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“Downhill” varices in the mid- to distal esophagus as an iatrogenic complication of upper extremity hemodialysis access
AJG – September, 2000
admitted to moderate alcohol consumption. Abdominal ultrasound showed gall stones. Laproscopic cholecystectomy was done, however pain continued. Physical examination was unremarkable. Liver function tests, amylase and lipase were normal. She underwent a colonoscopy and upper gastrointestinal endoscopy which revealed multiple 0.5–1 cm submucosal nodules in the rectum, transverse colon, cecum, esophagus and body of the stomach. Abdominal CT showed a dilated pancreatic duct and a possible mass at the junction of the body and tail of the pancreas. ERCP showed a normal proximal pancreatic duct with stricture in the mid body and dilated distal pancreatic duct. Because of the concern of malignant stricture, the patient underwent surgery which showed multiple 0.5–1 cm nodules under the serosal surface of the stomach one of which was biopsied. The pancreas appeared normal in size though somewhat atrophic. A distal pancreatectomy with splenectomy was done. Histology of the gastric nodule and pancreatic mass showed granular cells. Special stains for S-100 protein were positive confirming GCT involving the pancreatic duct and the stomach. Discussion: This is the fourth case of granular cell tumor involving the pancreas and the first case where it involved the pancreas and the stomach. GCT is believed to be Schwann cell in origin, the presence of S-100 protein supports this. Three out of four reported cases of GCT involving the pancreas occurred in females, two of these individuals were African Americans. GCT may mimic pancreatic cancer because of ductal obstruction or the presence of a mass lesion on imaging studies. GCT should be kept in the differential diagnosis in a relatively young African American female with abdominal pain, a pancreatic mass on CT and/or chronic pancreatitis.
527 “Downhill” varices in the mid- to distal esophagus as an iatrogenic complication of upper extremity hemodialysis access Michael E Blam, Sidney Kobrin, Evan S Siegelman, Ilias A Scotiniotis*. Hospital of University of Pennsylvania, Philadelphia, PA. Purpose: “Uphill” varices are due to portal venous hypertension or obstruction. “Downhill” varices rarely occur as a consequence of shunting in cases of upper body (systemic) venous obstruction and usually are limited to the proximal esophagus. We report a case of extensive “downhill” varices due to superior vena cava (SVC) obstruction as a complication of hemodialysis venous access. Methods: Case report. Results: A 42-year-old African-American female with a history of sarcoidosis resulting in uveitis, chronic hypoxemia, and end-stage renal disease requiring 23 years of hemodialysis presented with intermittent nausea and abdominal discomfort. There was no associated vomiting, heartburn, dysphagia, overt gastrointestinal bleeding, or weight loss. She has required temporary upper extremity venous catheters for hemodialysis access following 2 failed renal allograft transplants. A 95% SVC stenosis was dilated 3.5 years prior to presentation but SVC occlusion was re-demonstrated by venography 2 years later. The patient denied any symptoms consistent with hepatic insufficiency. Risk factors for acquired hepatic disease were exposure to hemodialysis and prior blood transfusions. Physical examination was notable for dilated subcutaneous veins along the anterior abdominal wall. Evaluation with esophago-gastric duodenoscopy revealed 3 columns of grade 2 varices in the mid- to distal esophagus. Work-up for liver disease revealed normal liver associated enzymes, serum protein and albumin, and no evidence of ascites, cirrhosis, or granulomas of the liver or spleen on abdominal magnetic resonance imaging. Portal and splenic vein occlusions and periportal venous collaterals were excluded by magnetic resonance venogram (MRV). MRV did demonstrate “downhill” flow in the azygous vein and extensive venous collaterals in the subcutaneous tissue of the abdominal and chest wall. Venography was performed via a right-sided arterio-venous graft given the development of ipsilateral digital gangrene. Complete occlusion of the SVC at a site closer to the heart than the insertion of the azygous system and a large hemiazygous vein that emptied into the inferior vena cava through collaterals were noted.
Abstracts
2565
Conclusions: “Downhill” esophageal varices should be considered in the differential diagnosis when liver disease and other causes of portal hypertension are excluded. We highlight the development of extensive “downhill” esophageal varices as an iatrogenic complication of hemodialysis access. A more frequent appearance of this complication may be expected and be of clinical importance given the growing number of patients maintained on long-term hemodialysis.
528 Colonic carcinoma presenting with generalized lymphadenopathy Ernst Bontemps, Adnan M Khdair, Celia Quinnonez, Irwin M Grosman*. Long Island College Hospital, Brooklyn, NY. Purpose: A 41 year old female with no significant past medical history presented with a 3-week history of progressive weakness and fatigue associated with a 10-pound weight loss and loss of appetite. She denied any change in bowel habits, nausea, vomiting, hematochezia or menometrorrhagia. Physical examination was notable for generalized lymphadenopathy and guaiac positive brown stool. Labs revealed a severe iron deficiency anemia, increased LDH and prolonged ESR. CT scan of the chest and abdomen showed bilateral cervical and para-aortic lymphadenopathy with normal liver and spleen. Lymph node biopsy revealed metastatic poorly differentiated adenocarcinoma. The CEA and CA 19-9 were increased. Mammogram was normal. An EGD showed extrinsic compression of the duodenum. Colonoscopy revealed a large cecal mass. The biopsy showed signet cell adenocarcinoma. The patient underwent a right hemicolectomy followed by chemotherapy. The patient succumbed 4 months later to sepsis. Signet cell carcinomas carry a poor prognosis and tend to occur in younger patients. We report an unusual case of colon cancer that presented with generalized lymphadenopathy. To our knowledge this unusual presentation of a common diagnosis has not been previously reported.
529 Interferon associated ischemic retinopathy with complete resolution after discontinuation of treatment Ernst Bontemps, Toomas M Sorra*. Long Island College Hospital, Brooklyn, NY. Purpose: A 53 y/o female with history of hypertension for 5 years recently diagnosed with diabetes mellitus was evaluated for abnormal LFTs and positive serology for hepatitis C. Her physical examination was normal. After confirmation of viremia with a quantitative PCR test the patient underwent a liver biopsy and was found to have chronic hepatitis with grade II activity and stage II fibrosis. A month prior to our evaluation the patient’s fundoscopic examination done routinely for hypertension and diabetes was normal. The patient was started on interferon alpha 3 million units three times weekly and 1 g of ribavirin daily. One week into the treatment she complained of pressure behind both eyes. Subsequently she described fixed scotomata in the near-central visual field of both eyes. Her visual acuity was otherwise normal. Retinoscopy revealed innumerable cotton-wool spots. After discontinuation of the treatment, repeat examination of the retina at 6 weeks and 6 months showed partial, then complete resolution of the cotton-wool spots. Interferon therapy has been used for various conditions with different dosage schedules with some reports of dose dependent ocular toxicity. With the widespread use of interferon, physicians, especially gastroenterologists should be aware of this potential reversible complication. To our knowledge this is the first reported case from the USA of ocular toxicity associated with interferon treatment for chronic hepatitis C followed by complete resolution of the symptoms and ophthalmoscopic findings after discontinuation of the drug.
admitted to moderate alcohol consumption. Abdominal ultrasound showed gall stones. Laproscopic cholecystectomy was done, however pain continued. Physical examination was unremarkable. Liver function tests, amylase and lipase were normal. She underwent a colonoscopy and upper gastrointestinal endoscopy which revealed multiple 0.5–1 cm submucosal nodules in the rectum, transverse colon, cecum, esophagus and body of the stomach. Abdominal CT showed a dilated pancreatic duct and a possible mass at the junction of the body and tail of the pancreas. ERCP showed a normal proximal pancreatic duct with stricture in the mid body and dilated distal pancreatic duct. Because of the concern of malignant stricture, the patient underwent surgery which showed multiple 0.5–1 cm nodules under the serosal surface of the stomach one of which was biopsied. The pancreas appeared normal in size though somewhat atrophic. A distal pancreatectomy with splenectomy was done. Histology of the gastric nodule and pancreatic mass showed granular cells. Special stains for S-100 protein were positive confirming GCT involving the pancreatic duct and the stomach. Discussion: This is the fourth case of granular cell tumor involving the pancreas and the first case where it involved the pancreas and the stomach. GCT is believed to be Schwann cell in origin, the presence of S-100 protein supports this. Three out of four reported cases of GCT involving the pancreas occurred in females, two of these individuals were African Americans. GCT may mimic pancreatic cancer because of ductal obstruction or the presence of a mass lesion on imaging studies. GCT should be kept in the differential diagnosis in a relatively young African American female with abdominal pain, a pancreatic mass on CT and/or chronic pancreatitis.
527 “Downhill” varices in the mid- to distal esophagus as an iatrogenic complication of upper extremity hemodialysis access Michael E Blam, Sidney Kobrin, Evan S Siegelman, Ilias A Scotiniotis*. Hospital of University of Pennsylvania, Philadelphia, PA. Purpose: “Uphill” varices are due to portal venous hypertension or obstruction. “Downhill” varices rarely occur as a consequence of shunting in cases of upper body (systemic) venous obstruction and usually are limited to the proximal esophagus. We report a case of extensive “downhill” varices due to superior vena cava (SVC) obstruction as a complication of hemodialysis venous access. Methods: Case report. Results: A 42-year-old African-American female with a history of sarcoidosis resulting in uveitis, chronic hypoxemia, and end-stage renal disease requiring 23 years of hemodialysis presented with intermittent nausea and abdominal discomfort. There was no associated vomiting, heartburn, dysphagia, overt gastrointestinal bleeding, or weight loss. She has required temporary upper extremity venous catheters for hemodialysis access following 2 failed renal allograft transplants. A 95% SVC stenosis was dilated 3.5 years prior to presentation but SVC occlusion was re-demonstrated by venography 2 years later. The patient denied any symptoms consistent with hepatic insufficiency. Risk factors for acquired hepatic disease were exposure to hemodialysis and prior blood transfusions. Physical examination was notable for dilated subcutaneous veins along the anterior abdominal wall. Evaluation with esophago-gastric duodenoscopy revealed 3 columns of grade 2 varices in the mid- to distal esophagus. Work-up for liver disease revealed normal liver associated enzymes, serum protein and albumin, and no evidence of ascites, cirrhosis, or granulomas of the liver or spleen on abdominal magnetic resonance imaging. Portal and splenic vein occlusions and periportal venous collaterals were excluded by magnetic resonance venogram (MRV). MRV did demonstrate “downhill” flow in the azygous vein and extensive venous collaterals in the subcutaneous tissue of the abdominal and chest wall. Venography was performed via a right-sided arterio-venous graft given the development of ipsilateral digital gangrene. Complete occlusion of the SVC at a site closer to the heart than the insertion of the azygous system and a large hemiazygous vein that emptied into the inferior vena cava through collaterals were noted.
Abstracts
2565
Conclusions: “Downhill” esophageal varices should be considered in the differential diagnosis when liver disease and other causes of portal hypertension are excluded. We highlight the development of extensive “downhill” esophageal varices as an iatrogenic complication of hemodialysis access. A more frequent appearance of this complication may be expected and be of clinical importance given the growing number of patients maintained on long-term hemodialysis.
528 Colonic carcinoma presenting with generalized lymphadenopathy Ernst Bontemps, Adnan M Khdair, Celia Quinnonez, Irwin M Grosman*. Long Island College Hospital, Brooklyn, NY. Purpose: A 41 year old female with no significant past medical history presented with a 3-week history of progressive weakness and fatigue associated with a 10-pound weight loss and loss of appetite. She denied any change in bowel habits, nausea, vomiting, hematochezia or menometrorrhagia. Physical examination was notable for generalized lymphadenopathy and guaiac positive brown stool. Labs revealed a severe iron deficiency anemia, increased LDH and prolonged ESR. CT scan of the chest and abdomen showed bilateral cervical and para-aortic lymphadenopathy with normal liver and spleen. Lymph node biopsy revealed metastatic poorly differentiated adenocarcinoma. The CEA and CA 19-9 were increased. Mammogram was normal. An EGD showed extrinsic compression of the duodenum. Colonoscopy revealed a large cecal mass. The biopsy showed signet cell adenocarcinoma. The patient underwent a right hemicolectomy followed by chemotherapy. The patient succumbed 4 months later to sepsis. Signet cell carcinomas carry a poor prognosis and tend to occur in younger patients. We report an unusual case of colon cancer that presented with generalized lymphadenopathy. To our knowledge this unusual presentation of a common diagnosis has not been previously reported.
529 Interferon associated ischemic retinopathy with complete resolution after discontinuation of treatment Ernst Bontemps, Toomas M Sorra*. Long Island College Hospital, Brooklyn, NY. Purpose: A 53 y/o female with history of hypertension for 5 years recently diagnosed with diabetes mellitus was evaluated for abnormal LFTs and positive serology for hepatitis C. Her physical examination was normal. After confirmation of viremia with a quantitative PCR test the patient underwent a liver biopsy and was found to have chronic hepatitis with grade II activity and stage II fibrosis. A month prior to our evaluation the patient’s fundoscopic examination done routinely for hypertension and diabetes was normal. The patient was started on interferon alpha 3 million units three times weekly and 1 g of ribavirin daily. One week into the treatment she complained of pressure behind both eyes. Subsequently she described fixed scotomata in the near-central visual field of both eyes. Her visual acuity was otherwise normal. Retinoscopy revealed innumerable cotton-wool spots. After discontinuation of the treatment, repeat examination of the retina at 6 weeks and 6 months showed partial, then complete resolution of the cotton-wool spots. Interferon therapy has been used for various conditions with different dosage schedules with some reports of dose dependent ocular toxicity. With the widespread use of interferon, physicians, especially gastroenterologists should be aware of this potential reversible complication. To our knowledge this is the first reported case from the USA of ocular toxicity associated with interferon treatment for chronic hepatitis C followed by complete resolution of the symptoms and ophthalmoscopic findings after discontinuation of the drug.