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Anisakiasis of the colon presenting as bowel obstruction
S158
Abstracts
polypoid raised areas of the distal esophageal mucosa confined to solely to the mucosa. Case Presentation: 2 male patients, 76 and 50 years of age, were referred to our institution for BE. At endoscopy, both had extensive, linear, polypoid raised areas in the distal esophagus that was histologically found to be BE. Endoscopic ultrasonography (EUS) in both cases demonstrated that the mucosa was thickened and no evidence of submucosal involvement. In one case, biopsies revealed extensive intramucosal adenocarcinoma that was present throughout the polypoid area involving the distal 5 cm of the esophagus. In the other case, the polypoid area involved the distal 6 cm of the esophagus with biopsies showing high– grade dysplasia. The patient with intramucosal carcinoma had a thickened mucosa that measured 0.5 cm by EUS, and was treated with photodynamic therapy with total eradication of the cancer and no evidence of disease after a follow– up of 4.5 years. The younger patient had an esophagectomy, which confirmed that the diffusely raised areas of BE involved only the mucosa, measuring 6 x 5.8 x 0.5 cm, with no submucosal involvement. No malignancy was found at surgery and regional lymph nodes were negative. Immunohistological studies found genetic events such as E–Cadherin loss and Her–2–Neu overexpression were actually normal in the tissue, though there was overexpression of p53. On the other hand, the tissues demonstrated increased proliferation with Ki– 67 staining in 50% of cells (as high as 80% in some areas) and increased Cyclin D1 expression that suggests that there is an underlying defect in the cell cycle explaining the mucosal growth pattern. Conclusion: These 2 cases demonstrated that extensive polypoid lesions in Barretts esophagus can still represent superficial lesions. Defects in the cell cycle and proliferation help us understand why these areas were more neoplastic. The EUS appearance in both cases and the surgical specimen in one case proved that these lesions remained superficial. 477 ANISAKIASIS OF THE COLON PRESENTING AS BOWEL OBSTRUCTION Rob Schuster, M.D., John L. Petrini, M.D.,FACG* and Rosa Choi, M.D. Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA; Division of Gastroenterology, Sansum–Santa Barbara Medical Clinic, Santa Barbara, CA and Department of Surgery, Sansum–Santa Barbara Medical Clinic, Santa Barbara, CA. Purpose: A healthy 25–year old woman with no prior abdominal surgeries presented to the emergency room with a complaint of sudden onset of crampy, diffuse abdominal pain with anorexia, nausea and vomiting for 24 hours. She had several small loose stools in the 24 hours prior to admission. There was no history of recent travel. The patient ate sushi (sashimi) three weeks earlier, and again 2 days prior to the onset of symptoms. She was afebrile, with normal vital signs. Moderate abdominal distention was present with diffuse tenderness, more so in the right lower abdomen. The patient was without evidence of peritonitis. Laboratory examination was significant for a leukocytosis of 19,100 cells/mm 3 with 10% eosinophils. CT of the abdomen with oral and IV contrast revealed ascites with multiple distended loops of small intestine. A hererogeneous mass was pesent in the right abdomen and a small amount of ascites was present. At explortory laparotomy, a small dense mass was present in the mesenteric wall of the ascending colon with extensive lymphadenopathy. The bowel was run with no significant findings. A right hemicoletomy was performed. Hospital course was complicated by prolonged ileus and superior mesentaric venous thrombosis. The ileus resolved spontaneuously and the thrombosis was treated initially with enoxaprin and later warfarin. The patient was discharged two weeks after surgery with no other problems. EGD and colonoscopy were normal except for the surgical changes. Pathologic evaluation showed a 2.4 cm organized eosinophilic abscess within the mesentaric wall of the ascending colon A degernerating worm was found in the central portion of the mass. A patchy eosinophilic serositis was also present on the ileum, cecum and ascending colon. The findings are consistent with intestinal anisakiasis. IgE specific to anisakisis simplex was highly positive at 6.75 kU/L. This report appears to represent the first case of intestinal anisakiasis in
AJG – Vol. 97, No. 9, Suppl., 2002
the US. Reports from Japan and Europe describe similar symptoms and findings. In these coutries, the condition is not unusual and responds to conservative treatment. A more typical presentation is that of a gastritis with one or more worms visible in the stomach. We present this case to alert physicians in the US of the condition to be incorporated into the differential diagnosis of unexplained bowel obstruction.
478 PSEUDOXANTHOMA ELASTICUM: A RARE CAUSE OF GASTROINTESTINAL BLEEDING Kioumars Mostafizi, M.D. and Steve Goldschmid, M.D., FACG*. Arizona Medical Services, Tucson, AZ and University of Arizona Health Sciences Center, Department of Medicine, Tucson, AZ. Purpose: Pseudoxanthoma elasticum (PSE) is a rare genetic disorder of connective tissue characterized by elastic tissue degeneration involving many organ systems. Between 8% and 13% of patients with PSE experience gastrointestinal (GI) bleeding. Bleeding may occur early in the course of the disease and is often the presenting symptom. The stomach is the most common site of bleeding. GI bleeding tends to occur during pregnancy, in younger patients, and may be recurrent. Once bleeding begins, the vasculature is less capable of constriction and retraction prohibiting spontaneous cessation of bleeding. Most cases of GI bleeding manifest before the cutaneous and ocular changes have fully evolved. Case Report: A 33 year old man from Bangladesh was admitted to the hospital with a chief complaint of melena and dizziness. He had no history of peptic ulcer disease and he was taking no medications. Approximately 10 years earlier he had one episode of GI bleeding after taking aspirin. He required transfusion. He denied alcohol or cigarettes. On admission, he was a well–nourished individual with a blood pressure of 110/80 mm/Hg and a pulse of 100 beats/min. Abdominal examination was unremarkable and he had melena on rectal examination. His Hematocrit was 36% but dropped to 21% four hours later as a result of continued bleeding. Initial upper endoscopy showed blood in the stomach with no definitive site of bleeding. There was diffuse oozing from gastric mucosa. During this first admission he had multiple endoscopies which all failed to identify the cause of bleeding. His coagulation profile was normal. A bleeding scan was done which confirmed the stomach as the site of bleeding. Subsequently, an abdominal angiogram showed angiomatous malformation of the vessels supplying the greater curvature of the stomach with narrowing and irregularity of the splenic artery. During this hospitalization, the patient received 20 units of blood. Bleeding ceased spontaneously. A few months later he developed diabetes mellitus and retinal examination revealed angioid streaks. A skin biopsy confirmed the diagnosis of pseudoxanthoma elasticum. Discussion: Pseudoxanthoma elasticum is a rare connective tissue disorder, which involves the skin, eyes and blood vessels. The most frequent vascular complication is GI bleeding and a common site of bleeding is the stomach. Endoscopy does not always identify the cause of bleeding and angiogram may be necessary. Skin biopsy and retinal examination help to confirm the diagnosis.
479 PRIMARY COLONIC LYMPHOMA: REPORT OF 14 CASES Sarah L. Cutrona, M.D., Victoria Reyes, M.D., Fred Schiffman, M.D., Edward Wittels, M.D. and Edward Feller, M.D.*. Internal Medicine, Brown Medical School, Providence, RI. Purpose: Colonic lymphoma is rare, comprising less than 1% of large bowel malignancies. To alert clinicians to the diverse presentations of this malignancy, we describe 14 immunocompetent adults with primary large bowel lymphoma. Methods: Retrospective chart review yielded 14 patients in an 8 year period. All cases were confirmed by histopathology. No patient had palpable lymphadenopathy, mediastinal node enlargement or evidence of
Abstracts
polypoid raised areas of the distal esophageal mucosa confined to solely to the mucosa. Case Presentation: 2 male patients, 76 and 50 years of age, were referred to our institution for BE. At endoscopy, both had extensive, linear, polypoid raised areas in the distal esophagus that was histologically found to be BE. Endoscopic ultrasonography (EUS) in both cases demonstrated that the mucosa was thickened and no evidence of submucosal involvement. In one case, biopsies revealed extensive intramucosal adenocarcinoma that was present throughout the polypoid area involving the distal 5 cm of the esophagus. In the other case, the polypoid area involved the distal 6 cm of the esophagus with biopsies showing high– grade dysplasia. The patient with intramucosal carcinoma had a thickened mucosa that measured 0.5 cm by EUS, and was treated with photodynamic therapy with total eradication of the cancer and no evidence of disease after a follow– up of 4.5 years. The younger patient had an esophagectomy, which confirmed that the diffusely raised areas of BE involved only the mucosa, measuring 6 x 5.8 x 0.5 cm, with no submucosal involvement. No malignancy was found at surgery and regional lymph nodes were negative. Immunohistological studies found genetic events such as E–Cadherin loss and Her–2–Neu overexpression were actually normal in the tissue, though there was overexpression of p53. On the other hand, the tissues demonstrated increased proliferation with Ki– 67 staining in 50% of cells (as high as 80% in some areas) and increased Cyclin D1 expression that suggests that there is an underlying defect in the cell cycle explaining the mucosal growth pattern. Conclusion: These 2 cases demonstrated that extensive polypoid lesions in Barretts esophagus can still represent superficial lesions. Defects in the cell cycle and proliferation help us understand why these areas were more neoplastic. The EUS appearance in both cases and the surgical specimen in one case proved that these lesions remained superficial. 477 ANISAKIASIS OF THE COLON PRESENTING AS BOWEL OBSTRUCTION Rob Schuster, M.D., John L. Petrini, M.D.,FACG* and Rosa Choi, M.D. Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA; Division of Gastroenterology, Sansum–Santa Barbara Medical Clinic, Santa Barbara, CA and Department of Surgery, Sansum–Santa Barbara Medical Clinic, Santa Barbara, CA. Purpose: A healthy 25–year old woman with no prior abdominal surgeries presented to the emergency room with a complaint of sudden onset of crampy, diffuse abdominal pain with anorexia, nausea and vomiting for 24 hours. She had several small loose stools in the 24 hours prior to admission. There was no history of recent travel. The patient ate sushi (sashimi) three weeks earlier, and again 2 days prior to the onset of symptoms. She was afebrile, with normal vital signs. Moderate abdominal distention was present with diffuse tenderness, more so in the right lower abdomen. The patient was without evidence of peritonitis. Laboratory examination was significant for a leukocytosis of 19,100 cells/mm 3 with 10% eosinophils. CT of the abdomen with oral and IV contrast revealed ascites with multiple distended loops of small intestine. A hererogeneous mass was pesent in the right abdomen and a small amount of ascites was present. At explortory laparotomy, a small dense mass was present in the mesenteric wall of the ascending colon with extensive lymphadenopathy. The bowel was run with no significant findings. A right hemicoletomy was performed. Hospital course was complicated by prolonged ileus and superior mesentaric venous thrombosis. The ileus resolved spontaneuously and the thrombosis was treated initially with enoxaprin and later warfarin. The patient was discharged two weeks after surgery with no other problems. EGD and colonoscopy were normal except for the surgical changes. Pathologic evaluation showed a 2.4 cm organized eosinophilic abscess within the mesentaric wall of the ascending colon A degernerating worm was found in the central portion of the mass. A patchy eosinophilic serositis was also present on the ileum, cecum and ascending colon. The findings are consistent with intestinal anisakiasis. IgE specific to anisakisis simplex was highly positive at 6.75 kU/L. This report appears to represent the first case of intestinal anisakiasis in
AJG – Vol. 97, No. 9, Suppl., 2002
the US. Reports from Japan and Europe describe similar symptoms and findings. In these coutries, the condition is not unusual and responds to conservative treatment. A more typical presentation is that of a gastritis with one or more worms visible in the stomach. We present this case to alert physicians in the US of the condition to be incorporated into the differential diagnosis of unexplained bowel obstruction.
478 PSEUDOXANTHOMA ELASTICUM: A RARE CAUSE OF GASTROINTESTINAL BLEEDING Kioumars Mostafizi, M.D. and Steve Goldschmid, M.D., FACG*. Arizona Medical Services, Tucson, AZ and University of Arizona Health Sciences Center, Department of Medicine, Tucson, AZ. Purpose: Pseudoxanthoma elasticum (PSE) is a rare genetic disorder of connective tissue characterized by elastic tissue degeneration involving many organ systems. Between 8% and 13% of patients with PSE experience gastrointestinal (GI) bleeding. Bleeding may occur early in the course of the disease and is often the presenting symptom. The stomach is the most common site of bleeding. GI bleeding tends to occur during pregnancy, in younger patients, and may be recurrent. Once bleeding begins, the vasculature is less capable of constriction and retraction prohibiting spontaneous cessation of bleeding. Most cases of GI bleeding manifest before the cutaneous and ocular changes have fully evolved. Case Report: A 33 year old man from Bangladesh was admitted to the hospital with a chief complaint of melena and dizziness. He had no history of peptic ulcer disease and he was taking no medications. Approximately 10 years earlier he had one episode of GI bleeding after taking aspirin. He required transfusion. He denied alcohol or cigarettes. On admission, he was a well–nourished individual with a blood pressure of 110/80 mm/Hg and a pulse of 100 beats/min. Abdominal examination was unremarkable and he had melena on rectal examination. His Hematocrit was 36% but dropped to 21% four hours later as a result of continued bleeding. Initial upper endoscopy showed blood in the stomach with no definitive site of bleeding. There was diffuse oozing from gastric mucosa. During this first admission he had multiple endoscopies which all failed to identify the cause of bleeding. His coagulation profile was normal. A bleeding scan was done which confirmed the stomach as the site of bleeding. Subsequently, an abdominal angiogram showed angiomatous malformation of the vessels supplying the greater curvature of the stomach with narrowing and irregularity of the splenic artery. During this hospitalization, the patient received 20 units of blood. Bleeding ceased spontaneously. A few months later he developed diabetes mellitus and retinal examination revealed angioid streaks. A skin biopsy confirmed the diagnosis of pseudoxanthoma elasticum. Discussion: Pseudoxanthoma elasticum is a rare connective tissue disorder, which involves the skin, eyes and blood vessels. The most frequent vascular complication is GI bleeding and a common site of bleeding is the stomach. Endoscopy does not always identify the cause of bleeding and angiogram may be necessary. Skin biopsy and retinal examination help to confirm the diagnosis.
479 PRIMARY COLONIC LYMPHOMA: REPORT OF 14 CASES Sarah L. Cutrona, M.D., Victoria Reyes, M.D., Fred Schiffman, M.D., Edward Wittels, M.D. and Edward Feller, M.D.*. Internal Medicine, Brown Medical School, Providence, RI. Purpose: Colonic lymphoma is rare, comprising less than 1% of large bowel malignancies. To alert clinicians to the diverse presentations of this malignancy, we describe 14 immunocompetent adults with primary large bowel lymphoma. Methods: Retrospective chart review yielded 14 patients in an 8 year period. All cases were confirmed by histopathology. No patient had palpable lymphadenopathy, mediastinal node enlargement or evidence of