- Email: [email protected]
A case of zinc toxicity due to massive coin ingestion
AJG – September, Suppl., 2001
jury and proliferation, and fibrosis. Hepatic dry wt. Cu-940mcg/gm. Genetic tests for Wilsons disease did not reveal known mutations. Conclusions: A diagnosis of Wilsons disease and PBC was made and treatment with D-Penicillamine and ursodeoxycholic acid initiated. To our knowledge this is the first case of Wilsons disease and PBC overlap reported. 676 Hemosuccus pancreaticus presenting as massive, recurrent upper gastrointestinal bleeding. Control by angiographic embolization Asif Khalid1, Arthur J Moser2 and Adam Slivka1*. 1Medicine, Division of Gastroenterology and Hepatology, University of Pittsburgh, Pittsburgh, Pa; and 2Surgery, University of Pittsburgh, Pittsburgh, Pa. Purpose: We present a case of hemosuccus pancreaticus in a patient with recurrent pancreatitis and polycystic kidney disease. We will discuss diagnostic and therapeutic steps taken in this very unusual case of massive gastrointestinal bleeding. Results: A 58 year old white female was admitted with melena and hemodynamic instability. She gave history of an episode of hemetemesis leading to vascular collapse 6 weeks earlier, the etiology for which remained unclear at an outside facility, despite extensive work-up. She was accompanied by CT films that documented a cystic structure in the head of the pancreas. Her past history was significant for alcohol abuse, recurrent episodes of epigastric and back pain with elevated pancreatic enzymes. This pain also occurred at the time of previous bleed. Emergent endoscopy after resuscitation with a side viewing duodenoscope revealed blood emanating from the major papilla. Celiac and superior mesenteric arteriogram revealed aneurysmal dilation of the inferior pancreato-duodenal artery. Coil embolization was performed of this vessel. No recurrent bleeding has occurred over the last 6 months and repeat CT scan shows a clip in the region of the head of the pancreas and resolution of the cyst seen previously. Conclusions: Hemosuccus panreaticus refers to hemmorrhage into the pancreatic duct. Eighty eight cases have been described so far. It most commonly occurs in the setting of chronic pancreatitis and pseudoaneurysm of the splenic artery. Diagnosis requires a high index of suspicion in the setting of acute or chronic pancreatitis, gastrointestinal bleeding associated with abdominal pain and hyperamylasemia. Angiography is the diagnostic test of choice and permanent coil embolization is recommended as the first therapy. Surgery should be reserved for failure of control of bleeding by angiography and embolization, or if there are pancreatitis related indications for surgical intervention. 677 A case of zinc toxicity due to massive coin ingestion Ahmad Khalifa, MD, Firdous Siddiqui, MD, Murray Ehrinpreis, MD, FACG. Wayne State University, Detroit, MI. The major cause of zinc toxicity in adults is massive coin ingestion in psychiatric patients. From the reported cases, mortality of zinc toxicity has been high. We report a case of zinc toxicity in a patient from massive pennies ingestion who survived. A 47 Y/O AA male with a history of schizophrenia was referred for outpatient EGD for nausea and vomiting. He was noted to have numerous coins in the gastric fundus and multiple ulcers. Abdominal x-rays showed coins throughout the GI tract with a big stalk in the stomach. Surgery was recommended, however, he refused. A few days later, he returned with worsening abdominal symptoms. The patient developed acute renal failure with hematuria, severe anemia, leukopenia, elevated LFT’s and a coagulopathy. His zinc level was 2891 Gm/dl (normal 60 –130). Serum copper level was 6 Gm/dl (normal 70 –155). Initial management included resuscitation with IV fluids, PRBC’s, chelation therapy for zinc using Calcium EDTA, proton pump inhibitors along with copper supplements. Gastrotomy was performed where 178 pennies, one dime and one nickel were retrieved. Postoperatively, the patient’s clinical status improved rapidly. His renal function returned to normal
Abstracts
S213
within a few days and hemoglobin rose to 11 gm/dl. He was discharged a few days later. In 1982, the composition of pennies was changed from copper to zinc. Zinc is highly acid digestible and pennies degrade rapidly in the stomach causing erosions, ulcers, GI bleeding and even perforation. Zinc is rapidly absorbed and deposits in liver, pancreas and kidneys presenting as hepatic necrosis, pancreatitis and renal failure. Zinc toxicity can also lead to coagulopathy, leukopenia and hypo-cupremic anemia. Surgery should be considered early when a large number of coins have been ingested to prevent zinc toxicity. It should be done also if complications like perforation, severe bleeding, or bowel obstruction occurred. In cases of limited number of coins, endoscopic removal should be attempted first. During removal, the airways should be protected with either an overtube or endotracheal intubation. Mortality remains high following zinc intoxication even with chelation therapy. Prompt removal of the source is the primary goal. Preoperative chelation of zinc with Calcium EDTA and maximum gastric acid suppression to reduce the rate of zinc release will help reduce mortality. 678 Multiple liver abscesses due to Yersinia enterocolitica reveal hereditary hemochromatosis Nabeel H Khan, M.D., Robert Hally, M.D. and Luis A Balart, M.D., FACG*. New Orleans, LA, United States. Purpose: Yersinia enterocolitica is a gram negative bacillus that is iron dependent and relies entirely on exogenous iron for growth. Clinical manifestations include enterocolitis, mesenteric adenitis and terminal ileitis. Invasive diseases such as septicemia and hepatosplenic abscesses are usually associated with underlying diseases. Review of the literature revealed 35 reported cases of Y. enterocolitis liver abscesses. 21(60%) of these were associated with hemochromatosis. Case Report: A 43-year-old male presented with fever, rigors and diarrhea of one-week duration. On physical examination, he was found to be jaundiced and had hepatosplenomegaly. A CT scan revealed multiple hepatic and splenic abscesses. Blood cultures grew Y. enterocolitis. He was placed on ciprofloxacin (to which he developed an allergy), switched to ceftriaxone which was continued for 3 months. A repeat CT scan showed complete resolution of the abscesses. During hospitalization, he was found to have an iron saturation of 81% and after completion of therapy, he underwent a liver biopsy. The biopsy showed cirrhosis and analysis of the hepatic tissue showed an iron content of 8268 micrograms/gram dry weight (normal 400 –2200) and an iron index of 3.4 micromoles/gram/year (normal ⬍1) which was consistent with hemochromatosis. Genetic testing was not available at that time. Conclusion: Liver abscesses due to Y. enterocolitis, although exceedingly rare, should be considered a ‘red flag’ that should prompt a thorough investigation to rule out hereditary hemochromatosis as early detection and treatment can prevent complications. Conversely, Y. enterocolitica should be suspected in a patient with liver disease who develops gram negative sepsis. 679 Bombesinoma: a new etiology of intestinal pseudoobstruction Vikas Khurana, M.D, Ritu Khurana, M.D, Jamie S. Barkin, MD, MACG, Arvey I. Rogers, MD, MACG. University of Miami, School of Medicine/ Mount Sinai Medical Center Division of GI, Miami, FL, United States. Background: Bombesin is a tetradecapeptide obtained from the skins of toads. Several Bombesin-like peptides consisting of forms of gastrinreleasing peptide (GRP) that cause a clinical significant syndrome, have been identified in mammals. This is the first report of a Bombesin-producing tumor, causing pseudoobstruction. Case Report: A 55-year-old woman had the gradual onset of abd. distention and pain, progressive wt. loss, intermittent watery diarrhea, nausea and vomiting for 3 years. Past history included oophorectomy 11 years prior for a benign ovarian tumor and hypertension and she was on no medications.
jury and proliferation, and fibrosis. Hepatic dry wt. Cu-940mcg/gm. Genetic tests for Wilsons disease did not reveal known mutations. Conclusions: A diagnosis of Wilsons disease and PBC was made and treatment with D-Penicillamine and ursodeoxycholic acid initiated. To our knowledge this is the first case of Wilsons disease and PBC overlap reported. 676 Hemosuccus pancreaticus presenting as massive, recurrent upper gastrointestinal bleeding. Control by angiographic embolization Asif Khalid1, Arthur J Moser2 and Adam Slivka1*. 1Medicine, Division of Gastroenterology and Hepatology, University of Pittsburgh, Pittsburgh, Pa; and 2Surgery, University of Pittsburgh, Pittsburgh, Pa. Purpose: We present a case of hemosuccus pancreaticus in a patient with recurrent pancreatitis and polycystic kidney disease. We will discuss diagnostic and therapeutic steps taken in this very unusual case of massive gastrointestinal bleeding. Results: A 58 year old white female was admitted with melena and hemodynamic instability. She gave history of an episode of hemetemesis leading to vascular collapse 6 weeks earlier, the etiology for which remained unclear at an outside facility, despite extensive work-up. She was accompanied by CT films that documented a cystic structure in the head of the pancreas. Her past history was significant for alcohol abuse, recurrent episodes of epigastric and back pain with elevated pancreatic enzymes. This pain also occurred at the time of previous bleed. Emergent endoscopy after resuscitation with a side viewing duodenoscope revealed blood emanating from the major papilla. Celiac and superior mesenteric arteriogram revealed aneurysmal dilation of the inferior pancreato-duodenal artery. Coil embolization was performed of this vessel. No recurrent bleeding has occurred over the last 6 months and repeat CT scan shows a clip in the region of the head of the pancreas and resolution of the cyst seen previously. Conclusions: Hemosuccus panreaticus refers to hemmorrhage into the pancreatic duct. Eighty eight cases have been described so far. It most commonly occurs in the setting of chronic pancreatitis and pseudoaneurysm of the splenic artery. Diagnosis requires a high index of suspicion in the setting of acute or chronic pancreatitis, gastrointestinal bleeding associated with abdominal pain and hyperamylasemia. Angiography is the diagnostic test of choice and permanent coil embolization is recommended as the first therapy. Surgery should be reserved for failure of control of bleeding by angiography and embolization, or if there are pancreatitis related indications for surgical intervention. 677 A case of zinc toxicity due to massive coin ingestion Ahmad Khalifa, MD, Firdous Siddiqui, MD, Murray Ehrinpreis, MD, FACG. Wayne State University, Detroit, MI. The major cause of zinc toxicity in adults is massive coin ingestion in psychiatric patients. From the reported cases, mortality of zinc toxicity has been high. We report a case of zinc toxicity in a patient from massive pennies ingestion who survived. A 47 Y/O AA male with a history of schizophrenia was referred for outpatient EGD for nausea and vomiting. He was noted to have numerous coins in the gastric fundus and multiple ulcers. Abdominal x-rays showed coins throughout the GI tract with a big stalk in the stomach. Surgery was recommended, however, he refused. A few days later, he returned with worsening abdominal symptoms. The patient developed acute renal failure with hematuria, severe anemia, leukopenia, elevated LFT’s and a coagulopathy. His zinc level was 2891 Gm/dl (normal 60 –130). Serum copper level was 6 Gm/dl (normal 70 –155). Initial management included resuscitation with IV fluids, PRBC’s, chelation therapy for zinc using Calcium EDTA, proton pump inhibitors along with copper supplements. Gastrotomy was performed where 178 pennies, one dime and one nickel were retrieved. Postoperatively, the patient’s clinical status improved rapidly. His renal function returned to normal
Abstracts
S213
within a few days and hemoglobin rose to 11 gm/dl. He was discharged a few days later. In 1982, the composition of pennies was changed from copper to zinc. Zinc is highly acid digestible and pennies degrade rapidly in the stomach causing erosions, ulcers, GI bleeding and even perforation. Zinc is rapidly absorbed and deposits in liver, pancreas and kidneys presenting as hepatic necrosis, pancreatitis and renal failure. Zinc toxicity can also lead to coagulopathy, leukopenia and hypo-cupremic anemia. Surgery should be considered early when a large number of coins have been ingested to prevent zinc toxicity. It should be done also if complications like perforation, severe bleeding, or bowel obstruction occurred. In cases of limited number of coins, endoscopic removal should be attempted first. During removal, the airways should be protected with either an overtube or endotracheal intubation. Mortality remains high following zinc intoxication even with chelation therapy. Prompt removal of the source is the primary goal. Preoperative chelation of zinc with Calcium EDTA and maximum gastric acid suppression to reduce the rate of zinc release will help reduce mortality. 678 Multiple liver abscesses due to Yersinia enterocolitica reveal hereditary hemochromatosis Nabeel H Khan, M.D., Robert Hally, M.D. and Luis A Balart, M.D., FACG*. New Orleans, LA, United States. Purpose: Yersinia enterocolitica is a gram negative bacillus that is iron dependent and relies entirely on exogenous iron for growth. Clinical manifestations include enterocolitis, mesenteric adenitis and terminal ileitis. Invasive diseases such as septicemia and hepatosplenic abscesses are usually associated with underlying diseases. Review of the literature revealed 35 reported cases of Y. enterocolitis liver abscesses. 21(60%) of these were associated with hemochromatosis. Case Report: A 43-year-old male presented with fever, rigors and diarrhea of one-week duration. On physical examination, he was found to be jaundiced and had hepatosplenomegaly. A CT scan revealed multiple hepatic and splenic abscesses. Blood cultures grew Y. enterocolitis. He was placed on ciprofloxacin (to which he developed an allergy), switched to ceftriaxone which was continued for 3 months. A repeat CT scan showed complete resolution of the abscesses. During hospitalization, he was found to have an iron saturation of 81% and after completion of therapy, he underwent a liver biopsy. The biopsy showed cirrhosis and analysis of the hepatic tissue showed an iron content of 8268 micrograms/gram dry weight (normal 400 –2200) and an iron index of 3.4 micromoles/gram/year (normal ⬍1) which was consistent with hemochromatosis. Genetic testing was not available at that time. Conclusion: Liver abscesses due to Y. enterocolitis, although exceedingly rare, should be considered a ‘red flag’ that should prompt a thorough investigation to rule out hereditary hemochromatosis as early detection and treatment can prevent complications. Conversely, Y. enterocolitica should be suspected in a patient with liver disease who develops gram negative sepsis. 679 Bombesinoma: a new etiology of intestinal pseudoobstruction Vikas Khurana, M.D, Ritu Khurana, M.D, Jamie S. Barkin, MD, MACG, Arvey I. Rogers, MD, MACG. University of Miami, School of Medicine/ Mount Sinai Medical Center Division of GI, Miami, FL, United States. Background: Bombesin is a tetradecapeptide obtained from the skins of toads. Several Bombesin-like peptides consisting of forms of gastrinreleasing peptide (GRP) that cause a clinical significant syndrome, have been identified in mammals. This is the first report of a Bombesin-producing tumor, causing pseudoobstruction. Case Report: A 55-year-old woman had the gradual onset of abd. distention and pain, progressive wt. loss, intermittent watery diarrhea, nausea and vomiting for 3 years. Past history included oophorectomy 11 years prior for a benign ovarian tumor and hypertension and she was on no medications.