- Email: [email protected]
Ecstasy induced fulminant liver failure—half is enough
S230
Abstracts
Conclusion: Glutaraldehyde causes direct injury to the crypt epithelium with histopathologic findings that cannot be differentiated from ischemic or pseudomembraneous colitis. An acute onset after a lower GI endoscopy and rapid resolution documented by follow-up procedures confirms this unusual type of colitis which has a more favorable prognosis. 732 AIDS cholangiopathy: ultrasound, ERCP and CT findings in HIV cholangitis David J. Ott, M.D., F.A.C.G.*, Michael Y. Chen, M.D. Department of Radiology, Wake Forest University School Medicine, Winston-Salem, NC 27157. HIV cholangiopathy is one of many multi-system disorders that occurs in patients with AIDS. We present a 28 year-old female with HIV cholangitis, likely related to cryptosporidium infection, who had multiple imaging examinations which showed a variety of abnormalities that may be seen in this disorder. In this exhibit, the clinical history, laboratory results, and imaging findings in this patient are presented more thoroughly and illustrated. The etiology, pathology, and clinical features of AIDS cholangiopathy are discussed and differential considerations, such as sclerosing cholangitis, are outlined. The imaging findings in these biliary tract disorders are compared and the efficacy and role of these modalities in evaluating patients with AIDS and biliary tract signs and symptoms are reviewed and updated. 733 Islet cell tumor: ERCP and CT correlation in patient with hypoglycemia David J. Ott, M.D., F.A.C.G.*, Michael Y. Chen, M.D. Department of Radiology, Wake Forest University School Medicine, Winston-Salem, NC 27157. Islet cell tumors of the pancreas are rare; insulinoma is the most common but is often small (⬍2 cm) and may be difficult to identify preoperatively. We present a 64 year-old man with hypoglycemic episodes who had an insulinoma in the head of the pancreas. Biochemical evidence of the tumor was present, and multiple imaging examinations were performed, including an ERCP which showed a ‘mass’ effect; pancreatic ductal stenting was performed before surgical removal of the mass to help prevent ductal injury. In this exhibit, the clinical history and operative procedure are discussed more thoroughly and imaging findings are illustrated. The classification, pathology and clinical features of islet cell tumors are discussed in general with an emphasis on insulinomas. The imaging modalities used to identify these neoplasms are compared and more recent imaging techniques updated.
AJG – Vol. 96, No. 9, Suppl., 2001
temperature of 101.3F, hepatomegaly and jaundice. Otherwise the patient had stable vital signs, no lymphadenopathy or asterixis, and normal mental status. Laboratory data showed: WBC 16.9 th/cmm, Hgb 7.3 g/dl, Plt 213 th/cmm, T Bili 15.6 mg/dl, D Bili 12.8 mg/dl, ALT 511 u/l, AST 587 u/l, Alk Phos 845 u/l, PT 20.9 sec. Ultrasound of the liver showed multiple “bull’s-eye” lesions, and CT showed diffuse hypodense hepatic lesions. A CT-guided biopsy of the liver was significant for Non-Hodgkin’s lymphoma (NHL), diffuse large B-cell type. Soon after admission, the patient developed worsening coagulopathy and severe encephalopathy progressing to the point of death within a week of hospitalization. A bone marrow evaluation was not done. However, the normal WBC and platelet counts, and lack of intraabdominal or peripheral lymphadenopathy are consistent with primary hepatic lymphoma. While the association of NHL and HIV is well established, hepatic involvement is often associated with systemic disease. Primary hepatic lymphoma is uncommon. Our case reports a rare presentation of primary hepatic lymphoma with FHF. 735 Celiac disease (CD) presenting as chronic unexplained elevation of liver enzymes Nuri Ozden1, John K DiBaise1* and Frederick F Paustian1. 1Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States. Purpose: The wide spectrum of clinical presentations associated with CD oftentimes makes for a challenging diagnosis. Methods: We report an unusual presentation of CD in a 40 year-old Caucasian woman with SLE who we were asked to see for evaluation of chronically elevated liver enzymes (AST 225, ALT 157, AP 736) and a gradually declining albumin (2.5 g/dl). Results: Previous workup was as follows: Hepatitis A, B, C serologies, antismooth muscle, anti-LKM, ANA, anti-dsDNA, and AMA were negative; abdominal CTscan revealed splenic atrophy and multiple 1-cm size mesenteric lymph nodes; and, percutaneous liver biopsy identified nonspecific portal lymphocytic infiltration. Upon further evaluation, we identified history of intermittent diarrhea and mild iron deficiency anemia (Hgb 10.6 g/dl, MCV 73). Peripheral blood smear revealed anisocytosis, Heinz bodies and poikilocytosis. Anti-gliadin, anti-reticulin and anti-endomysial antibody titers were subsequently obtained and were positive. Upper endoscopy with small bowel biopsy confirmed the diagnosis of CD. After a year on a gluten free diet, her clinical condition had improved considerably; liver enzymes and hemoglobin had returned to normal after 3 months. Conclusions: This case highlights the importance of including celiac disease as a potential cause of chronically elevated liver enzymes of unknown etiology. Elevated liver tests, most commonly seen in CD cases of long duration, usually normalize within 6 months of initiating a gluten free diet. Interestingly, CD patients with liver test abnormalities seem to have a higher incidence of lymphoma and small intestinal adenocarcinoma.
734 Fulminant hepatic failure in a patient with primary hepatic lymphoma and HIV Oubre, B., MD, Sood, G., MD, Donelson, S., MD. University of Mississippi/VA Medical Center, Jackson, MS. Hepatic involvement in HIV disease is common. Viral pathogens (Hepatitis A, B, C, CMV, Herpes virus) are the most common cause of HIV associated hepatobiliary disease, followed by opportunistic pathogens (Cryptosporidium, Candida, MAC), neoplasms (Kaposi’s Sarcoma, NonHodgkin’s Lymphoma), and hepatotoxic drugs. Abnormal liver chemistries are seen in two-thirds of HIV patients, jaundice in five to ten percent, and fulminant hepatic failure (FHF) rarely. We present a case of FHF caused by primary hepatic lymphoma in an HIV positive patient. A 39 y/o white man with HIV, a CD4 count of 400, and a viral load of 3,501 copies, on antiretroviral therapy (lamivudine, zidovudine, and nelfinavir) presented with 10 lb. weight loss over 4 weeks, abdominal distention, early satiety, fever, chills, and jaundice. Physical examination was remarkable for a
736 Ecstasy induced fulminant liver failure— half is enough Nuri Ozden, M.D.1, Jesus Carale, M.D.1, Sandeep Mukherjee, M.D.1 and Rowen Zetterman, M.D. FACG, FACP1*. 1Medicine/Hepatology, University of Nebraska Medical Center, Omaha, NE, United States. Purpose: 3,4-Methylenedioxymethamphetamine (MDMA or Ecstasy) is a synthetic amphetamine widely used as weekend recreational drug during RAVE parties. Toxicity ranges from hepatitis like presentation (mimicking viral hepatitis) to fulminant hepatitis with hepatic necrosis and multisystem failure. Methods: A 24 yr old Caucasian female was transferred to our hepatology unit with 48 hour duration of progressive jaundice and Grade II hepatic encephalopathy. She admitted taking half tablet of ecstasy 24 hour prior to initial presentation to an outside facility. She denied using any street drugs or alcohol prior to this incident. Her labs during hospitalization at our facility were AST 2100 ALT 4069, PT/INR ⬎ 10, Cr 4.5 mg/dl. Her
AJG – September, Suppl., 2001
clinical condition deteriorated considerably within 24 hour at our liver intensive care unit. She was subsequently intubated and had to be placed on pressors for hemodynamic stabilization. She was listed as Status I according to UNOS guidelines. Suitable cadaveric donor has been identified which was much larger than the recipient was and therefore auxiliary liver transplant using the left lateral segment of cadaveric donor has been performed. Her liver was pale and biopsy revealed massive hepatic necrosis. She developed graft failure secondary to hepatic artery thrombosis. Her clinical condition worsened gradually with seizure activity. Head CT revealed progression of cerebral edema, descending transtentorial herniation with brainstem compression. Life support was withdrawn per family request considering dismal prognosis. Results: Despite possible risk of severe hepatotoxicity, consumption of the Ecstasy is increasing among young people in developed countries. Patients developing jaundice or with evidence of hepatic failure particularly encephalopathy and prolongation of PT/INR, or both, whether or not preceded by hyperthermia, should be referred to a specialised liver unit. Conclusions: Physicians should be aware of the possibility that acute hepatitis with no recognized etiology in young adults may be related to ecstasy and should not hesitate referring the case to a specialized center. It should also be noted that 8 cases that required transplant including this case, mortality even after transplant was 50%.
737 Severe protein calorie malnutrition as a late complication post bariatric surgery: a case report Rajesh R Panchwagh, DO and Toby Graham, MD*. 1Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States. Purpose: Protein calorie malnutrition is a rare and serious complication which can occur following bariatric surgery for super morbid obesity. This has previously been reported as an early complication, developing within the first 3– 6 months in the post operative period due to sudden and excessive weight loss. We report a case of severe protein calorie malnutrition as a late complication post bariatric surgery. Methods: A 32 year old female underwent laparoscopic Roux-en-Y gastric bypass surgery for super morbid obesity (pre-op wt 330 lbs and BMI ⫽ 65) and presented 9 months later with nausea, vomiting, meat aversion, anorexia, hypersalivation, generalized weakness, dizziness, muscle aches, and paresthesias of the hands. She had lost a total of 194 lbs, including 100 lbs in the first 2 months after the procedure. She required hospitalization with admission assessment revealing wt of 136 lbs (100% of ideal body wt and 39% of pre-op wt), ht 5ft 6in, BP 106/80, and HR 108 (with symptomatic orthostatic hypotension and tachycardia). The rest of her physical examination was remarkable for dry mucous membranes, poor skin turgor, and increased skin folds. Results: Laboratory tests revealed a microcytic anemia (Hgb 10.6, Hct 31.3, MCV 77.6, RDW 18.6), hypokalemia (2.7mEq/l), hypomagnesemia (1.1mEq/dl), low total protein (4.4gm/dl), hypoalbuminemia (1.3gm/dl), PT/INR ⫽ 16.8/1.5, iron deficiency (ferritin 46mcg/l, iron 10mcg/dl, TIBC 76mcg/dl, iron saturation 3%), low transferrin 56mcg/dl, low copper 62mcg/dl, low zinc 0.20mcg/ml, low selenium 58mcg/l, low prealbumin 10, low folate 1.2nMol/l, and low levels of VIT A (14.4mg/dl), VIT E (4.4mg/ml), and VIT D(⬍5). An UGI SBFT showed no obstruction. A 24 hour urine collection revealed no significant proteinuria. Calorie counts on two successive days were 1032tkcal/d and 753tkcal/d. Our assessment was a young female with dehydration, macro and micronutrient deficiency, and motor and sensory neuropathy in the setting of severe protein calorie malnutrition. Her other problems included hypersalivation and depression. She was treated with TPN, parenteral iron, multivitamins, and intensive physical therapy. The hypersalivation was primarily functional and she was given intensive behavioral and psychiatric therapy in the eating disorders center. Conclusions: Although protein calorie malnutrition is a rare complication following bariatric surgery, it can occur in a small subset of patients,
Abstracts
S231
especially with rapid and excessive weight loss. These patients need close monitoring and intensive pre and post operative counseling to ensure adequate nutrition and realistic goals for weight loss. 738 Gastric plasmacytoma presenting as upper GI bleed Priti Pandya, MD1, Archana Verma, MD1, Bashar M Attar, MD, FACG1*, Bourke Firfer, MD3 and Frida Abrahamian, MD1. 1Medicine, Cook County Hospital, Chicago, IL, United States; 2Medicine, Rush Medical College, Chicago, IL, United States; and 3Pathology, Cook County Hospital, Chicago, IL, United States. GI involvement accounts for 2%–13% of all extramedullary plasmacytomas. The latter accounts for only 2% of multiple myelomas. We report an extremely rare case of gastric plasmacytoma presenting with upper GI bleeding. A 63-yr-old female presented with a 3-wk history of anorexia, epigastric pain and melena. She denied the use of ETOH or NSAIDs. Physical exam was notable for normal vital signs with no orthostatic changes and liver span of 14 cm. Initial laboratory tests were significant for normocytic anemia (6.8 gm%), thrombocytopenia (74) and low iron indices (Ferritin 8). Liver function tests were suggestive of decompensation (Albumin (2.3), Cholesterol (31), INR (1.6). There was mild increase of ALT 62, AST 60. Total serum protein was 9.8 gm% with albumin of 2.3 gm%. Serum electrophoresis showed IgA of 5.7 gm % with suppression of IgG (0.394 gm%) and IgM (0.03 gm%). Immunoelectrophoresis showed IgA kappa light chain spike. Serum creatinine was 1.7gm% and UA was negative for proteins. CT Scan was done to evaluate abdominal pain and showed gastric wall thickening, moderate cardiomegaly and hepatomegaly. Esophagogastroduodenoscopy was performed and showed edematous gastric mucosa with multiple discrete erythematous spots in the body and fundus of stomach. There was a 5mm mucosal nodule in the fundus and an 8 mm firm submucosal nodule in the bulb. Biopsies of the gastric nodule showed dense diffuse infiltrates of atypical plasmacells in the lamina propria consistent with multiple myeloma. There was associated H. pylori positive antral gastritis and chronic duodenitis. Subsequent Bone Marrow biopsy showed 95% infiltration of bone marrow by plasma cells consistent with multiple myeloma. Bone survey was negative for lytic lesions. Patient was discharged to be followed by oncology but she had a cardiorespiratory arrest and expired 2 days after discharge. 739 Gastrointestinal (GI) bleeding as the presenting feature of an ovarian lymphoma masquerading as adenocarcinoma Sonali Parekh, B.A., Howard Safran, M.D., Edward Feller, M.D., FACG. Brown Univ., Providence, R.I. Introduction: Primary ovarian lymphoma is rare and rarely presents as GI bleeding. To alert clinicians to this association, we report iron deficiency anemia as the initial manifestation of an ovarian lymphoma masquerading as ovarian adenocarcinoma. Case Report: An 80 y.o. woman presented to the hospital with several weeks of weakness and black stools. Physical exam showed a lower abdominal mass with stool black and positive for occult blood. Hemoglobin ⫽ 7.4 g%. CT scan demonstrated a large left-sided abdominal mass without lymphadenopathy. Serum CA 125 ⫽ 317 (Normal to 35) leading to a pre-operative diagnosis of ovarian carcinoma. Laparotomy revealed an ovarian lymphoma, B-cell type, with multiple metastatic small bowel mucosal implants with bleeding. Discussion: Ovarian tumors rarely present with GI bleeding and are, similarly, a rare cause of digestive hemorrhage. The mechanism of bleeding may be direct erosion of a contiguous tumor or by metastatic lesions in any part of the GI tract. Our patient is particularly unusual because her underlying pathology was a lymphoma masquerading as carcinoma. Serum CA 125 is non-specific and may be elevated in a myriad of gynecologic and non-gynecologic benign or malignant disorders, including lymphoma. Di-
Abstracts
Conclusion: Glutaraldehyde causes direct injury to the crypt epithelium with histopathologic findings that cannot be differentiated from ischemic or pseudomembraneous colitis. An acute onset after a lower GI endoscopy and rapid resolution documented by follow-up procedures confirms this unusual type of colitis which has a more favorable prognosis. 732 AIDS cholangiopathy: ultrasound, ERCP and CT findings in HIV cholangitis David J. Ott, M.D., F.A.C.G.*, Michael Y. Chen, M.D. Department of Radiology, Wake Forest University School Medicine, Winston-Salem, NC 27157. HIV cholangiopathy is one of many multi-system disorders that occurs in patients with AIDS. We present a 28 year-old female with HIV cholangitis, likely related to cryptosporidium infection, who had multiple imaging examinations which showed a variety of abnormalities that may be seen in this disorder. In this exhibit, the clinical history, laboratory results, and imaging findings in this patient are presented more thoroughly and illustrated. The etiology, pathology, and clinical features of AIDS cholangiopathy are discussed and differential considerations, such as sclerosing cholangitis, are outlined. The imaging findings in these biliary tract disorders are compared and the efficacy and role of these modalities in evaluating patients with AIDS and biliary tract signs and symptoms are reviewed and updated. 733 Islet cell tumor: ERCP and CT correlation in patient with hypoglycemia David J. Ott, M.D., F.A.C.G.*, Michael Y. Chen, M.D. Department of Radiology, Wake Forest University School Medicine, Winston-Salem, NC 27157. Islet cell tumors of the pancreas are rare; insulinoma is the most common but is often small (⬍2 cm) and may be difficult to identify preoperatively. We present a 64 year-old man with hypoglycemic episodes who had an insulinoma in the head of the pancreas. Biochemical evidence of the tumor was present, and multiple imaging examinations were performed, including an ERCP which showed a ‘mass’ effect; pancreatic ductal stenting was performed before surgical removal of the mass to help prevent ductal injury. In this exhibit, the clinical history and operative procedure are discussed more thoroughly and imaging findings are illustrated. The classification, pathology and clinical features of islet cell tumors are discussed in general with an emphasis on insulinomas. The imaging modalities used to identify these neoplasms are compared and more recent imaging techniques updated.
AJG – Vol. 96, No. 9, Suppl., 2001
temperature of 101.3F, hepatomegaly and jaundice. Otherwise the patient had stable vital signs, no lymphadenopathy or asterixis, and normal mental status. Laboratory data showed: WBC 16.9 th/cmm, Hgb 7.3 g/dl, Plt 213 th/cmm, T Bili 15.6 mg/dl, D Bili 12.8 mg/dl, ALT 511 u/l, AST 587 u/l, Alk Phos 845 u/l, PT 20.9 sec. Ultrasound of the liver showed multiple “bull’s-eye” lesions, and CT showed diffuse hypodense hepatic lesions. A CT-guided biopsy of the liver was significant for Non-Hodgkin’s lymphoma (NHL), diffuse large B-cell type. Soon after admission, the patient developed worsening coagulopathy and severe encephalopathy progressing to the point of death within a week of hospitalization. A bone marrow evaluation was not done. However, the normal WBC and platelet counts, and lack of intraabdominal or peripheral lymphadenopathy are consistent with primary hepatic lymphoma. While the association of NHL and HIV is well established, hepatic involvement is often associated with systemic disease. Primary hepatic lymphoma is uncommon. Our case reports a rare presentation of primary hepatic lymphoma with FHF. 735 Celiac disease (CD) presenting as chronic unexplained elevation of liver enzymes Nuri Ozden1, John K DiBaise1* and Frederick F Paustian1. 1Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States. Purpose: The wide spectrum of clinical presentations associated with CD oftentimes makes for a challenging diagnosis. Methods: We report an unusual presentation of CD in a 40 year-old Caucasian woman with SLE who we were asked to see for evaluation of chronically elevated liver enzymes (AST 225, ALT 157, AP 736) and a gradually declining albumin (2.5 g/dl). Results: Previous workup was as follows: Hepatitis A, B, C serologies, antismooth muscle, anti-LKM, ANA, anti-dsDNA, and AMA were negative; abdominal CTscan revealed splenic atrophy and multiple 1-cm size mesenteric lymph nodes; and, percutaneous liver biopsy identified nonspecific portal lymphocytic infiltration. Upon further evaluation, we identified history of intermittent diarrhea and mild iron deficiency anemia (Hgb 10.6 g/dl, MCV 73). Peripheral blood smear revealed anisocytosis, Heinz bodies and poikilocytosis. Anti-gliadin, anti-reticulin and anti-endomysial antibody titers were subsequently obtained and were positive. Upper endoscopy with small bowel biopsy confirmed the diagnosis of CD. After a year on a gluten free diet, her clinical condition had improved considerably; liver enzymes and hemoglobin had returned to normal after 3 months. Conclusions: This case highlights the importance of including celiac disease as a potential cause of chronically elevated liver enzymes of unknown etiology. Elevated liver tests, most commonly seen in CD cases of long duration, usually normalize within 6 months of initiating a gluten free diet. Interestingly, CD patients with liver test abnormalities seem to have a higher incidence of lymphoma and small intestinal adenocarcinoma.
734 Fulminant hepatic failure in a patient with primary hepatic lymphoma and HIV Oubre, B., MD, Sood, G., MD, Donelson, S., MD. University of Mississippi/VA Medical Center, Jackson, MS. Hepatic involvement in HIV disease is common. Viral pathogens (Hepatitis A, B, C, CMV, Herpes virus) are the most common cause of HIV associated hepatobiliary disease, followed by opportunistic pathogens (Cryptosporidium, Candida, MAC), neoplasms (Kaposi’s Sarcoma, NonHodgkin’s Lymphoma), and hepatotoxic drugs. Abnormal liver chemistries are seen in two-thirds of HIV patients, jaundice in five to ten percent, and fulminant hepatic failure (FHF) rarely. We present a case of FHF caused by primary hepatic lymphoma in an HIV positive patient. A 39 y/o white man with HIV, a CD4 count of 400, and a viral load of 3,501 copies, on antiretroviral therapy (lamivudine, zidovudine, and nelfinavir) presented with 10 lb. weight loss over 4 weeks, abdominal distention, early satiety, fever, chills, and jaundice. Physical examination was remarkable for a
736 Ecstasy induced fulminant liver failure— half is enough Nuri Ozden, M.D.1, Jesus Carale, M.D.1, Sandeep Mukherjee, M.D.1 and Rowen Zetterman, M.D. FACG, FACP1*. 1Medicine/Hepatology, University of Nebraska Medical Center, Omaha, NE, United States. Purpose: 3,4-Methylenedioxymethamphetamine (MDMA or Ecstasy) is a synthetic amphetamine widely used as weekend recreational drug during RAVE parties. Toxicity ranges from hepatitis like presentation (mimicking viral hepatitis) to fulminant hepatitis with hepatic necrosis and multisystem failure. Methods: A 24 yr old Caucasian female was transferred to our hepatology unit with 48 hour duration of progressive jaundice and Grade II hepatic encephalopathy. She admitted taking half tablet of ecstasy 24 hour prior to initial presentation to an outside facility. She denied using any street drugs or alcohol prior to this incident. Her labs during hospitalization at our facility were AST 2100 ALT 4069, PT/INR ⬎ 10, Cr 4.5 mg/dl. Her
AJG – September, Suppl., 2001
clinical condition deteriorated considerably within 24 hour at our liver intensive care unit. She was subsequently intubated and had to be placed on pressors for hemodynamic stabilization. She was listed as Status I according to UNOS guidelines. Suitable cadaveric donor has been identified which was much larger than the recipient was and therefore auxiliary liver transplant using the left lateral segment of cadaveric donor has been performed. Her liver was pale and biopsy revealed massive hepatic necrosis. She developed graft failure secondary to hepatic artery thrombosis. Her clinical condition worsened gradually with seizure activity. Head CT revealed progression of cerebral edema, descending transtentorial herniation with brainstem compression. Life support was withdrawn per family request considering dismal prognosis. Results: Despite possible risk of severe hepatotoxicity, consumption of the Ecstasy is increasing among young people in developed countries. Patients developing jaundice or with evidence of hepatic failure particularly encephalopathy and prolongation of PT/INR, or both, whether or not preceded by hyperthermia, should be referred to a specialised liver unit. Conclusions: Physicians should be aware of the possibility that acute hepatitis with no recognized etiology in young adults may be related to ecstasy and should not hesitate referring the case to a specialized center. It should also be noted that 8 cases that required transplant including this case, mortality even after transplant was 50%.
737 Severe protein calorie malnutrition as a late complication post bariatric surgery: a case report Rajesh R Panchwagh, DO and Toby Graham, MD*. 1Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States. Purpose: Protein calorie malnutrition is a rare and serious complication which can occur following bariatric surgery for super morbid obesity. This has previously been reported as an early complication, developing within the first 3– 6 months in the post operative period due to sudden and excessive weight loss. We report a case of severe protein calorie malnutrition as a late complication post bariatric surgery. Methods: A 32 year old female underwent laparoscopic Roux-en-Y gastric bypass surgery for super morbid obesity (pre-op wt 330 lbs and BMI ⫽ 65) and presented 9 months later with nausea, vomiting, meat aversion, anorexia, hypersalivation, generalized weakness, dizziness, muscle aches, and paresthesias of the hands. She had lost a total of 194 lbs, including 100 lbs in the first 2 months after the procedure. She required hospitalization with admission assessment revealing wt of 136 lbs (100% of ideal body wt and 39% of pre-op wt), ht 5ft 6in, BP 106/80, and HR 108 (with symptomatic orthostatic hypotension and tachycardia). The rest of her physical examination was remarkable for dry mucous membranes, poor skin turgor, and increased skin folds. Results: Laboratory tests revealed a microcytic anemia (Hgb 10.6, Hct 31.3, MCV 77.6, RDW 18.6), hypokalemia (2.7mEq/l), hypomagnesemia (1.1mEq/dl), low total protein (4.4gm/dl), hypoalbuminemia (1.3gm/dl), PT/INR ⫽ 16.8/1.5, iron deficiency (ferritin 46mcg/l, iron 10mcg/dl, TIBC 76mcg/dl, iron saturation 3%), low transferrin 56mcg/dl, low copper 62mcg/dl, low zinc 0.20mcg/ml, low selenium 58mcg/l, low prealbumin 10, low folate 1.2nMol/l, and low levels of VIT A (14.4mg/dl), VIT E (4.4mg/ml), and VIT D(⬍5). An UGI SBFT showed no obstruction. A 24 hour urine collection revealed no significant proteinuria. Calorie counts on two successive days were 1032tkcal/d and 753tkcal/d. Our assessment was a young female with dehydration, macro and micronutrient deficiency, and motor and sensory neuropathy in the setting of severe protein calorie malnutrition. Her other problems included hypersalivation and depression. She was treated with TPN, parenteral iron, multivitamins, and intensive physical therapy. The hypersalivation was primarily functional and she was given intensive behavioral and psychiatric therapy in the eating disorders center. Conclusions: Although protein calorie malnutrition is a rare complication following bariatric surgery, it can occur in a small subset of patients,
Abstracts
S231
especially with rapid and excessive weight loss. These patients need close monitoring and intensive pre and post operative counseling to ensure adequate nutrition and realistic goals for weight loss. 738 Gastric plasmacytoma presenting as upper GI bleed Priti Pandya, MD1, Archana Verma, MD1, Bashar M Attar, MD, FACG1*, Bourke Firfer, MD3 and Frida Abrahamian, MD1. 1Medicine, Cook County Hospital, Chicago, IL, United States; 2Medicine, Rush Medical College, Chicago, IL, United States; and 3Pathology, Cook County Hospital, Chicago, IL, United States. GI involvement accounts for 2%–13% of all extramedullary plasmacytomas. The latter accounts for only 2% of multiple myelomas. We report an extremely rare case of gastric plasmacytoma presenting with upper GI bleeding. A 63-yr-old female presented with a 3-wk history of anorexia, epigastric pain and melena. She denied the use of ETOH or NSAIDs. Physical exam was notable for normal vital signs with no orthostatic changes and liver span of 14 cm. Initial laboratory tests were significant for normocytic anemia (6.8 gm%), thrombocytopenia (74) and low iron indices (Ferritin 8). Liver function tests were suggestive of decompensation (Albumin (2.3), Cholesterol (31), INR (1.6). There was mild increase of ALT 62, AST 60. Total serum protein was 9.8 gm% with albumin of 2.3 gm%. Serum electrophoresis showed IgA of 5.7 gm % with suppression of IgG (0.394 gm%) and IgM (0.03 gm%). Immunoelectrophoresis showed IgA kappa light chain spike. Serum creatinine was 1.7gm% and UA was negative for proteins. CT Scan was done to evaluate abdominal pain and showed gastric wall thickening, moderate cardiomegaly and hepatomegaly. Esophagogastroduodenoscopy was performed and showed edematous gastric mucosa with multiple discrete erythematous spots in the body and fundus of stomach. There was a 5mm mucosal nodule in the fundus and an 8 mm firm submucosal nodule in the bulb. Biopsies of the gastric nodule showed dense diffuse infiltrates of atypical plasmacells in the lamina propria consistent with multiple myeloma. There was associated H. pylori positive antral gastritis and chronic duodenitis. Subsequent Bone Marrow biopsy showed 95% infiltration of bone marrow by plasma cells consistent with multiple myeloma. Bone survey was negative for lytic lesions. Patient was discharged to be followed by oncology but she had a cardiorespiratory arrest and expired 2 days after discharge. 739 Gastrointestinal (GI) bleeding as the presenting feature of an ovarian lymphoma masquerading as adenocarcinoma Sonali Parekh, B.A., Howard Safran, M.D., Edward Feller, M.D., FACG. Brown Univ., Providence, R.I. Introduction: Primary ovarian lymphoma is rare and rarely presents as GI bleeding. To alert clinicians to this association, we report iron deficiency anemia as the initial manifestation of an ovarian lymphoma masquerading as ovarian adenocarcinoma. Case Report: An 80 y.o. woman presented to the hospital with several weeks of weakness and black stools. Physical exam showed a lower abdominal mass with stool black and positive for occult blood. Hemoglobin ⫽ 7.4 g%. CT scan demonstrated a large left-sided abdominal mass without lymphadenopathy. Serum CA 125 ⫽ 317 (Normal to 35) leading to a pre-operative diagnosis of ovarian carcinoma. Laparotomy revealed an ovarian lymphoma, B-cell type, with multiple metastatic small bowel mucosal implants with bleeding. Discussion: Ovarian tumors rarely present with GI bleeding and are, similarly, a rare cause of digestive hemorrhage. The mechanism of bleeding may be direct erosion of a contiguous tumor or by metastatic lesions in any part of the GI tract. Our patient is particularly unusual because her underlying pathology was a lymphoma masquerading as carcinoma. Serum CA 125 is non-specific and may be elevated in a myriad of gynecologic and non-gynecologic benign or malignant disorders, including lymphoma. Di-