- Email: [email protected]
An interesting complication following diagnostic colonoscopy: intramural cecal hematoma
AJG – September, Suppl., 2001
fluoroscopic guidance and patient in left lateral position, SEMS appeared to be deployed coaxially in good position. Post procedure abdominal xray in supine position showed second stent being placed through the wall of the first stent being pinched off in its mid position in a cross position. Despite the positioning, patient had moderate symptom relief lasting for two months of follow up. Conclusions: Self-expandable metal stent is an effective re-decompression modality in patients with restenosed SEMS by tumor ingrowth. Our experience underscores the importance of confirmation of the wire position by changing patient’s position prior to the deployment of the stent to avoid through-thewall stent position, especially if there is more than usual resistance in positioning stent across the strictured area.
631 Nasal NK/T-cell lymphoma with liver infiltration: case report and literature review Juan F Gallegos-Orozco1, Sergio Zepeda1, Roberto I de la Pen˜ a2, Juan F Nuncio3, Carmen Lome3 and Marco A Olivera1*. 1Gastroenterology; 2 Hematology; and 3Pathology Departments, Instituto Nacional de Ciencias Me´ dicas y Nutricio´ n “Salvador Zubiran”, Mexico City, Mexico. Purpose: Natural Killer (NK)/T-cell lymphomas are uncommon nonHodgkin lymphomas that arise in peripheral tissue, most of them from nasal tissue, and have cellular morphology that suggests a NK-cell origin (CD56⫹). They are infrequent in the United States and Europe but are more common in Asia and Central America. They are frequently associated with Epstein-Barr virus, respond poorly to treatment and have a dismal prognosis. Current WHO classification divides NK cell neoplasias in 4 groups: 1. Nasal NK/T-cell lymphoma 2. Nasal-type NK/T-cell lymphoma 3. NK cell leukemia 4. Agressive (systemic) NK cell lymphoma/leukemia Few cases have been reported in which secondary liver involvement is demonstrated after an initial localized lesion has been diagnosed. We report the first such case at our Institution. Methods: Case presentation and literature review. Case report: A 25 year-old hispanic female was referred to the Liver clinic because of progressive increase in ALT, AST (4 times the upper normal limit, UNL) and alkaline phosphatase (5 times UNL). Her past medical history was relevant for the presence of a nasal NK/T-cell lymphoma that was diagnosed a year before and for which the patient had been treated with chemo- and radiotherapy. She was asymptomatic and physical exam was relevant only for painless hepato-splenomegaly. Abdominal CT scan and MRI confirmed the liver and spleen enlargement, no focal lesions or intraabdominal lymph nodes were detected. Liver biopsy was performed, no hepatic architectural changes were noted, there was mild cholestasis and sinusolds were occupied by atypical lymphocytes that were strongly positive for CD3⑀ (T-cell marker), and histologic diagnosis of liver infiltration by NK/T cell lymphoma was confirmed. The patient remained symptom-free for 5 months, at which time she was admitted to the hospital for sinusitis and systemic inflammatory response syndrome. Her LFT had markedly increased. She was started on systemic antibiotics with a favourable clinical response. A bone marrow aspirate revealed marrow infiltration. She is currently alive with disease. Conclusions: Patients with nasal NK/T-cell lymphoma should be closely followed with periodic LFTs and if these are abnormal, hepatic infiltration should be ruled out with prompt liver biopsy even in asymptomatic patients, as the presence of liver infiltration is a poor prognostic indicator and usually warrants agressive therapy.
Abstracts
S199
632 An interesting complication following diagnostic colonoscopy: Intramural cecal hematoma Dominic Gallo, M.D., Christopher Tebrock, M.D., Leonard Little, M.D., David Rivera, M.D. Eishenower Army Medical Center, Augusta, GA. Rarely encountered complications of colonoscopy include perforation and bleeding. The incidence of complications for diagnostic colonoscopy has been reported to be 0.07– 0.4%. Splenic and colonic mesenteric injuries have also been described in the literature. There have been no reports of cecal hematoma following colonoscopy to our knowledge. We report a case of intramural cecal hematoma following diagnostic colonoscopy. We present a 69 year old female with history of atrial fibrillation who underwent elective diagnostic colonoscopy through a heparin window. She returned 24 hours post-procedure with right lower quadrant pain. Serial laboratory studies revealed decrease in hemoglobin from 10.4mg/dl to 7.8mg/dl. Computerized tomography (CT) of the abdomen and pelvis was performed revealing a 15 ⫻ 10 ⫻ 9cm hematoma in close approximation to the posterior wall of the cecum. She was treated nonoperatively but early surgical consultation was obtained. Correction of coagulopathy required 8 units of fresh frozen plasma as well as 8 units of packed red blood cells to correct anemia. She was hemodynamically stable throughout hospitalization and further assessment with CT showed stability of the hematoma. Diagnosis of this complication requires a high index of suspicion and early CT evaluation can be confirmatory. Conservative management requires close monitoring and serial examinations.
633 Persistent elevation of HAV IgM antibody for more than 350 days following acute infection: a case report Hetal Gandhi BS and Ketan Rana BS*. 1Internal Medicine, Bonsecours Hospital, Gross Pointe, Michigan, United States; and 2Gastroenterology, Bonsecours Hospital, Grosse Pointe, Michigan, United States. Purpose: It is a widely accepted concept that hepatitis A virus (HAV) is an acute self-limited illness. Demonstration of hepatitis-A-specific IgM antibodies is diagnostic of recent hepatitis A infection. It is uncommon but possible that HAV IgM remains elevated for extended period after acute hepatitis A. Methods: A 63 year old female patient who was seen by us secondary to elevated serum aminotransferase levels and positive HAV IgM. History revealed that she was diagnosed with acute hepatitis A infection approximately 11 months ago. She had elevated liver enzymes (AP 187,SGOT 106,SGPT 430). Also, Hepatitis panel revealed positive HAV IgM with negative serology for hepatitis B. An ERCP with extraction of common bile duct stone was performed leading to normalization of serum aminotranseferase levels. Results: Patients serum remained persistently positive for Immunoglobulin M (IgM) for approximately 350 days after the acute episode. Conclusions: Studies have shown that most patients following acute episode of Hepatitis A become seronegative by 120 days. However 13.5% remain positive for prolonged periods for more than 200 days. Awareness of this marked variability is important in the interpretation of HAV IgM as a serologic marker of recent Hepatitis A. Other causes for elevated aminotranseferase levels should be excluded as persistent elevation of HAV IgM is not always consistent with acute HAV infection.
634 The role of enteroscopy in the diagnosis of gastrointestinal stromal tumor (GIST) presenting with gastro-intestinal bleeding: a case report Hetal GandhiBS and Wael DahhanBS*. 1Internal Medicine, Bon Secours Hospital, Gross Pointe, Michigan, United States; and 2Gastroenterology, Bon Secours Hospital, Grosse Pointe, Michigan, United States.
fluoroscopic guidance and patient in left lateral position, SEMS appeared to be deployed coaxially in good position. Post procedure abdominal xray in supine position showed second stent being placed through the wall of the first stent being pinched off in its mid position in a cross position. Despite the positioning, patient had moderate symptom relief lasting for two months of follow up. Conclusions: Self-expandable metal stent is an effective re-decompression modality in patients with restenosed SEMS by tumor ingrowth. Our experience underscores the importance of confirmation of the wire position by changing patient’s position prior to the deployment of the stent to avoid through-thewall stent position, especially if there is more than usual resistance in positioning stent across the strictured area.
631 Nasal NK/T-cell lymphoma with liver infiltration: case report and literature review Juan F Gallegos-Orozco1, Sergio Zepeda1, Roberto I de la Pen˜ a2, Juan F Nuncio3, Carmen Lome3 and Marco A Olivera1*. 1Gastroenterology; 2 Hematology; and 3Pathology Departments, Instituto Nacional de Ciencias Me´ dicas y Nutricio´ n “Salvador Zubiran”, Mexico City, Mexico. Purpose: Natural Killer (NK)/T-cell lymphomas are uncommon nonHodgkin lymphomas that arise in peripheral tissue, most of them from nasal tissue, and have cellular morphology that suggests a NK-cell origin (CD56⫹). They are infrequent in the United States and Europe but are more common in Asia and Central America. They are frequently associated with Epstein-Barr virus, respond poorly to treatment and have a dismal prognosis. Current WHO classification divides NK cell neoplasias in 4 groups: 1. Nasal NK/T-cell lymphoma 2. Nasal-type NK/T-cell lymphoma 3. NK cell leukemia 4. Agressive (systemic) NK cell lymphoma/leukemia Few cases have been reported in which secondary liver involvement is demonstrated after an initial localized lesion has been diagnosed. We report the first such case at our Institution. Methods: Case presentation and literature review. Case report: A 25 year-old hispanic female was referred to the Liver clinic because of progressive increase in ALT, AST (4 times the upper normal limit, UNL) and alkaline phosphatase (5 times UNL). Her past medical history was relevant for the presence of a nasal NK/T-cell lymphoma that was diagnosed a year before and for which the patient had been treated with chemo- and radiotherapy. She was asymptomatic and physical exam was relevant only for painless hepato-splenomegaly. Abdominal CT scan and MRI confirmed the liver and spleen enlargement, no focal lesions or intraabdominal lymph nodes were detected. Liver biopsy was performed, no hepatic architectural changes were noted, there was mild cholestasis and sinusolds were occupied by atypical lymphocytes that were strongly positive for CD3⑀ (T-cell marker), and histologic diagnosis of liver infiltration by NK/T cell lymphoma was confirmed. The patient remained symptom-free for 5 months, at which time she was admitted to the hospital for sinusitis and systemic inflammatory response syndrome. Her LFT had markedly increased. She was started on systemic antibiotics with a favourable clinical response. A bone marrow aspirate revealed marrow infiltration. She is currently alive with disease. Conclusions: Patients with nasal NK/T-cell lymphoma should be closely followed with periodic LFTs and if these are abnormal, hepatic infiltration should be ruled out with prompt liver biopsy even in asymptomatic patients, as the presence of liver infiltration is a poor prognostic indicator and usually warrants agressive therapy.
Abstracts
S199
632 An interesting complication following diagnostic colonoscopy: Intramural cecal hematoma Dominic Gallo, M.D., Christopher Tebrock, M.D., Leonard Little, M.D., David Rivera, M.D. Eishenower Army Medical Center, Augusta, GA. Rarely encountered complications of colonoscopy include perforation and bleeding. The incidence of complications for diagnostic colonoscopy has been reported to be 0.07– 0.4%. Splenic and colonic mesenteric injuries have also been described in the literature. There have been no reports of cecal hematoma following colonoscopy to our knowledge. We report a case of intramural cecal hematoma following diagnostic colonoscopy. We present a 69 year old female with history of atrial fibrillation who underwent elective diagnostic colonoscopy through a heparin window. She returned 24 hours post-procedure with right lower quadrant pain. Serial laboratory studies revealed decrease in hemoglobin from 10.4mg/dl to 7.8mg/dl. Computerized tomography (CT) of the abdomen and pelvis was performed revealing a 15 ⫻ 10 ⫻ 9cm hematoma in close approximation to the posterior wall of the cecum. She was treated nonoperatively but early surgical consultation was obtained. Correction of coagulopathy required 8 units of fresh frozen plasma as well as 8 units of packed red blood cells to correct anemia. She was hemodynamically stable throughout hospitalization and further assessment with CT showed stability of the hematoma. Diagnosis of this complication requires a high index of suspicion and early CT evaluation can be confirmatory. Conservative management requires close monitoring and serial examinations.
633 Persistent elevation of HAV IgM antibody for more than 350 days following acute infection: a case report Hetal Gandhi BS and Ketan Rana BS*. 1Internal Medicine, Bonsecours Hospital, Gross Pointe, Michigan, United States; and 2Gastroenterology, Bonsecours Hospital, Grosse Pointe, Michigan, United States. Purpose: It is a widely accepted concept that hepatitis A virus (HAV) is an acute self-limited illness. Demonstration of hepatitis-A-specific IgM antibodies is diagnostic of recent hepatitis A infection. It is uncommon but possible that HAV IgM remains elevated for extended period after acute hepatitis A. Methods: A 63 year old female patient who was seen by us secondary to elevated serum aminotransferase levels and positive HAV IgM. History revealed that she was diagnosed with acute hepatitis A infection approximately 11 months ago. She had elevated liver enzymes (AP 187,SGOT 106,SGPT 430). Also, Hepatitis panel revealed positive HAV IgM with negative serology for hepatitis B. An ERCP with extraction of common bile duct stone was performed leading to normalization of serum aminotranseferase levels. Results: Patients serum remained persistently positive for Immunoglobulin M (IgM) for approximately 350 days after the acute episode. Conclusions: Studies have shown that most patients following acute episode of Hepatitis A become seronegative by 120 days. However 13.5% remain positive for prolonged periods for more than 200 days. Awareness of this marked variability is important in the interpretation of HAV IgM as a serologic marker of recent Hepatitis A. Other causes for elevated aminotranseferase levels should be excluded as persistent elevation of HAV IgM is not always consistent with acute HAV infection.
634 The role of enteroscopy in the diagnosis of gastrointestinal stromal tumor (GIST) presenting with gastro-intestinal bleeding: a case report Hetal GandhiBS and Wael DahhanBS*. 1Internal Medicine, Bon Secours Hospital, Gross Pointe, Michigan, United States; and 2Gastroenterology, Bon Secours Hospital, Grosse Pointe, Michigan, United States.