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Ogilvie’s syndrome associated with corynebacterium jeikeium induced sepsis in a leukemic patient
S168
Abstracts
tion of a submucosal lesion. We report a case of endoscopic polypectomy of a large Brunner’s gland hamartoma with aid from EUS. A 70 –year– old male presented with complaints of daily black bowel movements for one week. His medications included aspirin and celecoxib. Physical exam revealed dark brown, hemoccult positive stool. Hematocrit was 32.4%. Upper endoscopy identified an 8 cm submucosal, polypoid lesion with a long, thick stalk in the second duodenum (figure 1A). Biopsies revealed normal duodenal villous architecture. EUS showed that the polyp head was homogeneous and hyperechoic, and contained two cysts measuring 8 to 9 mm in diameter. The underlying duodenal muscularis propria was not involved and the stalk did not contain any visible vessels. Endoscopic polypectomy was then performed. A detachable endoloop was maneuvered around the polyp head and tightened around the stalk close to its base. A snare was then used to capture the polyp on the stalk, 5 mm distal to the endoloop’s position (figure 1B). Electrocautery was then applied with successful removal of the polyp (figure 1C). The polyp was then retrieved with a stone basket. There were no immediate or delayed bleeding complications. Histologically, the polyp was composed of densely packed lobules of Brunner’s glands lined by normal duodenal mucosa, consistent with a Brunner gland hamartoma (figure 1D).
AJG – Vol. 97, No. 9, Suppl., 2002
emia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. We report a case of a young woman who presented with a history of intermittent postprandial abdominal pain without weight loss. A 30 –year– old white woman presented with intermittent episodes of epigastric abdominal pain of two years’ duration. The pain was worsened by eating and was sharp, non–radiating in nature. These episodes occurred every 2 months. The pain improved by curling up in a fetal position or by taking morphine and increased in intensity with attempting to lie flat. She denied any nausea, diarrhea, constipation, bright red bleeding per rectum or dark tarry stools. She had visited the ER at least 5 times in the past because of the abdominal pain but all tests, including computed tomographic scan of abdomen, MRI and upper GI series, had been unremarkable. She had never had an EGD or colonoscopy. Her past medical history was otherwise unremarkable. There was no family history of liver disease, inflammatory bowel disease, or cancer. Physical examination revealed a pleasant female in no obvious distress. Her vitals signs were stable; heart and lung examination were normal. Abdominal examination revealed mild distention with an epigastric bruit on auscultation. Rectal exam was normal and Heme occult testing was negative. Plain abdominal radiograph showed no pathology. A duplex ultrasound of abdominal vessels was performed which revealed extremely elevated systolic velocity at the celiac axis. An abdominal lateral aortogram revealed 60 % stenosis of the celiac axis with post–stenotic dilatation. She underwent surgical resection of the median arcuate ligament and made an uneventful recovery. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament. Treatment can often be limited to longitudinal incision of the ligament; reconstructive procedures of the celiac artery are sometimes necessary.
511 OGILVIE’S SYNDROME ASSOCIATED WITH CORYNEBACTERIUM JEIKEIUM INDUCED SEPSIS IN A LEUKEMIC PATIENT Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecicut, Farmington, CT.
Endoscopic resection of Brunner’s gland hamartomas has been previously reported and may be complicated by bleeding. EUS helps to determine the appropriateness of endoscopic resection and the use of a disposable endoloop prior to snare electrocautery may minimize potential bleeding complications. EUS– guided endoscopic polypectomy may be an acceptable alternative to surgery for large submucosal polypoid lesions. 510 MEDIAL ARCUATE LIGAMENT SYNDROME Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecticut, Farmington, CT. Conclusions: Medial arcuate ligament syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with extrinsic compression by fibrous diaphragmatic bands or sympathetic neural fibers of the celiac axis near its takeoff from the aorta. Symptoms of mesenteric isch-
Conclusions: Acute colonic pseudo– obstruction is a motility disorder characterized by massive colonic dilation in the absence of mechanical obstruction. Presented below is a case of acute colonic pseudo– obstruction caused by Corynebacterium jk septicemia. A 53–year– old white male presented to his doctor with worsening fatigue. On testing he was found to be leukopenic and thrombocytopenic prompting a bone marrow biopsy, which revealed Acute Myeloid Leukemia (42% bands). Cytogenetic studies confirmed the diagnosis. He was admitted to the Oncology service and started on chemotherapy. Initially, he tolerated chemotherapy well but two days later he spiked a temperature of 103° F. After obtaining blood and urine cultures, he was started empirically on ceftazidime. His cytopenia worsened to pancytopenia. Fluconazole, acyclovir, & GM–CSF were also initiated. Despite these interventions his condition worsened and he was transferred to the ICU. He was found to be tachycardiac (125 bpm), with very dry oral mucosa. His chest exam revealed bilateral crackles; heart examination revealed tachycardia. Abdominal exam was remarkable for diffusely decreased bowel sounds. He was intubated because of worsening shortness of breath, hypoxemia and acidosis. Chest x–ray revealed diffuse infilterates. He underwent an uneventful bronchoscopy. Both his blood cultures and endotracheal washings grew Corynebacterium jeikeium. Vancomycin was added, but he kept spiking fevers. He developed tense distention of his abdomen, with decreased bowel sounds and tympany on percussion unrelieved by intermittent suction. An abdominal x–ray revealed increased air in the transverse colon and cecum without evidence of obstruction. Abdominal computed tomographic scan with contrast confirmed the results. Supportive treatment with IV fluids and colonic decom-
AJG – September, Suppl., 2002
pression failed to relieve his symptoms. Neostigmine (to increase cholinergic drive) was started and Erythromycin (to stimulate the motilin receptors) added with an excellent response. His bowel sounds improved and the size of his belly decreased. Ogilvie’s syndrome (colonic pseudo– obstruction) is believed to result from an imbalance between parasympathetic and sympathetic control of intestinal motility. Neostigmine is an effective treatment for patients who have failed conservative management. Several small uncontrolled case series have also reported benefit from intravenous erythromycin and cisapride. 512 FORMALDEHYDE INGESTION Ramon Garcia, M.D. and Lannie Cation, M.D., F.A.C.P.*. Internal Medicine Department, OSF St Francis Medical Center, Peoria, IL. Purpose: 67 year old white male was admitted after acute ingestion of 100 –200 ml of formaldehyde. He had previously put formaldehyde on his mosquito bites which “helped” the itching. Now his toes began to hurt and he thought that by drinking some formaldehyde his pain would be relieved. His wife kept some formaldehye in the garage from a past project she had done. After the ingestion, he became severly nauseated and vomitted violently. He was taken to the emergency room. Upon arrival to the emergency room, the patient was found to have severe hypotension, an anion gap acidosis and acute renal failure. All of these were attributed to the acute ingestion of the formaldehyde. He was promptly admitted to the intensive care unit. Soon after he began to have respiratory dificulty and was intubated secondary to respiratory failure. The patient maintained adequate oxygenation but began to have copious thick secretions and airway protection continued to be a factor. He was initialy volume resuscitated with fluids but eventualy did require dopamine. His creatinine peaked at 2.7 but trended downward. Once extubated and not requiring blood pressure agents, he underwent esophogastroduodenoscopy. There was some caustic damage to the stomach and duodenum. Both showed ischemic changes. He later underwent a thin barrium swallow study that demonstrated marked aspiration into bronchi. The patient required a nasal feeding tube for nutrition and eventualy needed a percutaneous gastric tube. But the later was not attempted for fear of gastric rupture until a period of time passed. The patient did not have any ischemic changes of his heart recorded on EKG. He did not have elevation of cardiac enzymes or wall motion abnormalities on on echocardiography. His initial complaint of toe pain continued and further work up revealed mild ischemic changes of his lower extremities documentated by arterial brachial indicies. After several months of hospitalization , he slowly improved. The patient required daily physical therapy and nutritional support. His family refused to have him placed in a nursing home. He eventually went home but came back to the hospital after a brief stay away. Speech pathology assesed the patient to have severe vocal cord impairment. He developed malnutrition and further decompensationof his gastrointestinal and renal systems. He died approximately six months after the formaldehyde ingestion. Conclusions: This patient suffered acute and chronic impacts from chemical ingestion but his gastrointestinal system was especially affected. 513 PNEUMATOSIS COLI ASSOCIATED WITH CRYPTOSPORIDIOSIS OF THE GI TRACT IN AIDS PATIENTS Omar Al–Subee, M.D., Murray Ehrinpreis, M.D.* and James Tyberski, M.D. Internal Medicine, Wayne State University, Detroit, MI; Internal Medicine, Wayne State University, Detroit, MI and General Surgery, Wayne State University, Detroit, MI. Purpose: A 50 –year– old male with advanced AIDS presented with abdominal pain, diarrhea and weight loss over a period of 3 weeks. He did not have any history of chronic lung disease, abdominal trauma or surgery. The physical examination revealed diffuse abdominal tenderness without peritoneal signs or fever. The abdominal X–ray showed pneumatosis coli (PC)
Abstracts
S169
with air dissecting in a linear fashion throughout the right colonic wall but no free air seen in the peritoneum. The patient was kept NPO and managed conservatively. Stool studies were positive for leukocytes and cryptosporidia but negative for mycobacterial culture, microsporidia, ova & parasites, and for C. difficile toxins. Treatment with paromomycin was initiated. Lower endoscopy to the distal transverse colon with random biopsies did not show significant pathology. The patients’ abdominal pain and diarrhea persisted as did the finding of PC. Subsequently, total colectomy with ileostomy was performed. Histopathologic examination showed involvement of the terminal ileum and colon with cryptosporidia in addition to small spaces lined with histiocytes observed in the cecal wall, a finding compatible with PC. The patient did well after the surgery and his ileostomy output improved with continuation of medical treatment. He was discharged after 6 weeks from presentation. Review of the literature revealed 5 reported cases of PC in AIDS patients associated with cryptosporidiosis. It seems that in all of the observed case (including our case) there is a particular pattern of disease involvement. It affects male patients, involves of the right side of the colon with or without the left side, and there is a linear gas distribution, with no other organisms isolated. Interestingly all of previously reported cases were managed conservatively with favorable outcome after 7–10 days of presentation. However, our patient did not improve and he was offered surgery after 12 days. The pathophysiology of PC is better understood with other invasive organisms seen in advanced AIDS like CMV or MAC. However, in cryptosporidiosis, it is proposed that the massive diarrhea with increased intraluminal pressure can predispose to this phenomenon despite the lack of significant mucosal pathology. With more cases of cryptosporidial isolation described in AIDS patients presenting with PC, the association between the two is becoming clearer and should be considered in such a case scenario.
514 SMALL BOWEL PERFORATION AND RECURRENT GASTROINTESTINAL BLEEDING IN WEGENER’S GRANULOMATOSIS: A CASE REPORT Suryakanth R. Gurudu, M.D. and Jeffry A. Katz, M.D.*. GI Division, Department of Medicine, University Hospitals of Cleveland, Cleveland, OH. Purpose: We report a rare gastrointestinal manifestation of Wegener’s granulomatosis. A 54 year old Caucasian male patient was admitted to our hospital with a history of recurrent sinus infections and a newly diagnosed pulmonary nodule. A wedge biopsy of the pulmonary nodule revealed necrotizing vasculitis. C–ANCA was indeterminate at 1:16. Therapy with cyclophosphamide and prednisone was begun. On the 10th hospital day he developed maroon colored stools, severe acute abdominal pain, and abdominal distention. CT scan of the abdomen revealed free air. At emergency laparotomy multiple perforations of the small bowel were found and 60cms of small bowel was removed. Histopathology showed focal mucosal ulceration with transmural acute inflammation and focal angiitis. One week later he had recurrent gastrointestinal bleeding. Upper endoscopy revealed a few irregular, shallow non– bleeding ulcers in the esophagus and biopsies were consistent with Herpes simplex esophagitis. Colonoscopy showed a few small ulcers in the terminal ileum and a large ulcer at the ileo– cecal valve. Ileal biopsies showed no abnormality, colonic biopsy showed colonic mucosa with fibrinous material. A nuclear scan showed a bleeding site in the proximal small bowel. Repeat laparotomy and intraoperative enteroscopy was performed which revealed a small bleeding ulcer proximal to the prior surgical anastomosis. Eight centimeters of small bowel was resected. Histopathology showed similar findings to the prior small bowel specimen. The patient subsequently recovered and went to a rehabilitation center. Discussion: Gastrointestinal involvement in the Wegener’s granulomatosis is uncommon, occuring in 10 –12% of patients at presentation or during the course of illness. Wegener’s granulomatosis can involve any part of gastrointestinal tract. Only 4 case reports of small bowel perforation have been reported in the literature( Medline search:1966 –2002). Recurrent small
Abstracts
tion of a submucosal lesion. We report a case of endoscopic polypectomy of a large Brunner’s gland hamartoma with aid from EUS. A 70 –year– old male presented with complaints of daily black bowel movements for one week. His medications included aspirin and celecoxib. Physical exam revealed dark brown, hemoccult positive stool. Hematocrit was 32.4%. Upper endoscopy identified an 8 cm submucosal, polypoid lesion with a long, thick stalk in the second duodenum (figure 1A). Biopsies revealed normal duodenal villous architecture. EUS showed that the polyp head was homogeneous and hyperechoic, and contained two cysts measuring 8 to 9 mm in diameter. The underlying duodenal muscularis propria was not involved and the stalk did not contain any visible vessels. Endoscopic polypectomy was then performed. A detachable endoloop was maneuvered around the polyp head and tightened around the stalk close to its base. A snare was then used to capture the polyp on the stalk, 5 mm distal to the endoloop’s position (figure 1B). Electrocautery was then applied with successful removal of the polyp (figure 1C). The polyp was then retrieved with a stone basket. There were no immediate or delayed bleeding complications. Histologically, the polyp was composed of densely packed lobules of Brunner’s glands lined by normal duodenal mucosa, consistent with a Brunner gland hamartoma (figure 1D).
AJG – Vol. 97, No. 9, Suppl., 2002
emia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. We report a case of a young woman who presented with a history of intermittent postprandial abdominal pain without weight loss. A 30 –year– old white woman presented with intermittent episodes of epigastric abdominal pain of two years’ duration. The pain was worsened by eating and was sharp, non–radiating in nature. These episodes occurred every 2 months. The pain improved by curling up in a fetal position or by taking morphine and increased in intensity with attempting to lie flat. She denied any nausea, diarrhea, constipation, bright red bleeding per rectum or dark tarry stools. She had visited the ER at least 5 times in the past because of the abdominal pain but all tests, including computed tomographic scan of abdomen, MRI and upper GI series, had been unremarkable. She had never had an EGD or colonoscopy. Her past medical history was otherwise unremarkable. There was no family history of liver disease, inflammatory bowel disease, or cancer. Physical examination revealed a pleasant female in no obvious distress. Her vitals signs were stable; heart and lung examination were normal. Abdominal examination revealed mild distention with an epigastric bruit on auscultation. Rectal exam was normal and Heme occult testing was negative. Plain abdominal radiograph showed no pathology. A duplex ultrasound of abdominal vessels was performed which revealed extremely elevated systolic velocity at the celiac axis. An abdominal lateral aortogram revealed 60 % stenosis of the celiac axis with post–stenotic dilatation. She underwent surgical resection of the median arcuate ligament and made an uneventful recovery. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament. Treatment can often be limited to longitudinal incision of the ligament; reconstructive procedures of the celiac artery are sometimes necessary.
511 OGILVIE’S SYNDROME ASSOCIATED WITH CORYNEBACTERIUM JEIKEIUM INDUCED SEPSIS IN A LEUKEMIC PATIENT Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecicut, Farmington, CT.
Endoscopic resection of Brunner’s gland hamartomas has been previously reported and may be complicated by bleeding. EUS helps to determine the appropriateness of endoscopic resection and the use of a disposable endoloop prior to snare electrocautery may minimize potential bleeding complications. EUS– guided endoscopic polypectomy may be an acceptable alternative to surgery for large submucosal polypoid lesions. 510 MEDIAL ARCUATE LIGAMENT SYNDROME Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecticut, Farmington, CT. Conclusions: Medial arcuate ligament syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with extrinsic compression by fibrous diaphragmatic bands or sympathetic neural fibers of the celiac axis near its takeoff from the aorta. Symptoms of mesenteric isch-
Conclusions: Acute colonic pseudo– obstruction is a motility disorder characterized by massive colonic dilation in the absence of mechanical obstruction. Presented below is a case of acute colonic pseudo– obstruction caused by Corynebacterium jk septicemia. A 53–year– old white male presented to his doctor with worsening fatigue. On testing he was found to be leukopenic and thrombocytopenic prompting a bone marrow biopsy, which revealed Acute Myeloid Leukemia (42% bands). Cytogenetic studies confirmed the diagnosis. He was admitted to the Oncology service and started on chemotherapy. Initially, he tolerated chemotherapy well but two days later he spiked a temperature of 103° F. After obtaining blood and urine cultures, he was started empirically on ceftazidime. His cytopenia worsened to pancytopenia. Fluconazole, acyclovir, & GM–CSF were also initiated. Despite these interventions his condition worsened and he was transferred to the ICU. He was found to be tachycardiac (125 bpm), with very dry oral mucosa. His chest exam revealed bilateral crackles; heart examination revealed tachycardia. Abdominal exam was remarkable for diffusely decreased bowel sounds. He was intubated because of worsening shortness of breath, hypoxemia and acidosis. Chest x–ray revealed diffuse infilterates. He underwent an uneventful bronchoscopy. Both his blood cultures and endotracheal washings grew Corynebacterium jeikeium. Vancomycin was added, but he kept spiking fevers. He developed tense distention of his abdomen, with decreased bowel sounds and tympany on percussion unrelieved by intermittent suction. An abdominal x–ray revealed increased air in the transverse colon and cecum without evidence of obstruction. Abdominal computed tomographic scan with contrast confirmed the results. Supportive treatment with IV fluids and colonic decom-
AJG – September, Suppl., 2002
pression failed to relieve his symptoms. Neostigmine (to increase cholinergic drive) was started and Erythromycin (to stimulate the motilin receptors) added with an excellent response. His bowel sounds improved and the size of his belly decreased. Ogilvie’s syndrome (colonic pseudo– obstruction) is believed to result from an imbalance between parasympathetic and sympathetic control of intestinal motility. Neostigmine is an effective treatment for patients who have failed conservative management. Several small uncontrolled case series have also reported benefit from intravenous erythromycin and cisapride. 512 FORMALDEHYDE INGESTION Ramon Garcia, M.D. and Lannie Cation, M.D., F.A.C.P.*. Internal Medicine Department, OSF St Francis Medical Center, Peoria, IL. Purpose: 67 year old white male was admitted after acute ingestion of 100 –200 ml of formaldehyde. He had previously put formaldehyde on his mosquito bites which “helped” the itching. Now his toes began to hurt and he thought that by drinking some formaldehyde his pain would be relieved. His wife kept some formaldehye in the garage from a past project she had done. After the ingestion, he became severly nauseated and vomitted violently. He was taken to the emergency room. Upon arrival to the emergency room, the patient was found to have severe hypotension, an anion gap acidosis and acute renal failure. All of these were attributed to the acute ingestion of the formaldehyde. He was promptly admitted to the intensive care unit. Soon after he began to have respiratory dificulty and was intubated secondary to respiratory failure. The patient maintained adequate oxygenation but began to have copious thick secretions and airway protection continued to be a factor. He was initialy volume resuscitated with fluids but eventualy did require dopamine. His creatinine peaked at 2.7 but trended downward. Once extubated and not requiring blood pressure agents, he underwent esophogastroduodenoscopy. There was some caustic damage to the stomach and duodenum. Both showed ischemic changes. He later underwent a thin barrium swallow study that demonstrated marked aspiration into bronchi. The patient required a nasal feeding tube for nutrition and eventualy needed a percutaneous gastric tube. But the later was not attempted for fear of gastric rupture until a period of time passed. The patient did not have any ischemic changes of his heart recorded on EKG. He did not have elevation of cardiac enzymes or wall motion abnormalities on on echocardiography. His initial complaint of toe pain continued and further work up revealed mild ischemic changes of his lower extremities documentated by arterial brachial indicies. After several months of hospitalization , he slowly improved. The patient required daily physical therapy and nutritional support. His family refused to have him placed in a nursing home. He eventually went home but came back to the hospital after a brief stay away. Speech pathology assesed the patient to have severe vocal cord impairment. He developed malnutrition and further decompensationof his gastrointestinal and renal systems. He died approximately six months after the formaldehyde ingestion. Conclusions: This patient suffered acute and chronic impacts from chemical ingestion but his gastrointestinal system was especially affected. 513 PNEUMATOSIS COLI ASSOCIATED WITH CRYPTOSPORIDIOSIS OF THE GI TRACT IN AIDS PATIENTS Omar Al–Subee, M.D., Murray Ehrinpreis, M.D.* and James Tyberski, M.D. Internal Medicine, Wayne State University, Detroit, MI; Internal Medicine, Wayne State University, Detroit, MI and General Surgery, Wayne State University, Detroit, MI. Purpose: A 50 –year– old male with advanced AIDS presented with abdominal pain, diarrhea and weight loss over a period of 3 weeks. He did not have any history of chronic lung disease, abdominal trauma or surgery. The physical examination revealed diffuse abdominal tenderness without peritoneal signs or fever. The abdominal X–ray showed pneumatosis coli (PC)
Abstracts
S169
with air dissecting in a linear fashion throughout the right colonic wall but no free air seen in the peritoneum. The patient was kept NPO and managed conservatively. Stool studies were positive for leukocytes and cryptosporidia but negative for mycobacterial culture, microsporidia, ova & parasites, and for C. difficile toxins. Treatment with paromomycin was initiated. Lower endoscopy to the distal transverse colon with random biopsies did not show significant pathology. The patients’ abdominal pain and diarrhea persisted as did the finding of PC. Subsequently, total colectomy with ileostomy was performed. Histopathologic examination showed involvement of the terminal ileum and colon with cryptosporidia in addition to small spaces lined with histiocytes observed in the cecal wall, a finding compatible with PC. The patient did well after the surgery and his ileostomy output improved with continuation of medical treatment. He was discharged after 6 weeks from presentation. Review of the literature revealed 5 reported cases of PC in AIDS patients associated with cryptosporidiosis. It seems that in all of the observed case (including our case) there is a particular pattern of disease involvement. It affects male patients, involves of the right side of the colon with or without the left side, and there is a linear gas distribution, with no other organisms isolated. Interestingly all of previously reported cases were managed conservatively with favorable outcome after 7–10 days of presentation. However, our patient did not improve and he was offered surgery after 12 days. The pathophysiology of PC is better understood with other invasive organisms seen in advanced AIDS like CMV or MAC. However, in cryptosporidiosis, it is proposed that the massive diarrhea with increased intraluminal pressure can predispose to this phenomenon despite the lack of significant mucosal pathology. With more cases of cryptosporidial isolation described in AIDS patients presenting with PC, the association between the two is becoming clearer and should be considered in such a case scenario.
514 SMALL BOWEL PERFORATION AND RECURRENT GASTROINTESTINAL BLEEDING IN WEGENER’S GRANULOMATOSIS: A CASE REPORT Suryakanth R. Gurudu, M.D. and Jeffry A. Katz, M.D.*. GI Division, Department of Medicine, University Hospitals of Cleveland, Cleveland, OH. Purpose: We report a rare gastrointestinal manifestation of Wegener’s granulomatosis. A 54 year old Caucasian male patient was admitted to our hospital with a history of recurrent sinus infections and a newly diagnosed pulmonary nodule. A wedge biopsy of the pulmonary nodule revealed necrotizing vasculitis. C–ANCA was indeterminate at 1:16. Therapy with cyclophosphamide and prednisone was begun. On the 10th hospital day he developed maroon colored stools, severe acute abdominal pain, and abdominal distention. CT scan of the abdomen revealed free air. At emergency laparotomy multiple perforations of the small bowel were found and 60cms of small bowel was removed. Histopathology showed focal mucosal ulceration with transmural acute inflammation and focal angiitis. One week later he had recurrent gastrointestinal bleeding. Upper endoscopy revealed a few irregular, shallow non– bleeding ulcers in the esophagus and biopsies were consistent with Herpes simplex esophagitis. Colonoscopy showed a few small ulcers in the terminal ileum and a large ulcer at the ileo– cecal valve. Ileal biopsies showed no abnormality, colonic biopsy showed colonic mucosa with fibrinous material. A nuclear scan showed a bleeding site in the proximal small bowel. Repeat laparotomy and intraoperative enteroscopy was performed which revealed a small bleeding ulcer proximal to the prior surgical anastomosis. Eight centimeters of small bowel was resected. Histopathology showed similar findings to the prior small bowel specimen. The patient subsequently recovered and went to a rehabilitation center. Discussion: Gastrointestinal involvement in the Wegener’s granulomatosis is uncommon, occuring in 10 –12% of patients at presentation or during the course of illness. Wegener’s granulomatosis can involve any part of gastrointestinal tract. Only 4 case reports of small bowel perforation have been reported in the literature( Medline search:1966 –2002). Recurrent small