- Email: [email protected]
Crohn’s disease presenting as small bowel adenocarcinoma
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Abstracts
hemorrhage in the distal small bowel. These findings were consistent with Crohn’s disease. Medical therapy was empirically started in one patient with excellent results. Discussion: Both patients were diagnosed with isolated small bowel Crohn’s disease using capsule endoscopy after undergoing an extensive negative work– up. The diagnosis of Crohn’s disease in children is often difficult and subsequently delayed. A delayed diagnosis may prolong suffering and inhibit proper development. Nonspecific symptoms and the desire to avoid unnecessary invasive testing have intensified the search for a noninvasive method of diagnosis. Recent modalities have consisted of serological testing, leukocyte scintigraphy, and contrast radiography. Unfortunately, although helpful, none of these methods alone are enough to exclude or diagnose inflammatory bowel disease. Using capsule endoscopy in these cases, the early diagnosis of Crohn’s disease was made. Therapeutic decisions were then made and significant clinical improvement occurred. In children with symptoms suspicious for Crohn’s disease, the use of capsule endoscopy may provide an early diagnosis, therapeutic intervention and improved clinical outcome. 236 SEVERE STRONGYLOIDIASIS – A CLINICO–PATHOLOGIC STUDY IN A BRAZILIAN POPULATION Luiz J. Abrahao, M.D.*, Luiz J. Abrahao–Junior, M.D.,M.P.H., Ana A. Abrahao, M.D., Dora M.F. Menezes, M.D. and Jose L. Rosati, M.D. Gastroenterology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil; Gastroenterology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil and Pathology, Instituto Fernandes Figueira, Rio de Janeiro, Brazil. Purpose: Strongyloidiasis typically affects small bowel but with immunosuppression can spread to all GI tract and distant organs.The aim of this study was to describe clinical aspects of severe strongyloidiasis and correlate with anatomo–pathologic findings. Methods: Retrospective study that included 33 patients with severe strongyloidiasis divided in 3 groups: pediatric, surgical and imunosupressed group.We reviewed demographic data, clinical,macroscopic and microscopic findings at autopsy (surgical group had no deaths). Results: Pediatic group (n⫽22, 13[59%] males, mean age of 3.8 y[5 months –15 y]). Presenting signs/symptoms: diarrhea/vomiting – 19(86%), dyspnea – 9(40%), gastrointestinal bleeding – 7 (32%) , abdominal pain – 5(23%), hemoptysis – 2 (9%), denutrition in all patients, hepatomegaly– 17 (77%), lower limbs edema – 9 (41%), anemia – 7 (32%), splenomegaly – 3 (13.6%). Most common affected organs were lungs, liver, pancreas, abdominal cavity, brain, stomach, duodenum, small and large bowel. Severe inflamatory reaction with edema, ulceration, perforation (bowel) and S. stercoralis were observed in almost all organs. Immunosuppressed group included 5 patients (4 males mean age⫽52 years [40 –72 years]), with abdominal pain and distension, diarrhea and vomiting, 4 under corticotherapy for thrombocytopenic purpura (1), penphigus (1), brain metastasis (2, one HIV⫹) and 1 with severe denutrition. Autopsy disclosed involvement of gut, liver and lungs. Surgical group included 6 patients (3 males), mean age 51 y (39 –56 y), 4 patients operated (perforation of ileum/ cecum–1, sigmoid volvulus–1, intestinal obstruction–1, acute apendicitis–1) with high output fistula formation that closed after thiabendazol treatment; 1 operated of a lung mass (inflamatory mass with S. stercoralis worms) and 1 with a severe malabsorption and eosinophilia that cured after thiabendazol. Conclusions: Strongyloidiasis can cause high morbidity and even mortality in patients with severe denutrition and/or imunosupression and should be considered in post–surgical fistuas with eosinophilia. 237 DIGESTIVE DISEASES AND NON–DISEASES: BIG IMPLICATIONS BUT LITTLE AGREEMENT Jyothi Dodlapati, M.D., Colin W. Howden, M.D. and Michael P. Jones, M.D.*. Division of Gastroenterology, Northwestern University, Chicago, IL.
AJG – Vol. 97, No. 9, Suppl., 2002
Purpose: There are emotional, social and financial implications associated with having a disease (DIS). Most pts however are simply unwell and not diseased. This distinction is important for prognosis and treatment. The definition of DIS however, is elusive. To better understand how DIS defined, we polled MDs and RNs regarding common digestive disorders. Methods: Gastroenterologists(GI), primary care MDs(PC), residents(Res) and RNs were given a list of digestive disorders and asked to indicate which they felt to be DIS. They also rated each condition’s severity on a 100mm visual analogue scale (VAS) (0⫽ “not at all severe;” 100⫽ “extremely severe”). For each condition, % differences among groups were compared using critical values and standard error (SE) of the differences. Differences in severity for each condition across groups were calculated by ANOVA with Bonferroni’s post–test comparisons. Data are expressed as mean ⫾ SE. Results: 200 indiv (50 in each group) were polled. % of respondents classifying the conditions as DIS are shown in the figure. No significant differences existed among groups although RNs were less likely to view conditions as DIS. Good agreement was seen for colon cancer, colitis and peptic ulcer but other conditions had divergent responses. A strong correlation existed between classification as DIS and perceived severity (r⫽0.85; p⬍0.001). In general, RN ratings of severity (52⫾1) were higher than GIs or Res (both 47⫾1; p⬍0.05) but not PC (49⫾1). This was particularly true for IBS, diverticulosis and anal fissure. While RNs rated heartburn as more severe than GI (p⬍0.001), the latter rated Barrett’s esophagus as less severe than all other groups (p⬍0.0011). Conclusions: Substantial variability exists regarding classification and perceived severity of a number of GI disorders. Compared with MDs, RNs are less likely to consider conditions as DIS but view them as more severe. Given the impact of being labeled with a DIS, educational efforts are warranted regarding concepts and implications of the terms “illness” and “disease”.
238 CROHN’S DISEASE PRESENTING AS SMALL BOWEL ADENOCARCINOMA Michael S. Morelli, M.D. and John D. Long, M.D.* . Purpose: Gastrointestinal malignancy is an extremely uncommon mode of presentation of Crohn’s disease. We report the case of Crohn’s disease presenting initially as a small bowel adenocarcinoma. A 52 year– old female with longstanding dyspepsia presented with a small bowel obstruction from biopsy proven moderately differentiated adenocarcinoma in the jejunum. Two years after the small bowel resection, the patient had another small bowel obstruction with terminal ileal narrowing seen on a small bowel follow through. At that point a colonoscopy revealed a cecal stricture, the biopsy of which revealed a villous adenoma. A right hemicolectomy was done and surgical specimen showed an infiltrative moderately differentiated adenocarcinoma. Chemotherapy was started but abdominal pain and diarrhea persisted. The patient developed another small bowel obstruction that was managed conservatively. Repeat colonoscopy showed ulcerated and friable ileal and sigmoid mucosa. Biopsy showed changes consistent with Crohn’s disease. Retrospective review of the old surgical report showed signs suggestive of Croh’s diseas-
AJG – September, Suppl., 2002
e.The patient was started on mesalamine, metronidazole, and prednisone and improved. It is well established that Crohn’s disease is associated with a high risk of small bowel and colorectal carcinoma. There are only a few case reports of adenocarcinoma as an initial presentation of Crohn’s. It appears to be more common in males, always develops in areas involved by Crohn’s, and is thought to follow a dysplasia carcinoma sequence. Most lesions are high grade and present clinically with obstructive symptoms. Physicians should consider inflammatory bowel disease in patients with small bowel adenocarcinoma who have persistent gastrointestinal symptoms.
239 SURVEY QUESTIONNAIRE AND SEROLOGIC SCREENING FOR CELIAC SPRUE IN FIRST–DEGREE RELATIVES OF PATIENTS WITH CELIAC SPRUE Robert D. Hower, D.O., David L. Limauro, M.D., David V. Glorioso, M.D. and Tony Colatrella, M.D.*. Internal Medicine, Mercy Hospital, Pittsburgh, PA. Purpose: The purpose of this study was to more accurately assess the prevalence of Celiac Sprue in first degree relatives and to evaluate their associated symptoms and diseases with a survey and serologic screening. The study population was a western Pennsylvania population in a mixed urban–suburban setting. Methods: A Celiac Disease seminar was held at the Mercy Hospital of Pittsburgh in conjunction with the Pittsburgh Celiac Sprue Association. Interested participants voluntarily underwent a serologic tissue transglutaminase (tTG) assay along with a survey consisting of general questions concerning age, sex, symptoms, and concurrent medical illnesses. The participants that had a positive tTG assay were contacted for future endoscopic evaluation and counseling. Results: A total of 182 people participated in the study, 77 male and 105 female. There were 128 participants that had a first degree relative with CS. Nine of 128 persons (7%) with first– degree relatives tested positive for the tTG antibody. The ratio of male to female positives was 1.75 to 1. The most common symptoms reported in the tTG positive population were abdominal gas (56%), bloating (33%), and diarrhea (22%). Forty–four percent of tTG positive persons reported having no subjective symptoms. The prevalence of concurrent disease states in the tTG positives were asthma (33%), depression (22%), and anemia, eczema, alopecia, each with (11%). The most prevalent symptoms in the entire tTG negative group were: abdominal gas 92 (50.5%), malaise 62 (34%), and bloating 56 (30.7%). The most common disease states of the entire tTG negative group were asthma 23 (13%), and anemia 16 (9%). Conclusions: Positive serology for the tTG antibody was more common in first– degree relatives of patients with CS than would be expected in a general population. Nonspecific gastrointestinal symptoms, while common in the tTG positive persons, were also common in subjects without CS. Practitioners need to be aware of the increased prevalence of CS in family members of those with CS, and testing should not be limited to only those with gastrointestinal symptoms.
240 HYPERBARIC OXYGEN THERAPY FOR PNEUMATOSIS CYSTOIDES INTESTINALIS Waqar A. Qureshi, M.D., FACG, Gregory Shannon, M.D., Fife Caroline, M.D. and Atilla Ertan, M.D., FACG*. Gastroenterology, Baylor College of Medicine and VAMC, Houston, TX and Hyperbaric Medicine, University of Texas, Houston, TX. Purpose: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas–filled cysts in the gastrointestinal tract. Many theories have been proposed to explain the pathogenesis of PCI. The mechanical theory postulates that intestinal gas dissects
Abstracts
S79
into the bowel wall through a breach in the intestinal mucosa. The pulmonary theory suggests that air released from ruptured alveoli dissects through the mediastinum, along the aorta and mesenteric arteries to the bowel. The bacterial theory proposes that gas–forming organisms, such as Clostridium perfringens, cause gaseous dissection within the bowel wall. The rationale for using hyperbaric oxygen is that breathing pure oxygen at enhanced atmospheric pressure causes resorption of gases such as nitrogen by increasing the driving force for gas diffusion. Methods: A 69 yr. old man presented with incapacitating abdominal pain, diarrhea and weight loss for over 2 years. About 2 yr. ago the patient underwent a laparotomy for acute abdominal pain and pneumoperitoneum, and was diagnosed with PCI. He failed to respond to supportive therapy including dietary changes, use of antidiarrheals and antacids. PMH was significant for hypertension, atrial fibrillation, Bell’s palsy, and diabetes. At the time of the present admission, in addition to chronic diarrhea the patient showed signs of wasting with marked weight loss and cachexia. The patient was treated with three sessions of hyperbaric oxygen therapy, each delivered at 2.4 times atmospheric pressure for 110 minutes in an oxygen chamber. A comprehensive Medline search identified fourteen cases of PCI managed by this approach but without standardized recommendations. Results: There was dramatic improvement in symptoms with complete resolution of the abdominal pain and distention by the second treatment. Radiological studies revealed resolution of the cysts at week two post therapy. At six months follow up, the patient was completely asymptomatic and his weight had returned to baseline. Conclusions: Hyperbaric oxygen appears to be an effective treatment for symptomatic patients with pneumatosis cystoides intestinalis. However, more studies are needed to define the ideal atmosphere level and duration of hyperbaric oxygen therapy required in symptomatic patients with pneumatosis cystoides intestinalis.
241 A NOVEL GAS CHROMATOGRAPHIC METHOD FOR DETECTION OF URINARY SUCRALOSE: APPLICATION TO THE ASSESSMENT OF INTESTINAL PERMEABILITY Ashkan Farhadi, M.D., Ali Keshavarzian, M.D.*, Earle W. Holmes, Ph.D., Jeremy Fields, Ph.D., Lei Zhang, M.D., PH.D. and Ali Banan, Ph.D. Department of Internal Medicine, Section of Gastroenterology and Nutrition, Rush Medical College, Rush University, Chicago, IL and Department of Pathology, Loyola University, Chicago, IL. Purpose: The most direct and accurate method to quantitatively assess intestinal barrier function is by measurement of intestinal permeability. To assess human intestinal permeability, we developed a highly–sensitive gas chromatography (GC) method for the measurement of urinary sucralose (S) along with three other sugar probes, including sucrose, lactulose (L) and mannitol (M). We also investigated the intestinal bacterial metabolism of these sugar probes to evaluate whether these probes are suitable for assessement of the whole gut permeability. Methods: To this end, 14 healthy controls were enrolled. 5– h and 19 – h urine samples were collected after ingestion of a water– based solution containing 7.5g L, 2.0 g M, 1 g S and 40 g sucrose. These sugar probes were then measured using a unique capillary column GC technique. Metabolism of sugar probes by intestinal bacteria was also evaluated by in vitro incubation of an iso– osmolar mixture of M, L and S with fecal bacteria at 37° C for 19 hours. Sugar concentration and pH of the mixture were monitored for 19 h. Results: All 4 sugars were detected in the urine samples without interference (see Table 1). The capillary column substantially enhanced the sensitivity of detection of sugar probes by 200 –2000 times as compared to a Packed Column GC method. It also lowered the coefficient of variation from 15% to 3.95%. The detection limit was 0.2 and 0.5 mg/L for S and L, respectively. While intestinal bacteria metabolized L by 51% and acidified the environment (pH 7.2 to 4.8) during incubation, they did not metabolize S or M.
Abstracts
hemorrhage in the distal small bowel. These findings were consistent with Crohn’s disease. Medical therapy was empirically started in one patient with excellent results. Discussion: Both patients were diagnosed with isolated small bowel Crohn’s disease using capsule endoscopy after undergoing an extensive negative work– up. The diagnosis of Crohn’s disease in children is often difficult and subsequently delayed. A delayed diagnosis may prolong suffering and inhibit proper development. Nonspecific symptoms and the desire to avoid unnecessary invasive testing have intensified the search for a noninvasive method of diagnosis. Recent modalities have consisted of serological testing, leukocyte scintigraphy, and contrast radiography. Unfortunately, although helpful, none of these methods alone are enough to exclude or diagnose inflammatory bowel disease. Using capsule endoscopy in these cases, the early diagnosis of Crohn’s disease was made. Therapeutic decisions were then made and significant clinical improvement occurred. In children with symptoms suspicious for Crohn’s disease, the use of capsule endoscopy may provide an early diagnosis, therapeutic intervention and improved clinical outcome. 236 SEVERE STRONGYLOIDIASIS – A CLINICO–PATHOLOGIC STUDY IN A BRAZILIAN POPULATION Luiz J. Abrahao, M.D.*, Luiz J. Abrahao–Junior, M.D.,M.P.H., Ana A. Abrahao, M.D., Dora M.F. Menezes, M.D. and Jose L. Rosati, M.D. Gastroenterology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil; Gastroenterology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil and Pathology, Instituto Fernandes Figueira, Rio de Janeiro, Brazil. Purpose: Strongyloidiasis typically affects small bowel but with immunosuppression can spread to all GI tract and distant organs.The aim of this study was to describe clinical aspects of severe strongyloidiasis and correlate with anatomo–pathologic findings. Methods: Retrospective study that included 33 patients with severe strongyloidiasis divided in 3 groups: pediatric, surgical and imunosupressed group.We reviewed demographic data, clinical,macroscopic and microscopic findings at autopsy (surgical group had no deaths). Results: Pediatic group (n⫽22, 13[59%] males, mean age of 3.8 y[5 months –15 y]). Presenting signs/symptoms: diarrhea/vomiting – 19(86%), dyspnea – 9(40%), gastrointestinal bleeding – 7 (32%) , abdominal pain – 5(23%), hemoptysis – 2 (9%), denutrition in all patients, hepatomegaly– 17 (77%), lower limbs edema – 9 (41%), anemia – 7 (32%), splenomegaly – 3 (13.6%). Most common affected organs were lungs, liver, pancreas, abdominal cavity, brain, stomach, duodenum, small and large bowel. Severe inflamatory reaction with edema, ulceration, perforation (bowel) and S. stercoralis were observed in almost all organs. Immunosuppressed group included 5 patients (4 males mean age⫽52 years [40 –72 years]), with abdominal pain and distension, diarrhea and vomiting, 4 under corticotherapy for thrombocytopenic purpura (1), penphigus (1), brain metastasis (2, one HIV⫹) and 1 with severe denutrition. Autopsy disclosed involvement of gut, liver and lungs. Surgical group included 6 patients (3 males), mean age 51 y (39 –56 y), 4 patients operated (perforation of ileum/ cecum–1, sigmoid volvulus–1, intestinal obstruction–1, acute apendicitis–1) with high output fistula formation that closed after thiabendazol treatment; 1 operated of a lung mass (inflamatory mass with S. stercoralis worms) and 1 with a severe malabsorption and eosinophilia that cured after thiabendazol. Conclusions: Strongyloidiasis can cause high morbidity and even mortality in patients with severe denutrition and/or imunosupression and should be considered in post–surgical fistuas with eosinophilia. 237 DIGESTIVE DISEASES AND NON–DISEASES: BIG IMPLICATIONS BUT LITTLE AGREEMENT Jyothi Dodlapati, M.D., Colin W. Howden, M.D. and Michael P. Jones, M.D.*. Division of Gastroenterology, Northwestern University, Chicago, IL.
AJG – Vol. 97, No. 9, Suppl., 2002
Purpose: There are emotional, social and financial implications associated with having a disease (DIS). Most pts however are simply unwell and not diseased. This distinction is important for prognosis and treatment. The definition of DIS however, is elusive. To better understand how DIS defined, we polled MDs and RNs regarding common digestive disorders. Methods: Gastroenterologists(GI), primary care MDs(PC), residents(Res) and RNs were given a list of digestive disorders and asked to indicate which they felt to be DIS. They also rated each condition’s severity on a 100mm visual analogue scale (VAS) (0⫽ “not at all severe;” 100⫽ “extremely severe”). For each condition, % differences among groups were compared using critical values and standard error (SE) of the differences. Differences in severity for each condition across groups were calculated by ANOVA with Bonferroni’s post–test comparisons. Data are expressed as mean ⫾ SE. Results: 200 indiv (50 in each group) were polled. % of respondents classifying the conditions as DIS are shown in the figure. No significant differences existed among groups although RNs were less likely to view conditions as DIS. Good agreement was seen for colon cancer, colitis and peptic ulcer but other conditions had divergent responses. A strong correlation existed between classification as DIS and perceived severity (r⫽0.85; p⬍0.001). In general, RN ratings of severity (52⫾1) were higher than GIs or Res (both 47⫾1; p⬍0.05) but not PC (49⫾1). This was particularly true for IBS, diverticulosis and anal fissure. While RNs rated heartburn as more severe than GI (p⬍0.001), the latter rated Barrett’s esophagus as less severe than all other groups (p⬍0.0011). Conclusions: Substantial variability exists regarding classification and perceived severity of a number of GI disorders. Compared with MDs, RNs are less likely to consider conditions as DIS but view them as more severe. Given the impact of being labeled with a DIS, educational efforts are warranted regarding concepts and implications of the terms “illness” and “disease”.
238 CROHN’S DISEASE PRESENTING AS SMALL BOWEL ADENOCARCINOMA Michael S. Morelli, M.D. and John D. Long, M.D.* . Purpose: Gastrointestinal malignancy is an extremely uncommon mode of presentation of Crohn’s disease. We report the case of Crohn’s disease presenting initially as a small bowel adenocarcinoma. A 52 year– old female with longstanding dyspepsia presented with a small bowel obstruction from biopsy proven moderately differentiated adenocarcinoma in the jejunum. Two years after the small bowel resection, the patient had another small bowel obstruction with terminal ileal narrowing seen on a small bowel follow through. At that point a colonoscopy revealed a cecal stricture, the biopsy of which revealed a villous adenoma. A right hemicolectomy was done and surgical specimen showed an infiltrative moderately differentiated adenocarcinoma. Chemotherapy was started but abdominal pain and diarrhea persisted. The patient developed another small bowel obstruction that was managed conservatively. Repeat colonoscopy showed ulcerated and friable ileal and sigmoid mucosa. Biopsy showed changes consistent with Crohn’s disease. Retrospective review of the old surgical report showed signs suggestive of Croh’s diseas-
AJG – September, Suppl., 2002
e.The patient was started on mesalamine, metronidazole, and prednisone and improved. It is well established that Crohn’s disease is associated with a high risk of small bowel and colorectal carcinoma. There are only a few case reports of adenocarcinoma as an initial presentation of Crohn’s. It appears to be more common in males, always develops in areas involved by Crohn’s, and is thought to follow a dysplasia carcinoma sequence. Most lesions are high grade and present clinically with obstructive symptoms. Physicians should consider inflammatory bowel disease in patients with small bowel adenocarcinoma who have persistent gastrointestinal symptoms.
239 SURVEY QUESTIONNAIRE AND SEROLOGIC SCREENING FOR CELIAC SPRUE IN FIRST–DEGREE RELATIVES OF PATIENTS WITH CELIAC SPRUE Robert D. Hower, D.O., David L. Limauro, M.D., David V. Glorioso, M.D. and Tony Colatrella, M.D.*. Internal Medicine, Mercy Hospital, Pittsburgh, PA. Purpose: The purpose of this study was to more accurately assess the prevalence of Celiac Sprue in first degree relatives and to evaluate their associated symptoms and diseases with a survey and serologic screening. The study population was a western Pennsylvania population in a mixed urban–suburban setting. Methods: A Celiac Disease seminar was held at the Mercy Hospital of Pittsburgh in conjunction with the Pittsburgh Celiac Sprue Association. Interested participants voluntarily underwent a serologic tissue transglutaminase (tTG) assay along with a survey consisting of general questions concerning age, sex, symptoms, and concurrent medical illnesses. The participants that had a positive tTG assay were contacted for future endoscopic evaluation and counseling. Results: A total of 182 people participated in the study, 77 male and 105 female. There were 128 participants that had a first degree relative with CS. Nine of 128 persons (7%) with first– degree relatives tested positive for the tTG antibody. The ratio of male to female positives was 1.75 to 1. The most common symptoms reported in the tTG positive population were abdominal gas (56%), bloating (33%), and diarrhea (22%). Forty–four percent of tTG positive persons reported having no subjective symptoms. The prevalence of concurrent disease states in the tTG positives were asthma (33%), depression (22%), and anemia, eczema, alopecia, each with (11%). The most prevalent symptoms in the entire tTG negative group were: abdominal gas 92 (50.5%), malaise 62 (34%), and bloating 56 (30.7%). The most common disease states of the entire tTG negative group were asthma 23 (13%), and anemia 16 (9%). Conclusions: Positive serology for the tTG antibody was more common in first– degree relatives of patients with CS than would be expected in a general population. Nonspecific gastrointestinal symptoms, while common in the tTG positive persons, were also common in subjects without CS. Practitioners need to be aware of the increased prevalence of CS in family members of those with CS, and testing should not be limited to only those with gastrointestinal symptoms.
240 HYPERBARIC OXYGEN THERAPY FOR PNEUMATOSIS CYSTOIDES INTESTINALIS Waqar A. Qureshi, M.D., FACG, Gregory Shannon, M.D., Fife Caroline, M.D. and Atilla Ertan, M.D., FACG*. Gastroenterology, Baylor College of Medicine and VAMC, Houston, TX and Hyperbaric Medicine, University of Texas, Houston, TX. Purpose: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas–filled cysts in the gastrointestinal tract. Many theories have been proposed to explain the pathogenesis of PCI. The mechanical theory postulates that intestinal gas dissects
Abstracts
S79
into the bowel wall through a breach in the intestinal mucosa. The pulmonary theory suggests that air released from ruptured alveoli dissects through the mediastinum, along the aorta and mesenteric arteries to the bowel. The bacterial theory proposes that gas–forming organisms, such as Clostridium perfringens, cause gaseous dissection within the bowel wall. The rationale for using hyperbaric oxygen is that breathing pure oxygen at enhanced atmospheric pressure causes resorption of gases such as nitrogen by increasing the driving force for gas diffusion. Methods: A 69 yr. old man presented with incapacitating abdominal pain, diarrhea and weight loss for over 2 years. About 2 yr. ago the patient underwent a laparotomy for acute abdominal pain and pneumoperitoneum, and was diagnosed with PCI. He failed to respond to supportive therapy including dietary changes, use of antidiarrheals and antacids. PMH was significant for hypertension, atrial fibrillation, Bell’s palsy, and diabetes. At the time of the present admission, in addition to chronic diarrhea the patient showed signs of wasting with marked weight loss and cachexia. The patient was treated with three sessions of hyperbaric oxygen therapy, each delivered at 2.4 times atmospheric pressure for 110 minutes in an oxygen chamber. A comprehensive Medline search identified fourteen cases of PCI managed by this approach but without standardized recommendations. Results: There was dramatic improvement in symptoms with complete resolution of the abdominal pain and distention by the second treatment. Radiological studies revealed resolution of the cysts at week two post therapy. At six months follow up, the patient was completely asymptomatic and his weight had returned to baseline. Conclusions: Hyperbaric oxygen appears to be an effective treatment for symptomatic patients with pneumatosis cystoides intestinalis. However, more studies are needed to define the ideal atmosphere level and duration of hyperbaric oxygen therapy required in symptomatic patients with pneumatosis cystoides intestinalis.
241 A NOVEL GAS CHROMATOGRAPHIC METHOD FOR DETECTION OF URINARY SUCRALOSE: APPLICATION TO THE ASSESSMENT OF INTESTINAL PERMEABILITY Ashkan Farhadi, M.D., Ali Keshavarzian, M.D.*, Earle W. Holmes, Ph.D., Jeremy Fields, Ph.D., Lei Zhang, M.D., PH.D. and Ali Banan, Ph.D. Department of Internal Medicine, Section of Gastroenterology and Nutrition, Rush Medical College, Rush University, Chicago, IL and Department of Pathology, Loyola University, Chicago, IL. Purpose: The most direct and accurate method to quantitatively assess intestinal barrier function is by measurement of intestinal permeability. To assess human intestinal permeability, we developed a highly–sensitive gas chromatography (GC) method for the measurement of urinary sucralose (S) along with three other sugar probes, including sucrose, lactulose (L) and mannitol (M). We also investigated the intestinal bacterial metabolism of these sugar probes to evaluate whether these probes are suitable for assessement of the whole gut permeability. Methods: To this end, 14 healthy controls were enrolled. 5– h and 19 – h urine samples were collected after ingestion of a water– based solution containing 7.5g L, 2.0 g M, 1 g S and 40 g sucrose. These sugar probes were then measured using a unique capillary column GC technique. Metabolism of sugar probes by intestinal bacteria was also evaluated by in vitro incubation of an iso– osmolar mixture of M, L and S with fecal bacteria at 37° C for 19 hours. Sugar concentration and pH of the mixture were monitored for 19 h. Results: All 4 sugars were detected in the urine samples without interference (see Table 1). The capillary column substantially enhanced the sensitivity of detection of sugar probes by 200 –2000 times as compared to a Packed Column GC method. It also lowered the coefficient of variation from 15% to 3.95%. The detection limit was 0.2 and 0.5 mg/L for S and L, respectively. While intestinal bacteria metabolized L by 51% and acidified the environment (pH 7.2 to 4.8) during incubation, they did not metabolize S or M.