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1st case report of colitis cystica profunda (CCP) related to Crohn’s disease
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Abstracts
699 Acute right-sided colitis secondary to Aeromonas species infection Victor I Machicao1, Frank J Lukens1 and Michael F Picco1*. 1Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Aeromonas sp. is a gram-negative bacillus that can produce diarrhea, particularly among travelers. The following case illustrates an unusual presentation of acute colitis caused by Aeromonas sp. Methods: A 75 yr-old male with a history of osteoarthritis (OA) was admitted to our institution for an elective total knee arthroplasty. At the time of admission he described a 2-day history of loose bowel movements and low-grade fever. He eventually underwent the planned surgery without immediate complications. However, his diarrhea persisted in the postoperative period and developed right-sided abdominal pain. He denied any other symptom including hematochezia. His past medical history included OA, gout and hypertension. Results: At the time of his admission he was taking allopurinol and hydrochlorothiazide. Abnormal physical findings included an oral temperature of 101°F and a distended abdomen with hyperactive bowel sounds and mild tenderness on palpation. Laboratory findings included a normal complete blood count, chemistry profile, and hepatic enzymes. Stool studies included many white blood cells, two specimens negative for Clostridium difficile toxin, and negative ova and parasites. Stool culture was obtained. An abdominal flat plate showed large amount of gas scattered throughout the colon. Patient had a colonoscopy, which revealed proximal to the hepatic flexure a friable mucosa covered by large amount of exudate and several ulcerations. The remainder of the colon and terminal ileum appeared normal. Biopsies obtained from the affected mucosa revealed acute active colitis. Abdominal CT disclosed slight thickening of the ascending colon wall. Stool cultures became positive for Aeromonas sp. Patient was started on oral trimethoprim-sulfamethoxazole for ten days. Patient’s symptoms resolved completely by the fifth day of therapy. Conclusions: To our knowledge, this is the first report of acute right-sided colitis associated to Aeromonas sp. infection. Aeromonas should be considered as part of the differential diagnosis in individuals with acute colitis.
700 Arterioportal fistula causing acute pancreatitis and hemobilia postliver biopsy Victor I Machicao1, Frank J Lukens1, Stephen M Lange1* and James S Scolapio1. 1Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Hemobilia is a rare complication of percutaneous liver biopsy (PLB). The following case illustrates the unusual association of hemobilia and acute pancreatitis as a late complication of PLB. Methods: A 49-year-old male with hepatitis C infection presents 9 days after ultrasound (US)-guided liver biopsy performed for the evaluation of hepatitis. He complained of a 4-day history of severe epigastric pain and a 1-day history of bright red blood per rectum. His medical history was remarkable for hypertension, chronic renal insufficiency and gout. Medications included colchicine, furosemide, amlodipine and clonidine. He smoked 2 packs of cigarettes per day and was a social drinker. On presentation he had scleral icterus, a distended, diffusely tender abdomen and rectal exam revealed bright red blood. The remainder of his examination was unremarkable. Results: Laboratory abnormalities included hemoglobin ⫽ 7.7 g/dL, creatinine ⫽ 6.2 mg/dL, BUN ⫽ 86 mg/dL, AST ⫽ 195 U/L, ALT ⫽ 126 U/L, alkaline phosphatase ⫽ 335 U/L, amylase ⫽ 828 U/L, lipase ⫽ 1536 U/L, and total bilirubin ⫽ 4.3 mg/dL. Abdominal US revealed the gallbladder contained echogenic material suspicious for sludge with no biliary ductal dilatation. Abdominal CT disclosed dense material in the gallbladder, suggestive of sludge and peripancreatic fat stranding consistent with mild pancreatitis. Esophagogastroduodenoscopy revealed small amount of fresh blood within the second portion of the duodenum without obvious source
AJG – Vol. 96, No. 9, Suppl., 2001
of bleeding. Over the ensuing 48-hours he had recurrent bouts of severe abdominal pain, melena, and liver tests consistent with worsening cholestasis. He required multiple blood transfusions. An endoscopic retrograde cholangiopancreatography (ERCP) revealed blood flowing out of the major papilla. Cholangiography documented multiple irregular filling defects in the extrahepatic biliary tract. A sphincterotomy was performed and large clots were extracted from the common bile duct. Following ERCP, the patient underwent hepatic angiography which documented an arteriovenous fistula (AVF) between the left hepatic artery and left branch of the portal vein that was embolized with microcoils. The patient then improved, liver and pancreatic enzymes normalized, hemoglobin remained stable and he was discharged 5 days later. Conclusions: Our case is the first description of an AVF after PLB manifested with delayed hemobilia and acute pancreatitis. This entity should be in the differential diagnosis of acute pancreatitis following PLB. 701 Severe esophagitis mimicking esophageal squamous cell carcinoma in a patient on chronic alendronate Victor I Machicao1, Frank L Lukens1 and Timothy A Woodward1*. 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Esophagitis is a potential complication of alendronate use. There has been no described association between alendronate use and esophageal malignancy. We describe an unusual case of severe esophagitis mimicking squamous cell carcinoma of the esophagus in a patient on chronic bisphosphonate therapy. Methods: A 69-year-old female presented with a 1-month history of solid food dysphagia. She denied any other symptom. Her past medical history included a previous CVA, atrial fibrillation and osteoporosis. Her medications included alendronate. Results: Physical examination was unremarkable with the exception of an irregular pulse and expressive aphasia. Her laboratory studies included a normal complete blood count and chemistry profile. Chest x-ray was normal. Esophagogastroduodenoscopy (EGD) disclosed a 3-cm hiatal hernia and a distal esophageal stricture. Severe extensive ulcerative esophagitis was identified proximal to the stricture. Biopsies disclosed marked inflammation with no malignant cells. Alendronate was discontinued and an eventual EGD was repeated. Three months later, an EGD was repeated. A bilobed 3-cm friable esophageal mass at 31 cm below the incisors was identified. Biopsies showed ulceration with extensive exudate and granulation tissue, with fragments of atypical mucosa. Brush cytology was consistent with squamous cell carcinoma. Endoscopic ultrasound (EUS) revealed a friable exophytic hypoechoic 3-cm mass. Patient had negative CT exam of chest, abdomen and pelvis. Cardiothoracic surgery considered the patient at high risk for esophageal surgery. Repeated EUS 4 weeks later including biopsies demonstrated severe esophagitis with cellular atypia. During EGD performed 6 months after presentation a residual polypoid lesion was removed. Specimen was consistent with inflammatory granulation tissue with focal epithelial atypia. Subsequent endoscopic examinations have disclosed no abnormality, including a negative lugol staining. Fifteen months after presentation, patient is asymptomatic. Conclusions: This is the first case reported of ulcerative esophagitis secondary to alendronate with cytologic specimen with features mimicking squamous cell carcinoma of the esophagus. 702 1st case report of colitis cystica profunda (CCP) related to Crohn’s disease Anand Madan, MD, Kalyana Lavu, MD, Poonputt Chotiprasidhi, MD, Anil Minocha, MD, FACG. Southern Illinois University School of Medicine, Spfld, IL. A 37 y/o white male presented with one day h/o of N&V, abdominal pain and watery, progressing to bloody diarrhea. He appeared toxic on admis-
AJG – September, Suppl., 2001
sion with fever up to 40C. Abdomen was diffusely tender and distended with hyperactive bowel sounds. Labs showed WBC of 18k with 28% bands. Stool studies were negative for O&P and other enteric pathogens. Abdominal CT revealed diffuse bowel wall thickening extending from rectosigmoid to ascending colon. Flex/sig showed few diverticuli, apthous ulcers and severe bowel edema, preventing advancement of scope beyond 25cm. Biopsies showed nonspecific chronic inflammatory infiltrate in lamina propria, focal mucosal hemorrhages and edema. Patient was treated with IV ciprofloxacin and metronidazole but did not improve. Repeat flex/sig done one week later showed similar endoscopic and biopsy findings. At this time, patient was treated empirically with steroids for presumptive inflammatory bowel disease, with only brief improvement. On day 15, patient developed a distal colonic obstruction. Urgent surgery was performed and he was found to have sigmoid stricture with fat creeping of serosa around the colon requiring sigmoidectomy and end colostomy. Pathology of resected colon revealed colitis cystica profunda, mucosal ulcers, diverticuli, acute inflammatory infiltrate with necrotic debris and fibroconnective tissue within serosa. Presumptive diagnosis of perforated diverticulits/CCP was suggested. Patient’s symptoms improved after surgery, but on day 25 he was noted to have an enterocutaneous fistula with intra-abdominal abscess, requiring drainage. Repeat colonoscopy revealed extensive patchy ulceration of the colon. Biopsies were consistent with Crohn’s disease. ASCA was positive with negative pANCA. Patient was treated with infliximab, resulting in remission. Colitis cystica profunda is a rare and benign condition, most often associated with solitary rectal ulcer syndrome. It is a difficult diagnosis to make during endoscopy. This is the first case report of CCP occurrence related to Crohn’s disease.
703 Bloodless care of severely anemic patients with gastrointestinal bleeding: feasibility in a community hospital setting Srinivas J Madane, Mohamed Heikal and Irwin M Grosman*. 1Division of Gastroenterology, Long Island College Hospital, Brooklyn, NY, United States. Purpose: To review the clinical features and outcomes of patients with severe anemia due to gastrointestinal hemorrhage treated in a community hospital based bloodless medicine and surgery program. Methods: Retrospective chart review and patient interviews. Results: Using a database of nearly 5,000 patients evaluated since 1997 by The Bloodless Medicine and Surgery Program of New York, 439 patients with a gastrointestinal and anemia diagnosis were identified. Hospital, clinic and endoscopy records were reviewed. Of the 439 patients identified, 21 had significant gastrointestinal bleeding (compatible history, hemodynamic compromise and/or anemia). All patients underwent endoscopic evaluation at our institution. Thirteen of these patients had severe anemia— defined as a hemoglobin (Hgb) ⬍8.0 g/dL (mean Hgb ⫽ 5.7 g/dL; range ⫽ 3.7–7.8 g/dL). Nine patients were female and 4 were male. The median age was 62 years (range ⫽ 23– 89; 11/13 patients ⬎50 years old). Clinical presentations included anemia with fecal occult blood in 6 patients, hematochezia and/or melena in 5 patients and hematemesis in 2. In all, 20 endoscopic procedures were performed in the 13 patients. All patients received conscious sedation. No procedure or sedation related complications were seen. In 2 patients the cause of bleeding could not be identified. Six bled from peptic disease of the upper GI tract (3 GU, 1 DU, 1 severe ulcerative esophagitis and 1 duodenitis associated with marked thrombocytopenia), 2 bled from colonic diverticulosis, 1 had gastric cancer, 1 had AVMs in the duodenum and colon and 1 bled from large hemorrhoids. All patients were treated with iron (oral or parenteral) and erythropoietin (10,000u SQ tiw). Three patients underwent surgery (1 gastrectomy for cancer and 2 colectomies for diverticular bleeding). All 13 patients were discharged in satisfactory condition. Length of stay averaged 10.5 days (range ⫽ 2–28 d). Follow up data was available for 12 patients. Two patients expired (at 2 and 4 months post-discharge). The other 10 patients were all alive at a median follow up of 17 months (range ⫽ 12–36 months).
Abstracts
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Follow up hemoglobin was available in 8 patients. None of these patients were anemic on follow up. Conclusions: Bloodless care of severely anemic patients with GI bleeding is feasible in a community hospital setting. Endoscopy with conscious sedation can be performed in severely anemic patients without untoward consequences. 704 Symptomatic colonic sarcoidosis and the role of steroid therapy Mitchell Mah’moud M.D.*, William Pittman M.D., Robert Schellenberg M.D., Julia Whitehurst. Section of Gastroenterology and Hepatology, Boice-Willis Clinic, Rocky Mount, North Carolina. Purpose: Sarcoidosis is a systemic granulomatous disorder that can affect any organ in the body with gastrointestinal manifestations being extremely rare. Even when it involves the digestive tract, the stomach is the most common site with the incidence of colonic involvement being less common. In this vignette, we present a patient with colonic sarcoidosis masquerading as inflammatory bowel disease that was successfully treated with steroid therapy. Method: Patient is a 32 year old lady with history of pulmonary sarcoidosis who presented in October 2000 with weight loss and three months history of increased watery bowel motions of up to 7– 8 times per day. There were also associated tenesmus and blood in stool. Her other symptoms were odynophagia and nausea. At the time of the presentation, she had been on maintenance dose of Prednisone 2mg/day for several years as recommended by her Rheumatologist at Duke Medical Center. Her stool studies were negative for any infectious etiology and the CBC revealed leukocytosis. She subsequently underwent EGD and colonoscopy with biopsies, which showed diffuse ulcerations throughout the colon. Histology of the biopsy specimen showed chronic active colitis with formed granulomata in the lamina propria consistent with inflammatory bowel disease. AFB and PAS stains were negative. Serum P-ANCA and ASCA were negative. Review of the histologic findings at the AFIP showed active crypt-sparing colitis with intact crypt architecture and granulomas. Patient was subsequently treated with high dose Prednisone with excellent symptomatic response with no relapse of symptoms. Conclusion: This case suggests that 1) colonic sarcoidosis can masquerade as inflammatory bowel disease. 2) Steroids are effective in symptomatic relief of colonic sarcoidosis. 705 Early diagnosis of pancreatic cancer by endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in a patient with chronic pancreatitis (CP) can be curative: a case report Ravish J. Mahajan M.D., Jonathan Kerley M.D., Connie McMahan, CNP, Michael Travis R.N., Linas J. Adams M.D. Division of Gastroenterology, University of Tennessee Medical Center, Knoxville, TN. Pancreatic cancer has very poor prognosis. We would like to present a case of 35 year old Caucasian female with chronic pancreatitis who was diagnosed early with pancreatic cancer using EUS guided FNA, possibly leading to complete cure. Case History: The patient had alcohol induced chronic pancreatitis. She claimed to be sober for the last five years. She has had cholecystectomy, pseudocyst drainage and roux-en-y choledochojejunostomy. Patient had poor pain control with oral narcotic pills. Since December 1999, she was receiving EUS guided celiac plexus block (CPB) using 20 cc of 0.25% Bupivacaine and 80 mg Triamcinolone via echo-tip needle thru Linear array EUS Olympus scope. Initially patient had some pain relief. But, patient stopped having sufficient pain control. Her Liver function tests and CA 19-9 had been normal in the past. However, in October 2000, her CA 19-9 was noted to be 1004.9 (normal 0 –37 U/ml). Magnetic Resonance Cholangiopancreatography showed decreased density and calcification of pancreatic head such that malignancy could not be excluded. Whole body
Abstracts
699 Acute right-sided colitis secondary to Aeromonas species infection Victor I Machicao1, Frank J Lukens1 and Michael F Picco1*. 1Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Aeromonas sp. is a gram-negative bacillus that can produce diarrhea, particularly among travelers. The following case illustrates an unusual presentation of acute colitis caused by Aeromonas sp. Methods: A 75 yr-old male with a history of osteoarthritis (OA) was admitted to our institution for an elective total knee arthroplasty. At the time of admission he described a 2-day history of loose bowel movements and low-grade fever. He eventually underwent the planned surgery without immediate complications. However, his diarrhea persisted in the postoperative period and developed right-sided abdominal pain. He denied any other symptom including hematochezia. His past medical history included OA, gout and hypertension. Results: At the time of his admission he was taking allopurinol and hydrochlorothiazide. Abnormal physical findings included an oral temperature of 101°F and a distended abdomen with hyperactive bowel sounds and mild tenderness on palpation. Laboratory findings included a normal complete blood count, chemistry profile, and hepatic enzymes. Stool studies included many white blood cells, two specimens negative for Clostridium difficile toxin, and negative ova and parasites. Stool culture was obtained. An abdominal flat plate showed large amount of gas scattered throughout the colon. Patient had a colonoscopy, which revealed proximal to the hepatic flexure a friable mucosa covered by large amount of exudate and several ulcerations. The remainder of the colon and terminal ileum appeared normal. Biopsies obtained from the affected mucosa revealed acute active colitis. Abdominal CT disclosed slight thickening of the ascending colon wall. Stool cultures became positive for Aeromonas sp. Patient was started on oral trimethoprim-sulfamethoxazole for ten days. Patient’s symptoms resolved completely by the fifth day of therapy. Conclusions: To our knowledge, this is the first report of acute right-sided colitis associated to Aeromonas sp. infection. Aeromonas should be considered as part of the differential diagnosis in individuals with acute colitis.
700 Arterioportal fistula causing acute pancreatitis and hemobilia postliver biopsy Victor I Machicao1, Frank J Lukens1, Stephen M Lange1* and James S Scolapio1. 1Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Hemobilia is a rare complication of percutaneous liver biopsy (PLB). The following case illustrates the unusual association of hemobilia and acute pancreatitis as a late complication of PLB. Methods: A 49-year-old male with hepatitis C infection presents 9 days after ultrasound (US)-guided liver biopsy performed for the evaluation of hepatitis. He complained of a 4-day history of severe epigastric pain and a 1-day history of bright red blood per rectum. His medical history was remarkable for hypertension, chronic renal insufficiency and gout. Medications included colchicine, furosemide, amlodipine and clonidine. He smoked 2 packs of cigarettes per day and was a social drinker. On presentation he had scleral icterus, a distended, diffusely tender abdomen and rectal exam revealed bright red blood. The remainder of his examination was unremarkable. Results: Laboratory abnormalities included hemoglobin ⫽ 7.7 g/dL, creatinine ⫽ 6.2 mg/dL, BUN ⫽ 86 mg/dL, AST ⫽ 195 U/L, ALT ⫽ 126 U/L, alkaline phosphatase ⫽ 335 U/L, amylase ⫽ 828 U/L, lipase ⫽ 1536 U/L, and total bilirubin ⫽ 4.3 mg/dL. Abdominal US revealed the gallbladder contained echogenic material suspicious for sludge with no biliary ductal dilatation. Abdominal CT disclosed dense material in the gallbladder, suggestive of sludge and peripancreatic fat stranding consistent with mild pancreatitis. Esophagogastroduodenoscopy revealed small amount of fresh blood within the second portion of the duodenum without obvious source
AJG – Vol. 96, No. 9, Suppl., 2001
of bleeding. Over the ensuing 48-hours he had recurrent bouts of severe abdominal pain, melena, and liver tests consistent with worsening cholestasis. He required multiple blood transfusions. An endoscopic retrograde cholangiopancreatography (ERCP) revealed blood flowing out of the major papilla. Cholangiography documented multiple irregular filling defects in the extrahepatic biliary tract. A sphincterotomy was performed and large clots were extracted from the common bile duct. Following ERCP, the patient underwent hepatic angiography which documented an arteriovenous fistula (AVF) between the left hepatic artery and left branch of the portal vein that was embolized with microcoils. The patient then improved, liver and pancreatic enzymes normalized, hemoglobin remained stable and he was discharged 5 days later. Conclusions: Our case is the first description of an AVF after PLB manifested with delayed hemobilia and acute pancreatitis. This entity should be in the differential diagnosis of acute pancreatitis following PLB. 701 Severe esophagitis mimicking esophageal squamous cell carcinoma in a patient on chronic alendronate Victor I Machicao1, Frank L Lukens1 and Timothy A Woodward1*. 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, United States. Purpose: Esophagitis is a potential complication of alendronate use. There has been no described association between alendronate use and esophageal malignancy. We describe an unusual case of severe esophagitis mimicking squamous cell carcinoma of the esophagus in a patient on chronic bisphosphonate therapy. Methods: A 69-year-old female presented with a 1-month history of solid food dysphagia. She denied any other symptom. Her past medical history included a previous CVA, atrial fibrillation and osteoporosis. Her medications included alendronate. Results: Physical examination was unremarkable with the exception of an irregular pulse and expressive aphasia. Her laboratory studies included a normal complete blood count and chemistry profile. Chest x-ray was normal. Esophagogastroduodenoscopy (EGD) disclosed a 3-cm hiatal hernia and a distal esophageal stricture. Severe extensive ulcerative esophagitis was identified proximal to the stricture. Biopsies disclosed marked inflammation with no malignant cells. Alendronate was discontinued and an eventual EGD was repeated. Three months later, an EGD was repeated. A bilobed 3-cm friable esophageal mass at 31 cm below the incisors was identified. Biopsies showed ulceration with extensive exudate and granulation tissue, with fragments of atypical mucosa. Brush cytology was consistent with squamous cell carcinoma. Endoscopic ultrasound (EUS) revealed a friable exophytic hypoechoic 3-cm mass. Patient had negative CT exam of chest, abdomen and pelvis. Cardiothoracic surgery considered the patient at high risk for esophageal surgery. Repeated EUS 4 weeks later including biopsies demonstrated severe esophagitis with cellular atypia. During EGD performed 6 months after presentation a residual polypoid lesion was removed. Specimen was consistent with inflammatory granulation tissue with focal epithelial atypia. Subsequent endoscopic examinations have disclosed no abnormality, including a negative lugol staining. Fifteen months after presentation, patient is asymptomatic. Conclusions: This is the first case reported of ulcerative esophagitis secondary to alendronate with cytologic specimen with features mimicking squamous cell carcinoma of the esophagus. 702 1st case report of colitis cystica profunda (CCP) related to Crohn’s disease Anand Madan, MD, Kalyana Lavu, MD, Poonputt Chotiprasidhi, MD, Anil Minocha, MD, FACG. Southern Illinois University School of Medicine, Spfld, IL. A 37 y/o white male presented with one day h/o of N&V, abdominal pain and watery, progressing to bloody diarrhea. He appeared toxic on admis-
AJG – September, Suppl., 2001
sion with fever up to 40C. Abdomen was diffusely tender and distended with hyperactive bowel sounds. Labs showed WBC of 18k with 28% bands. Stool studies were negative for O&P and other enteric pathogens. Abdominal CT revealed diffuse bowel wall thickening extending from rectosigmoid to ascending colon. Flex/sig showed few diverticuli, apthous ulcers and severe bowel edema, preventing advancement of scope beyond 25cm. Biopsies showed nonspecific chronic inflammatory infiltrate in lamina propria, focal mucosal hemorrhages and edema. Patient was treated with IV ciprofloxacin and metronidazole but did not improve. Repeat flex/sig done one week later showed similar endoscopic and biopsy findings. At this time, patient was treated empirically with steroids for presumptive inflammatory bowel disease, with only brief improvement. On day 15, patient developed a distal colonic obstruction. Urgent surgery was performed and he was found to have sigmoid stricture with fat creeping of serosa around the colon requiring sigmoidectomy and end colostomy. Pathology of resected colon revealed colitis cystica profunda, mucosal ulcers, diverticuli, acute inflammatory infiltrate with necrotic debris and fibroconnective tissue within serosa. Presumptive diagnosis of perforated diverticulits/CCP was suggested. Patient’s symptoms improved after surgery, but on day 25 he was noted to have an enterocutaneous fistula with intra-abdominal abscess, requiring drainage. Repeat colonoscopy revealed extensive patchy ulceration of the colon. Biopsies were consistent with Crohn’s disease. ASCA was positive with negative pANCA. Patient was treated with infliximab, resulting in remission. Colitis cystica profunda is a rare and benign condition, most often associated with solitary rectal ulcer syndrome. It is a difficult diagnosis to make during endoscopy. This is the first case report of CCP occurrence related to Crohn’s disease.
703 Bloodless care of severely anemic patients with gastrointestinal bleeding: feasibility in a community hospital setting Srinivas J Madane, Mohamed Heikal and Irwin M Grosman*. 1Division of Gastroenterology, Long Island College Hospital, Brooklyn, NY, United States. Purpose: To review the clinical features and outcomes of patients with severe anemia due to gastrointestinal hemorrhage treated in a community hospital based bloodless medicine and surgery program. Methods: Retrospective chart review and patient interviews. Results: Using a database of nearly 5,000 patients evaluated since 1997 by The Bloodless Medicine and Surgery Program of New York, 439 patients with a gastrointestinal and anemia diagnosis were identified. Hospital, clinic and endoscopy records were reviewed. Of the 439 patients identified, 21 had significant gastrointestinal bleeding (compatible history, hemodynamic compromise and/or anemia). All patients underwent endoscopic evaluation at our institution. Thirteen of these patients had severe anemia— defined as a hemoglobin (Hgb) ⬍8.0 g/dL (mean Hgb ⫽ 5.7 g/dL; range ⫽ 3.7–7.8 g/dL). Nine patients were female and 4 were male. The median age was 62 years (range ⫽ 23– 89; 11/13 patients ⬎50 years old). Clinical presentations included anemia with fecal occult blood in 6 patients, hematochezia and/or melena in 5 patients and hematemesis in 2. In all, 20 endoscopic procedures were performed in the 13 patients. All patients received conscious sedation. No procedure or sedation related complications were seen. In 2 patients the cause of bleeding could not be identified. Six bled from peptic disease of the upper GI tract (3 GU, 1 DU, 1 severe ulcerative esophagitis and 1 duodenitis associated with marked thrombocytopenia), 2 bled from colonic diverticulosis, 1 had gastric cancer, 1 had AVMs in the duodenum and colon and 1 bled from large hemorrhoids. All patients were treated with iron (oral or parenteral) and erythropoietin (10,000u SQ tiw). Three patients underwent surgery (1 gastrectomy for cancer and 2 colectomies for diverticular bleeding). All 13 patients were discharged in satisfactory condition. Length of stay averaged 10.5 days (range ⫽ 2–28 d). Follow up data was available for 12 patients. Two patients expired (at 2 and 4 months post-discharge). The other 10 patients were all alive at a median follow up of 17 months (range ⫽ 12–36 months).
Abstracts
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Follow up hemoglobin was available in 8 patients. None of these patients were anemic on follow up. Conclusions: Bloodless care of severely anemic patients with GI bleeding is feasible in a community hospital setting. Endoscopy with conscious sedation can be performed in severely anemic patients without untoward consequences. 704 Symptomatic colonic sarcoidosis and the role of steroid therapy Mitchell Mah’moud M.D.*, William Pittman M.D., Robert Schellenberg M.D., Julia Whitehurst. Section of Gastroenterology and Hepatology, Boice-Willis Clinic, Rocky Mount, North Carolina. Purpose: Sarcoidosis is a systemic granulomatous disorder that can affect any organ in the body with gastrointestinal manifestations being extremely rare. Even when it involves the digestive tract, the stomach is the most common site with the incidence of colonic involvement being less common. In this vignette, we present a patient with colonic sarcoidosis masquerading as inflammatory bowel disease that was successfully treated with steroid therapy. Method: Patient is a 32 year old lady with history of pulmonary sarcoidosis who presented in October 2000 with weight loss and three months history of increased watery bowel motions of up to 7– 8 times per day. There were also associated tenesmus and blood in stool. Her other symptoms were odynophagia and nausea. At the time of the presentation, she had been on maintenance dose of Prednisone 2mg/day for several years as recommended by her Rheumatologist at Duke Medical Center. Her stool studies were negative for any infectious etiology and the CBC revealed leukocytosis. She subsequently underwent EGD and colonoscopy with biopsies, which showed diffuse ulcerations throughout the colon. Histology of the biopsy specimen showed chronic active colitis with formed granulomata in the lamina propria consistent with inflammatory bowel disease. AFB and PAS stains were negative. Serum P-ANCA and ASCA were negative. Review of the histologic findings at the AFIP showed active crypt-sparing colitis with intact crypt architecture and granulomas. Patient was subsequently treated with high dose Prednisone with excellent symptomatic response with no relapse of symptoms. Conclusion: This case suggests that 1) colonic sarcoidosis can masquerade as inflammatory bowel disease. 2) Steroids are effective in symptomatic relief of colonic sarcoidosis. 705 Early diagnosis of pancreatic cancer by endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in a patient with chronic pancreatitis (CP) can be curative: a case report Ravish J. Mahajan M.D., Jonathan Kerley M.D., Connie McMahan, CNP, Michael Travis R.N., Linas J. Adams M.D. Division of Gastroenterology, University of Tennessee Medical Center, Knoxville, TN. Pancreatic cancer has very poor prognosis. We would like to present a case of 35 year old Caucasian female with chronic pancreatitis who was diagnosed early with pancreatic cancer using EUS guided FNA, possibly leading to complete cure. Case History: The patient had alcohol induced chronic pancreatitis. She claimed to be sober for the last five years. She has had cholecystectomy, pseudocyst drainage and roux-en-y choledochojejunostomy. Patient had poor pain control with oral narcotic pills. Since December 1999, she was receiving EUS guided celiac plexus block (CPB) using 20 cc of 0.25% Bupivacaine and 80 mg Triamcinolone via echo-tip needle thru Linear array EUS Olympus scope. Initially patient had some pain relief. But, patient stopped having sufficient pain control. Her Liver function tests and CA 19-9 had been normal in the past. However, in October 2000, her CA 19-9 was noted to be 1004.9 (normal 0 –37 U/ml). Magnetic Resonance Cholangiopancreatography showed decreased density and calcification of pancreatic head such that malignancy could not be excluded. Whole body