin 7 and strong nuclear staining for TTF-1. The positive TTF-1 staining virtually excluded a colorectal primary malignancy. The combination of immunostains plus histology was consistent with a metastatic non-small cell carcinoma from a pulmonary primary. The patient had no history of pulmonary symptoms such as cough, chest pain or dyspnea. He underwent a CT scan of the chest which showed multiple pulmonary nodules, largest measuring 5.5 x 3.3 cm with mediastinal lymph adenopathy. A flexible bronchoscopy was performed and biopsy from the lung confirmed the diagnosis of grade 3/4 adenocarcinoma of the lung. Later he was evaluated in oncology where a review of systems revealed occasional headache without any other neurological symptoms. His clinical examination was again unremarkable however a CT scan of the head showed multiple cystic lesions with vasogenic edema. Treatment was started with Carboplatin and Paclitaxel, but disease progression occurred on combination chemotherapy. Gastrointestinal metastasis from the lung cancer is rare, and to the best of our knowledge this is the first case report of stage IV metastatic lung presenting as sessile polyp in an asymptomatic patient.
Abstract:
Ronald Concha, MD*, Ayse Aytaman, MD, Mujtaba Butt, MD, Rosemary Wieczorek, MD, Fidelina Desoto-Lapaix, MD, Gerald Fruchter, MD. Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY, Pathology, Gastroenterology, VA New York Harbor Health Care System, Brooklyn, NY.
Purpose: The purpose of this report is to raise an awareness of spirochetosis as a possible but rare cause of diarrhea and/or hematochezia in humans Case 1: A 60 year old white male was evaluated for the complaints of watery intermittent chronic diarrhea of more than 2 years duration. Stool studies including ova and parasites, fecal leukocytes and stool cultures have been negative. Colonoscopy was performed and showed normal appearing mucosa. Random biopsies were obtained and were notable for a continuous layer of spirochetes covering the luminal surface of the epithelium. He received oral metronidazole 500 mg three times per day for 10 days with a complete resolution of his symptoms. Case 2: A 48 year old white male was evaluated for a low grade hematochezia, abdominal bloating and excessive flatulence. Colonoscopy revealed patchy erythema in the transverse and sigmoid colon. Representative biopsies were obtained and showed focal hemorrhage and a layer of spirochetes covering the colonic epithelium. In view of spontaneous resolution of symptoms no therapy was given. Patient remains asymptomatic after 4 months follow-up. Discussion: Intestinal spirochetosis is defined as the colonization of the luminal surface of the colonic epithelial cells with the weakly beta-hemolytic spirochetes: Brachyspira aalborgi and Brachyspira pilosicoli. Spirochetes are well known pathogens in dogs, pigs and birds. Infected humans can present with a variety of symptoms including diarrhea and rectal bleeding. However, some investigators report a lack of association between symptoms and the presence of spirochetes. It is therefore unclear whether the spirochetes colonizing the colon are true pathogens. Diagnosis requires a biopsy specimen from the colon. Based on a very few small case series, the disappearance of the infection (whether spontaneous or following treatment) paralleled a clinical sustained recovery. It is important not to minimize the significance of this infection, since invasive spirochetosis has been reported. Intestinal Spirochetosis should be considered in the differential diagnosis of chronic diarrhea and/or rectal bleeding. Further studies and case series reports are warranted.
Abstract:
Robert Wells, MD*, Luis Pena, MD, Karl Schulstad, MD. Division of Gastroenterology, University of Kentucky, Lexington, KY, General Surgery, Harrison Memorial Hospital, Cynthiana, KY.
Purpose: Gastric glomus tumors are rare neoplasms originating from modified smooth muscle cells of glomus bodies. Glomus bodies are temperature sensitive neuromyoarterial receptors that help regulate arterial blood flow. We describe a rare occurrence of a patient with a gastric glomus tumor. Case: A 62 year old white man presented with a one month history of lower abdominal pain radiating to the back, exacerbated by bending or stooping. He complained of decreased appetite, nausea and vomiting, but denied weight loss, fever or chills. On physical exam he was afebrile and vital signs were normal. He was in obvious discomfort. Bowel sounds were normoactive. His abdomen was soft, tender over the RUQ. There was no obvious organomegaly or discrete mass. Labs revealed a WBC count 8.3 k/uL, Hgb 12.9 g/dL and platelets 361 k/uL. Amylase, lipase and complete metabolic panel were unremarkable except for albumin 2.8 g/dL and globulin 4.1 g/dL. CT abdomen without contrast showed a 2.8 cm mucosal mass near the anterior gastric body. Esophagogastroduodenoscopy (EGD) revealed a 3 cm submucosal mass with two small centrally located ulcers in the distal gastric body. Biopsies revealed atypical lymphoid infiltrate suspicious for a lymphoproliferative disorder. Repeat EGD with biopsies was unremarkable for flow cytometry; histology revealed gastric glomus tumor and chronic active H. pylori gastritis. Endoscopic ultrasound revealed an oval intramural (subepithelial) heterogeneous lesion originating from the muscularis propria (Layer 4) with well defined outer borders and an intact interface between the mass and adjacent structures, suggesting lack of invasion. Transgastric fine needle aspiration revealed a lesion infiltrated by round, uniform cells with moderate amounts of cytoplasm amid numerous large vessels. Immunostains were positive for muscle specific actin and vimentin and negative for leukocyte common antigen and chromagranin. Cytopathology and flow cytometry were unremarkable. A diagnosis of gastric glomus tumor and chronic active H. pylori gastritis was made. Laparoscopic excision of the 2.5 x 2.3 x 1.9 cm tumor was performed with free margins, three (0/3) negative perigastric lymph nodes and no evidence of vascular invasion. Pathology interpreted as glomus tumor of the stomach. Discussion: Although they may be located anywhere in the body, glomus tumors are most commonly found in the distal peripheral soft tissues of the fingers and toes. Gastric glomus tumors are rare, and generally considered benign solitary neoplasms. However, cases of multiple glomus tumors of the stomach and gastric glomus tumor with liver metastasis have been described and therefore, surgical resection is generally recommended.
Methods: N/A
Results: N/A
Conclusion: N/A
Abstract:
Maria Lufrano, DO*, Thomas Bradley, MD, John Costable, MD, Ian Storch, DO. Medicine, North Shore University Hospital, Manhasset, NY.
Purpose: Introduction: Pseudomyxoma peritonei is a rare clinical entity typically diagnosed on clinical presentation with increased abdominal girth, abdominal mass, or abdominal pain mimicking acute appendicitis. We present a morbidly obese male with vague gastrointestinal complaints and right upper quadrant fullness who was found to have carcinomatosis on computed tomography. Multiple fine needle aspirations failed to yield a diagnosis. Laparotomy was performed and revealed pseudomyxoma peritonei. Case: A 55 year old, morbidly obese Caucasian man presented with a six month history of intermittent diarrhea, occasional nausea and vomiting, and dyspeptic symptoms. He reported a family history of pancreatic malignancy. On physical examination, the patient was a large male (BMI 43) with right upper quadrant fullness, however no distinct mass was appreciated. Computed tomography of the abdomen and pelvis revealed ascites and marked infiltration of the omentum, suggestive of carcinomatosis. Upper endoscopy and colonoscopy were normal. Tumor markers including CA 19-9, CEA, and alpha-fetoprotein were also within normal limits. Fine needle aspiration of the peritoneum revealed fibroadipose tissue and cytopathology of the ascites was negative for malignant cells. Repeat aspiration yielded similar results. A diagnostic laparoscopy with omental biopsy revealed mucin, with rare clusters of well-differentiated adenocarcinoma, consistent with a diagnosis of pseudomyxoma peritonei. Discussion: Pseudomyxoma peritonei is manifested by diffuse gelatinous implantation of the peritoneal cavity and omentum most commonly from an appendiceal mucinous neoplasm. The diagnosis is often challenging in part due to its non-specific symptoms at presentation. Classic radiographic findings include scalloping of organs, ascitic septations and curvilinear calcifications. Our patient had vague gastrointestinal complaints and radiographic findings consistent with carcinomatosis. "Pseudocarcinomatosis" has been described in association with peritoneal fascioliasis, coccidioidomycosis and intraperitoneal endometriosis. Our case illustrates the importance of considering pseudomyxoma peritonei in the differential diagnosis of patients presenting with radiographic findings consistent with carcinomatosis, especially when no primary malignancy can be identified and repeat cytology is negative.
Methods: N/A
Results: N/A
Conclusion: N/A
Abstract:
Aparna Repaka, MD*, Robert Fontana, MD. Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, MI.
Purpose: Peliosis hepatis is characterized by the presence of blood-filled spaces throughout the hepatic parenchyma with clinical manifestations ranging from asymptomatic serum aminotransferase elevations to focal masses and liver failure. Causes of peliosis hepatis include medications (androgens, steroids), TB, malignancy and infection with Bartonella henselae particularly in HIV positive patients. We describe a case of hepatic peliosis due to B. henselae infection in a kidney transplant recipient who presented with acute cholestatic hepatitis, thrombocytopenia and myocardial infarction.
Methods: Case Report
Results: A 51 year old Caucasian male was hospitalized 36 days after living donor kidney transplantation with fatigue, myalgias, left axillary adenopathy and jaundice. Medications included cyclosporine, prednisone and cellcept. At presentation, he had acute renal failure (Cr 3.1 mg/dl), hgb 7.9 g/dl, platelet count 33 K, AST 28 IU/L, ALT 39 IU/L, alkaline phosphatase 307 IU/L, total bilirubin 11 mg/dl (predominantly direct) and INR of 1.3. Pre-op LFT's and CBC were normal. He was also found to have a NSTEMI, with new focal hypokinesis on echocardiography. Work up for viral, autoimmune and metabolic liver disease was unrevealing. TTP was entertained but unproven. A transplant kidney biopsy showed ATN. Abdominal ultrasound showed a normal liver and splenomegaly. Subsequently, the patient reported being scratched by a cat a few days prior to his transplant, but had no skin abnormalities at presentation. Bartonella titers showed rising serial B. henselae IgG titers, 1:512 and >1:1024 while IgM titers were < 1:20. A liver biopsy showed hepatic peliosis, intense sinusoidal dilation, atrophy of hepatic cords and superimposed canalicular cholestasis. Warthin-Starry stain showed abundant debris but no organisms were identified. However, a DNA-based PCR assay for Bartonella henselae on the liver tissue was positive. Following a 1 month course of Doxycycline and Azithromycin, his liver enzymes and cytopenias improved and completely normalized in 2 months. Immunosuppression was modified to tacrolimus and prednisone.
Conclusion: Bartonella henselae is a gram negative bacteria that causes cat scratch disease. Our case shows that organ transplant recipients may develop hepatic peliosis due to disseminated bartonella infection, as previously reported in patients with HIV. Since the vascular endothelium can be involved, ischemic manifestations such as myocardial infarction can occur, as noted in this patient. Establishing a diagnosis of Bartonella infection is frequently difficult, but highly sensitive and specific PCR based assays are now available. Once identified, antibiotic therapy can lead to rapid resolution of clinical manifestations.
Abstract:
Joseph Cheatham, MD*, Thomas Summers, MD, Pranav Patel, MD, John David Horwhat, MD. Hematology and Oncology, Pathology, Gastroenterology, Walter Reed Army Medical Center, Washington., DC.
Purpose: INTRODUCTION: We describe the unusual case of an isolated duodenal polyp formed by submucosal globular amyloid deposition in an asymptomatic 79 year old patient with chronic hepatitis C. The patient had no specific gastrointestinal complaints or signs/symptoms of malabsorption. ENDOSCOPIC FINDINGS: During endoscopic screening for varices, a solitary polyp was found in the duodenal bulb. The consistency was soft when probed, resulting in a positive pillow sign but not completely consistent with a lipoma as the overlying mucosa yielded a healthy pink hue. Utilizing a 12 MHz endoscopic ultrasound probe, the polyp was found to be a 8.2 x 7.3 mm hypoechoic lesion arising within the submucosa and deep mucosa. With bite on bite biopsies a pearly opaque gelatinous material was visualized. Push enteroscopy into the mid-jejunum revealed no further findings. PATHOLOGY/HEMATOLOGY FINDINGS: On hematoxylin and eosin stain the lesion consisted of a large submucosal collection of an amorphous material. Immunohistochemical stains for smooth muscle actin highlighted the muscularis mucosa. Congo red highlighted the material orange; under polarized light, this stain showed the characteristic apple green birefringence expected for amyloid which was deposited around, but did not appear to impinge upon a Brunner's gland. Subsequent evaluation demonstrated an abnormal serum Kappa/Lambda ratio with faint IgG kappa bands on serum electrophoresis, and 3-4% Kappa restricted plasma cells on bone marrow biopsy - but negative for amyloid. DISCUSSION: The patient was diagnosed with MGUS with no evidence of oral, cardiac, hepatic, cutaneous, joint or bone marrow involvement. The patient's chronic hepatitis C has been quiescent for years with normal liver associated enzymes and liver synthetic function. No evidence of cirrhosis or hepatocellular carcinoma. This case is most consistent with AL or primary amyloidosis in the setting of a monoclonal gammopathy. CONCLUSION: Primary amyloid is usually diagnosed with rectal, skin, bone marrow, tongue or subcutaneous fat biopsies that may reveal amyloid deposition within blood vessel walls, muscle layers and the muscularis mucosa of patients suspected of having the disease. It is a rare presentation and to our knowledge represents only the second reported case of globular primary duodenal amyloid deposition.
Abstract:
Anand Gupta, MD*, Jeanette Smith, MD, John Scholes, MD, Martin Hoffman, MD, Michael Butensky, MD. Gastroenterology, Internal Medicine, University of Connecticut, Hartford, CT, CT, Pathology, Gastroenterology, St. Francis Hospital, Hartford, CT.
Purpose: A 65 year old man with a history of metastatic prostate cancer was being treated in a clinical trial with ipilimumab when he presented to the hospital with fever and 10-12 episodes of bloody diarrhea. The patient had recently received a course of antibiotics for bronchitis. His stool cultures were positive for C. difficile and he was begun on treatment with metronidazole. However, over the next few days his diarrhea did not improve with appropriate therapy. His physical exam revealed him to be afebrile with moderate diffuse abdominal tenderness without any evidence of peritoneal signs. Laboratory evaluation revealed normal blood count and chemistry except for an elevated ESR of 65. A CT of his abdomen revealed evidence of diffuse colonic thickening. With his lack of improvement, a colonoscopy was performed which revealed severe erythema and ulceration throughout the entire colon consistent with diffuse colitis without any evidence of pseudo- membranes. Histopathology of the colonic biopsy showed a severe acute and chronic colitis with features essentially identical to and indistinguishable from those of active inflammatory bowel disease. It was determined that ipilimumab which results in stimulation of the immune system can precipitate a colitis which mimics inflammatory bowel disease in presentation both clinically, endoscopically and histologically. Ipilimumab is a human monoclonal antibody that binds to CTLA-4 (cytotoxic T lymphocyte-associated antigen 4), a molecule on T-cells that plays a critical role in regulating immune responses. Ipilimumab is designed to block the activity of CTLA-4, thereby sustaining an active immune response. Ipilimumab is currently being used in clinical trials for patients with melanoma and prostate cancer with known gastrointestinal side effects of colitis. Through protocol the colitis has been treated with high dose intravenous steroids, with failures requiring treatment with infliximab and colectomy. Our patient was started on high dose steroids with significant improvement in his symptoms. Overall this presentation demonstrates a case of colitis due to immune stimulation from a medication perfectly imitating inflammatory bowel disease both clinically, endoscopically and histologically. It is important to be aware of the gastrointestinal complications of this medication so as not to confuse with IBD. The long-term ramifications of this medication are unknown. It may be possible that this medication could result in chronic IBD secondary to initiation of the immune cascade. Also, it is important to consider that this immune pathway may hold potential future immunological treatment options for IBD patients.
Abstract:
Patrick McDevitt, DO, Msc*, Matthew Moyer, MD, MSc, Abraham Mathew, MD, Msc. Department of Gastroenterology and Hepatology, Department of Internal Medicine, The Penn State Hershey Medical Center, Hershey, PA.
Conclusion: A 35 year old male presents with hematemesis and abdominal pain. His prior history is significant for idiopathic pancreatitis diagnosed 10 years prior complicated by portal vein thrombosis requiring placement of a spleeno-renal shunt. He had a known history of low grade varices identified on recent EGD and a large mass in the porta-hepatis noted on enhanced CT imaging, and what was described as extensive tumor surrounding the distal gastric body filling the gastro-hepatic ligament with extension around the lower esophagus to the GE junction. EUS was performed to obtain a tissue diagnosis, however; the lesion appeared to be more suggestive of a congregation of varices with further varices visualized around the esophagus and porta-hepatis. MRI previously ordered as a follow-up to the CT again described a large non-enhancing soft tissue mass within the upper abdomen surrounding the porta- hepatis with extension towards the stomach was again seen and speculated to represent malignancy or fibrotic tissue. Given these conflicting impressions, a biopsy of the mass was recommended for further evaluation which returned negative for malignancy or any pathology. With EUS findings being consistent with a vascular structure and CT/ MRI findings showing a mass, along with negative biopsy results, angiography was then performed for further evaluation. The findings on angiography confirmed that the identified mass was massive cavernous transformation of numerous collaterals, consistent with the EUS findings of a vascular structure. While EUS has been routinely used for assessment of gastrointestinal tumor staging along with differentiation of submucosal lesions, there is limited data comparing CT, MRI, and EUS in abdominal mass evaluation. CT has been shown to be inferior to EUS in assessing extraluminal compression and evaluating local and regional tumor extension. To date, this is the first case in the literature where an abdominal mass concerning for malignancy on radiographic studies was found to be massive cavernous transformation of vessels by EUS. In this instance, EUS was more accurate than CT and MRI for diagnosis of this unusual structure. The contrast load on CT was likely not enough to visualize all of the vessels given the large volume of collaterals, the MRI was not likely delayed enough to capture the numerous collaterals, but EUS afforded not only tissue visualization, but dynamic vascular evaluation and tissue sampling if necessary.
Abstract:
Rajeswari Anaparthy, MD*, Advitya Malhotra, MD, Andrew Dupont, MD. UTMB, Galveston, TX.
Purpose: Gastric cancer is an infrequent neoplasm in North America and is very rare before the age of 40 years. Although uncommon in younger people, gastric cancer should be remembered as a possible cause of malignant ascites especially in the presence of relevant clinicopathologic and radiological findings. Presentation 27 year old Hispanic male, with no past medical history presented with worsening abdominal distension, nausea, vomiting and 40 lb weight loss. Social history was significant for smoking, alcohol and cocaine abuse. He reported no sick contacts but had a recent travel to Mexico. Examination was significant for diffuse tenderness in the abdomen without guarding or rebound but had marked shifting dullness.
Methods: Diagnostic evaluation Analysis of paracentesis fluid revealed a serum ascites albumin gradient of < 1.1. Peritoneal fluid adenosine deaminase was negative. AFB stain and culture were negative Cytology revealed cells consistent with metastatic adenocarcinoma. Barium swallow showed poorly distended stomach with thickening of the mucosal folds. CT abdomen and upper GI Endoscopy are shown in the figure. Colonoscopy was unremarkable. Stomach biopsy revealed diffuse poorly differentiated adenocarcinoma. Immuno histological stain was positive for H. pylori.
Results: Considering the age of the patient, travel history and significant weight loss initial working diagnosis was peritoneal tuberculosis, but further investigation proved otherwise. Treatment was initiated with Etoposide, 5- Fluorouracil and Leucovorin, but patient opted for no further treatment and died the subsequent day.
Conclusion: In United States, very few gastric cancers are detected at an early age, leading to 5 year survival rate of less than 20%. H. pylori infection, dietary factors (nitroso compounds, low intake of fruits and vegetables, smoking and genetic predisposition (BRCA-2 mutations, HNPCC, Li- fraumeni syndrome) are the major risk factors for gastric cancer. In a low incidence country like United States, screening is not recommended. But, in the planning of prevention and control of gastric cancer, modifiable risk factors and high risk populations need to be considered for screening and surveillance.
Abstract:
Amer Skopic, DO*, Dong Lee, MD. Gastroenterology, National Naval Medical Center, Bethesda, MD.
Purpose: Gastric Small-Cell carcinoma (SmCC) is a rare and aggressive tumor. There are 60 cases reported in literature. Estimated survival is 6 to 12 months. Most patients present with metastatic disease. Histologically, gastric SmCC is identical to pulmonary SmCC, therefore it is important to exclude a pulmonary primary. Combination of chemotherapy directed toward SmCC of lung with surgery offers the best chance for survival. Case: A 62-year old male presented to the ED with 12 hours of sudden, severe, persistent epigastric pain. Prior to this, the patient was asymptomatic. Past medical history included coronary artery disease, gastroesophageal reflux disease, hypertension and hyperlipidemia. Medications included clopidogrel, aspirin, ramipril, simvastatin, rabeprazole. The patient had a 20 pack-year history of tobacco use and reported rare alcohol use. Physical exam was remarkable only for mild tenderness to palpation in the epigastrium with no rebound or guarding. Data: Blood counts and chemistries were normal. Abdominal CT demonstrated a large gastric mass measuring 8.5 cm x 5.7 cm with no invasion to adjacent organs or pathological lymph nodes. PET scan demonstrated no evidence of metastatic disease. A CT of the chest, abdomen and pelvis did not show a lung primary or metastatic disease. EGD visualized a large mass in fundus of stomach. The patient underwent a total gastrectomy. The gross specimen included a 10 cm tumor with negative margins and the lymph nodes were negative for malignancy. The tumor was sent to the Armed Forces Institute of Pathology (AFIP) for a second opinion. Histologically, the tumor consisted of poorly differentiated small cells with hyperchromatic nuclei, high nucleus to cytoplasm ratio, nuclear molding, prominent necrosis and a high mitotic rate. Immunohistochemical stains were positive for CD 56, CD 117 and synaptophysin. AFIP concluded that the histologic and immunophenotypic profile supported the diagnosis of primary gastric SmCC. Discussion: Gastric SmCC is a rare disease with less that 10% long-term survival. Diagnosis is based on histological and immunohistochemical characteristics and the exclusion of a primary lung cancer. They are classified as pure-type or composite-type tumors. The TNM system is used for staging. Etiology is unclear, but most patients are men, smokers, use alcohol, and are of Japanese descent. Treatment is based on small retrospective series. The only chance for cure is total gastectomy with lymph node dissection in combination with post-operative chemotherapy. Our patient received this treatment and remains disease free, 2 years after diagnosis. This case represents a rare successful outcome of uncommon malignancy.
Abstract:
Aja Smith, MD*, Matthew Cole, MD, Kenneth Vega, MD, Juan Munoz, MD. Division of Gastroenterology, University of Florida/ Jacksonville, Jacksonville, FL.
Purpose: Malignancy is the most common cause of colorectal obstruction. Relief can be obtained surgically with significant morbidity and mortality. However, self-expandable metal stents (SEMS) have become widely accepted for relief of obstruction in primary colonic neoplasms as well as extracolonic metastatic disease. Limited data exists on placement and outcome of colorectal SEMS for obstruction relief in locally invasive prostate cancer. We describe a case of successful placement of two overlapping SEMS in the rectosigmoid in a patient with biopsy proven locally invasive prostate cancer to alleviate left sided colonic obstruction. A 47 year old male with locally advanced prostate cancer presented with obstipation, bloating, nausea, intermittent hematochezia and new onset lymphedema. The patient was currently receiving hormonal therapy with Lupron.
Methods: Flexible sigmoidoscopy revealed an infiltrative, partially obstructing mass in the rectosigmoid colon 10 cm long involving two-thirds of the lumen circumference. Stigmata of bleeding with oozing was observed at sigmoidoscopy. Biopsies confirmed the presence of a poorly differentiated adenocarcinoma with immunoprofile consistent with locally advanced prostate cancer. The patient chose SEMS for palliation. Abdominopelvic CT scan prior to SEMS placement revealed prominent lymphadenopathy and extrinsic compression of the rectosigmoid colon. Consent for repeat flexible sigmoidoscopy with SEMS placement was obtained from the patient. Flexible sigmoidoscopy was performed with a standard sigmoidoscope (CF-Q160S, Olympus). At 15 cm from the anal verge, the previously seen mass with luminal narrowing was visualized. The narrowing was negotiated successfully by insertion of a guide wire proximally and advancing the sigmoidoscope over the visualized wire. No dilation was required. Hemoclips were placed at the proximal and distal ends of the stricture for marking. An initial SEMS (WallFlex.sup.[R] Colonic Stent, 25 mm diameter, 120 mm long; Boston Scientific) was placed at the level of the proximal clip followed by deployment of a second SEMS (WallFlex.sup.[R], 25 mm diameter, 60 mm long) distally. The second SEMS overlapped the first by approximately 1 cm. Endoscopic and fluoroscopic guidance was used throughout deployment.
Results: Nearly instant relief of obstruction with passage of flatus occurred after placement. Abdominal radiography was performed immediately post procedure and did not reveal perforation. Two months post SEMS placement, no obstruction or complication was reported.
Conclusion: Multiple rectosigmoid SEMS placement for obstruction relief due to locally invasive prostate cancer is a safe and effective therapeutic treatment option.
Abstract:
Anand Gupta, MD*, Purva Kumari, MD, James Dougherty, MD, Michael Lawlor, MD, Joseph Cappa, MD, Kasturi Ranga, MD. Internal Medicine, Univ of CT Health Center, Farmington, CT, Internal Medicine, Hartford Hospital, Hartford, CT.
Purpose: Adenoviral infections are commonly described in pediatric transplant populations. However, much less information is available regarding the incidence of infection and clinical spectrum of disease in adult transplant recipients. Moreover, this usually manifests as involvement of the transplanted organ in one pathologic form or the other in addition to other systemic manifestations. A 58 year old male, status post heart transplant in 1997 was admitted with high grade fever and loose stools for three days. Immunosuppression consisted of Mycophenolate Mofetil (MMF), Tacrolimus, and Prednisone. Examination showed right hypochondriac and periumbilical tenderness, but no guarding or rigidity. Initial blood cultures and urinalysis were negative. Hematological parameters were also normal on admission, except for elevated ESR of 84. Liver function tests showed elevated transaminases (AST-400, ALT-377, Alk Phos-53, LDH-307, total bilirubin-0.4.). Stool studies, and serologic studies for hepatitis viruses, CMV, EBV and HSV were all negative. The patient was started on empirical antibiotics despite which he continued to spike high grade fevers. Colonoscopy was normal. CT imaging of the abdomen showed normal bowel, and multiple indeterminate low attenuation masses in the liver. MRI abdomen was then performed showing multiple unenhancing lesions throughout the liver. The lesions demonstrated intermediate low T1 and low T2-weighted signal intensity and no enhancement, and were thought to be echinococcal in etiology. Echinococcal serology done subsequently was however negative. CT guided liver biopsy revealed focal areas of extensive necrosis with relatively spared bile ducts. Staining for fungal elements, PAS for E. histolytica, Gram stain, AFB stain were all negative. Immunohistochemical staining was positive for Adenovirus, and negative for CMV and HSV. PCR for adenoviral DNA revealed 289,300 copies/ml. Histologic features were consistent with Adenovirus hepatitis. The patient's immunosuppression was decreased by dropping MMF, and reducing Tacrolimus dosage. Over the next 2 weeks, serum transaminases started trending down, and constitutional symptoms improved. Subsequently, due to reduced immunosuppression, the patient underwent a cardiac transplant biopsy which was negative for adenovirus and rejection. CT abdomen repeated after a month showed significant resolution of the hypoattenuated lesions, with near normalization of transaminases. This case represents a very distinctive scenario of involvement of a different organ without any involvement of the primary transplanted organ, 10 years after the transplantation.
Abstract:
Mohit Jindal, MD*, Rohit Jindal, MD, Ayse Aytaman, MD. Gastroenterology, VA NYHHS, Brooklyn, NY.
Purpose: Inlet patch is a heterotopic site of gastric mucosa in the upper esophagus. Its endoscopic prevalence has been reported to be ranging from 0.1-10%. Heliobacter pylori can infect heterotopic gastric mucosa anywhere in the gastrointestinal tract, including in the upper esophagus, and may rarely produce symptoms. We present a case of H. pylori infection in an inlet patch. Case Report: A 51 year old man with past history of ankylosing spondylitis and diabetes mellitus reported post-prandial burning epigastric pain of 1 month's duration, associated with occasional heartburn and weight loss of seven pounds in the past year. Dypepsia did not respond to empiric therapy with a proton-pump inhibitor and the patient was not anemic. He underwent elective esophagogastroduodenoscopy (EGD) that revealed antral gastritis and a 15 mm elliptical area of salmon colored mucosa just below the upper esophageal sphincter, suggestive of inlet patch. Biopsy from the patch revealed body type gastric mucosa and focal antral features. H. pylori was detected in the specimen on Giemsa staining. Chronic inflammatory infiltrate was noted with mild acute inflammatory activity. No intestinal metaplasia was reported in the biopsy specimen. Patient was given treatment for H. pylori with amoxicillin, clarithromycin and omeprazole for two weeks. Dyspepsia resolved completely and the patient has been symptom-free since treatment. Discussion: Inlet patch is a possible site for H. pylori infection. The infection closely correlates with presence of H. pylori in the stomach, and independent infection of the inlet patch has not been reported. Detection of inlet patch appears to be endoscopist dependent and careful examination of the upper esophagus should be performed during every EGD. The exact significance of eradication of H. pylori from the inlet patch is not known, however inlet patch has been postulated to be a source of oral transmission of H. pylori. Inlet patch may also be a site of persistent infection after conventional treatment given to eradicate H. pylori.
Abstract:
Srinivas Kalala, MD*, Augustine Moscatello, MD, Shireen Pais, MD. Otolaryngology, Gastroenterology, New York Medical College, Valhalla, NY.
Purpose: A 79 year old male presented with 4 weeks of hemoptysis, dysphagia, and weight loss. He had lost 6 pounds in one month and noted greater difficulty swallowing solid material versus liquids. Medical history was significant for laryngeal cancer diagnosed in 2006, and treated with neck dissection, total laryngectomy with skin graft, and adjuvant radiation. He was a 50 pack year smoker and had quit at the time of cancer diagnosis. Physical exam was significant for a tracheostomy. No cervical adenopathy was noted. CT scan of the thorax demonstrated a 5.5 cm x 3.8 cm mass in the superior mediastinum abutting and compressing the trachea and esophagus (Fig. 1). A whole body bone scan showed increased uptake at the T3 vertebrae suspicious for neoplasm. Upper endoscopy demonstrated a skin flap (from prior skin graft) with overlying hair at 14 cm from the incisors. Apparent esophageal extrinsic compression extended from 15 to 20 cm from the incisors. Endoscopic ultrasound revealed a 6 cm x 6 cm hypoechoic and heterogeneous mass (Fig. 2). The linear echoendoscope was unable to be advanced further than 15 cm due to resistance and luminal narrowing. FNA of the mediastinal mass demonstrated malignant cells consistent with recurrent laryngeal cancer. Additional treatment with radiation is now planned for this patient. Discussion: This represents the utility of EUS-FNA in the diagnosis of superior mediastinal masses. EUS-FNA is minimally invasive, safe and sensitive method and may avoid the need for mediastinoscopy or other more invasive techniques for diagnosis of these neoplasms This represents the first reported use of EUS in the diagnosis of laryngeal cancer presenting as a superior mediastinal mass.
Abstract:
Brian Yu, MD*, Aekarach Ariyachaipanich, MD, Ghassan Zalzaleh, MD, Hareth Raddawi, MD, FACG. Department of Internal Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, IL, Gastroenterology, Oncology-Hematology, Advocate Christ Medical Center, Oak Lawn, IL.
Purpose: Although combination therapy with bevacizumab (a monoclonal antibody against vascular endothelial growth factor) and paclitaxel has shown improvement in progression-free survival in patients with metastatic breast cancer, bevacizumab has been linked to an increased risk of severe bowel complications.
Methods: NA
Results: A 71 year old Caucasian female with history of metastatic breast cancer presented to her oncologist's clinic with rectal bleeding. Her medical history began four years ago when she was diagnosed with stage IIB estrogen and progesterone-receptor positive, HER2-negative breast adenocarcinoma, which was treated with mastectomy and hormonal therapy. Three months prior to this presentation, she was found to have liver and bone metastases, and was started on bevacizumab and paclitaxel therapy. Her past medical history was also significant for a history of paroxysmal atrial fibrillation for which she was on warfarin therapy. At her oncologist's office, the patient reported several days of mild left lower quadrant abdominal cramps and then one episode of rectal bleeding that morning. The patient denied any previous episode of rectal bleeding or thrombotic events. On exam, she was found to be hypotensive. Her physical exam was otherwise normal except for tenderness to palpation in the left lower quadrant. The patient was administered IV fluids and admitted to the hospital, where initial laboratory evaluation was notable for a hemoglobin level of 9.5 and INR of 1.9. Colonoscopy revealed focal ischemia within the sigmoid colon spanning approximately 8 cm with surrounding ulceration and edema. Histological examination was consistent with ischemic colitis. Her rectal bleeding was of a self limited nature with no further episodes of bleeding during the hospitalization and stable hemoglobin prior to discharge.
Conclusion: This case illustrates a serious complication of bevacizumab therapy. Although ischemic colitis has been reported in treatment for metastatic cancer in patients who have received prior radiation therapy, to our knowledge, this is the first documented case of ischemic colitis in the treatment of metastatic cancer in the absence of radiation. Treatment with bevacizumab increases the risk of ischemic damage to the bowel. This could possibly be due to its anti-angiogenic properties. However, treatment with bevacizumab has also been shown to increase the risk of arterial thromboembolism which could also potentially lead to bowel ischemia. Other known complications of bevacizumab therapy include abdominal pain, vomiting, gastrointestinal hemorrhage, and perforation. New abdominal symptoms must be taken seriously in patients treated with bevacizumab and caution must be used when prescribing this therapy to patients.
Abstract:
Lubin Arevalo, MD*, Julio Defillo, MD, Young Lee, MD, Shobhana Chaudhari, MD. Internal Medicine, New York Medical College, New York, NY.
Purpose: INTRODUCTION Von Hippel-Lindau disease (VHL) is a rare, genetic multi-system disorder, characterized by a propensity for developing retinal, cerebellar and spinal hemangioblastomas, pancreatic cysts, renal cell carcinomas, and pheochromocytomas. We report a case of a patient with spinal hemangioblastomas due to Von Hippel Lindau syndrome who was found to have numerous pancreatic cysts on abdominal imaging. Biopsy revealed a diffuse variant of microcystic adenoma of the pancreas which, according to literature review, is extremely rare. CASE A 43 year-old Haitian female with two year history of back pain was seen in the Neurology Clinic for recent episodes of left arm numbness. MRI with gadolinium showed hemangioblastomas in the 4th ventricle as well as the upper and lower cervical cord. The patient was referred to neurosurgery for resection of the cervical hemangioblastomas. Oncogenetic testing proved VHL. Abdominal CT revealed numerous pancreatic cysts ranging in size from 5-10 mm, along with multiple diminutive cysts in the liver and kidneys. EUS revealed multiple pancreatic cysts, FNA biopsy of these cysts showed elevated CEA. The patient subsequently underwent distal pancreatectomy and splenectomy. Histopathologic examination of the surgical specimen was significant for diffuse microcystic adenoma of the pancreas. No other coexistent pancreatic malignancy was identified. The patient is currently in good condition. DISCUSSION Von Hippel-Lindau (VHL) is caused by mutations of the VHL tumor suppressor gene on the short arm of chromosome 3. The disease is inherited in an autosomal dominant pattern. The pancreatic lesions in VHL disease are usually classified as nonsecretory (cyst and cystadenoma) or secretory (islet cell tumors). Pancreatic cyst is the most common pancreatic lesion, and it is observed in about 15% to 30% of patients with VHL. Microcystic adenoma of the pancreas is the rarest pancreatic lesion in VHL disease. Usually unifocal, they present as single, large, well-demarcated multiloculated cystic tumors. Multifocal variants or diffuse serous cystadenomas are extremely rare. Pancreatic cysts usually do not produce any symptoms and are diagnosed incidentally by abdominal imaging studies. In spite of this uncommon presentation, the possibility of diffuse microcystic adenoma should be kept in mind in VHL patients, and careful examination of the pancreas is warranted to rule out a possible coexistent pancreatic malignancy.
Abstract:
Rebecca Kowalczyk, MD*, Sunanda Kane, MD. Mayo Clinic, Rochester, MN.
Purpose: A 39 year old female with a history of Crohn's ileocolitis presented to the outpatient gastroenterology clinic for further evaluation of her disease. She was first diagnosed with Crohn's disease at age 16 after having symptoms for 4 years prior. At 26 years of age she underwent resection of the terminal ileum and right colon with continued multiple episodes of loose stool. After she failed to gain weight during pregnancy she underwent repeat colonoscopy and was found to have recurrent disease and underwent resection of diseased bowel with primary anastomosis at age 37. Post operative course was complicated by anastomotic leak, pelvic sepsis and enterocutaneous fistula requiring repeat surgical repair. She continues to have approximately 20 loose stools a day, poor weight gain, and severe lower abdominal pain. Only treatment at presentation was Imodium and Lortab. Physical exam did not reveal any extraintestinal manifestations of Crohn's disease. Abdominal examination was significant for multiple well-healed surgical scars, hyperactive bowel sounds but no tenderness, distention or masses. CT enterography was positive for mild active disease of the descending colon. Incidentally found on the CT scan was a large right adnexal cyst for which the patient was evaluated by gynecology. It was felt this was most likely a physiologic cyst and should be monitored prior to surgical intervention. To treat the patient's active disease she was started on Azathioprine 50 mg orally daily. Upon follow up her diarrhea had improved after 3 months of therapy and her abdominal pain was improved but was still narcotic dependent. She had also developed a perianal fistula and was started on ciprofloxacin. The patient returned 1 month later with continued improvement in her diarrheal symptoms and abdominal pain. Repeat ultrasound was done and revealed complete resolution of her ovarian cyst. Ovarian cysts occur in about 5-7% of the general population and up to 25% of women with inflammatory bowel disease. This increased incidence is most likely secondary to the up-regulation of inflammatory mediators that have an inhibitory effect on LH interfering with reabsorption of the immature follicle. Ovarian cysts are related to increased rates of pelvic and abdominal pain, and should be considered in the differential in those women with IBD and refractory abdominal pain. Given that these cysts are related to hormonal imbalances secondary to inflammation it is likely that these cysts would decrease in size or resolve with treatment of active IBD, as was seen in this patient. Further research into the incidence of ovarian cysts in IBD and effect of treatment of IBD on ovarian cysts is needed.
Abstract:
Amer Skopic, DO*, James Lewis, MD. Gastroenterology, National Naval Medical Center, Bethesda, MD, Gastroenterology, Georgetown University Hospital, Washington, DC.
Purpose: Background: Dicloxacillin (Diclox) is semi-synthetic penicillin (PCN) used for treatment of a variety staphylococcal infections. It is the predominant beta-lactam PCN prescribed in the U.S. Severe liver reactions associated with its use are very rare. Case: A previously healthy 74 year-old white male presented with a 2 week history of jaundice, severe pruritus, dark urine, nausea and anorexia. He received a 10 day course of diclox 250 mg po qid for cellulitis of his right arm one month prior to this presentation. Pretreatment LFT's had been normal. Atorvastatin, which he had taken for three years was discontinued at the onset of his jaundice. He was non-smoker and drank alcohol rarely. His physical exam was remarkable only for scleral icterus and jaundice. An ultrasound of the abdomen was normal. Serological evaluation was negative for viral, autoimmune, chronic cholestatic, and hereditary liver diseases. He was started on ursodiol 300 mg po tid and also received a short tapering course of prednisone. A marked clinical improvement paralleled a decrease in liver enzymes over the course of next several weeks. Discussion: The clinical picture of a mixed cholestatic-hepatocellular injury pattern, significant eosinophilia, and a negative evaluation for other potential causes of liver injury was felt to be most consistent with a diclox-induced drug reaction, likely due to hypersensitivity. The long prior use of atorvastatin with normal LFTs just prior to diclox excluded statin induced hepatopathy. Given the improvement in LFTs and clinical improvement on ursodiol therapy, no liver biopsy was performed. Diclox induced liver injury is rare with an estimated frequency of adverse hepatic events of 1.8 reactions per million daily doses. An immunoallergic reaction mediated through formation of drug modified hepatic protein adducts is the likely mechanism. Older age and a prolonged course of therapy are important risk factors. Mixed cholestatic injury can occur up to several weeks after taking diclox, similar to that seen with amoxicillin-clavulante. Jaundice and pruritus typically are severe and protracted. Conclusion: Bile duct loss has been reported and liver tests may remain abnormal for months after resolution of clinical symptoms, although ursodiol therapy may shorten the course.
Abstract:
Peter Sargon, MD*, Baseer Qazi, MD, Timothy Laurie, MD, Hymie Kavin, MD. Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, IL.
Purpose: A 68 year-old woman on capecitabine for metastatic bilateral breast cancer presented with a two-week history of diffuse lower abdominal discomfort, diarrhea, fever, nausea and loss of appetite. Diarrhea was high volume, intermittently bloody, and watery. Physical exam revealed a soft, mildly distended abdomen, tender to palpation in the lower quadrants. Labs revealed WBC 25.4 k/mcL and negative C. difficile toxins x3, stool cultures and O&P. AST was 53 u/L, ALT 56 u/L, ALP 173 u/L, and bilirubin 0.8 mg/dL. Non-contrast CT revealed a small amount of ascites in the abdomen. Colonoscopy revealed pancolitis, which was friable, granular, erythematous, and edematous, with a loss of normal vascular pattern. Random biopsy showed distorted mucosa and lamina propria with chronic inflammatory infiltrate and multiple dilated cystic glands lined with cuboidal epithelium. Pt was treated with IV steroids as an inpatient and a taper of oral steroids upon discharge. Prior to that, she did not respond to therapy with multiple abx and was refractory to cholestyramine, somatostatin, tincture of opium, metamucil, and imodium. The patient was diagnosed with capecitabine-induced colitis. Capecitabine is a 5-FU prodrug that is selectively converted in tumor cells and liver tissue. Through its use in the treatment of colorectal and breast cancer, capecitabine has been shown to induce GI toxicity including common side effects such as diarrhea, abdominal pain, nausea, and vomiting, as well as rare side-effects such as necrotizing enterocolitis. Our literature search produced only one reported case of capecitabine-induced pancolitis. In our case, the patient was able to achieve complete resolution of symptoms after one week of steroids.
Abstract:
Steven Naymagon, MD*, Kalpesh Patel, MD, Max Sung, MD, Michelle Kim, MD, MSc. Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY.
Purpose: Introduction: Radioembolization is an emerging tumoricidal modality that allows targeted delivery of radioactive microspheres. While the precision of this technique offers several advantages over traditional external beam radiation therapy, it still poses significant risks to non-target organs. In this report, we present a case of gastroduodenal ulceration and concomitant cytomegalovirus (CMV) infection in a patient treated with Yttrium-90 microsphere radioembolization. Case Presentation: A 66 year old man with a history of chronic hepatitis B infection and previously resected hepatocellular carcinoma, developed tumor recurrence one year prior, and was treated with Yttrium-90 microsphere radioembolization via the left hepatic artery. At the time of radioembolization, radioactivity was confirmed in the left lobe of the liver and signal was also noted in the duodenum and the head of the pancreas. The patient presented one month after radioembolization complaining of abdominal pain and 30 pound weight loss. An upper endoscopy was performed, revealing multiple erosions in the body of the stomach, a 3 cm, clean-based ulcer with pigmented spots involving most of the pylorus, and two smaller, clean-based ulcers in the duodenum. Biopsies from the ulcers revealed inflamed mucosa and submucosa with scattered synthetic microspherules and CMV inclusion bodies. The patient was treated with intravenous proton pump inhibitors and nutritional support. Symptoms resolved within one week and the patient was discharged, tolerating oral intake. Discussion: We present a case of concomitant radiation-induced gastroduodenal ulceration and CMV infection in a patient treated with intra-arterial Yttrium-90 microsphere radioembolization. Due to the interrelated arterial supply of the liver, pancreas, stomach, and duodenum, the potential delivery of radioactive microspheres to non-target organs, with subsequent injury, is a recognized phenomenon. Furthermore, radiation can lead to local immunosuppression and subsequent opportunistic infections. CMV is known to cause gastritis and ulceration in the setting of immunosuppression and may have contributed to the severity of disease in this patient. We hypothesize that the initial insult caused by ionizing radiation led to local inflammation and immunosuppression that, in turn, allowed latent CMV infection to reemerge and exacerbate the patient's condition. Conclusion: Patients undergoing radiation therapy commonly suffer damage to the alimentary tract. This case suggests that in patients with presumed radiation-induced gastrointestinal disease, infectious etiologies must be considered and ruled out in order to optimize treatment and outcome.
Abstract:
Juan Carlos Bucobo, MD*, Robert Shaw, MD, Michael Harris, MD, Kai Matthes, MD, Bhawna Halwan, MD, MS, Everson Artifon, MD, PhD, Vivek Mittal, MD, Atul Kumar, MD. Division of Gastroenterology and Hepatology, Stony Brook University Medical Center, Stony Brook, NY, Harvard Medical School, Boston, MA, University of Sao Paulo Medical School, Sao Paulo, Brazil, SUNY Downstate Medical Center, Brooklyn, NY, UT Southwestern, Dallas, TX, Northport Veterans Affairs Medical Center, Northport, NY.
Purpose: Evidence supports the use of thermocoagulation for endoscopic treatment of high-risk stigmata (HRS) in patients with bleeding peptic ulcer disease (PUD). If thermocoagulation cannot be performed, epinephrine injection (EI) may help tamponade bleeding vessels. We report the injection of albumin in 2 patients to treat bleeding PUD since thermocoagulation was technically unfeasible. 1) A 1.5 cm ulcer with oozing was noted on the superior and posterior aspect of the duodenal bulb in a 77 year old male. The ulcer, immediately adjacent to the pylorus, was inadequately visualized to perform thermocoagulation (Fig. 1). The bleeding site was injected with 20 cc of 25% albumin. Next day endoscopy revealed a healing white-based ulcer and relatively normal appearing adjacent mucosa. 2) Active bleeding from recurrent gastric ulcers in an 85 year old male was treated with endoclips. Ongoing oozing and inaccurate clip deployment led to difficulty in deploying additional endoclips or performing coaptive thermocoagulation. 20 cc of 25% albumin was injected with excellent results. Both patients recovered uneventfully. Coaptive thermocoagulation, i.e. forceful tamponade & welding of bleeding peptic ulcers is challenging. The presence of active bleeding may render it difficult to pinpoint the bleeding site, ulcer location may make it difficult to apply maximal forward pressure for coaptation, prior endoscopic therapy may obliterate the field making it impossible to intervene, and physicians with low GI bleeding case volume may lack the necessary skill. Although EI may help tamponade the bleeding vessel, its effect is short lived. Suboptimal thermocoagulation may cause tissue damage and increase risk of bleeding, especially in patients with low platelet count and/or coagulopathy. Various viscous solutions such as albumin have been utilized for submucosal cushions and may be injected for prolonged tamponade of bleeding vessels. Mechanical obliteration using visco-elastic material injection is a simple, safe and effective strategy for endoscopic hemostasis. Studies to evaluate the appropriate injectate and effectiveness of these strategies are underway.
Abstract:
Satya Mishra, MD*, Melchor Demetria, MD, Bashar Attar, MD, PhD. Division of Gastroenterology and Hepatology, Cook County- John H. Stroger Hospital, Rush University, Chicago, IL.
Purpose: Plummer-Vinson syndrome is defined by the classic triad of dysphagia, iron deficiency anemia, and esophageal web. The syndrome is rare and the prevalence has fallen in the last few years. We present a case of Plummer-Vinson syndrome in an Asian Indian male associated with ulcerative colitis.
Methods: 58 yr old Asian Indian male presented with intermittent dysphagia to solids for over 5 years and symptomatic anemia. Physical examination was unremarkable except for koilonychia. Laboratory data showed a hemoglobin 0f 6.5 gm/dl, MCV of 53 fl, Ferritin of 1.7 ng/ml, negative tTG. Esophogram showed narrowing of the esophagus at C7 T1 level. On upper endoscopy patient had a proximal esophageal web and gastric atrophy with biopsy showing H. Pylori infection. The duodenum appeared normal. Colonoscopy was performed to evaluate for iron deficiency anemia. It showed mild pan colitis with histopathology suggestive of ulcerative colitis.
Results: Patient underwent Savary dilatation of the esophageal web and was started on oral Iron supplements and Mesalamine. On follow up at 6 months the anemia had completely resolved and, patient did not have any symptoms of dysphagia.
Conclusion: Plummer-Vinson syndrome is rare. Different case series suggest an association with Celiac disease, menorrhagia, hiatal hernia and gastric cancer. The pathogenesis is unknown and iron deficiency, malnutrition, genetic predisposition and autoimmune process have been proposed as putative factors. Our patient's iron deficiency was most likely due to Ulcerative colitis. He was a vegetarian and high fiber and phytate in the diet typical of Asian Indians could have also contributed by reducing iron absorption. Based on literature review this is the first case report of Plummer-Vinson syndrome in association with ulcerative colitis.
Abstract:
Abstract:
Jack Braha, DO*, Ting-Hui Hsieh, MD, Jai Mirchandani, MD, Kadirawel Iswara, MD, Jianjun Li, MD, Scott Tenner, MD, MPH. Medicine, Maimonides Medical Center, Brooklyn, NY, Medicine, State University of New York - Health Sciences Center, Brooklyn, NY.
Purpose: Sarcoidosis is an idiopathic granulomatous disease that has a myriad of manifestations. We present a patient who presented with obstructive jaundice and a periportal mass, initially thought to have either cholangiocarcinoma or lymphoma, found, after extensive evaluation, to have Hepatobiliary Sarcoidosis.
Methods: A 42 year-old female presented to our institution with jaundice, right upper quadrant pain, nausea and non-bloody, non-bilious vomiting for three days. She reported a 60 lb weight loss in the previous six months and had recently quit cigarette smoking. Past medical history was significant for hypertension. She denied any history of alcohol, drug abuse or hepatobiliary disease. Physical examination was significant for mild hepatomegaly, right upper quadrant tenderness and absence of a Murphy's sign. Laboratory examination revealed elevated liver function testing, bilirubin 2.8 mg/dl. Computed Tomographic scan showed a 1.6 cm mass anterior to the left portal vein, compressing the common hepatic bile ducts resulting in ductal dilatation. There was diffuse periportal lymphadenopathy. Endoscopic ultrasound was performed confirming the 1 cm periportal mass, an FNA was performed. Cytology was non-specific, negative for malignancy.
Results: Laproscopy was performed with biopsy of the periportal adenopathy revealing non-necrotizing granuloma. Chest radiograph revealed diffuse interstitial infiltrates. PPD was negative. The patient was diagnosed with sarcoidosis. Biliary obstruction was treated by ERCP and stent placement. Oral steroid therapy was begun. The patient quickly responded with resolution of symptoms, weight gain, and normalization of LFTs.
Conclusion: This case supports the importance of obtaining histology to confirm the diagnosis of a suspected malignancy. Sarcoidosis should be considered in the differential diagnosis of biliary obstruction mimicking carcinoma. Prompt endoscopic and medical therapy appears to result in a quick resolution of symptoms.
Abstract:
Richard Johnston, MD*, Afonso Ribeiro, MD. University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, FL.
Purpose: Primary adenocarcinoma of the small intestine is the most common of primary small intestinal malignant neoplasms. The majority of these occur in the duodenum and are typically diagnosed by endoscopy, CT, or some type of contrast study. We present the case of a patient diagnosed with small intestinal adenocarcinoma with EUS-FNA after an array of other tests were unrevealing. Case: A 73 year-old black female was referred for evaluation of epigastric pain. She experienced gradual onset of the pain 4 months prior and it had been worsening over this time. She described it as a dull ache with radiation to the back and somewhat relieved with oxycodone. This was associated with intermittent nausea and vomiting 4-5 times per week which was not related to food intake and alternated between bilious and undigested food. She experienced an unexplained 40 lb weight loss, decreased appetite, and intermittent loose, watery stools. Physical exam findings included a soft abdomen with mild tenderness in epigastrium but no distention. She was mildly anemic with normal liver chemistries, amylase, lipase, and basic metabolic profile. CA19-9 was mildly elevated at 39 ng/mL. She had previously undergone an upper endoscopy that revealed antral gastritis, a CT colonography that showed only diverticulosis, and a video capsule endoscopy that revealed a few superficial ulcerations in the proximal small bowel. An abdominal CT revealed minimal dilation of CBD with no intrahepatic dilation, slight dilation of PD, streaking within fat planes inferior to pancreas, diverticulosis, and no masses. She was referred for an upper EUS to evaluate for a possible pancreatic head mass. EUS showed undigested food in the stomach and no pancreatic tumor. A hypoechoic solid lesion was seen in the third portion of the duodenum near the SMA that was biopsied via FNA. Enteroscopy was then performed revealing a malignant appearing stricture in the 4th portion of the duodenum that was biopsied. The biopsies obtained during enteroscopy were negative but the FNA revealed adenocarcinoma. Surgery confirmed a primary small bowel adenocarcinoma with positive nodes. Conclusion: Small intestinal adenocarcinoma accounts for only [proportional to]2% of GI malignancies but can be some of the most devastating, particularly with lymph node positive disease. This illustrates a serendipitous EUS FNA diagnosis of small bowel tumor after multiple equivocal imaging tests results.
Abstract:
Sadat Rashid, MD*, Jaspreet Singh, MD, Rahul Sehgal, MD, Prachi Anand, MD, FACP, Paul Mustacchia, MD. Internal Medicine, Gastroenterology, Nassau University Medical Center, East Meadow, NY.
Purpose: Hepatitis C virus (HCV) infection is often associated with extrahepatic manifestations involving hematological, renal, dermatologic, rheumatologic and ocular systems. We report a rare case of bilateral Mooren's corneal ulcer and inflammatory arthritis in a patient with Hepatitis C who showed dramatic improvement with systemic steroid therapy.
Methods: 47-year-old African-American male with chronic hepatitis C presented with bilateral painful red eye and photophobia along with painful swelling in right hand and left knee for five days. Detailed clinical history, physical examination, slit-lamp biomicroscopy and fluorescein staining of the cornea, routine blood tests, rhematologic markers, and radiographs were obtained to document initial presentation and diagnosis of bilateral Mooren's corneal ulcer, and HCV arthropathy and their therapeutic response to systemic steroids.
Results: Patient was started on oral prednisone (1 mg/kg/day) with documented symptomatic and clinical improvement in both keratitis and arthritis within one week of treatment.
Conclusion: Given the high prevalence of HCV, it is important for clinicians to recognize and optimally treat the extra-hepatic manifestations of HCV infection. This case supports the previously reported cases of association between Mooren's corneal ulcer and seronegative arthritis with hepatitis C and adds to use of oral steroids as a therapeutic option.
Abstract:
Mohammad Titi, MD*, T. Kothari, MD, S. Devgun, MD, P. Leve, MD, K. Patel, MD. Internal Medicine, Unity Hospital, Rochester, NY.
Purpose: Muir-Torre syndrome is a rare autosomal dominant condition characterized by the combination of sebaceous gland tumors and at least one visceral cancer especially colonic. It has been recognized as a subtype of Lynch Type II hereditary nonpolyposis colon cancer. Early recognition of the syndrome in patients with sebaceous gland tumors should facilitate early detection of subsequent malignancies if the patients and their relatives are entered into appropriate screening programs. Case presentation: A 46 years old asymptomatic male was referred by his dermatologist and primary care physician for screening colonoscopy before the age 50. The patient had no gastrointestinal symptoms and had no previous history of inflammatory or any other bowel disease. His paternal grandmother had colon cancer at old age but he denied any other family history of cancer. Patient had no significant past medical or surgical history. However, he recently had an excision of a sebaceous cyst from the nose and the histology showed sebaceous carcinoma. Histological findings of sebaceous carcinoma raised concerns about the possibility of Muir-Torre Syndrome which involves an increased risk of concomitant visceral malignancy especially colonic carcinoma in such patients and indicates regular colonic screening. Based on this clinical concern the patient was referred for screening colonoscopy. Patient had colonoscopy performed which showed an ulcerated circumferential mass at the level of the cecum, biopsies confirmed the diagnosis of moderately and poorly differentiated adenocarcinoma of the colon. Staging investigations were normal and patient was referred for surgical colonic resection. Patient also had an upper endoscopy and chest radiograph which were normal. Conclusion: Patients with Muir-Torre Syndrome are probably more common than is recognized, but sebaceous gland tumors are rare and the diagnosis of such a tumor should suggest the possibility of the syndrome and prompt a search for associated malignancies especially colonic carcinoma and to investigate for the underlying genetic mutation. Timely diagnosis of colonic malignant neoplasm in this subset of patients, before the screening age of 50 can cure the disease and save many lives.
Abstract:
Satya Mishra, MD*, Gijo Vettiankal, MD, Bashar Attar, MD, PhD. Division of Gastroenterology and Hepatology, Cook County - John H. Stroger Hospital, Rush University, Chicago, IL.
Purpose: The gastrointestinal tract is the most common site of extra-pelvic endometriosis. Most commonly the rectum, sigmoid colon, terminal ileum and appendix are involved. Patients can present with abdominal pain, rectal bleeding, bowel obstruction or perforation. We present a young asymptomatic patient with endometriosis of the Ileocecal valve.
Methods: 22 yr old African American female was found to have bilateral complex ovarian cysts on evaluation for an episode of left flank pain. CT Abdomen and Pelvis showed a soft tissue density in the cecum. Patient was lost to follow up and presented 3 years later with right lower quadrant abdominal pain and diarrhea for 1 day. On physical examination there was right lower quadrant abdominal tenderness and thick, foul smelling, vaginal discharge. Laboratory studies showed a normal CBC and Urinalysis with 24 RBC,47 WBC, small leukocyte esterase. Repeat CT Abdomen and Pelvis showed no interval change in the cecal mass, no evidence of appendicitis and reduction in size of the ovarian cysts. Patient was treated for PID with resolution of her abdominal pain. Colonoscopy showed a large, irregular, polypoidal mass in the cecum which seemed to originate from the ileocecal valve. Biopsy showed colonic mucosa with non-specific chronic inflammation. Patient was asymptomatic and delayed her surgery for five months.
Results: Because of diagnostic uncertainty and the large mass patient underwent right hemicolectomy. Intraoperatively a firm rubbery mass involving the terminal ileum and cecum was found with enlarged mesenteric lymph nodes. There were dense pelvic adhesions. On pathological examination there was 6.5 cm endometrioma of the ileocecal valve and endometriosis of terminal ileum. The mesenteric lymph nodes were reactive.
Conclusion: Our case illustrates the diagnostic challenge of intestinal endometriosis. Our patient had cecal involvement which is uncommon. She also did not have recurrent abdominal symptoms that could be ascribed to the ileocecal endometriosis. Endoscopic biopsies as in our case, usually yield insufficient tissue for a definitive pathologic diagnosis as endometriosis involves the deeper layers of the bowel wall. Laparotomy/Laparoscopy is often required for making a diagnosis and for treatment.
Abstract:
Rajeswari Anaparthy, MD*, Aravind Sugumar, MD, MPH. Mayo clinic, Rochester, MN.
Purpose: A 19 yr old man was referred to our GI clinic for evaluation of abdominal pain. He initially presented 3 weeks ago for nonspecific abdominal pain and constipation. He was prescribed some laxatives which helped him for a while but the abdominal pain recurred in 2 weeks at which time he had a CT scan done which was read as "acute appendicitis". The patient underwent appendectomy. He was found to have some mesenteric lymph nodes and milky looking fluid at surgery. 50 cc's of this fluid was sent for analysis. He had an uneventful postoperative course till day 3 when the same abdominal pain recurred. It was treated with pain killers. The pathology of the resected appendix was unremarkable. At this point he was referred to our GI clinic for Chylous ascitis. By this time he had had multiple bouts of abdominal pain and he characterized it as 10/10 pain which was diffuse, associated with nausia, vomiting and constipation. There were no specific triggers and relieved only by pain medications. He had no significant past medical history except hypertension and no family history. He had never smoked, did not drink alcohol and did not use any drugs.
Methods: His physical exam revealed a normal abdomen exam and some gynecomastia. He had bilateral lower extremity edema. Initial labs which included a CBC, Basic chemistry, LFTs, LDH, ESR and U/A were normal. His Beta HCG and AFP were normal
Results: He had a CT abdomen done which showed a a 2 x 3 cm mass between the right Psoas muscle and right common iliac (Fig. 1) and a 2 x 3 Cm mass below the right renal vein (Fig. 2) and CT guided Biopsy revealed a mixed germ cell tumor. The primary was later on found to be in the Right scrotum. He underwent radical orchectomy and chemotherapy and is tumor free at 1 yr follow up.
Conclusion: Chylous ascitis in an uncommon phenomenon and the incidence of chylous ascites is 1 case in 20,000 hospital admissions. The diagnosis is established when the concentration of triglycerides in the ascitic fluid is >200 mg/dl. The etiologies in adults can be broadly classified due to malignant and non malignant cause. The malignant causes include lymphomas and metastatic lesions from stomach, pancreas and ovarian cancer. In any young man with abdominal pain and ascities germ cell tumors must be kept in mind and a through scrotal exam must be performed.
Abstract:
Rajeswari Anaparthy, MD*, Aravind Sugumar, MD, MPH. UTMB, Galveston, TX.
Purpose: Introduction Black esophagus or esophageal necrosis is a rare condition diagnosed on endoscopy from dark pigmented appearance of the esophagus. Presentation 67 year old female presented with vomiting, diarrhea, epigastric pain, and melena. Vomiting has limited her oral intake leading to dehydration and 7 lb weight loss in one week. She had a history of hypertension, GERD and alcohol abuse. Examination showed BP of 90/60, pulse 98 with positive tilt testing. She had epigastric tenderness without guarding or rebound. She was guaiac positive.
Methods: Diagnostic evaluation She had a hemoglobin of 9 g/dl. Basic metabolic panel and stool studies were unremarkable. LFTs revealed total bilirubin of 1.8 mg/dl, conjugated 1.2 mg/dl, unconjugated 0.1 mg/dl, albumin 2.0 g/dl, alkaline phosphatase 151 U/L, ALT 34 U/L, AST 46 U/L. PT 16.3 seconds and INR 1.5. Abdominal sonogram revealed fatty infiltration of the liver. Hepatitis serologies and colonoscopy were unremarkable. Endoscopic appearance is shown in the figure Histology revealed necrosis and inflammation with leukocyte infiltration.
Results: She was resuscitated with fluids and was started on intravenous Pantoprazole. Sucralfate was added for cytoprotective effect with good symptomatic relief. Patient was gradually transitioned to regular diet.
Conclusion: Discussion The dramatic appearance of the esophagus on endoscopy results from circumferential black discoloration in the distal esophagus that ends at the gastroesophageal junction. Mucosal necrosis with inflammation on histology is the hallmark of diagnosis. Low flow state due to hemodynamic instability or ischemia is the main inciting factor. The condition is characterized by rapid resolution following hemodynamic stabilization. This case illustrates esophageal necrosis in a malnourished patient in the setting of acute hemodynamic stability from hypovolemic shock. The important compounding factor is poor nutritional status that can result in mucosal necrosis from compromised mucosal defense mechanism or impaired healing after insult either form acid or ischemia. This case supports previous literature that esophageal necrosis is not just a pure local phenomenon, but a manifestation of poor general condition and underlying co morbidities. Early recognition is important as this condition is potentially reversible.
Abstract:
Rajeswari Anaparthy, MD*, Chandandeep Takkar, MD. UTMB, Galveston, TX.
Purpose: Superior Mesenteric Artery syndrome (SMAS), mesenteric duodenal compression or Wilkie's syndrome is an uncommon condition characterized by the compression of third segment of duodenum between superior mesenteric artery and aorta
Methods: Presentation 32 year old female presented with severe dull nonradiating epigastric abdominal pain. Pain was intermittent with worsening in supine position and relief with sitting. There was associated nausea, bilious vomiting, fullness and early satiety. She denied altered bowel habits, hemetemesis, hematochezia, dysmenorrhea, vaginal or urinary symptoms. She reported multiple episodes of similar pain in the past one year and had a significant weight loss of about 40 pounds in the same time period. Past medical history was significant for depression. Examination showed a BMI of 18 and remarkable epigastric tenderness without guarding or rebound CBC, BMP, LFTs, amylase, lipase and urine analysis were unremarkable. Upper GI series showed mild proximal dilation of the duodenum. Endoscopy was unremarkable. CT abdomen and MRA: Figure.
Results: SMAS is diagnosed based on intermittent abdominal pain with positional variation, nausea, vomiting and rapid weight loss after exclusion of other conditions. Findings on CT and MRA further support the diagnosis.
Conclusion: SMA syndrome results from reduction in the aortomesenteric angle (normal 25-60 degrees) and distance between SMA and aorta (normal 10-28 mm) resulting in compression of third portion of duodenum between SMA anteriorly and aorta posteriorly with concurrent duodenal dilation. It is common in females and subjects with low BMI. Asthenic body habitus and depletion of aortomesenteric fat from rapid weightloss could have contributed to duodenal compression and clinical spectrum in our patient. Treatment is conservative and includes nutritional support. For refractory cases surgical options include duodenojejunostomy or transposition of third part of duodenum. Given the minor degree of duodenal stenosis, our patient responded to conservative measures with weight gain and symptom relief. Endoscopic and conventional radiological investigations of these cases may be normal findings are transitory. Diagnosis may easily be overlooked if investigations are performed between manifest periods. High index of suspicion is needed for this potentially treatable condition.
Abstract:
Chandandeep Takkar, MD*, Rajeswari Anaparthy, MD. UTMB, Galveston, TX.
Purpose: Cannabis is well recognized for its antiemetic properties. Interestingly, chronic cannabis use can lead to paroxysmal vomiting which can present in a pattern identical to cyclic vomiting syndrome. It is associated with compulsive bathing which patients report can relieve their intense nausea and vomiting.
Methods: We report a case of 19 year old male who presented with relentless nausea and vomiting of one day duration. Patient claimed that warm showers alleviated the intensity of his symptoms. Of note, he had several admissions to the pediatric service for similar symptoms in the past. Social history was remarkable for marijuana abuse for last four years. He also mentioned that paroxysms of vomiting started after marijuana use. Exam revealed moderate dehydration, otherwise normal. Labs revealed positive drug screen for THC and evidence of intravascular depletion and hypokalemia which resolved with replacement. After extensive work up including normal CBC, amylase, lipase, LFTs, ferritin, ceruloplasmin; negative hepatitis serologies and porphyria screen; negative advanced imaging including a CT abdomen, HIDA scan, upper GI series, gastric emptying study and endoscopy revealing erythema of distal esophagus, stomach cardia and proximal body with submucosal hemorrhage consistent with retching trauma, diagnosis of 'Cannabis hyperemesis' was made. Patient was managed with IV fluids, antiemetics and alprazolam to reduce anxiety. His symptoms improved by third day and he was able to tolerate oral intake. Patient declined outpatient drug rehabilitation but agreed to abstain on his own. Subsequent clinical course was marked for periods of abstinence which were symptom free and relapses of marijuana use associated with recurrence of same symptoms.
Results: Discussion Marijuana use is widely prevalent in the United States. Delta-9 tetra hydro cannabinol, the active ingredient and synthetic derivatives of marijuana are used as antiemetic for refractory vomiting. Cannabinoid hyperemesis is a paradoxical reaction consisting of chronic cannabis use, episodic severe nausea, vomiting, abdominal pain and an abnormal bathing behavior. It is postulated that imbalance between autonomic and thermoregulatory centers in hypothalamus and limbic system is one of the mechanisms of causation. Also, a recent randomized controlled trial revealed that 9 THC has inhibitory effect on gastric emptying of solid food which could contribute to the clinical spectrum in these patients.
Conclusion: Our case suggests that in patients with chronic or episodic vomiting and abdominal pain without obvious etiology, especially if associated with compulsive bathing behavior, diagnosis of cyclic vomiting syndrome with concomitant cannabis abuse should be considered.
Abstract:
Sanjay Vinjamaram, MD*, Sapna Khubchandani, MD, Renuka Iyer, MD. Roswell Park Cancer Institute, Bufffalo, NY.
Purpose: Currently there are no guidelines to manage patients with carcinoid tumors who would benefit from sansdostatin but are unable to tolerate it. We attempt a desensitizing strategy in such patients.
Methods: 49-year old white male was evaluated for a history of painless jaundice of 1-week duration. He reported facial flushing, lasting years. Asymptomatic otherwise, and had no other significant personal or family history or physical examination findings other than facial flushing. Work up revealed distension of the gall bladder and dilatation of the common bile duct (CBD) (1.9 cm), hepatic ducts and a 3.5 cm hypodense lesion in the head of the pancreas. Patient underwent multiple endoscopic retrograde cholangiopancreatographies (ERCP) with stent placement; CBD biopsies and brushings did not reveal malignancy. Subsequent CT scan of the abdomen revealed multiple 10-15 mm ill-defined hepatic lesions and increased fullness in the pancreatic head. Biopsy of the pancreas revealed a low-grade neuroendocrine tumor of the pancreas head and neck. Octreotide uptake was noted in the head and neck of the pancreas and two hepatic lesions. Patient had an elevated chromogranin-A level of 6. While the patient was waiting for surgery (whipple procedure), he was started on sandostatin 150 mcg SQ bid, to be continued for 2 weeks, followed by long acting sandostatin once every month. However, patient reported severe nausea, vomiting, diarrhea, abdominal cramps after each dose of 150 mcg and was challenged a few days apart with 3 doses. There is no literature to guide management of these patients in terms of strategies for desensitizing patients as sandostatin can cause disease stabilization as well as minimize anesthesia complications during the peri-operative period and ultimately benefit the patient. We attempted a trial of gradually increasing the dose of sandostatin, starting at less than 1/3rd of the recommended dose, at 25 mcg subcutaneously (SQ) twice a day.
Results: As the patient tolerated the dose, it was doubled every 3 days to eventually reach a dose that is within the lower range of recommended for achieving steady state concentrations. Upon reaching the targeted dose of 150 mcg SQ bid, he tolerated it without the intial severe gastrointestinal effects. Following this he was given a long acting sandostatin LAR injection of 20 mg deep intramuscularly, which he tolerated well, with some relief of his flushing as well.
Conclusion: There are no guidelines to manage patients with carcinoid tumors who are unable to tolerate sandostatin. We report a desensitizing strategy that can be useful in such patients and situations where sandostatin is indicated for therapy of tumor (as a disease stabilizing agent) or for control of carcinoid symptoms.
Abstract:
Rebecca Kowalczyk, MD*, Norman Egger, MD. Mayo Clinic, Rochester, MN.
Purpose: A 29 year old female with a history of depression and migraines is hospitalized for evaluation of several weeks of abdominal pain. The patient first presented to the emergency department two weeks earlier with diffuse abdominal pain, nausea and severe anorexia. A pelvic exam was performed and was normal. Urinalysis revealed hyaline and leukocyte casts with no evidence of infection. Her alkaline phosphatase, amylase and lipase were elevated as well. Right upper quadrant ultrasound was negative as was the abdominal CT scan. The patient was released after her abdominal pain and liver enzymes resolved overnight. Symptoms on the day of current admission included diffuse abdominal pain, back pain, anorexia, facial tics, and complex visual hallucinations. Physical exam was significant for diffuse abdominal pain with no evidence of peritonitis. Laboratory analysis revealed an elevated alkaline phosphatase and gamma glutaminase. Urinalysis was positive for 1-3 WBCs, occasional RBCs and granular casts per hpf. It was noted that the urine was peach colored. A 24 hour urine was performed and the patient was found to have marked elevations of porphobilinogen and uroporphyrin, with mild to moderate elevations of heptacarboxyl porphyrin, pentacarboxyl porphyrin, and coproporphyrin. Stool porphyrins were negative and activity of erythrocyte PBG deaminase and ALA dehydratase were normal. The patient was diagnosed with acute intermittent porphyria. She was treated with IV dextrose and IV hemin with improvement of symptoms. She was dismissed with a list of medications to avoid, diet instructions, and strong advice for smoking cessation. Since initial diagnosis the patient has had acute exacerbations about every 3 months since initial diagnosis secondary to narcotic use and continued cigarette smoking. Most recently she was admitted with neurovisceral crisis with respiratory compromise secondary to abrupt discontinuation of Lupron and resumption of her menses. This case reiterates that abdominal pain is a symptom with a broad differential diagnosis which requires exhaustive work up prior to determining the cause is functional. In this patient, had we determined her symptoms were secondary to functional problems we would have missed a life threatening condition. As internists or gastroenterologists we evaluate and treat abdominal pain on a routine basis and it is important to remember that the differential includes not only infectious, inflammatory, and functional etiologies but metabolic abnormalities as well. It is only after a complete history were we able to determine the etiology of her pain thereby avoiding worsening of her symptoms and possible life threatening neurologic compromise.
Abstract:
Advitya Malhotra, MD*, Praveen Guturu, MD, Basim Mohammed, MD, G. Raju, MD. Department of Pathology, Gastroenterology and Hepatology, UTMB, Galveston, TX.
Purpose: 71-year-old Hispanic female patient underwent screening colonoscopy with complaints of recent onset of constipation and weight loss. At the same time an upper endoscopy was done to evaluate for decreased appetite and early satiety. She had significant past medical history for recurrence of breast cancer with diffuse skeletal metastasis 2 years ago after a decade of cancer free period. Currently, she was receiving palliative chemotherapy. On examination, she appeared cachectic and pale. Laboratory examination disclosed normocytic anemia, with a Hb level of 10.5 g/dL (normal range for Hb in our institution is 11.5-15.5 g/dL). Colonoscopy revealed an irregular configuration of the mucosal surface, luminal narrowing, and poor distensibility in the mid-transverse colon (Fig. A). Multiple biopsies were obtained. Histopathologic examination of the biopsy specimen revealed colonic mucosa with metastatic adenocarcinoma, morphologically consistent with lobular carcinoma of breast (Fig. B). EGD revealed thickened gastric folds; multiple biopsies were obtained. Histopathologic examination of the gastric biopsy specimens also revealed metastatic adenocarcinoma from breast. Extrahepatic gastrointestinal metastasis from breast cancer is uncommon. Metastases to the stomach and small bowel from breast cancer are reported to be more frequent than colonic and rectal involvement. Two reviews dealing with metastatic breast cancer have reported the involvement of colon in about 4% of the patients. Lobular carcinoma is the most common histological type of breast cancer that metastasizes to the colon and rectum. It is important to realize that patients with known breast cancer, especially of the lobular type, with vague, nonspecific abdominal signs and symptoms, particularly of an obstructing nature should be endoscopically screened for gastrointestinal metastases.
Abstract:
Adel Daas, MD*, Angel Alsina, MD, Haim Pinkas, MD. Digestive Diseases and Nutrition, University of South Florida College of Medicine, Tampa, FL, Lifelink Healthcare Institute, Tampa, FL.
Purpose: Peribiliary cysts are a poorly recognized and under-reported pathologic entity. They are believed to represent cystic dilatations of obstructed intrahepatic peribiliary glands in the periductal connective tissue. They are more commonly associated with the cirrhotic liver and with polycystic kidney disease. Typically, they are discovered incidentally at autopsy and rarely cause symptoms in healthy individuals. We present a case of a 60 year old patient in general good health presenting with obstructive jaundice and dull right upper quadrant abdominal discomfort. Radiological imaging demonstrated a solitary (7 cm) well-defined, smooth, thin-walled cystic lesion at the porta hepatis. Endoscopic retrograde cholangiopancreatography revealed lack of communication with the biliary tree. Attempted catheter drainage of the cyst yielded incomplete resolution of thecyst. Cyst fluid was negative for any fungal, bacterial or parasitic elements. Cytology was also negative. A wide excision of the roof of the cyst was then performed and the patient's jaundice resolved dramatically. Histologic examination of the cyst wall confirmed the cyst to benign. This case demonstrates an unexpected cause of obstructive jaundice in a patient without underlying hepatobiliary disease.
Abstract:
Richard Johnston, MD*, Marcelo Larsen, MD, Jeffrey Raskin, MD. Gastroenterology, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, FL.
Purpose: Background: A variety of anastamotic changes can occur in the colon after surgical resection, one of the most common of which is benign strictures. We describe a case of a patient who had a sigmoid colon resection 20 years ago and was incidentally found to have a symptomatic mucosal bridge that was transected with a combination of techniques ultimately requiring needle knife. Case Description: A 51 year-old male with hepatitis C and prior sigmoid resection [proportional to]20 years ago secondary to complicated diverticulitis was referred for a surveillance colonoscopy because of a history of previous colon polyps. He also described some bright red blood per rectum which he attributed to hemorrhoids and intermittent constipation associated with abdominal pain. On colonoscopy, the surgical anastamosis was seen at 20 cm from the rectum. In this area there was a thick, fibrotic mucosal bridge traversing the lumen but patent enough on each side to allow the adult colonoscope to pass. A polyp was removed just proximal to this anastamosis. The colonoscopy was completed to the cecum revealing left sided diverticulosis. Because of his intermittent constipation and abdominal pain, we felt that transection of this mucosal bridge might alleviate these symptoms. Technique: Initially, a hot biopsy forceps was used, grasping pieces of the bridge and applying cautery. This being unsuccessful, we decided to try argon plasma coagulation which was successful in partially completing the transection. The transection was then completed using a needle knife. The patient tolerated the procedure well without immediate or long term complications with resulting resolution of his abdominal pain and intermittent constipation. Discussion: A variety of anastamotic changes can be found in a significant number of patients after segmental colon resection. These are usually inflammatory polyps, visible suture or staples, or benign strictures. Strictures associated with a mucosal bridge have been very infrequently reported in the literature and we could find only one report of endoscopic transection of a mucosal bridge. This case illustrates an infrequent sequela of segmental colon resection and successful transection of this bridge with an electrosurgical transection.
Abstract:
Abstract:
Shivangi Kothari, MD*, Sohail Shaikh, MD, Rada Shakov, MD, Robert Spira, MD, Joseph DePasquale, MD, Walid Baddoura, MD. Gastroenterology, Seton Hall University School of Graduate Medical Education, South Orange, NJ.
Purpose: Mesentric lymphangioma is a rare benign cystic tumor of lymphatics of the bowel. It is usually found in the first decade of life and has a female predominance in adults. It differs from other mesenteric and retroperitoneal cysts, as it is proliferative and invasive in nature. It is usually asymptomatic in adults and found on surgery or autopsy. It rarely presents as occult GI bleed and iron deficiency anemia. We present such a patient in whom capsule endoscopy was diagnostic.
Methods: Our patient is a 36 year old female who presented with fatigue, shortness of breath, occassional diffuse abdominal pain, melena and dizziness for 6 months. She denied any nausea, vomiting, hematochezia, NSAID use or family h/o cancer. Labs revealed Hb of 3.7, Hct 12.5, MCV 60.4, Plt 461, WBC 7.2, Iron 2, Ferritin 3, TIBC 367 and positive FOBT x 3. After transfusion of 4 units PRBC, Hb improved to 9.8. Small bowel enteroscopy with biopsies revealed mild antral gastritis, H. pylori negative and normal villous architecture. Colonoscopy was completely normal. Abdominal CT and Small Bowel series showed luminal narrowing and thickening of small bowel loops in left upper quadrant. Patient was given a patency capsule which passed without any complications. Capsule endoscopy revealed a mass like lesion with yellowish - white discoloration with active bleeding in the small bowel. Laparoscopic resection of the lesion showed diffuse dilatation of the mucosal, submucosal and subserosal lymphatics consistent with small bowel lymphangioma. The post operative course was uneventful and patient was discharged.
Results:
Conclusion: Abdominal lymphangiomas are uncommon benign tumors. The mean age at presentation is 2.2 years with a male predominance. Etiology may be benign proliferation of ectopic lymphatics. 95% of lymphangiomas are found in the neck and axilla and very rarely found in the intestine. Clinical presentation include abdominal pain, distention, fever, and vomiting. There may be features of small bowel obstruction or volvulus. In an Australian study of 416 capsule endoscopies, 27 tumors were identified of which only 1 was a lymphangioma. Plain radiography may demonstrate small-bowel obstruction or noncalcified soft-tissue mass. CT and MRI may show multiloculated fluid-filled masses, thickening of the bowel wall and reveal size of the tumor, characteristics of the cyst wall and location. Capsule endoscopy may lead to earlier detection and treatment and an improved prognosis for patients with these neoplasms. The prognosis of lymphangiomas depends on location and extent of the lesion. Complete resection is the treatment of choice and has an excellent prognosis. The recurrence rate ranges from 0-13.6%. Malignant degeneration to a low-grade sarcoma is rare.
Abstract:
Julio Defillo, MD*, Lubin Arevalo, MD, Young Lee, MD, Jennifer Harley, MD, Shobhana Chaudhari, MD. Medicine, NYMC Metropolitan Hospital, NY, NY.
Purpose: We report a 67 year old female that presented with melena and profound anemia that was found to have an actively bleeding ampullary adenocarcinoma by esophagogastruoduodenoscopy (EGD) with biopsy. Endoscopic ultrasound (EUS) was done for local regional staging which showed a T1N0 lesion. The CT of chest, abdomen and pelvis as well as bone scan showed no distant metastasis or lymphadenopathy. Patient, subsequently, underwent pancreaticoduodenectomy and obtained cure with clean surgical margins confirming the T1N0 ampullary adenocarcinoma. Ampullary adenocarcinoma is a malignant tumor arising from ampulla of vater, an anatomic opening of pancreatic and biliary ductal systems to the duodenum. Survival rates are more favorable than pancreatic cancer (1). The most common clinical presentation of ampullary cancer is obstructive jaundice although other symptoms such as weight loss, general malaise and depression are also seen (2). However, Ampullary cancer presenting initially with gastrointestinal bleeding as in our case is uncommon. Ampullary carcinoma accounts for a 0.2-1% of GI malignancies (1, 2). In general the 5-year survival rate is 39-50%. After pancreaticoduodenectomy five-year survival rates range from 64 to 80 percent for patients with T1N0 disease like our case. An early diagnosis was possible in part due to atypical presentation and rapid use of gastrointestinal procedures. This permited a prompt diagnosis, staging and curable treatment. Note that as in our case the EUS for local regional staging is critical prior to comtemplating surgical resection.
Abstract:
Gerson Valdez, MD*, Abhijit Raval, MD, Roger Smalligan, MD, MPH, Christopher Mathews, MD. Internal Medicine Department, ETSU, Johnson city, TN.
Purpose: 1-Describe Localized gastrointestinal histoplasmosis as an unusual cause of lower GI bleeding in patients with HIV.
Methods: A 27 year old male from Guatemala with no PMH admitted with one-month history of hematochezia associated with LLQ abdominal pain, generalized weakness, intolerance to exercise and dizziness. No fever, chills, melena, and change in his weight. PE: BP108/61, HR100 bpm, T[degrees]97.5[degrees], RR 18. HEENT: Pale mucosal membranes, no ulcers, no thrush, Neck supple, no lymphadenopathy, Lungs clear, CVRR, Abdomen soft, NT, no organomegaly. LABS: BUN 17 mg/dl, creat 0.9 mg/dl, Na131, K 3.7, Cl 102, Ca 7.7, TP 7.3, ALB 2.3 gr/dl, AST 34 IU/lt, ALT 20 IU/lt, LDH 159 IU/Lt, Bil: 0.3 mg/dl, AP: 80 IU/dl, Hb 8.8, Ht 26.6%, WBC 4500/mm.sup.3, N: 64%, L: 27%, PLT 336,000/mm.sup.3, CT scan of the abdomen: diffuse periaortic and mesenteric lymph nodes, no hepato-splenic abnormalities, COLONOSCOPY: 2 colonic ulcers at 40 and 50 cms, multiple superficial ulcers, no hemorrhoids, BIOPSY: lymphoid aggregates and yeast morphologically compatible with histoplasma species. positive Elisa for HIV, negative urinary histoplasma Ag, Normal immunoglobulin level, CD4:104. Bone marrow biopsy normal and CT of the chest unremarkable. Patient was started on Amphotericin B with excellent clinical course no further bleeding episodes.
Results: Although gastrointestinal histoplasmosis is considered uncommon, Autopsy studies reveal GI involvement in 70-90% of patients with progressive disseminated histoplasmosis (PDH). Clinical manifestations range from diarrhea, dysphasia, intestinal perforation or obstruction. Gastrointestinal histoplasmosis is an unusual cause of lower gastrointestinal bleeding (LGIB) in AIDS population with only few cases reported. Most common causes of LGIB in AIDS population are CMV colitis, Idiopathic colonic ulcers, hemorrhoids, anal fissure and Kaposi's sarcoma. Our patient had no systemic symptoms at the time of presentation, and had negative urinary histoplasma antigen (which is positive only in 25% cases of localized forms). Although in 23% patients the colonic mucosa is grossly normal (specially inmunocompromised patients), colonic ulcers 0.2-4 cms diameter, with raised borders surrounded by erythema may be found with microscopy revealing lymphohystiocytic infiltrates, histiocytes and fungi inside macrophages, Treatment is with amphotericin B followed by itraconazole.
Conclusion: This case depicts gastrointestinal histoplasmosis as an unusual cause of LGIB in AIDS patients.
Abstract:
Shivangi Kothari, MD*, Nhat Nguyen, MD, Jennifer Brown, DO, Andre Fedida, MD. Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ, Internal Medicine, Gastroenterology, St. Michael's Medical Center, Newark, NJ.
Purpose: Collagenous Colitis (CC) is characterized by chronic watery diarrhea and thickened subepithelial collagen band on histology. It has a female predominance with a ratio of 15:1 to males. Few cases of CC induced by lansoprazole (LPZ) use have been reported. We report a case of collagenous colitis in a male complaining of diarrhea for 4 weeks while on LPZ.
Methods: Our patient is a 56 year old male with PMH of GERD being treated with LPZ for 4 months. He was started on LPZ 40 mg daily and dose was increased to 40 mg PO BID in November 2007. He presented in 2/08 with complaints of watery diarrhea for 4 weeks. He had 8-10 episodes per day, associated with abdominal pain, mild rectal bleeding but denied fever or weight loss. He denied any NSAID use, recent travel, ingestion of raw seafood or ill contacts. Physical exam was benign with unremarkable laboratory & stool analysis. Work up for inflammatory bowel disease was negative. He had a colonoscopy in 11/07 which was only significant for two small polyps, and no colitis. Colonoscopy with biopsies was done at the end of February 2008, which showed mild rectosigmoid colitis. However, the pathology report of the sigmoid colon and rectum biopsies was consistent with collagenous colitis. His LPZ was subsequently stopped. The patient was started on budesonide and within one to two weeks his symptoms improved dramatically. He is scheduled for repeat colonoscopy with biopsies to ensure improvement of CC.
Results:
Conclusion: Microscopic colitis is classified into lymphocytic colitis and collagenous colitis. Pathogenesis of LPZ associated CC remains unclear, although immunologic mechanisms might contribute to its development. Drugs such as NSAIDs, antibiotics, cimetidine, have been suggested to be associated with CC. Recently cases have been reported of LPZ associated CC. Symptoms include chronic watery diarrhea and rarely hematochezia. Linear mucosal defects and friable mucosa may be characteristic colonoscopic findings in patients with LPZ associated CC. According to a recent study, linear mucosal ulcerations were detected on colonoscopy in 78% of cases in the LPZ group. Such ulcerations are possibly associated with NSAIDs but our patient denied any NSAID use. Several theories have been proposed for LPZ-associated CC. Some of these theories are alteration of the composition and pH of colonic secretions triggering an immune response leading to CC, or difference in affinity to proton pump between LPZ and other PPI, which might cause LPZ-associated CC. Treatment includes removal of the offending agent and repeat colonoscopy after resolution of symptoms would reveal whitish linear scars covered by mucosa. Clinicians need to be vigilant for adverse reactions & appropriate use of medications.
Abstract:
Felice Schnoll-Sussman, MD*. Weill Cornell Medical Center, New York, NY.
Purpose: 62 year old male with an extensive medical history including brain chordoma resection, testicular cancer s/p orchiectomy and external beam radiation (XRT), melanoma and diabetes presented 3 years ago with locally unresectable distal esophageal adenocarcinoma. He was treated with chemotherapy and brachytherapy. He represented with a recurrent esophageal mass and as he had already received maximal standard therapy was treated with two cycles of photodynamic therapy. There was significant improvement in mass burden and dysphagia score. He remained essentially asymptomatic for a year and then developed progressive dysphagia. A esophageal stent was placed which dislodged twice and was removed. Shortly thereafter, he presented with melena and iron deficiency anemia. On EGD he now had a diffusely hemorrhagic infiltrative, circumferential mass extending from 30 to 40 cm. Futile attempts at control of the bleeding were made with APC. He became transfusion dependant and over a two week time period required 30 units of PRBC to maintain a hemoglobin of 8. Exploration of palliative treatment options lead to CryoSpray Ablation (CSA Medical, Baltimore, MD) therapy. The entire mass lesion was treated with two 30 seconds spray times of liquid nitrogen. The patient's subsequent course was complicated by a massive aspiration which led to intubation, sepsis and multisystem organ failure. Although he expired one month post CSA he only required one additional unit of blood. Discussion: CSA is an ablative modality that transports low pressure liquid nitrogen through a 7 French catheter via a standard upper scope. In clinical trials, it has been shown to be safe and effective in the treatment of high grade dysplasia and intramucosal carcinoma. It is postulated that cells die from the application of liquid nitrogen due to ice formation within the cell, and subsequent rupture of the cell during the thaw cycle. Additionally, the application of the extreme cold causes the tissue to loose its blood supply which seemed particularly attractive as a treatment option in this patient. Depth of injury correlates with the duration of freeze. In order to reach the submucosal blood supply, the patient's 10 cm long mass was treated with two 30 second sprays of liquid nitrogen. Conclusion: The preliminary evidence gleaned from this case suggests that CSA may be well suited to treat unresectable bleeding tumors in the esophagus. Although a longer follow-up period would be necessary to report extensive effects on transfusion needs, the remarkable reversal of transfusion dependence in this patient argues that CSA may be an effective modality for palliation in these types of diseases.
Abstract:
James Kao, MD*, Eric Shen, MD. Gastroenterology and Hepatology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ.
Purpose: We are reporting a case of segmental arterial mediolysis in a patient with Crohn's disease and chronic abdominal pain.
Methods: Data was obtained from an inpatient visit on the Gastroenterology service at Robert Wood Johnson Hospital, New Brunswick, NJ, in 2008. Studies preformed included: CT scan of the head, abdomen, and pelvis, upper GI (UGI) series, EGD, endoscopic ultrasound (EUS), colonoscopy, capsule endoscopy, gastric emptying study, CT angiogram, and abdominal duplex ultrasound.
Results: A 42-year-old patient with a past history of ileal Crohn's disease with erythema nodosum and small bowel resection presented to our hospital with postprandial nausea and vomiting for 5 months, along with severe diffuse sharp abdominal pain for several weeks. Her abdominal exam revealed diffuse tenderness to palpation. Workup included multiple abdominal CT scans, an UGI series, a colonoscopy, a CT scan of the head, and a capsule endoscopy which were all unrevealing. An endoscopy showed severe H. Pylori-positive diffuse gastritis with prominent rugal folds in the antrum. The results of a gastric emptying study were consistent with mild gastroparesis. An EUS was planned with the intent of performing a celiac plexus block for gastroparesis. However, the EUS revealed an abnormal celiac artery which appeared beaded and tortuous so the procedure was terminated. A CT angiogram with 3-D reconstruction revealed ectasia and beading of the celiac axis, superior mesenteric artery, and bilateral renal arteries which was interpreted as segmental arterial mediolysis. An abdominal duplex ultrasound showed hemodynamically-significant stenosis of the distal celiac axis. The patient was taken to the operating room for stenting of the celiac artery but this was unsuccessful due to technical difficulty. She was eventually discharged on erythromycin which improved her nausea and vomiting. The patient now awaits a repeat attempt at stenting of her celiac artery in the near future.
Conclusion: For patients with unexplained abdominal pain, segmental arterial mediolysis may be considered in the differential diagnosis when other etiologies have been excluded.
Abstract:
Sherif Abotaga, MD*, Madalina Butnariu, MD, Frank Gress, MD, Adam Goodman, MD. Internal Medicine, Staten Island University Hospital, Staten Island, NY, Division of Gastroenterology & Hepatology, SUNY Downstate Medical Center, Brooklyn, NY.
Purpose: A 49 year old female with a past medical history of anxiety and hypothyroidism presented to an outside institution with a complaint of intermittent epigastric abdominal pain and symptoms suggestive of biliary colic. The patient gave a history of having had a cholecystectomy and further workup with a CT scan revealed a common bile duct stone. No other abnormalities were noted except for an incidental finding of mal-rotation of the bowel. ERCP was attempted, but was unsuccessful due to difficulties related to her bowel anatomy. The patient then underwent a Percutaneous Trans-hepatic Cholangiogram (PTC) with successful CBD stone extraction and drainage. Two weeks later she began to complain of fever, cough and some abdominal pain and was started on Ciprofloxin by her primary doctor outside the hospital in attempt to treat what was thought to be pneumonia. Her stent was removed one week after the onset of fever via ERCP. The patient continued to have persistent fever and in addition, began to complain of worsening dyspnea and a dry cough. At this point she was suspected of having pneumonia and bronchodilators along with another antibiotic were started. Due to lack of improvement and persistent fever for four weeks a CT scan of the chest was performed as an outpatient which showed a pulmonary embolism and questionable early formation of a liver abscess. The patient was then admitted to our institution for further workup and care. On presentation, she had a fever of 101.7, tachycardia and hypotension. Except for a fever, the remainder of her physical exam was unremarkable. CT scan of the abdomen with IV contrast revealed an 8 cm lesion in the right hepatic lobe consistent with a neoplasm versus an abscess. In addition, there was thrombosis of the middle hepatic vein with extension into the inferior vena cava and the right atrium. There was also a right lower lung nodule, measuring 2 cm that appeared to have cavitations consistent with a septic embolus. Venous sonography of the lower extremities was positive for a left common femoral deep venous thrombosis. A needle biopsy of the liver lesion was performed with findings consistent with a hepatic abscess. The patient was treated in the intensive care unit with intravenous heparin and antibiotics, and her fever resolved within 24 hours of admission. She was discharged after 10 days of hospitalization on Coumadin and antibiotics. Although portal vein and hepatic vein thrombosis are associated with pyogenic liver abscesses, the extent of thrombosis from the hepatic veins into the inferior vena cava and right atrium, along with a septic pulmonary embolus as a complication to PTC and stent placement has not been reported.
Abstract:
Abstract:
Sohail Shaikh, MD*, Taraneh Soleymani, MD, Chintan Modi, MD, Joseph DePasquale, MD. Gastroenterology, Seton Hall University, South Orange, NJ.
Purpose: Introduction:Case Report:+ lipemic, Lipase 146, Amylase 52 (L/A: 2.8), Triglyceride 2158 (confirmed on dilution), Cholesterol 567, LDL 95, HDL 40, VLDL 432, Ca.sup.2+ 8.9, T. Bili 1.4, Glucose 103 TSH 1.33 and EtoH level <10 CT scan showed inflammation of the pancreatic head and uncinate process with fat stranding, as well as hepatomegaly and fatty liver. No pancreatic calcification, gallstones or biliary dilatation were noted. Amylase, lipase, and triglyceride levels improved with pain medication, NPO, IVF, and fenofibrate. The patient was discharged home in one week with resolution of symptoms. Conclusion:
Abstract:
Otis Stephen, MD*, Brent Neuschwander-Tetri, MD. Gastroenterology & Hepatology, U.C. Davis, Sacramento, CA, Gastroenterology & Hepatology, St. Louis University, St. Louis, MO.
Purpose: Defects in fatty-acid oxidation are generally seen in the pediatric population, characterized by metabolic decompensation during fasting, hypoglycemia, vomiting, encephalopathy, and severe skeletal muscle, heart, and liver dysfunction. The associated mitochondrial deficiencies often lead to microvesicular and macrovesicular hepatic steatosis with subsequent liver failure. Early infant death is common; hence, these disorders are rarely seen in the adult population. We present a rare case of an adult with a mitochondrial enzyme disorder and concurrent hepatitis C, with subsequent rapid acceleration to cirrhosis. Case Report: A 35 year old male was referred to us after work-up of a 5 year history of persistent nausea and vomiting revealed elevated transaminases and hepatitis C, genotype 2. Other symptoms included severe myalgias, episodic confusion, and fasting hypoglycemia. Laboratory studies revealed the following: Total bilirubin 0.8 mg/dl, Alkaline phosphatase 169 U/L, AST 529 U/L, ALT 906 U/L, INR 0.9, glucose 61 mg/dl, aldolase 34.9 IU/L and LDH 329 IU/L. Serologic studies for additional liver disorders were unremarkable. Liver biopsy revealed chronic hepatitis C, grade 2, stage 2, and steatohepatitis. Additional work-up for his symptoms including EGD, colonoscopy, and ultrasound were unremarkable. Metabolic testing revealed reduced carnitine palmitoyl transferase II (CPT II) in cultured skin fibroblasts, consistent with heterozygous CPT II deficiency. He was placed on a low-fat, high carbohydrate diet with some clinical improvement. Interferon therapy for hepatitis C was unsuccessful. He rapidly progressed from stage II fibrosis to cirrhosis within 2 years, subsequently requiring liver transplantation.
Conclusion: We present a patient with a rare deficiency of the mitochondrial enzyme CPT II and concurrent hepatitis C, genotype 2, with steatohepatitis, persistent nausea and vomiting, myalgias, fasting hypoglycemia, occasional encephalopathy, and subsequent rapid progression from stage 2 fibrosis to cirrhosis within two years. CPT II is important in mitochondrial fatty acid oxidation, and deficiency generally results in muscle necrosis. It only rarely presents with hepatic decompensation, except with severe deficiencies. Chronic hepatitis C has a variable rate of progression, but can progress to cirrhosis in as long as 20 years. Macrovesicular steatosis is occasionally seen in hepatitis C, but generally in genotype 3 infections. CPT II deficiency was likely the cause of his emesis and may have contributed to the steatosis and rapid progression to cirrhosis. Subclinical mitochondrial enzyme deficiencies should remain in the differential diagnosis for steatosis and for recurrent nausea and vomiting.
Abstract:
Shivangi Kothari, MD*, Nhat Nguyen, MD, Jennifer Brown, DO, Andre Fedida, MD. Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ, Internal Medicine, Gastroenterology, St. Michael's Medical Center, Newark, NJ.
Purpose: Tuberculous Colitis is a rare manifestation of abdominal tuberculosis (TB). It is located in the ileocecal area in 90% of cases. Since 10/01 a boxed warning is added to infliximab package insert advising physicians to screen for TB before treatment. We report a case of TB colitis in a patient with negative PPD & Crohn's disease after starting infliximab.
Methods: Our patient is a 23 year old Peruvian female who presented with abdominal pain, weight loss, diarrhea & hematochezia. Colonoscopy in 3/07 revealed edematous, friable and inflammed rectosigmoid. Biopsies and Prometheus-7 panel were consistent with Crohn's disease. Biopsy specimens were negative for AFB. She denied any h/o TB or HIV. She was started on Mesalamine with no relief & subsequently started on azathioprine. Colonoscopy in 7/07 showed severe Crohn's colitis in left colon. Infliximab was considered & patient had a PPD test which was negative with completely normal CXR. First dose of infliximab was given in 8/07 & second dose 2 weeks later. 4 weeks after starting infliximab she was hospitalised with high grade fever, diarrhea & abdominal pain. CT scan was negative for retroperitoneal adenopathy or abscesses & showed diffuse colonic thickening. Colonoscopy showed severely worsened pancolitis with biopsies from entire colon positive for AFB. Repeat PPD & CXR remained negative. She denied recent travel, ill contact or cough. She was started on quadruple therapy for possible TB & biopsy PCR confirmed the diagnosis of TB colitis. The patient improved dramatically on TB medications & has gained 20 lbs.
Conclusion: Infliximab is a chimeric monoclonal antibody to TNF-[alpha]. One of its FDA approvals is for treatment of Crohn's disease. From 1998-2001, out of 147,000 patients who received infliximab for RA or Crohn's disease, 70 cases of TB associated with infliximab were reported. The median time to onset from starting infliximab therapy to TB diagnosis is 10 months (1-72 months). TB Colitis can present as ulcerations, stenosis & shortening. It can mimic Crohn's disease making diagnosis difficult. CXR is often normal & 15-20% patients with abdominal TB present with active pulmonary TB. Retracted cecum & asymmetric wall thickening have been reported to be suggestive of TB. Clinicians should be vigilant for TB in patients on infliximab even if pretreatment PPD is negative, especially if risk factors for TB are present. Patients with demographic risk factors, h/o BCG, exposure to TB, GI resection & occupational exposure are at high risk for TB. Currently recommended screening such as risk assessment, tuberculin skin testing and CXR prior to anti-TNF-[alpha] treatment can reduce TB rates by up to 90% but newer screening interferon gamma assays may enhance screening efficacy.
Abstract:
Truptesh Kothari, MD, MS*, Shivangi Kothari, MD, Ahmed Aziz, MD, Mark Korsten, MD. Internal Medicine, J.J. Peters VA Medical Center and MSSM (Bronx) Program, Bronx, NY, Gastroenterology and Hepatology, St. Joseph's Regional Medical Center, Paterson, NJ.
Purpose: Acute pancreatitis is an inflammatory condition of the pancreas characterized clinically by abdominal pain and elevated levels of pancreatic enzymes in the blood. Various etiologies have been responsible for pancreatitis with alcohol and gallstone, as the leading cause. Studies have proven that HIV patients with CD4 less than 100, prone to opportunistic infections or HAART medication, are responsible for pancreatitis. Opportunistic infections include CMV, Cryptosporidium, Mycobacterium Avium-Intracellulare (MAI). We present a patient with AIDS, having elevated amylase, lipase, diagnosed with acute pancreatitis, due to MAI infection as the pancreatitis resolved after the treatment of MAI.
Methods: A 45 Year old Afro-American male with PMH of HIV (recently diagnosed, CD4-2, never on HAART medications), presented to the ER with fever, dizziness and lethargy. On examination, he was found to have hepatomegaly. Lab values showed Hb: 8.8 gm/dl with microcytic indices. Alkaline phosphatase: 1271, GGTP: 3870, Direct bilirubin: 1.5 and amylase, lipase and hepatitis serology was negative. Imaging studies were suggestive of hepatomegaly and a non-homogenous spleen. Cryptococcal Ag: negative, CMV-DNA (IgM) by PCR: negative, PPD: negative. Stool for Cyclospora, Isospora, CMV: negative. A liver biopsy was negative for fungal growth and acid fast bacilli. Tissue was sent for MAI culture and sensitivity. Meanwhile the patient developed fever, a tender abdomen and increase in amylase, lipase and bilirubin (to 20 mg/dl). ERCP and MRCP demonstrated irregular intrahepatic ducts with small stones in the CBD. The patient was started on empiric MAI treatment with ethambutol - clindamycin. Within 10 days of treatment, there was significant improvement in the clinical condition as well as laboratory values. After 4 weeks of treatment, bilirubin levels in addition to amylase, lipase returned to near normal values. Ultimately, after successful treatment with empiric antibiotics, the MAI cultures were reported as positive.
Conclusion: Thus as per the AGA guidelines, patients with first attack of pancreatitis should be evaluated with detailed history, examination, initial amylase, lipase, and abdominal ultrasound. If the etiology is still not clear, abdominal CT scan and Endoscopic ultrasound should be pursued. After all investigations, if the etiology is still unclear, rare causes should be considered especially in immunocompromised patients. Treatment is more etiology based with intravenous hydration and pain control. Mortality rate are very high in the first two weeks due to systemic inflammatory response syndrome with organ failure. Hence, rare etiology should always be considered in immunosuppresed patients with acute pancreatitis.
Abstract:
Parantap Gupta, MD*, Advitya Malhotra, MD. Gastroenterology and Hepatology, Internal Medicine, UTMB, Galveston, TX.
Purpose: A 41-year-old man with AIDS underwent endoscopy to evaluate dyspepsia and intermittent hemetemesis for 3 months. His last CD4 count was <50. He had been off anti-retroviral therapy for one year period. On physical examination, purplish nodular lesions were seen on his chest. Otherwise rest of the examination was unremarkable. Laboratory work-up revealed normocytic anemia. A sessile gastric polyp along with patchy gastritis was noted on esophagogastroduodenoscopy (Fig. A). Polypectomy was performed. Histopathologic examination demonstrated submucosal whorls of spindle-shaped cells with leukocytic infiltration (Fig. B). Immunostains for CD31 and CD34 were diffusely and strongly positive, confirming the diagnosis of Kaposi's sarcoma. Kaposi's sarcoma (KS), the most common tumor arising in HIV-infected persons, is a low-grade vascular tumor associated with human herpes virus 8. The gastrointestinal tract is involved in approximately 40 percent of patients with KS at initial diagnosis, and involvement can occur in the absence of skin involvement. The presentation could vary from being an asymptomatic finding on endoscopy (isolated or confluent hemorrhagic nodules) or present with weight loss, abdominal pain, nausea, vomiting, GI bleeding, malabsorption, intestinal obstruction, or diarrhea.
Abstract:
Susan Barton, MD*, Vandana Nehra, MD. Department of Gastroenterology, Mayo Clinic, Rochester, MN.
Purpose: 60-year-old female presented for further evaluation of a large mesenteric cyst noted incidentally on routine abdominal CT scanning performed during a preoperative evaluation for elective kidney donation. Clinically, she denied gastrointestinal symptoms. Past medical history was significant for recurrent episodes of diverticulitis, and hyperlipidemia. No prior history of pancreatitis. No significant family history of malignancy. Past surgeries included a transabdominal hysterectomy and three caesarean sections, all greater than twenty years prior to the current presentation. She reported two motor vehicle accidents in the remote past associated with unspecified abdominal trauma, managed conservatively. Labs showed normal hemoglobin, electrolytes, TSH, and liver function tests. Abdominal CT scan showed a 6.7 x 2.6 multilobulated, septated cystic lesion at the mesenteric root, inferior to the third portion of the duodenum, interpreted as a mesenteric cyst or potentially enteric cyst. The patient underwent endoscopic ultrasound guided biopsy of the mesenteric cyst. Cytology from multiple fine-needle aspirates was negative for malignancy, but showed abundant histiocytes and chronic inflammation. No epithelial cells were present. Approximately 10 cc of milky yellow fluid was aspirated from the cyst. CEA and CA 19-9 levels from the cyst fluid were unremarkable, but revealed elevated cholesterol and triglycerides, 256 mg/dL and 1131 mg/dL, respectively, consistent with a mesenteric chylous cyst. Discussion Mesenteric cysts are rare and frequently cause abdominal pain, distension, or intestinal obstruction due to the mass effect. Chylous mesenteric cysts, notably, are exceedingly rare with few case reports in the literature. Constitutional symptoms of malaise, fatigue, fever, and weight loss may develop though are infrequent. Mesenteric cysts are often large in size, cause acute or chronic symptoms, though have a very low malignant potential and associated morbidity. Underlying etiologies include congenital malformations and scarring of the mesenteric lymphatics due to chronic inflammatory states e.g. mesenteric panniculitis. Cysts are generally unilocular though may present with multiple loculations and, most importantly, lack solid components. Surgical excision is the recommended therapy in clinically symptomatic patients. Cyst drainage alone is not recommended, due to the high frequency of recurrence. Given the absence of clinical symptoms in this case, a conservative approach with observation was recommended.
Abstract:
Adel Daas, MD*, Prasad Kulkarni, MD. Division of Digestive Diseases and Nutrition, University of South Florida, Tampa, FL, James A Haley Veterans Affairs Hospital, Tampa, FL.
Purpose: Gastrointestinal luminal foreign bodies are frequently encountered by practicing gastroenterologists. Common causes of GI tract foreign bodies include ingestion, self-insertion and iatrogenic placement of objects inside the GI tract or those that have migrated from adjoining organ systems. Management of these is oftentimes a challenging endeavor. Given the popularity of minimally invasive surgery utilizing polyproplylene mesh for inguinal hernia repair, related complications such as organ injury and infection are increasingly noted. Contrarily, mesh migration has been rarely reported. We report a case of delayed mesh migration into the cecum in a 76 year old male veteran who underwent laparoscopic bilateral inguinal hernia (TEP) repair with bilateral mesh placement in 1996. In November 2004, the patient developed right lower quadrant abdominal pain. Physical examination was unremarkable. CT imaging of the abdomen revealed mass-like infiltration of the post-surgical site in the right inguinal region. Colonoscopy was performed revealing mesh-like foreign material protruding into the cecum. Given his surgical history, this was consistent with migration of surgical mesh into the cecum. The patient was referred for surgical exploration and extensive post-surgical scarring was evident requiring a right hemi-colectomy with removal of the mesh. The post-operative course was uneventful and the patient did well at follow-up.
Conclusion: This case illustrates an unexpected yet possible late complications related to inguinal hernia mesh repair.
Abstract:
Ravi Kurella, MD*, Lilah Mansour, MD, Stan Lightfoot, MD, John Maple, DO, Richard Harty, MD. Primary Care, VA Medical Center, Oklahoma City, OK, Pathology, Gastroenterology, OUHSC, Oklahoma City, OK.
Purpose: Langerhans' cell histiocytosis (LCH) is a granulomatous disorder of unknown cause. It is characterized by overproduction and accumulation of dendritic cells in granulomatous lesions in various tissues and organs of the body. It most often affects the bony skeleton and skin. Involvement of the lungs, liver, spleen, lymph nodes, pancreas and pituitary has been reported. Gastrointestinal involvement in Langerhans cell histiocytosis is rare and usually is associated with severe systemic illness. LCH presenting in a colon polyp has not been described before. We present a case of LCH isolated to the colon polyp with no involvement of other organs including skin and bones. Case report: 60 year old otherwise health white male underwent colonoscopy for heme occult positivity. He denied any gastrointestinal symptoms including nausea, vomiting, diarrhea or abdominal pain. He denied any skin rashes on bone abnormalities. His chronic medical problems included nicotine dependence, insomnia and hypercholesterolemia. He did have some knee pain which was attributed to old ligamental injury and arthritis. His routine investigations including complete blood count and serum chemistries were within normal limits. A colonoscopy was performed for further evaluation. On colonoscopy four sessile polyps were found in the ascending colon. The polyps were 3-5 mm in size. These polyps were removed with a cold forceps. Histopathology revealed granulomas in the lamina propria composed of numerous eosinophils and fibroblasts. Both AFB and fungal stains were negative. The S-100 and CD 1A stains were positive establishing the diagnosis of Langerhans cell histiocytosis. Whole body bone scan done for skeletal involvement was normal. A CT scan of the chest performed for pulmonary involvement was negative. Since polypectomy was complete and no other organs were involved a watchful waiting approach was determined to be optimal at the present time. Conclusion: Langerhans cell histiocytosis is rare in adult population (1-2/million). Skeletal involvement with bone pain, pulmonary involvement with dysnea and diabetes insipidus secondary to pituitary involvement are more common forms of presentation in adults. Involvement of gastro-intestinal tract is extremely rare. To our best knowledge this is the first ever reported case of Langerhans cell histiocytosis confined to colon polyps without any radiological evidence of skeletal involvement or any other systemic involvement.
Abstract:
Yuriy Tsirlin, MD*, Young Lee, MD, Susan Ramdhaney, MD, Michael Zelenetz, MD, Gerold Fruchter, MD, Frank Gress, MD. Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY, Gastroenterology, VA NY Harbor Healthcare System, Brooklyn Campus, Brooklyn, NY.
Purpose: A 74 y/o veteran with ESRD on HD was found to have a 4.5 cm lesion in the gastric wall on a non contrast CT scan of abdomen done to evaluate a suprapubic catheter site for infection. The patient had no GI complaints. Subsequent EGD revealed a submucosal lesion in the proximal body of the stomach measuring approximately 4 cm. EUS was done and identified a 3.7 by 5 cm subepithelial complex lesion with anechoic components arising possibly from the 4th EUS layer; suspicious for GIST. FNA was not done due to coagulopathy. Repeat EGD with EUS was performed 10 days later for FNA; previously seen lesion could no longer be identified, by EUS or by direct visualization. Repeat CT with IV contrast confirmed absence of previously seen lesion but revealed evidence of necrotizing pancreatitis. Unfortunately, the patient decompensated further and expired. Discussion: Lesions, often referred to as submucosal, are fairly common findings on upper endoscopy and usually seen as a bulge, mass, or impression within gastric lumen that is covered by normal appearing epithelium. These lesions are more correctly termed subepithelial since they may arise from layers other then histological submucosa or may even be from extrinsic compression by a number of intra-abdominal structures, normal and abnormal. Approach and management of these lesions are in evolution and varies depending on availability of resources and technical expertise. Differential diagnosis for subepithelial lesion is broad and includes extrinsic compression due to pancreatic pseudocyst. It has been well known that pancreatic pseudocyst may regress or self-decompress on its own. There has been reported case of a pancreatic pseudocyst mimicking as a subepithelial lesion on endoscopy and CT scan, which regressed spontaneously with conservative management. Given the subsequent findings of necrotizing pancreatitis on CT with IV contrast and complete disappearance of the subepithelial lesion in this presented case the subepithelial lesion thought to be originating from one of the gastric layers was in actuality a pseudocyst, which then decompressed into the stomach lumen.
Conclusion: Gastric subepithelial lesions are a common finding in endoscopy with a broad spectrum of differential diagnosis. Fortunately, with recent advances in imaging and EUS, these lesions are becoming easier to image and diagnose. However, clinicians should be aware of limitations of EUS. FNA in conjunction with EUS is crucial in initial assessment of these subepithelial lesions.
Abstract:
Michael Windham, MD*, Sufiyan Chaudhry, MD. Gastroenterology, University of Tennessee, Memphis, TN.
Purpose: INTRODUCTION Common Variable Immunodeficiency (CVID) occurs secondary to failure of B-cell proliferation resulting in low levels of immunoglobulin. We present an unusual case of CVID which initially presented with findings suggestive of celiac disease. CASE A 38 y/o female presented to our facility with complaints of diarrhea, intermittent abdominal pain, nausea, vomiting, and myalgias for 6 months. Also she reports weight loss of 50 pounds. According to the patient's history, she was diagnosed with celiac disease four months ago, and initially responded to a gluten-free diet. On presentation, she was afebrile, hypotensive and tachycardic. Clinical examination revealed diffuse, abdominal tenderness to palpation without guarding or rebound. Examination of skin was normal. Esophagogastroduodenoscopy (EGD) showed duodenitis and benign gastric mucosa. Histological examination of small bowel and gastric biopsy specimens revealed marked active enteritis with villous atrophy, and intraepithelial lymphocytosis and lymphocytic gastritis. Her IgA tissue transglutaminase and IgA AGA were normal. Colonoscopy showed active inflammation in the terminal ileum and pancolitis with rectal involvement. Histological examination of her colonic mucosa was normal. The diagnosis of celiac disease was reconfirmed on the basis of endoscopic and histiological findings. Diarrhea improved on discharge after treatment with Lomotil. After initial improvement, her symptoms returned. A repeat EGD with small bowel biopsies and a surgical laparotomy with mesenteric lymph node and small bowel biopsy were performed. The biopsy of the mesenteric lymph node showed aggregates of B-cell corresponding to follicles seen on hematoxylin and eosin-stained with T-cells in paracotical region. Flow cytometry of lymph node showed no evidence of clonal B-lymphocyte population or aberrant T-cell antigen expression. Small bowel biopsy displayed marked intraepithelial lymphocytosis with near-total villous atrophy and lymphocytic gastritis. HLA DQ2 and DQ8 were obtained which were negative. Patient did not have celiac disease. Additionally, Allergy and Immunology further evaluated her hypogammaglobunemia, ordering immunoglobulin levels as well as T and B cell enumeration studies as well as mitogen stimulation with lymphoblastic transformation studies. This data showed markedly decreased levels of IgG, IgA, and IgM. These findings along with the aforementioned tests were used to confirm a diagnosis of CVID. DISCUSSION Similarities between these two clinical entities may lead to an inappropriate diagnosis with associated morbidities.
Abstract:
Touraj Zolfaghari, MD*, Mohamad Erfani, MD, Pramod Joseph, MD, Hilary Hertan, MD, FACG, Nejat Kiyici, MD, FACG, Aaron Feliz, MD. Gastroenterology, Our Lady of Mercy Medical Center, Bronx, NY, Pathology, Our Lady of Mercy Medical Center, Bronx, NY.
Purpose: Sodium polystyrene sulfonate is a cation exchange resin, which primarily acts in the colon. It is often administered with an osmotic laxative (sorbitol), PO or rectally. Gastrointestinal adverse reactions include anorexia, nausea, vomiting, constipation, fecal impaction, and intestinal necrosis (rare). Here we present an uncommon case of ulceration of the ascending colon following multiple oral administrations of sodium polystyrene sulfonate-sorbitol.
Methods: A 70 yo♀ was admitted with urinary tract infection and pre-renal azotemia. She received 5 oral doses of Sodium polystyrene sulfonate-sorbitol for hyperkalemia and later developed lower abdominal pain. Colonoscopy revealed a solitary 5 cm raised erythematous ulcer in the ascending colon (Fig. 1). Biopsy showed necrotic tissue and purple crystals in inflammatory exudates (Fig. 2). Patient's symptoms were improved spontaneously after discontinuation of therapy.
Results: Colonoscopic and pathologic findings were consistent with Sorbitol induced colitis. First case of uremia and colonic necrosis after sodium polystyrene sulfonate-sorbitol enema was reported in 1987. A study in a rat model has shown that sorbitol is in fact the cause of the intestinal necrosis. The exact mechanism by which sorbitol induces intestinal necrosis is unknown.
Conclusion: Sorbitol induced colitis is a rare condition which may have significant morbidity and mortality. Considering the adverse reactions, this therapy must be used with caution and should be limited to life-threatening hyperkalemia. Physicians must remain vigilant for any signs or symptoms of intestinal problems.
Abstract:
Alastair Smith, MB, ChB*, Anand Lagoo, MD, PhD, John Perfect, MD. Pathology, Medicine, Duke University Medical Center, Durham, NC.
Purpose: Hodgkin's disease (HD) is a malignant B cell lymphoproliferative disorder. Fever, night sweats and weight loss are the clinical hallmarks; painless, palpable lymphadenopathy and hepatosplenomegaly are typically present on examination. Reported hepatic involvement varies from 14-50% depending on whether this determination is made on clinical grounds or at autopsy. However, even though liver infiltration may be relatively common, it is very rarely the predominant clinical feature. Features consistent with primary sclerosing cholangitis (PSC) are very uncommon indeed.
Methods: We describe an elderly man in whom the diagnosis of HD was made only at autopsy, in part because the clinical course latterly suggested underlying primary cholestatic liver disease.
Results: A 78 year-old man complained of persistent fever of five months duration prior to assessment here. No additional localizing symptoms were present then. Moreover, liver tests were normal, but as the illness progressed his alkaline phosphatase (ALP) increased progressively. Such was the severity of symptoms that hospital management was necessary on two occasions, one and two months after onset of the illness. Multiple investigations were undertaken: other than elevation of his sedimentation rate and C-reactive protein, repeated cross-sectional imaging studies including echocardiography, bi-directional gastrointestinal endoscopy with mucosal biopsy and numerous cultures of blood, urine, stool and sputum yielded normal or negative results respectively. Bone marrow assessment was normal: culture demonstrated no infection and histology was unremarkable. Shortly before assessment here liver biopsy was undertaken on the basis of increasing total serum bilirubin (8.2 mg%) and ALP (1016 U/L) concentrations, and a weakly positive mitochondrial antibody titer (1:40). This demonstrated expansion of portal triads with lymphocytes and non-caseating granulomata, occasional plasma cells and eosinophils. In some portal tracts inflammation was clearly centered on bile ducts resulting in injury and cholangiolar proliferation. Endoscopic cholangiography revealed widespread intra-hepatic bile duct stricture formation and dilatation consistent with PSC. In the absence of overt infection prednisone was added to ursodeoxycholic acid. Some improvement accrued, but the patient died several weeks later. Autopsy confirmed the diagnosis of HD.
Conclusion: This man's early clinical course was consistent with HD, despite the absence of lymphadenopathy. However, neither the liver biopsy findings nor the cholangiogram confirmed the diagnosis, leaving uncertainty as to the best course of action. The case serves as a reminder that despite age and atypical clinical features HD cannot be overlooked.
Abstract:
Payal Patel, MD*, Asif Zamir, MD, FACG, Muhammed Nathani, MD, FACP, FACG. Gastroenterology, kelsey-Seybold Clinic, Houston, TX, Internal Medicine, Baylor College of Medicine, Houston, TX, Internal Medicine, RAHC, Harlingen, TX.
Purpose: INTRODUCTION: Primary Pneumatosis Intestinalis (PI) is a rare clinical entity. It is often termed as pneumatosis cystoides intestinalis. It is a benign idiopathic condition characterized by multiple thin-walled cysts in the submucosa or subserosa of the colon. It is usually identified on abdominal x rays or CT scans. The identification on routine screening colonoscopy is extremely rare. We present a case where PI was identified as an incidental finding in an asymptomatic patient. CASE: This is a case of a 60 year old male with past medical history of hypertension and type II Diabetes. He presented for a routine screening colonoscopy. He did not have any acute GI symptoms. His bowel prep was uneventful. The colonoscopy suggested multiple large cystic lesions in the transverse and the proximal descending colon. These lesions appeared to be submucosal and 5-10 cm in sizes. The mucosa was shiny and cysts appeared to be air-filled. The patient did not have any significant gastrointestinal symptoms after the colonoscopy. He had a CT scan performed 3 days later which was normal suggesting spontaneous resolution of the cystic lesions. No obvious etiology was identified to explain the findings. DISCUSSION: PI in adults typically presents in the fifth to eighth decade and is idiopathic/primary (15 percent) or secondary (85 percent) to a wide variety of gastrointestinal and non-gastrointestinal illnesses. PI is considered an ominous finding in ischemic bowel disease. The disease is seen in other conditions, including chronic obstructive pulmonary disease, connective tissue disorders, infectious enteritis, steroid use and chemotherapy. It has also been reported after colonscopy, instrumentation and trauma. The treatment of Primary PI is conservative management. The secondary PI is often a serious illness and requires treatment of the underlying disease. The authors have done over 30000 endoscopies and this is the only case of coincidental asymptomatic pneumatosis intestinalis CONCLUSION: Pneumatosis Intetinalis is a sign rather than a disease. It is usually a result of serious underlying abdominal catastrophe. The idiopathic PI is less common and usualy recognized on imaging studies. The diagnosis on routine endoscopy is extremely rare and the treatment is usually conservative.
Methods: N/A
Results: N/A
Conclusion: N/A
Abstract:
Payal Patel, MD*, Angela McGee, MD, Muhammed Nathani, MD, FACP, FACG. Gastroenterology, kelsey-Seybold Clinic, Houston, TX, Internal Medicine, Baylor College of Medicine, Houston, TX.
Purpose: INTRODUCTION: Portal vein thrombosis is a very rare complication of gastric bypass surgery. We present a case of a young lady who presented with post-operative portal vein thrombosis leading to complications of portal hypertension and causing cavernous transformation of portal venous system. CASE: This is a 37 year old Caucasian woman with past medical history of obesity, congenital absence of right kidney and endometriosis. She underwent a Roex-en-Y gastric bypass surgery. A couple of weeks later, she presented with abdominal pain. Initially, there was suspicion of pancreatitis but was not confirmed. She was later diagnosed with portal vein thrombosis. Coagulation studies were negative. She was placed on warfarin and did well for several months. She then presented with acute gastrointestinal bleeding, anemia and thrombocytopenia. She required urgent upper endoscopy. There were multiple large esophageal varices identified and endoscopic band ligation (EBL) was performed. Ultrasound and CT scan suggested ascites, splenomegaly and nodular liver. There was an initial concern for possible cirrhosis. Liver biopsy was performed using a transjugular approach. The biopsy suggested minimal iron overload with no evidence of cirrhosis. The Doppler study was non diagnostic. Angiographic evaluation of portal system was performed suggesting thrombosis of splenic vein, portal vein and superior mesenteric vein with cavernous transformation of portal system. The surgical options were limited. Since then, she has been managed with beta blockade and periodic EBL. She has not had any further bleeding episodes in the last 6 months. Her ascites has resolved but thrombocytopenia and splenomegaly have persisted. DISCUSSION: Portal Vein thrombosis is an extremely rare complication of gastric bypass surgery. The database is very limited in terms of management and prognosis of patients with portal vein thrombosis after bariatric surgery. The portal vein thrombosis may be related to intra-operative injury to portal vein or may present post-operatively. The former is a life threatening complication and may require liver transplantation. The post-operative portal vein thrombosis without portal vein injury has a relatively benign course. However, our patient progressed to complications of portal hypertension with limited surgical options available for treatment. CONCLUSION:In summary, this is a case of a patient with an unusual complication of bariatric surgery. She presented with portal vein thrombosis, eventually developing stigmata of portal hypertension. With an increase in the number of bariatric surgeries, we may be able to characterize and recognize unusual complications and come up with treatment modalities.
Methods: N/A
Results: N/A
Conclusion: N/A
Abstract:
Ehi Osemobor, MD*, Rohit Jindal, MD, Michel-Jose Charles, MD. Department of Medicine, Division of Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY, Department of Medicine, Division of Gastroenterology, Brookdale University Hospital Medical Center, Brooklyn, NY.
Purpose: Mantle cell lymphoma of the colon is a rare entity and reported only in isolated case reports. It is known to comprise less than 0.2% of primary malignant turmors of the colon. We present a case of mantle cell lymphoma of the colon with lymphomatous polyposis and involvement of the brain and orbits. CASE: A 70 year old man, originally from Panama, who had migrated to United States at 33 years of age, with no significant past medical history, presented with a weight loss of 30 pounds over one year. The patient denied history of fever, chills, night sweats, abdominal pain, gastrointestinal bleeding, cough, shortness of breath or chest pain. On physical exam, there was marked proptosis, no lymphadenopathy and unremarkable abdominal exam. Labs revealed anemia with no iron deficiency. Colonoscopy revealed multiple polyps in the ascending, transverse, descending and sigmoid colon, and biopsies were suggestive of mantle cell lymphoma. Immunophenotype was CD5+, CD 20+, CD 43+, CD 23-, also BCL1+ consistent with mantle cell lymphoma. Flow cytometry showed CD 19+, CD 20+, CD5+, CD 38+ and CD 23-ve. EGD showed antral gastritis with intestinal metaplasia. MRI of the brain revealed multiple lesions in the brain and orbits. Bone marrow examination revealed no involvement with the lymphoma. The patient was started on chemptherapy with Rituximab, Adriamycin, Vincristine and Cyclophosphamide and survived for 8 months after diagnosis. Mantle cell lymphoma of the colon is a rare malignancy which may present as a solitary colonic nodule or as lymphomatous polyposis as in our patient. The current treatment approach for mantle cell lymphoma of the colon is still unsatisfactory and experimental chemotherapies are under investigation.
Abstract:
Vijaya Dasari, MD*, Venkatasubbaraya Achanta, MD. Internal Medicine, The Mount Vernon Hospital, Mount Vernon, NY.
Purpose: A thirty two year old African American female presented to the hospital with intermittent nausea for two months. Nausea is not associated with vomiting, changes in appetite or bowel habits. It is unrelated to food intake or diurnal variation. She presented to the emergency room twice in the past two months where she was treated symptomatically with intravenous metoclopromide. Labs then revealed mildly elevated liver enzymes and ultrasound of the abdomen did not show any cholelithiasis. This visit she complained of mild, non-radiating right lower quadrant pain with no aggravating or relieving factors. There is no history of headache, dizziness, palpitations, heat or cold intolerance and weight loss. She has no known food or drug allergies and denies social habits. Physical examination and vital signs are normal. Admission labs revealed mildly elevated liver transaminases and negative beta-hCG. Ultrasound abdomen and hepatitis profile was normal. CT scan of the abdomen and head were unrevealing. Later thyroid function tests showed markedly raised tri-iodothyronine, thyroxine and absent thyroid-stimulating hormone. Thyroid uptake scan showed increased uptake in both lobes consistent with Grave's disease. Symptoms improved after starting methimazole and propranolol. Her liver enzymes also normalized within a month after discharge from the hospital. Discussion: Nausea is a common presenting symptom in pregnancy, gastrointestinal, central nervous system, metabolic, infectious and psychiatric disorders, and medication side effect. Review of literature revealed that nausea, vomiting and abdominal pain are rare presenting complaints in hyperthyroidism. It is hypothesized that altered gastric motility or failure of the pyloric sphincter to function properly due to excess thyroid hormone might be the cause and also these toxic substances could be triggering the emesis center. But mechanisms causing these symptoms are yet to be identified. Thyrotoxicosis has also been implicated as a causative factor in hyperemesis gravidarum. Our case is unique, as the patient had no other signs and symptoms of hyperthyroidism except for nausea, abdominal pain and mildly elevated liver enzymes. Conclusion: Nausea, vomiting and abdominal pain are unusual presentations of thyrotoxicosis. We emphasize the importance of including thyroid function tests in the evaluation of patients with prolonged, unexplained gastrointestinal symptoms. Low threshold for this diagnosis had even led to unnecessary laparotomy in some cases. One must have high index of suspicion about the varied clinical manifestations of hyperthyroidism to improve the timeliness and cost effectiveness of the diagnosis in these conditions.
Abstract:
Murthy Muthuswamy, MD*, Zhenrong Zhang, MD, Eugene Stueben, MD. Internal Medicine, LSU HSC - University Medical Center, Lafayette, LA.
Purpose: We present a rare case of a gangliocytic paraganglioma (GP) in the common bile duct causing painless, obstructive jaundice.
Methods: Case Report
Results: A 71 year old female presented to the emergency room with a history of fluctuating jaundice with loose bowel movements for 8 weeks. Initial evaluation several weeks prior with ultrasound and abdominal CT were unremarkable. She denied most other symptoms including fever, chills, pain and bleeding. She did have a past history of breast cancer treated with lumpectomy and radiation. Physical examination showed scleral icterus and jaundice, but a benign abdominal exam. Laboratories were significant for a mild elevation in the CA 19-9 (114), normal CEA, total bilirubin of 11.5, Alkaline Phosphatase 42, INR 1.92, Albumin 1.8. A repeat ultrasound revealed evidence of a dilated common bile duct (12 mm) and intrahepatic biliary dilation. The patient underwent an endoscopic retrograde cholangiopancreatogram which revealed a 2 x 3 cm polypoid mass involving the distal common bile duct just above the intrapancreatic portion approximately 2-3 cm proximal to the ampulla. Brushing was performed for cytology, but this returned negative. A sphincterotomy with billiary stent placement was performed. The patient's jaundice improved substantially subsequent to this. CT and MR - cholangiogram of the abdomen showed a smooth soft tissue density in the common bile duct. There was still high suspicion for malignancy, so she then underwent an exploratory laparotomy. Cholecystectomy, common bile duct exploration and resection of the intra and extrahepatic common bile duct were performed, along with regional portal lymphadenectomy and a Roux-en-y choledochoduodenostomy. The specimen did show evidence of acute and chronic cholecystitis. The common bile duct revealed a 2.5 x 2 x 3 cm ulcerated polypoid mass. Microsocpic examination showed nests of ganglionic cells with enlarged densely hyperchromatic nuclei, some of which were multi-loculated, all compatible with gangliocytic paraganglioma. All other pathology specimens revealed no evidence of tumor. On follow up two months and eight months after surgery, the patient was doing well, without any further jaundice or symptoms.
Conclusion: GPs are rare tumors first described in 1962. The duodenum is the most common site for GPs. Gastrointestinal bleeding and abdominal pain are common presenting symptoms. Its usual endoscopic appearance is as a submucosal mass, often resulting in negative mucosal biopsies. These neoplasms are largely benign in clinical course, although a few cases of regional lymph node metastases have been noted. A review of the literature shows 4 cases similar to ours where the GP originated in the biliary system.
Abstract:
Patricia Kozuch, MD*. Gastroenterology/Internal Medicine, Thomas Jefferson University, Philadelphia, PA.
Purpose: Two 23 year-old women with histories of necrotizing enterocolitis (NEC) subsequently developed Crohn's disease (CD). The first had significant small bowel and colon resection as an infant; she required hyperalimentation until age 4. She was well until age 10, when she presented with abdominal pain and was found to have ileal CD. Her course was complicated by perirectal abscess/fistula treated with incision and drainage and later a fibrin plug. Past medical therapy for CD has included 5-ASAs and antibiotics; 6-mercaptopurine was recently initiated to treat mild active ileal disease and a small rectovaginal fistula. The second patient underwent extensive small bowel resection as an infant and 1 year of enteral tube feeding. She was well until age 19, when she developed diarrhea, nausea and weight loss, and eventually diagnosed with ileal CD: 5-ASA and steroids were not helpful. Adalimumab was initiated with good effect for several months but was stopped after miscommunication with her doctor. One month later, the patient presented with clinical and radiographic small bowel obstruction: surgical exploration revealed [proportional to] 130 cm of intact small bowel with two distal ileal strictures and an inflammatory mass; [proportional to] 10 cm was resected and a primary ileocolonic anastomosis performed. Post-operatively, she has been in clinical remission for 7 months; adalimumab was reinstituted given her previous response and the serious potential consequence of short-gut syndrome with a future flare and/or surgery. A colonoscopy 6 months after surgery showed minimal inflammation at the anastomosis. NEC is the most common life-threatening gastrointestinal disorder seen in neonates. The distal small bowel and proximal colon are usually involved, with extensive neutrophilic infiltrate and hemorrhagic necrosis seen on pathology. While the pathogenesis appears multifactorial, 90% of NEC cases occur in premature infants: intestinal ischemia combined with luminal antigen exposure during enteral feeding are key putative events. TNF-[alpha] is an important inflammatory mediator and potent vasoconstrictor which has been implicated mechanistically in both NEC and CD. Further, failure of enteric glial cells (EGC) to appropriately respond to ischemic injury has been demonstrated in NEC, and disruption of the EGC network in CD may increase mucosal permeability and vascular dysfunction. These possible links in the pathogenesis of NEC and CD coupled with the above two cases of CD post-NEC are compelling arguments for further study to delineate the commonalities between these two diseases.
Abstract:
Mitchell Mah'moud, MD, FACG*, Mark Anderson, MD, Robert Schellenberg, MD, Allison Taylor, MMS. Section of Digestive Diseases, Boice-Willis Clinic, Rocky Mount, NC, Section of Digestive Diseases, Duke University Medical School, Durham, NC.
Purpose: Background:Portal hypertension (PTHN) is a condition characterized by increased portal pressure due to underlying hepatic, nonhepatic, cirrhotic or noncirrhotic disorder. Direct consequences of the PTHN is formation of varices with some contribution from the local anatomic factors. Bleeding from ruptured esophageal and gastric varices which may be explained on the basis of Laplace's Law is the main complication of this condition. Despite the advances in the management, mortality from acute variceal bleeding remains still high, thus the need for early diagnosis and treatment of the etiology of the PTHN. In this clinical vignette, we present a case of congenital hepatic fibrosis (CHF) as a rare cause of recurrent variceal hemorrhage. Case Report:Patient is a 31 year old lady with history of stroke due to ruptured intracerebral aneurysm at age 13 without any neurologic deficit who was doing well until few weeks before her initial consultation when she experienced recurrent episodes of UGI bleeding due to esophageal variceal hemorrhage requiring a transfer to a local tertiary institution. She was subsequently referred to our Liver Clinic for further evaluation and management after an extensive negative work-up including viral serology for Hepatitis B&C, normal autoimmune markers, iron studies, ATP level and serology for cholestactic liver disorders. Imaging studies of the liver and the portal circulation including CT scan and doppler US were unremarkable. She also denied any known family history of chronic liver disease, personal history of granulomatous or obstructive vascular disorders. She was not on BCP or other hepatotoxins. Physical examination did not reveal any evidence of fluid retention or stigmata of chronic liver disease. Blood tests revealed thrombocytopenia and mild coagulopathy. Liver biopsy specimen confirmed by two independent pathologists showed CHF. Patient has since then undergone EGD with EVL and is doing well on nonselective b-blocker and Ursodiol without any recurrent UGI bleeding. Conclusion:This case illustrates an usual cause of portal hypertensive variceal hemorrhage due to a manisfestation of CHF, a rare autosomal recessive disorder, in a young healthy noncirrhotic female.
Abstract:
Mark Saxena, MD*. Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ.
Purpose: A 24-year-old male with poorly controlled type II diabetes, moderate obesity, and prior pancreatitis presents with acute onset of severe, diffuse abdominal pain. The patient reported similar symptoms during three recent admissions for acute pancreatitis. He reports being prescribed twice daily NPH/regular insulin and Gemfibrozil. He admits not taking these medications because he did not refill prescriptions, missed outpatient appointments, and was fearful of needle injections. He had no history of alcohol use or family history of pancreatitis. Physical examination revealed a moderately obese male in modest distress. He was afebrile, tachycardic to 135, and hypertensive to 161/98. The examination was only remarkable for dry mucous membranes with mild, diffuse abdominal tenderness. Initial laboratory evaluation was significant for a severe anion gap metabolic acidosis with serum blood glucose of 407-626 mg/dl. Serum ketones were absent and arterial pH was 7.21. Lipase was elevated to 119 u/L, amylase normal, lactate 6.0 mmol/L, and triglycerides 8387 mg/dl. Triglycerides during prior hospitalizations were also in the thousands. Computed tomography with intravenous contrast confirmed increased pancreatic inflammation since the prior study. No necrosis or distinct fluid collection was noted. The patient was diagnosed with recurrent triglyceride-induced pancreatitis and hyperosmolar nonketotic hyperglycemia. He was treated on a regular medical floor with pain control, aggressive intravenous hydration, subcutaneous insulin, and bowel rest. Six hours later, the patient developed systemic inflammatory response syndrome (SIRS) and hypovolemic shock resulting in lactic acidosis. He was transferred to the intensive care unit and started on an insulin drip. There he developed acute respiratory failure while compensating for his severe lactic acidosis. Immediately following intubation, the patient underwent cardiopulmonary arrest and expired.
Conclusion: Triglyceride-induced pancreatitis leading to death was precipitated by the precarious combination of dehydration from both hyperglycemia and acute pancreatitis. Profound hyperosmolar nonketotic hyperglycemia precipitated a perilous chain reaction. Profound hyperglycemia contributed to hypovolemic shock, when combined with volume depletion from acute pancreatitis. Shock caused hypoperfusion and severe lactic acidosis. The acidosis promoted a compensatory increase work of breathing that led to acute respiratory failure and death. The source of the tremendous, inciting dehydration was noncompliance with insulin therapy. This led to both the recurring triglyceride pancreatitis and severe hyperglycemia that began this patient's downward spiral.
Abstract:
Deepika Devuni, MD*, Tarun Kothari, MD, FACP, FACG. Internal Medicine, Unity Health System, Rochester, NY.
Purpose: Background: Gastric Cancer is the second most common cancer in the world. Even though its incidence is decreasing in United States, it's difficult to treat as most patients present with advanced disease. Gastric cancer mostly spreads to local lymph nodes and via direct extension. We present a rare case of gastric cancer with metastasis to colon. Case Report: A 63 yr old man with history of gastric ulcer resection with Roux-en Y was admitted to our hospital with nausea and vomiting. Before his admission, patient was recently evaluated by his urologist for urinary symptoms during which he was found to have mildly elevated CEA. Patient was scheduled for out patient colonoscopy to rule out colon cancer. During his hospital stay, patient was noted to have anemia and occult blood in stool. As part of work up, upper endoscopy was done. It showed a flat superficial ulcer at gastrojejunostomy site. Biopsy of ulcer showed poorly differentiated adenocarcinoma. Patient then underwent colonoscopy for his elevated CEA which showed multiple ulcerated lesions with heaped up edges in his colon. Biopsy of the lesion showed poorly differentiated adenocarcinoma consistent with metastatic carcinoma very similar to gastric biopsy specimen. These were thought to be gastric metastasis to colon Patient received chemotherapy and was found to be remission by PET scan after 5 months of diagnosis. Discussion: Gastric cancer is two types intestinal and diffuse. Diffuse cancer usually spreads to local lymph nodes. It also spreads via direct extension to Omenta, Pancreas and tranverse colon. Krukenberg tumors have also been reported in which gastric cancer spreads to ovaries. But metastasis to intestinal tract is very rare. It has been reported in poorly differentiated adenocarcinoma and from scirrhous type of the stomach. It is essential to differentiate primary colon cancer from gastric metastasis to colon. This will change the staging of the disease and will need a change in the course of treatment. As in our patient's case, we intiated systemic chemotherapy with good results for now.
Source Citation:"CLINICAL VIGNETTES." American Journal of Gastroenterology 103.s1 (Sept 2008): S206(1). Academic OneFile. Gale. BROWARD COUNTY LIBRARY. 16 Sept. 2009
Gale Document Number:A184410569
Disclaimer:This information is not a tool for self-diagnosis or a substitute for professional care.
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