Elevated serum tumor markers in niacin induced cholestatic jaundice

AJG – September, Suppl., 2003

461 AN UNUSUAL CASE OF PAPILLARY STENOSIS FROM Strongyloides stercoralis IN A PATIENT WITH HTLV-1 Thomas C. Caves, M.D. Gregory Albers, M.D.* University of California at Irvine, Orange, CA. Gastrointestinal infection with Strongyloides stercoralis is seen commonly throughout the world. Unlike with other parasitic infections such as Ascaris lumbricoides and Fasciola hepatica, hepatobiliary complications have rarely been described with S. stercoralis. We report a case of papillary stenosis and biliary obstruction caused by S. stercoralis. A 46 y/o male from the Virgin Islands presented with crampy abdominal pain and nausea. Exam showed a cachectic man with epigastric tenderness. Laboratory data revealed eosinophilia (21%), albumin 1.3 g/dl, alkaline phosphatase of 88 iu/l, and total bilirubin of 0.6mg/dl. Abdominal ultrasound and CT scan identified a dilated biliary duct (CBD 11mm) and pancreatic duct. An ERCP was performed demonstrating a swollen, edematous ampulla with dilated pancreatic and biliary ducts (treated by sphincterotomy). Biopsies of the ampulla revealed the presence of numerous S. stercoralis ova. Further evaluation revealed hyperinfection with the presence of pulmonary infiltrates while bronchoalveolar lavage was positive for adult parasites. He was HIV negative, however, immunosuppression from underlying infection with HTLV-1 was identified. The patient recovered following treatment with thiabendazole for 2 weeks. This case highlights the need to consider Strongyloides infection as a cause for papillary stenosis.

462 SYMPTOMATIC GASTRIC SARCOIDOSIS WITH CELIAC DISEASE: AN UNUSUAL ENTITY WITH AN UNCOMMON ASSOCIATION/ ?IMMUNE RESPONSE Deepika Laxmi Koya, M.D., Ellen W. Shaw, M.D.* Abington Memorial Hospital, Abington, PA and Gastrointestinal Associates, Inc., Abington, PA. Forty-six year-old white male with two prior episodes of UGI bleeding, presented with complaints of nausea, melena and hematemesis. An endoscopy showed exuberant gastric folds with erosive gastritis and biopsies of gastric mucosa at different locations showed chronic gastritis with multiple noncaseating granulomas and a positive CLO test. His S-ACE level was 167 (normal 35–140). He was treated for H. pylori and placed on proton pump inhibitor therapy. He had history of sarcoidosis diagnosed when he was 20 years old, by mediastinoscopy and biopsy of mediastinal lymph nodes. He was not recommended any treatment then. He has no other significant symptoms like fevers, night sweats, weight loss, nausea, vomiting or diarrhea at this time. Biopsy was negative for AFB, Fungi and any foreign particles. He had a normal CT abdomen, upper GI and small bowel series and a normal chest X-ray and diffusion capacity. Gastric sarcoidosis is considered the most likely diagnosis and he was treated with 20mg/day of oral predinsone for 6 months with follow up endoscopies every 3– 6 months showing significant improvement in the macroscopic appearance of the stomach and features of lesser inflammation and fewer granulomas on biopsies and remained H. pylori negative. About one year later he developed symptoms of diarrhea and weight loss and had positive antiendomysial antibodies in serum suggestive of celiac disease. Biopsies of the duodenum and small bowel showed villous atrophy and lymphoid infiltration of lamina propria compatible with celiac disease and showed histological response to gluten free diet. Given the side effects of long- term use of corticosteroids, he was placed on methotrexate, which was started at 10 mg/week and titrated to a maximum of 50 mg/week, which the patient tolerated well, and repeat endoscopies and biopsies showed significant improvement. He has not had any recurrent bleeding and successfully stayed off the immunosuppressive therapy for the last one year. Clinical Vignettes: Gastrointestinal bleeding as a presentation of Gastric sarcoidosis is rare. Although Gluten-associated immune reactivity is seen in patients with sarcoidosis, overt celiac disease with gastric sarcoidosis has never been reported. Methotrexate can be used for steroid sparing immu-

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nosuppressive therapy of symptomatic gastric sarcoidosis. With conservative treatment for gastric sarcoidosis serial endoscopies with biopsies are essential to document response to treatment 463 EOSINOPHILIC ESOPHAGITIS : A CLASSIC PRESENTATION Deepika Laxmi Koya, Stuart M. Lubinski*, Margot I. Boigon. Abington Memorial Hospital, Abington, PA. A 48 year-old man with history of solid food dysphagia and several self limiting episodes of food impaction for the last 15 years was admitted with acute dysphagia following food impaction. He had an endoscopy with dilatation several years ago for dysphagia but no biopsies were taken then. He denied typical reflux symptoms. His past medical history was significant for congenital hydrocephalus and congenital hearing loss and he does not take any medications. Initial lab evaluation showed peripheral eosinophilia (260/mm3; normal ⬍50/mm3). CT scan of the thorax with oral contrast showed thickened esophageal wall, with impacted food appearing as an intrinsic lesion in the esophagus and dilatation of proximal esophagus. An endoscopy showed the characteristic corrugated proximal esophagus (trachealization) with circumferential narrowing at 27 cm as well as an atrophic and inflamed stomach and duodenum. Biopsies taken from the esophagus, antrum and duodenum showed marked eosinophilic infiltration of the mucosa consistent with eosinophilic esophagitis and gastroduodenitis. He has no history of food allergies or atopic diseases. After a 3-week course of oral predinsone, he has remained symptom free. Eosinophilic esophagitis (EE) is an increasingly recognized clinical entity in adults. It has moved from relative obscurity to increasing attention in the adult literature with more adults being recognized with this condition. It is a chronic inflammatory disorder of the esophagus with symptoms typical of recurrent dysphagia and food impactions. Radiographic features range from a normal esophagus to a thickened esophageal wall or stricture. Typical endoscopic features described are a normal esophagus, corrugated ring pattern, fragile and inelastic mucosa (crepe-paper mucosa) and fine whitish mucosal plaques. The gold standard for diagnosis, demonstrated on endoscopic biopsies, is prominent tissue eosinophilia (more than 15 eosinophils per high power field). Pathogenesis includes immune dysregulation and allergy mediated responses. Eotaxin, a specific eosinophil chemo attractant, plays a pivotal role in eosinophilic migration to the esophagus. Classical treatments include elimination diets, local/systemic corticosteroids, leukotriene receptor antagonists and endoscopic dilatations. Clinical Vignettes: Suspect EE in young adults with recurrent dysphagia and food impactions. If suspected the proximal and distal esophagus should be biopsied, even if the mucosa appears normal. 464 ELEVATED SERUM TUMOR MARKERS IN NIACIN INDUCED CHOLESTATIC JAUNDICE Sundar Venkatesh, M.D., Tarun Kothari, M.D., FACG*, Abraham Joseph, M.D. Unity Health System, Rochester, NY and Fairmont, MN. Niacin is a commonly used vitamin that can cause potentially serious liver abnormalities. We present the case of a 70 year-old man who had cholestatic jaundice secondary to Niacin, that was associated with raised levels of serum tumor markers CA 19-9, and CEA. Though there have been previous case reports of Niacin induced cholestatic jaundice, to our knowledge, this is the first case where elevated serum tumor marker levels were also found. This case also illustrates the importance of obtaining a detailed history, and interpreting diagnostic tests appropriately in patients with deranged liver function tests. A 70 year-old white man presented with significant weight loss, malaise, and fatigue for three months. A questionnaire filled by the patient listed aspirin and vitamins as his medications. Physical exam was unremarkable except for marked scleral icterus. Laboratory data showed Conjugated Hyperbilirubinemia. CA 19-9 was 241u/ ml, and CEA was 22.8 ng/ml. A abdominal CT scan and ERCP were

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normal. On a subsequent office visit the patient was advised to bring all his medicines with him, and it was found that the patient was taking Niacin-2 grams per day in divided doses, which had been listed as vitamins. He was advised to stop the Niacin, and his liver function tests, and CA 19-9 and CEA levels returned to normal levels. Niacin, used to treat hypercholestrolemia, may cause a wide range of liver problems. These side effects are seen more often with the Sustained Release form rather than the Immediate Release form. Many patients report this as a vitamin, and if a more detailed history is not obtained this very important cause of liver abnormality may be missed. CA 19-9 and CEA are used as serum tumor markers especially for GI and Hepato-biliary malignancies. Levels are usually higher in malignancies compared to benign conditions, but because of the poor sensitivity and specificity, these markers are not recommended for screening for malignancies, and are usually used for confirming diagnoses and monitoring response to therapy. In patients with deranged liver function tests a detailed history should be obtained to exclude potentially hepatotoxic over-the-counter medications. Patients should be encouraged to bring their pill bottles to the office at the time of initial consultation. Serum tumor markers should be ordered selectively, and should be interpreted appropriately to avoid expensive, and potentially harmful invasive procedures.

465 RENAL TRANSPLANT PATIENT WITH MULTIPLE SURGERIES: ANOTHER CONSIDERATION FOR LOWER GI BLEED Sami A. Beg, M.D., Amy Lazarini, M.D., Robert Levine, M.D.* SUNY Upstate Medical University, Syracuse, NY. We present a case of a 51 year-old Renal Transplant patient that came in with lower GI bleed. Thorough work up, which included a colonoscopy, showed that the bleed was somewhere further above the reach of the scope. Subsequently, the patient went to surgery for a suspected ischemic etiology. However on surgical exploration the patient was found to have a right external iliac artery pseudoaneurysm that had eroded into the small bowel causing the bleed. Given multiple past surgeries, including failed renal transplants, such an etiology should be an important consideration when evaluating renal transplant patients or other patients with abdominal surgeries.

466 FLOUROSCOPICALLY ASSISTED WIREGUIDED RETROGRADE DILATION OF ESOPHAGEAL STRICTURE Bipin Saud, M.D., Ronald D. Szyjkowski, M.D.* SUNY Upstate Medical University, Syracuse, NY. Esophageal strictures requiring dilation is a common problem. Retrograde dilation of esophageal strictures is a relatively new technique. This technique should be considered in selected patients when the lumen cannot be identified on the anterograde endoscopy. We describe the unique case of a patient who successfully underwent retrograde esophageal dilation. Case: A 58 year-old female who was diagnosed with left hypopharyngeal squamous cell cancer underwent chemotherapy and radiation treatment. A PEG tube had been placed prior to initiation of radiation treatment. She continued to have otalgia and dysphagia. Repeat panendoscopy revealed residual tumor in the pyriform sinus. She underwent left modified radical neck dissection, total laryngectomy, partial pharyngectomy and left thyroid lobectomy. Patient developed dysphagia secondary to severe upper esophageal sphincter (UES) stricture. Barium swallow showed a minute tortous tract from the pharynx to the proximal esophagus as well as evidence of aspiration and pharyngocutaneous fistula. Anterograde endoscopy under flouroscopy was attempted but passage of the wire across the stricture was unsuccessful. Similarly, dilation by Otolaryngology Service was also not possible secondary to significant stenosis of upper esophageal inlet and

AJG – Vol. 98, No. 9, Suppl., 2003

limited view of the hypopharynx. Retrograde endoscopy via the PEG site was performed under general anesthesia. A guidewire was then passed across the stenosed area in the esophagus and through the mouth in a retrograde manner. Progressive anterograde savary dilation of the esophagus was then performed over the guide wire. A salivary bypass tube was placed. Subsequent dilation did not require retrograde endoscopic assistance. Discussion: Retrograde esophageal dilation is an option in high grade strictures following radiation or surgery located in the UES in patients with PEG tube when dilation in the anterograde fashion is not possible. Retrograde dilation should be considered as an alternative to surgery or long term PEG feeding. 467 CYSTIC DUCT-DUODENAL FISTULA: AN UNUSUAL COMPLICATION OF LAPAROSCOPIC CHOLECYSTECTOMY Jeffrey L. Kim, M.D., Basher Atiquzzaman, M.D., Irwin Grosman, M.D., Adnan Khdair, M.D.* Long Island College Hospital, Brooklyn, NY. A 47 year-old woman with a past medical history significant for hepatitis C presented 11 days after undergoing a laparoscopic cholecystectomy. The patient complained of acute right upper quadrant abdominal pain associated with nausea and vomiting. The patient denied any history of constipation, diarrhea, bright red blood per rectum, melena, fever, or chills. The patient’s admission laboratory values were significant for total bilirubin of 2.0 mg/dL, alkaline phosphatase of 49 U/L, AST of 317 U/L and ALT of 141 U/L with WBC of 10.3 K/CMM. The physical exam was only significant for right upper quadrant tenderness. The patient was afebrile and clinically stable. She was empirically started on IV antibiotics. CT of the abdomen and pelvis revealed surgical clips from the cholecystectomy and a small residual postoperative collection in the gallbladder fossa with no evidence of intra or extrahepatic biliary ductal dilatation. Hospital day two revealed changes in the laboratory values with total bilirubin of 4.4 mg/dL, alkaline phosphatase of 245 U/L, AST of 127 U/L and ALT of 89U/L. The patient subsequently underwent a HIDA scan revealing findings consistent with intrahepatic cholestasis versus partial common bile duct obstruction. The patient underwent an ERCP which revealed extravasation of contrast in the region of the cystic duct with two small filling defects in the common bile duct representing stones. After biliary sphincterotomy, the stones were extracted and a 7 Fr 7cm long straight plastic stent was successfully placed in the common bile duct. The patient was continued on antibiotics. One month later the patient returned for an ERCP to remove the biliary stent and to assess for residual bile duct stones. A single 4mm stone was identified and removed with a balloon from the common bile duct. On completion, a cholangiogram revealed a communication between the cystic duct and the duodenum. This case represents an unusual complication of laparoscopic cholecystectomy. The cytic duct to duodenum fistula was originally unnoticed because of the concomitant cystic duct leak. However, once the leak resolved the fistula became apparent. 468 HODGKIN’S LYMPHOMA PRESENTING WITH HEARING LOSS, PARESTHESIAS AND INTESTINAL PSEUDOOBSTRUCTION Amy S. Oxentenko, M.D., Glenn L. Alexander, M.D.*, Adil E. Bharucha, M.D. Mayo Clinic-Rochester, Rochester, MN. Introduction: Intestinal pseudo-obstruction is a known paraneoplastic manifestation, generally associated with small cell lung cancer and less frequently with carcinoid and ovarian malignancies. We present a case of Hodgkin’s lymphoma presenting as a paraneoplastic syndrome with hearing loss, paresthesias and intestinal pseudo-obstruction. Case: A 57 year-old non-smoking male presented with sudden bilateral sensorineuronal hearing loss and abdominal pain. He had clinical and radiographic features of recurrent small bowel obstructions, but laparotomy was unremarkable. He then developed progressive paresthesias, erectile