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Airway obstruction complicating esophageal stent placement in postpneumonectomy patients
AJG – September, Suppl., 2001
with no bowel movement in 2 months. Review of systems was notable for a 19 pound weight loss over 6 months. Past medical/surgical history was only significant for appendectomy in childhood. Pertinent findings on physical examination included abdominal distention to the point of respiratory compromise; rectal examination revealed fecal impaction. Acute abdominal series x-rays revealed marked colonic distention with a massive amount of stool present; the diaphragm was bilaterally elevated. The patient underwent immediate sigmoid colectomy and Hartman’s procedure with placement of a transverse colostomy for colonic decompression. Pathology of the resected sigmoid colon revealed megacolon with melanosis coli and marked hypertrophy; ganglia and neural elements were seen throughout the specimen. The patient was discharged in good condition. Subsequent outpatient evaluation included rectal manometry consistent with Hirschsprung’s disease. Full-thickness biopsy of the rectum revealed no neural elements. The patient subsequently underwent proctectomy with coloanal anastamosis for Hirschsprung’s disease and had a satisfactory post-operative course. Conclusions: Diagnosis of Hirschsprung’s disease in adulthood is very unusual and can have a dramatic presentation. Appropriate diagnostic evaluation and surgical intervention can not only provide relief of symptoms, but can lead to a significant improvement in lifestyle.
690 Airway obstruction complicating esophageal stent placement in postpneumonectomy patients Stanley W Lee1, Eric Vallieres2 and Kris V Kowdley1*. 1 Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States; and 2Surgery, University of Washington School of Medicine, Seattle, WA, United States. Purpose: Expandable metallic stents have been used effectively to treat both esophageal fistula and stricture. Airway obstruction is a rare complication of esophageal stent placement. Methods: We describe two cases of airway compression from placement of expandable esophageal stents in post-pneumonectomy patients. Results: Case 1. 40 year old female with malignant mesothelioma resulting in right-sided pneumonectomy in 1999. Two ribs were removed (Clagett window) to facilitate treatment of persistent empyema. She subsequently presented with obvious evidence of esophagopleural fistula. Upper GI series confirmed these findings. Esophagogastroduodenoscopy (EGD) was performed under general anesthesia, and an expandable covered esophageal stent was placed across the fistula. The patient developed respiratory difficulty immediately after extubation. Bronchoscopy revealed extrinsic compression of the distal trachea and left main bronchus in the region of the esophageal stent. A modified Herald Y stent was inserted into the bronchus to maintain airway patency. The patient was discharged home on postoperative day three without persistent fistula. Case 2. 56 year old female with non-small cell lung cancer underwent right-sided pneumonectomy in 1997. She noticed progressive dysphagia in January 2000. EGD showed a stricture that was negative for malignancy on biopsies, and felt to be due to previous radiation therapy. An expandable metallic esophageal stent was placed. She subsequently presented with progressive dyspnea. Bronchoscopy revealed subtotal occlusion of the proximal left main bronchus from extrinsic compression. The esophageal stent was removed with resolution of her dyspnea. Conclusions: These cases describe airway obstruction due to extrinsic compression from expandable metallic esophageal stents. Both these patients had undergone previous pneumonectomy. We speculate that weakening of mediastinal connective tissue and supporting structures after pneumonectomy resulted in greater extrinsic compression of the airway. Gastroenterologists should be aware of airway compression from placement of esophageal stents, particularly after pneumonectomy.
Abstracts
S217
691 Expanding the differential: lead toxicity as a cause of acute abdominal pain Lisa S. Lestina, MD. Dartmouth-Hitchcock Medical Center, Lebanon, NH. A 37-year-old Indian woman presented with 3 days of abdominal pain and anorexia, in addition to a longer history of constipation and fatigue. On exam she was afebrile with diffuse abdominal tenderness and voluntary guarding, but no peritoneal signs. Bowel sounds were normal. Pelvic exam was unremarkable. Rectal exam revealed minimal stool, occult blood positive. Hematocrit was 21, and peripheral smear demonstrated severe microcytosis, basophilic stippling and a few ovalocytes. Xray and computed tomography of the abdomen showed nondilated loops of small and large bowel with scattered stool. The patient was admitted, hydrated and prepped for colonoscopy. The next day, colonoscopy and upper endoscopy were normal. Further history revealed she had been taking several herbal remedies imported from India for arthritic pains. Differential diagnosis included vasculitis, acute intermittent porphyria, and heavy metal toxicity. She improved with conservative management and was discharged home. Later, a blood lead level (BLL) returned elevated at 85 mcg/dL. She was seen in follow-up and treated with succimer, an oral chelating agent. Testing of her husband and two children revealed BLL ⬍5mcg/dL. Component analysis of her herbal remedies revealed two were tainted with significantly high levels of lead. Her symptoms have abated on therapy, and she continues to do well today. Abdominal pain secondary to lead intoxication in adults is uncommon. In the United States, most adult exposure occurs in the workplace by inhalation. More recently, herbal preparations are a recognized source of lead and other heavy metals. Symptoms of lead toxicity are often vague and may arise acutely, although poisoning is usually chronic. Lead toxicity primarily affects the gastrointestinal, nervous, renal and hematopoietic systems. The best diagnostic test is measurement of a serum BLL. Lead toxicity in symptomatic adults is treated with chelating agents when the BLL exceeds 50 mcg/dL. All patients are treated at levels above 80 mcg/dL. As use of alternative remedies increases, awareness of potential toxicities is vital. One needs to consider lead toxicity in the differential diagnosis of acute abdominal pain that is not easily explained. Thorough history taking for nonprescription drugs can be crucial!
692 A case of collagenous colitis and pyoderma gangrenosum Ajay K. Batra M.D., John M. Levey M.D., Jon Trister M.D. and Rashmi V. Patwardhan M.D.*. 1Gastroenterology, University of Massachusetts Medical School, Worcester, MA, United States; and 2Gastroenterology, Worcester Medical Center/Fallon Clinic, Worcester, MA, United States. Purpose: Collagenous colitis (CC) is an inflammatory colonic disease of unknown etiology. Along with lymphocitic colitis, it is referred to as one of the microscopic colitides. Clinicians have wondered about its relationship to classical forms of inflammatory bowel disease. We discuss a case of pyoderma gangrenosum (PG) diagnosed in a patient with CC. To our knowledge there have been no previous reports of such an association. Methods: A 79 year-old female presented in July 1997 with progressively worsening watery, non-bloody diarrhea requiring hospitalization for dehydration and hypokalemia. Her past medical history included peptic ulcer disease, GERD, hypothyroidism, asthma, C. difficile colitis, appendectomy, cholecystectomy, and bilateral oophorectomy. Medications on admission included levothyroxine, omeprazole, and albuterol inhaler. Previously, in 1994 the patient developed a 15 cm. ⫻ 7 cm. gangrenous necrotic ulcer on her right calf and underwent excision and skin grafting. Biopsy revealed ulceration into the subcutaneous tissue, but no formal diagnosis was made. Upon admission, physical exam was unremarkable with the exception of a scar on the right calf from previous ulceration. Blood and stool specimens were negative, except for a serum potassium of 2.1 mEq/L, serum bicarbonate of 34 mEq/L, BUN 17 mg% and serum creatinine of 1.7
with no bowel movement in 2 months. Review of systems was notable for a 19 pound weight loss over 6 months. Past medical/surgical history was only significant for appendectomy in childhood. Pertinent findings on physical examination included abdominal distention to the point of respiratory compromise; rectal examination revealed fecal impaction. Acute abdominal series x-rays revealed marked colonic distention with a massive amount of stool present; the diaphragm was bilaterally elevated. The patient underwent immediate sigmoid colectomy and Hartman’s procedure with placement of a transverse colostomy for colonic decompression. Pathology of the resected sigmoid colon revealed megacolon with melanosis coli and marked hypertrophy; ganglia and neural elements were seen throughout the specimen. The patient was discharged in good condition. Subsequent outpatient evaluation included rectal manometry consistent with Hirschsprung’s disease. Full-thickness biopsy of the rectum revealed no neural elements. The patient subsequently underwent proctectomy with coloanal anastamosis for Hirschsprung’s disease and had a satisfactory post-operative course. Conclusions: Diagnosis of Hirschsprung’s disease in adulthood is very unusual and can have a dramatic presentation. Appropriate diagnostic evaluation and surgical intervention can not only provide relief of symptoms, but can lead to a significant improvement in lifestyle.
690 Airway obstruction complicating esophageal stent placement in postpneumonectomy patients Stanley W Lee1, Eric Vallieres2 and Kris V Kowdley1*. 1 Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States; and 2Surgery, University of Washington School of Medicine, Seattle, WA, United States. Purpose: Expandable metallic stents have been used effectively to treat both esophageal fistula and stricture. Airway obstruction is a rare complication of esophageal stent placement. Methods: We describe two cases of airway compression from placement of expandable esophageal stents in post-pneumonectomy patients. Results: Case 1. 40 year old female with malignant mesothelioma resulting in right-sided pneumonectomy in 1999. Two ribs were removed (Clagett window) to facilitate treatment of persistent empyema. She subsequently presented with obvious evidence of esophagopleural fistula. Upper GI series confirmed these findings. Esophagogastroduodenoscopy (EGD) was performed under general anesthesia, and an expandable covered esophageal stent was placed across the fistula. The patient developed respiratory difficulty immediately after extubation. Bronchoscopy revealed extrinsic compression of the distal trachea and left main bronchus in the region of the esophageal stent. A modified Herald Y stent was inserted into the bronchus to maintain airway patency. The patient was discharged home on postoperative day three without persistent fistula. Case 2. 56 year old female with non-small cell lung cancer underwent right-sided pneumonectomy in 1997. She noticed progressive dysphagia in January 2000. EGD showed a stricture that was negative for malignancy on biopsies, and felt to be due to previous radiation therapy. An expandable metallic esophageal stent was placed. She subsequently presented with progressive dyspnea. Bronchoscopy revealed subtotal occlusion of the proximal left main bronchus from extrinsic compression. The esophageal stent was removed with resolution of her dyspnea. Conclusions: These cases describe airway obstruction due to extrinsic compression from expandable metallic esophageal stents. Both these patients had undergone previous pneumonectomy. We speculate that weakening of mediastinal connective tissue and supporting structures after pneumonectomy resulted in greater extrinsic compression of the airway. Gastroenterologists should be aware of airway compression from placement of esophageal stents, particularly after pneumonectomy.
Abstracts
S217
691 Expanding the differential: lead toxicity as a cause of acute abdominal pain Lisa S. Lestina, MD. Dartmouth-Hitchcock Medical Center, Lebanon, NH. A 37-year-old Indian woman presented with 3 days of abdominal pain and anorexia, in addition to a longer history of constipation and fatigue. On exam she was afebrile with diffuse abdominal tenderness and voluntary guarding, but no peritoneal signs. Bowel sounds were normal. Pelvic exam was unremarkable. Rectal exam revealed minimal stool, occult blood positive. Hematocrit was 21, and peripheral smear demonstrated severe microcytosis, basophilic stippling and a few ovalocytes. Xray and computed tomography of the abdomen showed nondilated loops of small and large bowel with scattered stool. The patient was admitted, hydrated and prepped for colonoscopy. The next day, colonoscopy and upper endoscopy were normal. Further history revealed she had been taking several herbal remedies imported from India for arthritic pains. Differential diagnosis included vasculitis, acute intermittent porphyria, and heavy metal toxicity. She improved with conservative management and was discharged home. Later, a blood lead level (BLL) returned elevated at 85 mcg/dL. She was seen in follow-up and treated with succimer, an oral chelating agent. Testing of her husband and two children revealed BLL ⬍5mcg/dL. Component analysis of her herbal remedies revealed two were tainted with significantly high levels of lead. Her symptoms have abated on therapy, and she continues to do well today. Abdominal pain secondary to lead intoxication in adults is uncommon. In the United States, most adult exposure occurs in the workplace by inhalation. More recently, herbal preparations are a recognized source of lead and other heavy metals. Symptoms of lead toxicity are often vague and may arise acutely, although poisoning is usually chronic. Lead toxicity primarily affects the gastrointestinal, nervous, renal and hematopoietic systems. The best diagnostic test is measurement of a serum BLL. Lead toxicity in symptomatic adults is treated with chelating agents when the BLL exceeds 50 mcg/dL. All patients are treated at levels above 80 mcg/dL. As use of alternative remedies increases, awareness of potential toxicities is vital. One needs to consider lead toxicity in the differential diagnosis of acute abdominal pain that is not easily explained. Thorough history taking for nonprescription drugs can be crucial!
692 A case of collagenous colitis and pyoderma gangrenosum Ajay K. Batra M.D., John M. Levey M.D., Jon Trister M.D. and Rashmi V. Patwardhan M.D.*. 1Gastroenterology, University of Massachusetts Medical School, Worcester, MA, United States; and 2Gastroenterology, Worcester Medical Center/Fallon Clinic, Worcester, MA, United States. Purpose: Collagenous colitis (CC) is an inflammatory colonic disease of unknown etiology. Along with lymphocitic colitis, it is referred to as one of the microscopic colitides. Clinicians have wondered about its relationship to classical forms of inflammatory bowel disease. We discuss a case of pyoderma gangrenosum (PG) diagnosed in a patient with CC. To our knowledge there have been no previous reports of such an association. Methods: A 79 year-old female presented in July 1997 with progressively worsening watery, non-bloody diarrhea requiring hospitalization for dehydration and hypokalemia. Her past medical history included peptic ulcer disease, GERD, hypothyroidism, asthma, C. difficile colitis, appendectomy, cholecystectomy, and bilateral oophorectomy. Medications on admission included levothyroxine, omeprazole, and albuterol inhaler. Previously, in 1994 the patient developed a 15 cm. ⫻ 7 cm. gangrenous necrotic ulcer on her right calf and underwent excision and skin grafting. Biopsy revealed ulceration into the subcutaneous tissue, but no formal diagnosis was made. Upon admission, physical exam was unremarkable with the exception of a scar on the right calf from previous ulceration. Blood and stool specimens were negative, except for a serum potassium of 2.1 mEq/L, serum bicarbonate of 34 mEq/L, BUN 17 mg% and serum creatinine of 1.7