An unusual cause of abdominal pain with cecal mass
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splenic vein. The caliber exceeded that of the inferior vena cava. Ascites was absent, and esophageal and gastric varices were excluded by endos- copy (EGD). Due to significant impairment in quality of life and increased risk of medical complications from persistent HE, the patient and his wife were consented for an experimental procedure to reduce flow in his sple- norenal shunt. Procedure: The left renal vein and splenorenal conduit were accessed via percutaneous catheter. A Simon-Nitinol Filter was deployed into the shunt with the tip directed toward the renal vein. Six 10-12mm metal coils were deployed into the filter. Angiographic flow rate was subsequently reduced. Final hepatic vein pressure gradient remained unchanged at 28mmHg at the end of the procedure. Shunt flow could not be visualized on contrast ultrasound the following day. Two weeks later, ultrasound revealed im- proved hepatopetal flow within the portal vein and no ascites, and EGD revealed trace esophageal varices without bleeding. HE has improved without requirement for admission while on maintenance oral lactulose. Discussion: Spontaneous portosystemic shunting should be suspected in patients with cirrhosis, persistent HE, and lack of significant ascites or esophagogastric varices. Persistent HE refractory to medical therapy can be safely controlled by percutaneous embolization of portosystemic shunts. 622 AN UNUSUAL CAUSE OF ABDOMINAL PAIN WITH CECAL MASS Dhanasekaran Ramasamy, M.D., K. Shiva Kumar, M.D., Samiappan Muthusamy, M.D., FACG*. Cleveland Clinic, Cleveland, OH; Mayo Clinic, Rochester, MN and Center for Digestive Diseases, Union, NJ. Introduction: Intestinal tuberculosis (TB) is a rare disease in western countries and may mimic a variety of gastrointestinal disorders. The in- crease in incidence of the gastrointestinal (GI) TB over the past 20 years has been attributed to a rise in numbers of high-risk patients, such as HIV-infected and immunosuppressed patients. We report a case of cecal TB treated successfully with anti-TB therapy. Case Report: A 48 year-old Indian male was evaluated for a 2 year history of right lower abdominal pain and weight loss. Physical examination was unremarkable. CT abdomen revealed cecal wall thickening and infiltrative changes of the pericolonic mesenteric fat. Colonoscopy revealed a 3-cm ulcerated sessile mass lesion involving the ileocecal valve. Histology revealed caseating granulomas with Langerhans giant cells and epithelioid cells with central necrosis. AFB stain revealed acid fast bacilli. AFB culture was positive after 3 weeks of incubation. Antibiotic susceptibility revealed resistance to isoniazid and he was treated for 9 months with ethambutol, pyrazinamide, rifampin, and ofloxacin. He remained symptom free a year later and repeat colonoscopy revealed complete resolution of lesions. Discussion: The commonest sites of TB involvement of the GI tract are the ileocecal area, followed by the jejuno-ileum, colon, and rectum, although any area of the gut can be involved. Symptoms and signs are nonspecific, and unless a high index of suspicion is maintained, the diagnosis can be missed or delayed increasing morbidity and mortality. The manifestations are nonspecific and include fever, night sweats, weight loss, abdominal pain and diarrhea. Complications include severe diarrhea with malabsorp- tion and protein-losing enteropathy, hemorrhage, obstruction, fistulas and perforation. Only 25% of patients with gastrointestinal TB have primary pulmonary TB. Differential diagnosis includes Crohns, colon cancer, and a variety of infectious diseases. Other infections have to be ruled out by culture, serology and histology. Diagnosis is based on the demonstration of acid-fast bacilli in tissue or stool and culture. Treatment is the same as for pulmonary TB and surgery is reserved for complications. The diagnosis of colonic TB requires a high index of suspicion, especially in immigrants from areas endemic for TB and immunocompromised patients. It should be included in the differential diagnosis of ulcerative colorectal lesions in the western population as well. 623 WATERMELON STOMACH: AN UNCOMMON CAUSE OF CHRONIC ANEMIA Ramesh Krishnamurthi, M.D., Ronald Crock, M.D., Sanjiv Khullar, M.D.*. Northeastern Ohio Universities College of Medicine, Canton, OH. Gastric Antral Vascular Ectasia (GAVE), commonly known as Water- melon Stomach, is described as a vascular lesion commonly affecting the antrum. It consists of dilated tortuous vessels radiating outward from the pylorus appearing like the stripes on the skin of a watermelon. This often causes acute hemorrhage or chronic occult bleeding. It frequently presents in middle-age to older women, frequently associated with atrophic gastritis, achlorhydria, portal hypertension, and CREST syndrome. The etiology of GAVE is unidentified. Our patient, a 79 year-old caucasian female, pre- sented with a 6 month history of fatigue and non-specific abdominal pain. Her medical history was pertinent for gastroesophageal reflux disease and mitral valve prolapse. She was admitted for a hemoglobin of 8.8 mg/dl and found to have hemoccult positive stools. A CT scan of the abdomen was normal. An upper endoscopy previously performed at another hospital showed mild gastric Cameron’s erosions, a hiatal hernia, a Schatzki’s ring, and gastritis. A colonoscopy performed was normal. She was placed on oral iron supplementation and a proton pump inhibitor. Her abdominal pain resolved, yet despite her medical therapy she continued to have fatigue, iron deficiency, and additional GI blood loss. The chronic anemia required periodic transfusions of approximately 20 units of packed red blood cells over a 12 month period. During a recent EGD at our hospital, linear erythematous markings were found from the pylorus to the antrum. Biop- sies of the stomach and duodenum were consistent with GAVE. The patient underwent three sessions of Argon Plasma Coagulation therapy to success- fully treat all portions of the affected stomach. Only the antrum appeared to be involved, however several cases have been reported in which other areas of the stomach and rectum were affected. Her hemoglobin improved to 11.0 mg/dl in the months following coagulation and medical therapy. Previous endoscopies presumed that gastritis was the cause of her recurrent anemia, however this was not the case. Gastritis often presents with linear streaking of the gastric mucosa just as in GAVE. Portal Hypertensive Gastropathy also presents like GAVE, however this is more common in cirrhotics and less apt to improvement with coagulation therapy. This case reminds gastroenterologists, and other physicians, that Gastric Antral Vas- cular Ectasia should not be confused with gastritis, and should be consid- ered during esophagogastroduodenoscopy when evaluating a patient for chronic anemia. 624 ACUTE FOOD IMPACTION: A RARE PRESENTATION AND COMPLICATION OF HETEROTOPIC GASTRIC MUCOSA IN THE PROXIMAL ESOPHAGUS Wichit Srikureja, M.D., David Condon, M.D.*. Loma Linda University Medical Center, Loma Linda, CA. A 48 year-old man was transferred to the Emergency Department for acute food impaction. He had been having intermittent dysphagia of eight month’s duration for solid food but not liquids. The evening of presenta- tion, he ate chicken and felt the piece of meat lodged in the upper esophagus. He reported drooling and an inability to swallow saliva. He denied heartburn, acid regurgitation, weight loss, chest pain and ingestion of caustic substances. Other medical problems included diabetes mellitus type 2, hypertension, and hyperlipidemia. He did not use tobacco or alcohol. Examination was remarkable for hypersalivation. A barium esophagram done at the transferring institution revealed foreign body impaction in the upper esophagus. Upper endoscopy was urgently per- formed and revealed a 3cm piece of meat impacted in the upper esophagus, 15cm from the incisors. Although with some resistance, the meat was gently pushed into the stomach without complications. Careful evaluation of the upper esophagus revealed circumferential raised columns of salmon S207 AJG – September, Suppl., 2003 Abstracts
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Transcript of An unusual cause of abdominal pain with cecal mass
splenic vein. The caliber exceeded that of the inferior vena cava. Asciteswas absent, and esophageal and gastric varices were excluded by endos-copy (EGD). Due to significant impairment in quality of life and increasedrisk of medical complications from persistent HE, the patient and his wifewere consented for an experimental procedure to reduce flow in his sple-norenal shunt.Procedure: The left renal vein and splenorenal conduit were accessed viapercutaneous catheter. A Simon-Nitinol Filter was deployed into the shuntwith the tip directed toward the renal vein. Six 10-12mm metal coils weredeployed into the filter. Angiographic flow rate was subsequently reduced.Final hepatic vein pressure gradient remained unchanged at 28mmHg at theend of the procedure. Shunt flow could not be visualized on contrastultrasound the following day. Two weeks later, ultrasound revealed im-proved hepatopetal flow within the portal vein and no ascites, and EGDrevealed trace esophageal varices without bleeding. HE has improvedwithout requirement for admission while on maintenance oral lactulose.Discussion: Spontaneous portosystemic shunting should be suspected inpatients with cirrhosis, persistent HE, and lack of significant ascites oresophagogastric varices. Persistent HE refractory to medical therapy can besafely controlled by percutaneous embolization of portosystemic shunts.
622
AN UNUSUAL CAUSE OF ABDOMINAL PAIN WITH CECALMASSDhanasekaran Ramasamy, M.D., K. Shiva Kumar, M.D.,Samiappan Muthusamy, M.D., FACG*. Cleveland Clinic, Cleveland,OH; Mayo Clinic, Rochester, MN and Center for Digestive Diseases,Union, NJ.
Introduction: Intestinal tuberculosis (TB) is a rare disease in westerncountries and may mimic a variety of gastrointestinal disorders. The in-crease in incidence of the gastrointestinal (GI) TB over the past 20 yearshas been attributed to a rise in numbers of high-risk patients, such asHIV-infected and immunosuppressed patients. We report a case of cecalTB treated successfully with anti-TB therapy.Case Report: A 48 year-old Indian male was evaluated for a 2 year historyof right lower abdominal pain and weight loss. Physical examination wasunremarkable. CT abdomen revealed cecal wall thickening and infiltrativechanges of the pericolonic mesenteric fat. Colonoscopy revealed a 3-cmulcerated sessile mass lesion involving the ileocecal valve. Histologyrevealed caseating granulomas with Langerhans giant cells and epithelioidcells with central necrosis. AFB stain revealed acid fast bacilli. AFB culturewas positive after 3 weeks of incubation. Antibiotic susceptibility revealedresistance to isoniazid and he was treated for 9 months with ethambutol,pyrazinamide, rifampin, and ofloxacin. He remained symptom free a yearlater and repeat colonoscopy revealed complete resolution of lesions.Discussion: The commonest sites of TB involvement of the GI tract are theileocecal area, followed by the jejuno-ileum, colon, and rectum, althoughany area of the gut can be involved. Symptoms and signs are nonspecific,and unless a high index of suspicion is maintained, the diagnosis can bemissed or delayed increasing morbidity and mortality. The manifestationsare nonspecific and include fever, night sweats, weight loss, abdominalpain and diarrhea. Complications include severe diarrhea with malabsorp-tion and protein-losing enteropathy, hemorrhage, obstruction, fistulas andperforation. Only 25% of patients with gastrointestinal TB have primarypulmonary TB. Differential diagnosis includes Crohns, colon cancer, and avariety of infectious diseases. Other infections have to be ruled out byculture, serology and histology. Diagnosis is based on the demonstration ofacid-fast bacilli in tissue or stool and culture. Treatment is the same as forpulmonary TB and surgery is reserved for complications. The diagnosis ofcolonic TB requires a high index of suspicion, especially in immigrantsfrom areas endemic for TB and immunocompromised patients. It should beincluded in the differential diagnosis of ulcerative colorectal lesions in thewestern population as well.
623
WATERMELON STOMACH: AN UNCOMMON CAUSE OFCHRONIC ANEMIARamesh Krishnamurthi, M.D., Ronald Crock, M.D.,Sanjiv Khullar, M.D.*. Northeastern Ohio Universities College ofMedicine, Canton, OH.
Gastric Antral Vascular Ectasia (GAVE), commonly known as Water-melon Stomach, is described as a vascular lesion commonly affecting theantrum. It consists of dilated tortuous vessels radiating outward from thepylorus appearing like the stripes on the skin of a watermelon. This oftencauses acute hemorrhage or chronic occult bleeding. It frequently presentsin middle-age to older women, frequently associated with atrophic gastritis,achlorhydria, portal hypertension, and CREST syndrome. The etiology ofGAVE is unidentified. Our patient, a 79 year-old caucasian female, pre-sented with a 6 month history of fatigue and non-specific abdominal pain.Her medical history was pertinent for gastroesophageal reflux disease andmitral valve prolapse. She was admitted for a hemoglobin of 8.8 mg/dl andfound to have hemoccult positive stools. A CT scan of the abdomen wasnormal. An upper endoscopy previously performed at another hospitalshowed mild gastric Cameron’s erosions, a hiatal hernia, a Schatzki’s ring,and gastritis. A colonoscopy performed was normal. She was placed on oraliron supplementation and a proton pump inhibitor. Her abdominal painresolved, yet despite her medical therapy she continued to have fatigue,iron deficiency, and additional GI blood loss. The chronic anemia requiredperiodic transfusions of approximately 20 units of packed red blood cellsover a 12 month period. During a recent EGD at our hospital, linearerythematous markings were found from the pylorus to the antrum. Biop-sies of the stomach and duodenum were consistent with GAVE. The patientunderwent three sessions of Argon Plasma Coagulation therapy to success-fully treat all portions of the affected stomach. Only the antrum appearedto be involved, however several cases have been reported in which otherareas of the stomach and rectum were affected. Her hemoglobin improvedto 11.0 mg/dl in the months following coagulation and medical therapy.Previous endoscopies presumed that gastritis was the cause of her recurrentanemia, however this was not the case. Gastritis often presents with linearstreaking of the gastric mucosa just as in GAVE. Portal HypertensiveGastropathy also presents like GAVE, however this is more common incirrhotics and less apt to improvement with coagulation therapy. This casereminds gastroenterologists, and other physicians, that Gastric Antral Vas-cular Ectasia should not be confused with gastritis, and should be consid-ered during esophagogastroduodenoscopy when evaluating a patient forchronic anemia.
624
ACUTE FOOD IMPACTION: A RARE PRESENTATION ANDCOMPLICATION OF HETEROTOPIC GASTRIC MUCOSA INTHE PROXIMAL ESOPHAGUSWichit Srikureja, M.D., David Condon, M.D.*. Loma Linda UniversityMedical Center, Loma Linda, CA.
A 48 year-old man was transferred to the Emergency Department for acutefood impaction. He had been having intermittent dysphagia of eightmonth’s duration for solid food but not liquids. The evening of presenta-tion, he ate chicken and felt the piece of meat lodged in the upperesophagus. He reported drooling and an inability to swallow saliva. Hedenied heartburn, acid regurgitation, weight loss, chest pain and ingestionof caustic substances. Other medical problems included diabetes mellitustype 2, hypertension, and hyperlipidemia. He did not use tobacco oralcohol. Examination was remarkable for hypersalivation. A bariumesophagram done at the transferring institution revealed foreign bodyimpaction in the upper esophagus. Upper endoscopy was urgently per-formed and revealed a 3cm piece of meat impacted in the upper esophagus,15cm from the incisors. Although with some resistance, the meat wasgently pushed into the stomach without complications. Careful evaluationof the upper esophagus revealed circumferential raised columns of salmon
S207AJG – September, Suppl., 2003 Abstracts
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