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Endoscopic sonography and endoscopic resection of a duodenal carcinoid
S182
Abstracts
Discussion: Involvement of the gastrointestinal tract in Wegener’s granulomatosis is rare and usually occurs long after the onset of initial symptoms. Inflammatory ileocolitis with hemorrhage, cholecystitis and bowel infarction all have been reported. Acute colitis as a presenting feature of Wegener’s granulomatosis is very rare with only a few reports in the literature. This disease responds to cyclophosphamide, but relapse rate is common (50%), and intestinal complications may still occur after therapy begins.
542 AN UNUSUAL CAUSE OF PORTAL HYPERTENSION IN A 65 YEAR OLD WOMAN: CONGENITAL HEPATIC FIBROSIS Kevin T. White, M.D., Priya Grewal, M.D.* North Shore University Hospital, Manhasset, NY. A 65 year-old woman was referred for evaluation of cirrhosis. She had a history of abdominal pain one month prior. MRCP revealed a slightly dilated bile duct and she subsequently underwent an ERCP with a sphincterotomy and drainage of sludge. Incidentally noted during the ERCP were grade 1 esophageal varices. CT scan of the abdomen showed a normal sized liver, and splenomegaly with prominent varices in the splenic hilum. She denied any symptoms of chronic liver disease. Laboratory assessment includes platelets-114,000, INR-1.17, albumin-3.7, total bilirubin-0.8, AST-44, ALT-24, alkaline phosphatase-67, GGTP-25, AFP-13.1. Viral hepatitis markers, iron studies, AMA, ceruloplasmin and alpha-1-antitrypsin were normal. ANA was positive 1:160, ASMA 1:40 with an elevated IgG. A diagnosis of autoimmune hepatitis was entertained and a liver biopsy was performed. Liver biopsy revealed a diagnosis of congenital hepatic fibrosis. Congenital hepatic fibrosis (CHF) is a rare, autosomal recessive disease in which there is a persistence of the embryonic ductal plate and its biliary structures. It is often associated with autosomal recessive polycystic kidney disease, Caroli’s disease or choledochal cysts. There are four clinical forms of CHF: portal hypertensive, cholangitic, combined portal hypertensive-cholangitic, and latent. The portal hypertensive type usually presents as variceal bleeding in children or young adults. Liver size is often normal, as are liver chemistries, and splenomegaly with associated thrombocytopenia is frequent. The natural history is variable as the liver fibrosis may worsen, regress or remain unchanged. Complications of CHF include bleeding related to portal hypertension, repeated bouts of cholangitis and cholangiocarcinoma. Biopsy shows large bands of fibrous connective tissue of variable size and thickness, containing numerous ectatic bile duct structures. The remaining liver parenchyma is normal without nodular regeneration, as would be seen in cirrhosis. There is a reduction in size and number of portal vein branches, which may contribute to portal hypertension. Our case of an older adult with CHF, portal hypertensive type, without associated renal disease is extremely rare, with a limited number of cases having been reported in the literature.
543 ENDOSCOPIC SONOGRAPHY AND ENDOSCOPIC RESECTION OF A DUODENAL CARCINOID Ronald N. Wool, M.D., Michael J. Rensch, M.D.* Brooke Army Medical Center, San Antonio, TX. A 54 year-old man referred for recent melena was shown by endoscopy to have a 9mm polypoid lesion along the duodenal bulb anterior wall. Endoscopic biopsies confirmed the diagnosis of carcinoid tumor with rare mitoses. Subsequent endoscopic sonography revealed a 9mm homogenous, hypoechoic tumor, apparently originating from the mucosa. There was no evidence of submucosal or muscularis propria invasion. Surgical resection has traditionally been the standard treatment employed in foregut carcinoids, but there are several case reports of successful endoscopic resections over the past decade. Based on the small size of this patient’s tumor, shallow depth, and rare mitoses, endoscopic resection was pursued using a forward-viewing, diagnostic endoscope. Submucosal injection with epinephrine (1:10,000), was performed at the base of this pedunculated tumor
AJG – Vol. 98, No. 9, Suppl., 2003
to reduce potential bleeding, and the carcinoid was successfully removed using an electrocautery snare. There were no complications. 544 SELECTIVE ARTERIAL EMBOLIZATION FOR BLEEDING DUODENAL DIVERTICULUM: A CASE REPORT Ingrid M. Chacon, M.D., Vivek Raj, M.D.*, Dhiraj Yadav, M.D. University of Arkansas for Medical Sciences, Little Rock, AR. Duodenal diverticulum are found in 2–5% of Gastrointestinal Barium studies. They are a rare source of gastrointestinal bleeding. The initial treatment of bleeding duodenal diverticulum is endoscopic cauterization. Therapeutic options for massive bleeding not responding to endoscopic measures are controversial. Historically surgical excision of the diverticulum has been the most common approach. More recently, other less invasive modalities like laparoscopic diverticulotomy have been reported. Selective arterial embolization has been described only once in the literature. A 65 year-old Caucasian male was admitted with several episodes of melena. He was on chronic anticoagulation with warfarin for a mechanical Aortic Valve.Upon hospitalization his vital signs were stable, but he had a significant drop in his hemoglobin from baseline of 13.2 g/dL to 10.5g/dL. His INR was sub-therapeutic at 2.2. An initial EGD showed a large peri-ampullary diverticulum. A pool of blood was aspirated from the diverticulum but no definitive site of bleeding was identified inside the diverticulum nor in the stomach or esophagus. Colonoscopy performed the following day was negative. A repeat EGD the same day again showed a clot in the diverticulum. After aspiration of the clot active arterial oozing was seen at the base of the diverticulum. Aggressive endoscopic therapy with Epinephrine and Gold Probe was done with good immediate results. However, the patient continued to have melena requiring 4 Units of Packed Red Blood Cells over the next 2 days. In view of patient’s high risk for surgery, selective coil embolization of the gastroduodenal artery was performed. Patient was finally discharged in stable condition 2 days after the last procedure and anticoagulation was resumed. He remains symptomatic 4 months after the radiologic procedure. Massive bleeding from duodenal diverticulum bleed is rarely reported. In a patient with massive duodenal diverticular bleeding and unsuccessful endoscopic treatment, selective coil embolization of gastroduodenal artery should be considered. 545 GASTRIC OUTLET OBSTRUCTION BY GALLSTONEBOUVERET SYNDROME Franjo Vladic, M.D., Archana Verma, M.D., Gonzalo Pandolfi, M.D., Gijo Vettiankal, M.D., Frida Abrahamian, M.D., Bashar M. Attar, M.D., FACG* John H. Stroger Hospital of Cook County, Rush Medical College, Chicago, IL. Bouveret syndrome refers to gastric outlet obstruction from an impacted gallstone in the duodenal bulb. A cholecystoduodenal fistula is the underlying cause in most cases. Incidence of gallstone ileus occurs more often than gastric outlet obstruction.We present a case of a 79 year-old AfricanAmerican male with intractable vomiting for four days associated with left sided abdominal pain. CT scan showed gallstones and refluxed contrast from the GI tract into the gallbladder with space occupying mass in the duodenum. The esophagogastroduodenscopy revealed a large obstructing gallstone in the duodenal bulb with copious amount of fluid in the stomach. The second portion of duodenum could not be intubated. Thus, fluoroscopy with contrast was performed which confirmed the existence of a cholecystoduodenal fistula, gallstone in the duodenum, and gallstones in the gallbladder. The patient was taken to the operating room for correction of the underlying abnormalities. Bouveret Syndrome is a rare complication of cholelithiasis When treatment is delayed, it leads to high morbidity and mortality. In the past, imaging diagnosis relied primarily on conventional radiography and contrast-enhanced fluoroscopy. CT scan has subsequently been shown to be useful for this diagnosis. MRCP may be useful in select cases, when gallstones appear as isoattenuating relative to bile or fluid on
Abstracts
Discussion: Involvement of the gastrointestinal tract in Wegener’s granulomatosis is rare and usually occurs long after the onset of initial symptoms. Inflammatory ileocolitis with hemorrhage, cholecystitis and bowel infarction all have been reported. Acute colitis as a presenting feature of Wegener’s granulomatosis is very rare with only a few reports in the literature. This disease responds to cyclophosphamide, but relapse rate is common (50%), and intestinal complications may still occur after therapy begins.
542 AN UNUSUAL CAUSE OF PORTAL HYPERTENSION IN A 65 YEAR OLD WOMAN: CONGENITAL HEPATIC FIBROSIS Kevin T. White, M.D., Priya Grewal, M.D.* North Shore University Hospital, Manhasset, NY. A 65 year-old woman was referred for evaluation of cirrhosis. She had a history of abdominal pain one month prior. MRCP revealed a slightly dilated bile duct and she subsequently underwent an ERCP with a sphincterotomy and drainage of sludge. Incidentally noted during the ERCP were grade 1 esophageal varices. CT scan of the abdomen showed a normal sized liver, and splenomegaly with prominent varices in the splenic hilum. She denied any symptoms of chronic liver disease. Laboratory assessment includes platelets-114,000, INR-1.17, albumin-3.7, total bilirubin-0.8, AST-44, ALT-24, alkaline phosphatase-67, GGTP-25, AFP-13.1. Viral hepatitis markers, iron studies, AMA, ceruloplasmin and alpha-1-antitrypsin were normal. ANA was positive 1:160, ASMA 1:40 with an elevated IgG. A diagnosis of autoimmune hepatitis was entertained and a liver biopsy was performed. Liver biopsy revealed a diagnosis of congenital hepatic fibrosis. Congenital hepatic fibrosis (CHF) is a rare, autosomal recessive disease in which there is a persistence of the embryonic ductal plate and its biliary structures. It is often associated with autosomal recessive polycystic kidney disease, Caroli’s disease or choledochal cysts. There are four clinical forms of CHF: portal hypertensive, cholangitic, combined portal hypertensive-cholangitic, and latent. The portal hypertensive type usually presents as variceal bleeding in children or young adults. Liver size is often normal, as are liver chemistries, and splenomegaly with associated thrombocytopenia is frequent. The natural history is variable as the liver fibrosis may worsen, regress or remain unchanged. Complications of CHF include bleeding related to portal hypertension, repeated bouts of cholangitis and cholangiocarcinoma. Biopsy shows large bands of fibrous connective tissue of variable size and thickness, containing numerous ectatic bile duct structures. The remaining liver parenchyma is normal without nodular regeneration, as would be seen in cirrhosis. There is a reduction in size and number of portal vein branches, which may contribute to portal hypertension. Our case of an older adult with CHF, portal hypertensive type, without associated renal disease is extremely rare, with a limited number of cases having been reported in the literature.
543 ENDOSCOPIC SONOGRAPHY AND ENDOSCOPIC RESECTION OF A DUODENAL CARCINOID Ronald N. Wool, M.D., Michael J. Rensch, M.D.* Brooke Army Medical Center, San Antonio, TX. A 54 year-old man referred for recent melena was shown by endoscopy to have a 9mm polypoid lesion along the duodenal bulb anterior wall. Endoscopic biopsies confirmed the diagnosis of carcinoid tumor with rare mitoses. Subsequent endoscopic sonography revealed a 9mm homogenous, hypoechoic tumor, apparently originating from the mucosa. There was no evidence of submucosal or muscularis propria invasion. Surgical resection has traditionally been the standard treatment employed in foregut carcinoids, but there are several case reports of successful endoscopic resections over the past decade. Based on the small size of this patient’s tumor, shallow depth, and rare mitoses, endoscopic resection was pursued using a forward-viewing, diagnostic endoscope. Submucosal injection with epinephrine (1:10,000), was performed at the base of this pedunculated tumor
AJG – Vol. 98, No. 9, Suppl., 2003
to reduce potential bleeding, and the carcinoid was successfully removed using an electrocautery snare. There were no complications. 544 SELECTIVE ARTERIAL EMBOLIZATION FOR BLEEDING DUODENAL DIVERTICULUM: A CASE REPORT Ingrid M. Chacon, M.D., Vivek Raj, M.D.*, Dhiraj Yadav, M.D. University of Arkansas for Medical Sciences, Little Rock, AR. Duodenal diverticulum are found in 2–5% of Gastrointestinal Barium studies. They are a rare source of gastrointestinal bleeding. The initial treatment of bleeding duodenal diverticulum is endoscopic cauterization. Therapeutic options for massive bleeding not responding to endoscopic measures are controversial. Historically surgical excision of the diverticulum has been the most common approach. More recently, other less invasive modalities like laparoscopic diverticulotomy have been reported. Selective arterial embolization has been described only once in the literature. A 65 year-old Caucasian male was admitted with several episodes of melena. He was on chronic anticoagulation with warfarin for a mechanical Aortic Valve.Upon hospitalization his vital signs were stable, but he had a significant drop in his hemoglobin from baseline of 13.2 g/dL to 10.5g/dL. His INR was sub-therapeutic at 2.2. An initial EGD showed a large peri-ampullary diverticulum. A pool of blood was aspirated from the diverticulum but no definitive site of bleeding was identified inside the diverticulum nor in the stomach or esophagus. Colonoscopy performed the following day was negative. A repeat EGD the same day again showed a clot in the diverticulum. After aspiration of the clot active arterial oozing was seen at the base of the diverticulum. Aggressive endoscopic therapy with Epinephrine and Gold Probe was done with good immediate results. However, the patient continued to have melena requiring 4 Units of Packed Red Blood Cells over the next 2 days. In view of patient’s high risk for surgery, selective coil embolization of the gastroduodenal artery was performed. Patient was finally discharged in stable condition 2 days after the last procedure and anticoagulation was resumed. He remains symptomatic 4 months after the radiologic procedure. Massive bleeding from duodenal diverticulum bleed is rarely reported. In a patient with massive duodenal diverticular bleeding and unsuccessful endoscopic treatment, selective coil embolization of gastroduodenal artery should be considered. 545 GASTRIC OUTLET OBSTRUCTION BY GALLSTONEBOUVERET SYNDROME Franjo Vladic, M.D., Archana Verma, M.D., Gonzalo Pandolfi, M.D., Gijo Vettiankal, M.D., Frida Abrahamian, M.D., Bashar M. Attar, M.D., FACG* John H. Stroger Hospital of Cook County, Rush Medical College, Chicago, IL. Bouveret syndrome refers to gastric outlet obstruction from an impacted gallstone in the duodenal bulb. A cholecystoduodenal fistula is the underlying cause in most cases. Incidence of gallstone ileus occurs more often than gastric outlet obstruction.We present a case of a 79 year-old AfricanAmerican male with intractable vomiting for four days associated with left sided abdominal pain. CT scan showed gallstones and refluxed contrast from the GI tract into the gallbladder with space occupying mass in the duodenum. The esophagogastroduodenscopy revealed a large obstructing gallstone in the duodenal bulb with copious amount of fluid in the stomach. The second portion of duodenum could not be intubated. Thus, fluoroscopy with contrast was performed which confirmed the existence of a cholecystoduodenal fistula, gallstone in the duodenum, and gallstones in the gallbladder. The patient was taken to the operating room for correction of the underlying abnormalities. Bouveret Syndrome is a rare complication of cholelithiasis When treatment is delayed, it leads to high morbidity and mortality. In the past, imaging diagnosis relied primarily on conventional radiography and contrast-enhanced fluoroscopy. CT scan has subsequently been shown to be useful for this diagnosis. MRCP may be useful in select cases, when gallstones appear as isoattenuating relative to bile or fluid on