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Colonic involvement in diffuse lipomatosis
S194
Abstracts
induced by interferon alfa–2b did not interfere with this patient’s ability to mount an appropriate leukocytosis with left shift in response to an inflamed appendix. This evidence of immunocompetence despite therapy with interferon is probably attributable to the actual role of interferon, reversibly blocking the release of the white cells from the bone marrow but not arresting the maturation of any cell line. An important factor to acknowledge is that the baseline neutropenia that this patient exhibited raises the issue of whether a different criterium for neutropenia for African Americans should be used. This center is presently involved in a sub–study reviewing the racial differences in neutropenia in CHC patients on interferon therapy.
591 COLONIC INVOLVEMENT IN DIFFUSE LIPOMATOSIS Susana Lopes, M.D., Guilherme Macedo, M.D., FACG* and Fernando Tavarela Veloso, M.D.,Ph.D.,FACG. Gastroenterology Unit, H.S.Joa˜ o, Porto, Portugal. Purpose: A 53 years old female, single, housemaid with mental retardation, had been submitted to hysterectomy and anexectomy 5 years before, and ressection of 2 lipomas, in the dorsum and neck, in the last year . Her general practioner prescribed a barium enema because of recurrent abdominal pain and chronic constipation. The Xray report included “..a polypoid formation in the rectum, in the distal third of the sigmoid colon and another polyp in its middle third, that caused an irregular stenosis, which did not allow the barium progression to the proximal colon, suggesting malignant degeneration..”. She was referred to us, and throughout the colonoscopy, 3 large polypoid masses could be seen: they were ovoid, smooth, tender, yellowish, with short stalk and the covering mucosa was adherent to the mass itself and could not be isolated with the biopsy forceps. The most proximal, at the middle third, was the largest, but the scope was able to reach the cecum. There was no other lesions. At her physical examination, there was a subcutaneous lipoma with 6x4 cm long, on the inner aspect of the right tigh, a facial cavernous hemagioma, and a verruciform lesion on the back of the tongue. We present the endoscopic features found at the colonoscopy and further iconography demonstrating her non syndromic diffuse lipomatosis.
AJG – Vol. 97, No. 9, Suppl., 2002
592 HEPATOBILIARY STRONGYLOIDIASIS: REPORT OF A RARE CASE IN AN AIDS PATIENT Priti Pandya, M.D., William L. Riles, M.D., Bashar M. Attar, M.D.,FACG*, Melchor V. Demetria, M.D., Rafid J. Hussein, M.D., Patricia Simples, M.D. and Bhupat N. Mehta, M.D. Cook County Hospital, Rush Medical College, Chicago, IL. Purpose: Hepatobiliary strongyloidiasis is extremely rare. There are only 18 cases reported of disseminated strongyloides in HIV patients. AIDS cholangiopathy has been reported to be secondary to CMV, cryptosporidiosis, MAC and microsporidiosis, but never secondary to Strongyloides stercoralis. A 37–year– old Hispanic female with advanced AIDS and no recent travel history presented with a one–week history of abdominal pain, nausea, vomiting and diarrhea. This was accompanied by shortness of breath, fever, chills, nonproductive cough and a 20 lbs weight loss. Physical examination revealed: T 99.7, BP 89/59 mmHg, HR 130, RR 26, and hypoxia. She was dehydrated and cachectic. Her examination was remarkable for bilateral crackles, mild hepatomegaly, and right upper quadrant tenderness without rebound and heme positive stool. Laboratory analysis revealed a Pa O2 of 49, marked normocytic anemia (Hgb of 6.4) but no leukocytosis or eosinophilia. Total bilirubin was 1.4, alkaline phosphatase of 297, GGT 65, AST 89, ALT 76, lipase of 247 and an amylase of 109. Viral hepatitis serologies were negative. CD4 count was 17 with a viral load of 108,937 copies. A CXR showed diffuse bilateral infiltrates. An ultrasound revealed a dilated distal common bile duct (CBD) of 10mm. CT of chest and abdomen showed an acute pneumonitis with chronic interstitial changes, diffuse hepatomegaly, a slightly edematous pancreas, and a prominent CBD. ERCP revealed papillary stenosis, dilated CBD, and friability in the duodenum, ampulla, and periampullary region. Biliary brushings were positive for organisms consistent with Strongyloides stercoralis. The patient developed respiratory failure. Subsequent bronchoalveolar lavage was positive for S. stercoralis. The patient was treated with ivermectin, but continued to deteriorate and died. Although infection with Strongyloides stercoralis is widely prevalent, its association with HIV infection is very rare with only a few case reports found in the literature. Some patients may be carriers but hyperinfection of S. stercoralis in our patient was most likely precipitated by advanced AIDS (CD4 count: 17). Therefore, in AIDS patients with cholangiopathy, Strongyloides stercoralis should be considered as part of the differential diagnosis. Eosinophilia is frequently absent and a high index of suspicion is warranted in patients presenting with concomitant pulmonary and GI/Hepatobiliary symptoms.
593 ENDOSCOPIC RESECTION OF A GANGLIOCYTIC PARAGANGLIOMA INVOLVING THE AMPULLA OF VATER Klaus Mergener, M.D.*, Marla R. Fenske, M.D. and Richard A. Kozarek, M.D. Section of Gastroenterology, Virginia Mason Medical Center, Seattle, WA. Background: Gangliocytic paragangliomas (GP) are rare neuroendocrine tumors which are typically located in the duodenum but may develop in other areas of the intestine such as the jejunum or the appendix. We describe a patient with a large GP involving the ampulla of Vater, and describe endoscopic tumor removal. Case Report: A 53 year old woman presented to another institution with a 2 month history of intermittent melena, a hematocrit of 21. Upper endoscopy after transfusion of 4 units of red cells revealed a large pedunculated mass involving the ampulla of Vater. ERCP resulted in severe post–ERCP pancreatitis and the patient was transferred to our institution. Endoscopic ultrasound revealed a hypoechoic lesion expanding the submucosa. Due to acute peripancreatic fluid collections she was deemed a poor surgical candidate. She experienced recurrent GI bleeding and it was decided to attempt endoscopic management. ERCP revealed a normal pancreatic duct (PD) and common bile duct (CBD). PD and CBD stents
Abstracts
induced by interferon alfa–2b did not interfere with this patient’s ability to mount an appropriate leukocytosis with left shift in response to an inflamed appendix. This evidence of immunocompetence despite therapy with interferon is probably attributable to the actual role of interferon, reversibly blocking the release of the white cells from the bone marrow but not arresting the maturation of any cell line. An important factor to acknowledge is that the baseline neutropenia that this patient exhibited raises the issue of whether a different criterium for neutropenia for African Americans should be used. This center is presently involved in a sub–study reviewing the racial differences in neutropenia in CHC patients on interferon therapy.
591 COLONIC INVOLVEMENT IN DIFFUSE LIPOMATOSIS Susana Lopes, M.D., Guilherme Macedo, M.D., FACG* and Fernando Tavarela Veloso, M.D.,Ph.D.,FACG. Gastroenterology Unit, H.S.Joa˜ o, Porto, Portugal. Purpose: A 53 years old female, single, housemaid with mental retardation, had been submitted to hysterectomy and anexectomy 5 years before, and ressection of 2 lipomas, in the dorsum and neck, in the last year . Her general practioner prescribed a barium enema because of recurrent abdominal pain and chronic constipation. The Xray report included “..a polypoid formation in the rectum, in the distal third of the sigmoid colon and another polyp in its middle third, that caused an irregular stenosis, which did not allow the barium progression to the proximal colon, suggesting malignant degeneration..”. She was referred to us, and throughout the colonoscopy, 3 large polypoid masses could be seen: they were ovoid, smooth, tender, yellowish, with short stalk and the covering mucosa was adherent to the mass itself and could not be isolated with the biopsy forceps. The most proximal, at the middle third, was the largest, but the scope was able to reach the cecum. There was no other lesions. At her physical examination, there was a subcutaneous lipoma with 6x4 cm long, on the inner aspect of the right tigh, a facial cavernous hemagioma, and a verruciform lesion on the back of the tongue. We present the endoscopic features found at the colonoscopy and further iconography demonstrating her non syndromic diffuse lipomatosis.
AJG – Vol. 97, No. 9, Suppl., 2002
592 HEPATOBILIARY STRONGYLOIDIASIS: REPORT OF A RARE CASE IN AN AIDS PATIENT Priti Pandya, M.D., William L. Riles, M.D., Bashar M. Attar, M.D.,FACG*, Melchor V. Demetria, M.D., Rafid J. Hussein, M.D., Patricia Simples, M.D. and Bhupat N. Mehta, M.D. Cook County Hospital, Rush Medical College, Chicago, IL. Purpose: Hepatobiliary strongyloidiasis is extremely rare. There are only 18 cases reported of disseminated strongyloides in HIV patients. AIDS cholangiopathy has been reported to be secondary to CMV, cryptosporidiosis, MAC and microsporidiosis, but never secondary to Strongyloides stercoralis. A 37–year– old Hispanic female with advanced AIDS and no recent travel history presented with a one–week history of abdominal pain, nausea, vomiting and diarrhea. This was accompanied by shortness of breath, fever, chills, nonproductive cough and a 20 lbs weight loss. Physical examination revealed: T 99.7, BP 89/59 mmHg, HR 130, RR 26, and hypoxia. She was dehydrated and cachectic. Her examination was remarkable for bilateral crackles, mild hepatomegaly, and right upper quadrant tenderness without rebound and heme positive stool. Laboratory analysis revealed a Pa O2 of 49, marked normocytic anemia (Hgb of 6.4) but no leukocytosis or eosinophilia. Total bilirubin was 1.4, alkaline phosphatase of 297, GGT 65, AST 89, ALT 76, lipase of 247 and an amylase of 109. Viral hepatitis serologies were negative. CD4 count was 17 with a viral load of 108,937 copies. A CXR showed diffuse bilateral infiltrates. An ultrasound revealed a dilated distal common bile duct (CBD) of 10mm. CT of chest and abdomen showed an acute pneumonitis with chronic interstitial changes, diffuse hepatomegaly, a slightly edematous pancreas, and a prominent CBD. ERCP revealed papillary stenosis, dilated CBD, and friability in the duodenum, ampulla, and periampullary region. Biliary brushings were positive for organisms consistent with Strongyloides stercoralis. The patient developed respiratory failure. Subsequent bronchoalveolar lavage was positive for S. stercoralis. The patient was treated with ivermectin, but continued to deteriorate and died. Although infection with Strongyloides stercoralis is widely prevalent, its association with HIV infection is very rare with only a few case reports found in the literature. Some patients may be carriers but hyperinfection of S. stercoralis in our patient was most likely precipitated by advanced AIDS (CD4 count: 17). Therefore, in AIDS patients with cholangiopathy, Strongyloides stercoralis should be considered as part of the differential diagnosis. Eosinophilia is frequently absent and a high index of suspicion is warranted in patients presenting with concomitant pulmonary and GI/Hepatobiliary symptoms.
593 ENDOSCOPIC RESECTION OF A GANGLIOCYTIC PARAGANGLIOMA INVOLVING THE AMPULLA OF VATER Klaus Mergener, M.D.*, Marla R. Fenske, M.D. and Richard A. Kozarek, M.D. Section of Gastroenterology, Virginia Mason Medical Center, Seattle, WA. Background: Gangliocytic paragangliomas (GP) are rare neuroendocrine tumors which are typically located in the duodenum but may develop in other areas of the intestine such as the jejunum or the appendix. We describe a patient with a large GP involving the ampulla of Vater, and describe endoscopic tumor removal. Case Report: A 53 year old woman presented to another institution with a 2 month history of intermittent melena, a hematocrit of 21. Upper endoscopy after transfusion of 4 units of red cells revealed a large pedunculated mass involving the ampulla of Vater. ERCP resulted in severe post–ERCP pancreatitis and the patient was transferred to our institution. Endoscopic ultrasound revealed a hypoechoic lesion expanding the submucosa. Due to acute peripancreatic fluid collections she was deemed a poor surgical candidate. She experienced recurrent GI bleeding and it was decided to attempt endoscopic management. ERCP revealed a normal pancreatic duct (PD) and common bile duct (CBD). PD and CBD stents