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Esophageal intramural pseudodiverticulosis
AJG – September, Suppl., 2002
cases.This should always be considered in the list of diagnostic possibilities in elderly patients with recurrent attacks of confusion.
Abstracts
S139
423 CHRONIC APPENDICITIS PRESENTING AS CROHNS DISEASE Mike L. Anderson, M.D. and Fernando Ramos, M.D.*. Gastroenterology, Tripler Army Medical Center, Honolulu, HI.
421 OCCULT GASTROINTESTINAL INFECTION MIMICKING ADULT–ONSET STILL’S DISEASE Olaitan A. Adeniji, M.D. and Jack A. Di Palma, M.D.*. Division of Gstroenterology, University of South Alabama College of Medicine, Mobile, AL. Purpose: The diagnosis of adult– onset Still’s disease is based on clinical criteria. Exclusion of other conditions is essential for accurate diagnosis. This case illustrates the need for systematic evaluation for infection, including the gastrointestinal tract. Case Report: A 56 –year– old white male had one–year history of recurrent fevers, arthritis, myalgias, rash, diaphoresis and headaches. He specifically reported no episode of abdominal pain, diarrhea or hematochezia. Infectious disease and rheumatologic evaluation led to the diagnosis of adult– onset Still’s disease. He was placed on prednisone, methotrexate, chloroquine, azulfidine and rofecoxib without much response. The patient subsequently developed pneumaturia and fecaluria. Endoscopic and radiologic imaging revealed colovesical fistula and abscess with probable diverticular source. A quinolone and metronidazole was started with prompt improvement however fecaluria recurred two weeks later. The patient underwent sigmoid colectomy and closure of colovesical fistula. Pathologic specimens confirmed diverticulitis and marked acute inflammation with granulation tissue and foreign body–type giant cell reaction to fecal material of plant origin. All anti–inflammatory drugs were discontinued and the patient had complete resolution of his symptoms. He continues to be asymptomatic one year after the surgery. Conclusion: Abdominal imaging should be considered when evaluating patients with suspected Still’s disease, even if symptoms referable to the digestive system are lacking.
Purpose: Recurrent and chronic appendicitis are often overlooked in the differential diagnosis of chronic abdominal pain. The symptoms described in these entities overlap with numerous other more common conditions resulting in frequent misdiagnosis. Colonoscopy provided a diagnosis in this case which was not considered after CT evaluation. Despite an accuracy described as near 98%1, CT may result in misdiagnosis if not followed by colonoscopy. Case Presentation: This is a 40 year– old male with a 17 year history of recurrent abdominal pain accompanied by diarrhea and anorexia lasting 3 to 4 days occurring every 2 months on average. The patient presented after 24 hours of his usual abdominal pain with a new component of sharp right upper quadrant pain. He denied any history of hematochezia or melena. Previous workup included included flexible sigmoidoscopy and HIDA scan which were normal. Physical exam showed fever with tenderness to palpation in the lower abdomen. Labs revealed a white blood cell count of 10.6, and hemoglobin of 12.8. Right upper quadrant ultrasound was read as normal. Acute abdominal series showed diffuse small bowel dilation to 4cm with several areas of air–fluid levels. Abdominal/pelvis CT scan showed thickening of terminal ileum with fat stranding and multiple fluid collections. The patient responded well to a course of methylprednisolone (40mg IV Q6 hrs). Colonoscopy three days later revealed a bulging appendix with pus at the orifice. Given this finding the patient was diagnosed with chronic appendicitis. Conclusions: Our submission represents a case of chronic appendicitis with symptoms and CT findings mimicking Crohn’s disease. 1. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: Prospective evaluation of a focused appendix CT examination. Radiology 1997; 202(1): 139 – 44.
422 INFARCTED APPENDIX EPIPLOICA CLINICALLY MIMICKING ACUTE APPENDICITIS Olaitan A. Adeniji, M.D. and Jorge L. Herrera, M.D.*. Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, AL. Purpose: Acute appendicitis is the most common cause of right lower quadrant pain in men. We present a case of infarcted ascending colon epiploic appendix presenting clinically as acute appendicitis. Case Report: A 36 –year– old white male presented to the emergency department with one– day history of severe right lower quadrant pain. The pain was crampy, continuous and associated with nausea and anorexia. He also reported episodes of chills and generalized malaise. He had no vomiting or diarrhea. His physical examination was normal except a soft non– distended abdomen with tenderness and guarding in the right lower quadrant (McBurney’s point). His rectal examination was normal. Laboratory results revealed an elevated white blood cell count (11.5 cells/mL), normal hemoglobin and normal serum electrolytes. An abdominal plain radiograph was also normal. The patient was clinically diagnosed as acute appendicitis and a laparotomy revealed normal appearing appendix. Further exploration of the abdomen revealed an infarcted epiploic appendix of the ascending colon. The epiploic appendix was resected and the patient had a stable postoperative period with resolution of his symptoms. Conclusion: Infarcted appendix epiploica should be considered in patients presenting with symptoms of acute appendicitis in whom the appendix is normal on laparotomy.
424 ESOPHAGEAL INTRAMURAL PSEUDODIVERTICULOSIS Leka Gajula, M.D., Arturo Baez, M.D. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Introduction: Intramural Pseudodiverticulosis (IP) of the esophagus is very rare. We describe a case of IP and present a complete review of the literature of this topic. Case Report: A 50 year old female with AIDS underwent an ERCP for suspected choledocholithiasis – recurrent biliary colics, abnormal LFTs, dilated bile duct & cholelithiasis. She also had heartburn and intermittent dysphagia. Other medical problems include hypertension, diabetes mellitus, coronary artery disease, & chronic renal insufficiency. Intubation of the esophagus with a sideveiwing endoscope was limited as the lumen was plugged with creamish white material. A forward viewing endoscope was used to clear the lumen and exclude esophageal stenosis. On clearing the esophagus of the whitish material, extensive intramural pseudodiverticulosis was noted, which was later confirmed by a barium swallow. Gastroesophageal reflux was noted on barium swallow. Esophageal biopsies revealed acute erosive esophagitis with abundant invasive fungal pseudo– hyphae and yeasts consistent with candidial esophagitis. A CT scan of the chest demonstrated diffuse esophageal thickening without mediastinal disease. She made a remarkable improvement on treatment with Fluconazole and Omeprazole. She had undergone biliary sphincterotomy for ampullary stenosis and subsequently cholecystectomy was performed.
S140
Abstracts
Summary: Our case demonstrates several classic features of intramural pseudo– diverticulosis.
AJG – Vol. 97, No. 9, Suppl., 2002
vessel or feeder. Given the rebleeding within two weeks of initial hemostasis and the unusual nature of the problem (severe bleeding from a large diverticulum), a surgeon (GG) was called in to look at the lesion. Because of failure of therapy with clipping to the bleeding site and the easy accessibility of the artery proximal to the site of rupture for clipping, a surgeon recommended application of two additional hemoclips to the feeder, to prevent delayed rebleeding (fig 1D). The deployment of the clips to the feeder was successful. The patient tolerated the procedure well. There was no recurrence of bleeding during a follow– up of six months.
Conclusion: Hemoclipping is successful in controlling duodenal diverticular bleeding. Although it is unclear that the treatment of the feeding vessel leads to the successful treatment, and this remains a supposition, we believe that this prevented rebleeding. Techniques to detect the submucosal vessel, infrared fluorescence endoscopy and color doppler optical coherence tomography, may improve the ability to direct therapy to the feeder to control bleeding and prevent rebleeding
426 CHOLECYSTOKININ ASSISTED KNEEDLE KNIFE OF A FIBROTIC AMPULLA Arturo Baez, M.D., Samir Nath, M.D., Syed Jafri, M.D. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. 425 DUODENAL DIVERTICULAR HEMOSTASIS WITH ENDOCLIPPING OF THE BLEEDER AND THE FEEDER Gottumukkala S. Raju, M.D., FACG*, Samir Nath, M.D., Xiaotuan Zhao, M.D., Guillermo Gomez, M.D., Gurinder Luthra, D.O. and Syed Jafri, M.D. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Introduction: Experience on endoscopic management of duodenal diverticular bleeding is limited. We describe successful control of acute bleeding from a large, duodenal diverticulum with hemoclipping of the bleeder and the feeding vessel (feeder). Case Report: A 76 year– old man presented with severe GI bleeding. Endoscopy showed active bleeding from a large duodenal diverticulum (fig 1A). The bleeding was controlled by endoclips (fig 1B). In addition, 2 cc of 1:10,000 epinephrine was injected around the clips. He had an uneventful recovery. Two weeks later, he rebled with a 2 gram drop in hemoglobin. Endoscopy showed bleeding from the previous site. Only one of the three hemoclips was in–situ (fig 1C). The bleeding was stopped by the application of one hemoclip to the bleeding site. A linear submucosal vessel could be traced for a few centimeters proximal to the site of bleeding, the feeding
Introduction: Cholecystokinin (CCK) is widely used in the endoscopy units for collection of bile to diagnose microlithiasis. We describe another potential indication for CCK, “CCK assisted needle knife sphincterotomy” to improve access to the bile duct in patients with ampullary stenosis that are difficult & risky to access with conventional needle knife technique. Case Report: A 67 year old male was admitted with biliary colic and obstructive jaundice. An ultrasound showed gallbladder sludge and a non– dilated bile duct. At ERCP, there was no bile in the stomach or duodenum. It was hard to locate the ampulla. After searching carefully for several minutes, a flat ampulla flushed with the surface of duodenal wall was located (fig 1). Cannulation was unsuccessful with a sphincterotome and a wire. There was no bile seen comming out of the orifice. We defered undertaking needle knifing the flat ampulla with a non– dilated bile duct above it, as the risk of perforation was high. We injected CCK to see if we can identify any bile flow to aid in the cannulation. No bile came out. Instead, the bile duct and the ampulla bulged out from the duodenal wall (fig 2) making it possible for needle knife biliary sphincterotomy of a bulging ampulla and cannulation of the bile duct (fig 3). The sphincterotomy was extended with an ultratome, with excellent decompression of the bile duct of sludge (fig 4). His pain & obstructive jaundice resolved completely. The ampullary brushings were negative for cancer.
cases.This should always be considered in the list of diagnostic possibilities in elderly patients with recurrent attacks of confusion.
Abstracts
S139
423 CHRONIC APPENDICITIS PRESENTING AS CROHNS DISEASE Mike L. Anderson, M.D. and Fernando Ramos, M.D.*. Gastroenterology, Tripler Army Medical Center, Honolulu, HI.
421 OCCULT GASTROINTESTINAL INFECTION MIMICKING ADULT–ONSET STILL’S DISEASE Olaitan A. Adeniji, M.D. and Jack A. Di Palma, M.D.*. Division of Gstroenterology, University of South Alabama College of Medicine, Mobile, AL. Purpose: The diagnosis of adult– onset Still’s disease is based on clinical criteria. Exclusion of other conditions is essential for accurate diagnosis. This case illustrates the need for systematic evaluation for infection, including the gastrointestinal tract. Case Report: A 56 –year– old white male had one–year history of recurrent fevers, arthritis, myalgias, rash, diaphoresis and headaches. He specifically reported no episode of abdominal pain, diarrhea or hematochezia. Infectious disease and rheumatologic evaluation led to the diagnosis of adult– onset Still’s disease. He was placed on prednisone, methotrexate, chloroquine, azulfidine and rofecoxib without much response. The patient subsequently developed pneumaturia and fecaluria. Endoscopic and radiologic imaging revealed colovesical fistula and abscess with probable diverticular source. A quinolone and metronidazole was started with prompt improvement however fecaluria recurred two weeks later. The patient underwent sigmoid colectomy and closure of colovesical fistula. Pathologic specimens confirmed diverticulitis and marked acute inflammation with granulation tissue and foreign body–type giant cell reaction to fecal material of plant origin. All anti–inflammatory drugs were discontinued and the patient had complete resolution of his symptoms. He continues to be asymptomatic one year after the surgery. Conclusion: Abdominal imaging should be considered when evaluating patients with suspected Still’s disease, even if symptoms referable to the digestive system are lacking.
Purpose: Recurrent and chronic appendicitis are often overlooked in the differential diagnosis of chronic abdominal pain. The symptoms described in these entities overlap with numerous other more common conditions resulting in frequent misdiagnosis. Colonoscopy provided a diagnosis in this case which was not considered after CT evaluation. Despite an accuracy described as near 98%1, CT may result in misdiagnosis if not followed by colonoscopy. Case Presentation: This is a 40 year– old male with a 17 year history of recurrent abdominal pain accompanied by diarrhea and anorexia lasting 3 to 4 days occurring every 2 months on average. The patient presented after 24 hours of his usual abdominal pain with a new component of sharp right upper quadrant pain. He denied any history of hematochezia or melena. Previous workup included included flexible sigmoidoscopy and HIDA scan which were normal. Physical exam showed fever with tenderness to palpation in the lower abdomen. Labs revealed a white blood cell count of 10.6, and hemoglobin of 12.8. Right upper quadrant ultrasound was read as normal. Acute abdominal series showed diffuse small bowel dilation to 4cm with several areas of air–fluid levels. Abdominal/pelvis CT scan showed thickening of terminal ileum with fat stranding and multiple fluid collections. The patient responded well to a course of methylprednisolone (40mg IV Q6 hrs). Colonoscopy three days later revealed a bulging appendix with pus at the orifice. Given this finding the patient was diagnosed with chronic appendicitis. Conclusions: Our submission represents a case of chronic appendicitis with symptoms and CT findings mimicking Crohn’s disease. 1. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: Prospective evaluation of a focused appendix CT examination. Radiology 1997; 202(1): 139 – 44.
422 INFARCTED APPENDIX EPIPLOICA CLINICALLY MIMICKING ACUTE APPENDICITIS Olaitan A. Adeniji, M.D. and Jorge L. Herrera, M.D.*. Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, AL. Purpose: Acute appendicitis is the most common cause of right lower quadrant pain in men. We present a case of infarcted ascending colon epiploic appendix presenting clinically as acute appendicitis. Case Report: A 36 –year– old white male presented to the emergency department with one– day history of severe right lower quadrant pain. The pain was crampy, continuous and associated with nausea and anorexia. He also reported episodes of chills and generalized malaise. He had no vomiting or diarrhea. His physical examination was normal except a soft non– distended abdomen with tenderness and guarding in the right lower quadrant (McBurney’s point). His rectal examination was normal. Laboratory results revealed an elevated white blood cell count (11.5 cells/mL), normal hemoglobin and normal serum electrolytes. An abdominal plain radiograph was also normal. The patient was clinically diagnosed as acute appendicitis and a laparotomy revealed normal appearing appendix. Further exploration of the abdomen revealed an infarcted epiploic appendix of the ascending colon. The epiploic appendix was resected and the patient had a stable postoperative period with resolution of his symptoms. Conclusion: Infarcted appendix epiploica should be considered in patients presenting with symptoms of acute appendicitis in whom the appendix is normal on laparotomy.
424 ESOPHAGEAL INTRAMURAL PSEUDODIVERTICULOSIS Leka Gajula, M.D., Arturo Baez, M.D. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Introduction: Intramural Pseudodiverticulosis (IP) of the esophagus is very rare. We describe a case of IP and present a complete review of the literature of this topic. Case Report: A 50 year old female with AIDS underwent an ERCP for suspected choledocholithiasis – recurrent biliary colics, abnormal LFTs, dilated bile duct & cholelithiasis. She also had heartburn and intermittent dysphagia. Other medical problems include hypertension, diabetes mellitus, coronary artery disease, & chronic renal insufficiency. Intubation of the esophagus with a sideveiwing endoscope was limited as the lumen was plugged with creamish white material. A forward viewing endoscope was used to clear the lumen and exclude esophageal stenosis. On clearing the esophagus of the whitish material, extensive intramural pseudodiverticulosis was noted, which was later confirmed by a barium swallow. Gastroesophageal reflux was noted on barium swallow. Esophageal biopsies revealed acute erosive esophagitis with abundant invasive fungal pseudo– hyphae and yeasts consistent with candidial esophagitis. A CT scan of the chest demonstrated diffuse esophageal thickening without mediastinal disease. She made a remarkable improvement on treatment with Fluconazole and Omeprazole. She had undergone biliary sphincterotomy for ampullary stenosis and subsequently cholecystectomy was performed.
S140
Abstracts
Summary: Our case demonstrates several classic features of intramural pseudo– diverticulosis.
AJG – Vol. 97, No. 9, Suppl., 2002
vessel or feeder. Given the rebleeding within two weeks of initial hemostasis and the unusual nature of the problem (severe bleeding from a large diverticulum), a surgeon (GG) was called in to look at the lesion. Because of failure of therapy with clipping to the bleeding site and the easy accessibility of the artery proximal to the site of rupture for clipping, a surgeon recommended application of two additional hemoclips to the feeder, to prevent delayed rebleeding (fig 1D). The deployment of the clips to the feeder was successful. The patient tolerated the procedure well. There was no recurrence of bleeding during a follow– up of six months.
Conclusion: Hemoclipping is successful in controlling duodenal diverticular bleeding. Although it is unclear that the treatment of the feeding vessel leads to the successful treatment, and this remains a supposition, we believe that this prevented rebleeding. Techniques to detect the submucosal vessel, infrared fluorescence endoscopy and color doppler optical coherence tomography, may improve the ability to direct therapy to the feeder to control bleeding and prevent rebleeding
426 CHOLECYSTOKININ ASSISTED KNEEDLE KNIFE OF A FIBROTIC AMPULLA Arturo Baez, M.D., Samir Nath, M.D., Syed Jafri, M.D. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. 425 DUODENAL DIVERTICULAR HEMOSTASIS WITH ENDOCLIPPING OF THE BLEEDER AND THE FEEDER Gottumukkala S. Raju, M.D., FACG*, Samir Nath, M.D., Xiaotuan Zhao, M.D., Guillermo Gomez, M.D., Gurinder Luthra, D.O. and Syed Jafri, M.D. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Introduction: Experience on endoscopic management of duodenal diverticular bleeding is limited. We describe successful control of acute bleeding from a large, duodenal diverticulum with hemoclipping of the bleeder and the feeding vessel (feeder). Case Report: A 76 year– old man presented with severe GI bleeding. Endoscopy showed active bleeding from a large duodenal diverticulum (fig 1A). The bleeding was controlled by endoclips (fig 1B). In addition, 2 cc of 1:10,000 epinephrine was injected around the clips. He had an uneventful recovery. Two weeks later, he rebled with a 2 gram drop in hemoglobin. Endoscopy showed bleeding from the previous site. Only one of the three hemoclips was in–situ (fig 1C). The bleeding was stopped by the application of one hemoclip to the bleeding site. A linear submucosal vessel could be traced for a few centimeters proximal to the site of bleeding, the feeding
Introduction: Cholecystokinin (CCK) is widely used in the endoscopy units for collection of bile to diagnose microlithiasis. We describe another potential indication for CCK, “CCK assisted needle knife sphincterotomy” to improve access to the bile duct in patients with ampullary stenosis that are difficult & risky to access with conventional needle knife technique. Case Report: A 67 year old male was admitted with biliary colic and obstructive jaundice. An ultrasound showed gallbladder sludge and a non– dilated bile duct. At ERCP, there was no bile in the stomach or duodenum. It was hard to locate the ampulla. After searching carefully for several minutes, a flat ampulla flushed with the surface of duodenal wall was located (fig 1). Cannulation was unsuccessful with a sphincterotome and a wire. There was no bile seen comming out of the orifice. We defered undertaking needle knifing the flat ampulla with a non– dilated bile duct above it, as the risk of perforation was high. We injected CCK to see if we can identify any bile flow to aid in the cannulation. No bile came out. Instead, the bile duct and the ampulla bulged out from the duodenal wall (fig 2) making it possible for needle knife biliary sphincterotomy of a bulging ampulla and cannulation of the bile duct (fig 3). The sphincterotomy was extended with an ultratome, with excellent decompression of the bile duct of sludge (fig 4). His pain & obstructive jaundice resolved completely. The ampullary brushings were negative for cancer.