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Medial arcuate ligament syndrome
S168
Abstracts
tion of a submucosal lesion. We report a case of endoscopic polypectomy of a large Brunner’s gland hamartoma with aid from EUS. A 70 –year– old male presented with complaints of daily black bowel movements for one week. His medications included aspirin and celecoxib. Physical exam revealed dark brown, hemoccult positive stool. Hematocrit was 32.4%. Upper endoscopy identified an 8 cm submucosal, polypoid lesion with a long, thick stalk in the second duodenum (figure 1A). Biopsies revealed normal duodenal villous architecture. EUS showed that the polyp head was homogeneous and hyperechoic, and contained two cysts measuring 8 to 9 mm in diameter. The underlying duodenal muscularis propria was not involved and the stalk did not contain any visible vessels. Endoscopic polypectomy was then performed. A detachable endoloop was maneuvered around the polyp head and tightened around the stalk close to its base. A snare was then used to capture the polyp on the stalk, 5 mm distal to the endoloop’s position (figure 1B). Electrocautery was then applied with successful removal of the polyp (figure 1C). The polyp was then retrieved with a stone basket. There were no immediate or delayed bleeding complications. Histologically, the polyp was composed of densely packed lobules of Brunner’s glands lined by normal duodenal mucosa, consistent with a Brunner gland hamartoma (figure 1D).
AJG – Vol. 97, No. 9, Suppl., 2002
emia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. We report a case of a young woman who presented with a history of intermittent postprandial abdominal pain without weight loss. A 30 –year– old white woman presented with intermittent episodes of epigastric abdominal pain of two years’ duration. The pain was worsened by eating and was sharp, non–radiating in nature. These episodes occurred every 2 months. The pain improved by curling up in a fetal position or by taking morphine and increased in intensity with attempting to lie flat. She denied any nausea, diarrhea, constipation, bright red bleeding per rectum or dark tarry stools. She had visited the ER at least 5 times in the past because of the abdominal pain but all tests, including computed tomographic scan of abdomen, MRI and upper GI series, had been unremarkable. She had never had an EGD or colonoscopy. Her past medical history was otherwise unremarkable. There was no family history of liver disease, inflammatory bowel disease, or cancer. Physical examination revealed a pleasant female in no obvious distress. Her vitals signs were stable; heart and lung examination were normal. Abdominal examination revealed mild distention with an epigastric bruit on auscultation. Rectal exam was normal and Heme occult testing was negative. Plain abdominal radiograph showed no pathology. A duplex ultrasound of abdominal vessels was performed which revealed extremely elevated systolic velocity at the celiac axis. An abdominal lateral aortogram revealed 60 % stenosis of the celiac axis with post–stenotic dilatation. She underwent surgical resection of the median arcuate ligament and made an uneventful recovery. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament. Treatment can often be limited to longitudinal incision of the ligament; reconstructive procedures of the celiac artery are sometimes necessary.
511 OGILVIE’S SYNDROME ASSOCIATED WITH CORYNEBACTERIUM JEIKEIUM INDUCED SEPSIS IN A LEUKEMIC PATIENT Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecicut, Farmington, CT.
Endoscopic resection of Brunner’s gland hamartomas has been previously reported and may be complicated by bleeding. EUS helps to determine the appropriateness of endoscopic resection and the use of a disposable endoloop prior to snare electrocautery may minimize potential bleeding complications. EUS– guided endoscopic polypectomy may be an acceptable alternative to surgery for large submucosal polypoid lesions. 510 MEDIAL ARCUATE LIGAMENT SYNDROME Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecticut, Farmington, CT. Conclusions: Medial arcuate ligament syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with extrinsic compression by fibrous diaphragmatic bands or sympathetic neural fibers of the celiac axis near its takeoff from the aorta. Symptoms of mesenteric isch-
Conclusions: Acute colonic pseudo– obstruction is a motility disorder characterized by massive colonic dilation in the absence of mechanical obstruction. Presented below is a case of acute colonic pseudo– obstruction caused by Corynebacterium jk septicemia. A 53–year– old white male presented to his doctor with worsening fatigue. On testing he was found to be leukopenic and thrombocytopenic prompting a bone marrow biopsy, which revealed Acute Myeloid Leukemia (42% bands). Cytogenetic studies confirmed the diagnosis. He was admitted to the Oncology service and started on chemotherapy. Initially, he tolerated chemotherapy well but two days later he spiked a temperature of 103° F. After obtaining blood and urine cultures, he was started empirically on ceftazidime. His cytopenia worsened to pancytopenia. Fluconazole, acyclovir, & GM–CSF were also initiated. Despite these interventions his condition worsened and he was transferred to the ICU. He was found to be tachycardiac (125 bpm), with very dry oral mucosa. His chest exam revealed bilateral crackles; heart examination revealed tachycardia. Abdominal exam was remarkable for diffusely decreased bowel sounds. He was intubated because of worsening shortness of breath, hypoxemia and acidosis. Chest x–ray revealed diffuse infilterates. He underwent an uneventful bronchoscopy. Both his blood cultures and endotracheal washings grew Corynebacterium jeikeium. Vancomycin was added, but he kept spiking fevers. He developed tense distention of his abdomen, with decreased bowel sounds and tympany on percussion unrelieved by intermittent suction. An abdominal x–ray revealed increased air in the transverse colon and cecum without evidence of obstruction. Abdominal computed tomographic scan with contrast confirmed the results. Supportive treatment with IV fluids and colonic decom-
Abstracts
tion of a submucosal lesion. We report a case of endoscopic polypectomy of a large Brunner’s gland hamartoma with aid from EUS. A 70 –year– old male presented with complaints of daily black bowel movements for one week. His medications included aspirin and celecoxib. Physical exam revealed dark brown, hemoccult positive stool. Hematocrit was 32.4%. Upper endoscopy identified an 8 cm submucosal, polypoid lesion with a long, thick stalk in the second duodenum (figure 1A). Biopsies revealed normal duodenal villous architecture. EUS showed that the polyp head was homogeneous and hyperechoic, and contained two cysts measuring 8 to 9 mm in diameter. The underlying duodenal muscularis propria was not involved and the stalk did not contain any visible vessels. Endoscopic polypectomy was then performed. A detachable endoloop was maneuvered around the polyp head and tightened around the stalk close to its base. A snare was then used to capture the polyp on the stalk, 5 mm distal to the endoloop’s position (figure 1B). Electrocautery was then applied with successful removal of the polyp (figure 1C). The polyp was then retrieved with a stone basket. There were no immediate or delayed bleeding complications. Histologically, the polyp was composed of densely packed lobules of Brunner’s glands lined by normal duodenal mucosa, consistent with a Brunner gland hamartoma (figure 1D).
AJG – Vol. 97, No. 9, Suppl., 2002
emia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. We report a case of a young woman who presented with a history of intermittent postprandial abdominal pain without weight loss. A 30 –year– old white woman presented with intermittent episodes of epigastric abdominal pain of two years’ duration. The pain was worsened by eating and was sharp, non–radiating in nature. These episodes occurred every 2 months. The pain improved by curling up in a fetal position or by taking morphine and increased in intensity with attempting to lie flat. She denied any nausea, diarrhea, constipation, bright red bleeding per rectum or dark tarry stools. She had visited the ER at least 5 times in the past because of the abdominal pain but all tests, including computed tomographic scan of abdomen, MRI and upper GI series, had been unremarkable. She had never had an EGD or colonoscopy. Her past medical history was otherwise unremarkable. There was no family history of liver disease, inflammatory bowel disease, or cancer. Physical examination revealed a pleasant female in no obvious distress. Her vitals signs were stable; heart and lung examination were normal. Abdominal examination revealed mild distention with an epigastric bruit on auscultation. Rectal exam was normal and Heme occult testing was negative. Plain abdominal radiograph showed no pathology. A duplex ultrasound of abdominal vessels was performed which revealed extremely elevated systolic velocity at the celiac axis. An abdominal lateral aortogram revealed 60 % stenosis of the celiac axis with post–stenotic dilatation. She underwent surgical resection of the median arcuate ligament and made an uneventful recovery. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament. Treatment can often be limited to longitudinal incision of the ligament; reconstructive procedures of the celiac artery are sometimes necessary.
511 OGILVIE’S SYNDROME ASSOCIATED WITH CORYNEBACTERIUM JEIKEIUM INDUCED SEPSIS IN A LEUKEMIC PATIENT Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecicut, Farmington, CT.
Endoscopic resection of Brunner’s gland hamartomas has been previously reported and may be complicated by bleeding. EUS helps to determine the appropriateness of endoscopic resection and the use of a disposable endoloop prior to snare electrocautery may minimize potential bleeding complications. EUS– guided endoscopic polypectomy may be an acceptable alternative to surgery for large submucosal polypoid lesions. 510 MEDIAL ARCUATE LIGAMENT SYNDROME Mubashir A. Shah, M.D. and Khalid Aziz, M.D.*. Department of Gastroenterology/Hepatology, University of Connecticut, Farmington, CT. Conclusions: Medial arcuate ligament syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with extrinsic compression by fibrous diaphragmatic bands or sympathetic neural fibers of the celiac axis near its takeoff from the aorta. Symptoms of mesenteric isch-
Conclusions: Acute colonic pseudo– obstruction is a motility disorder characterized by massive colonic dilation in the absence of mechanical obstruction. Presented below is a case of acute colonic pseudo– obstruction caused by Corynebacterium jk septicemia. A 53–year– old white male presented to his doctor with worsening fatigue. On testing he was found to be leukopenic and thrombocytopenic prompting a bone marrow biopsy, which revealed Acute Myeloid Leukemia (42% bands). Cytogenetic studies confirmed the diagnosis. He was admitted to the Oncology service and started on chemotherapy. Initially, he tolerated chemotherapy well but two days later he spiked a temperature of 103° F. After obtaining blood and urine cultures, he was started empirically on ceftazidime. His cytopenia worsened to pancytopenia. Fluconazole, acyclovir, & GM–CSF were also initiated. Despite these interventions his condition worsened and he was transferred to the ICU. He was found to be tachycardiac (125 bpm), with very dry oral mucosa. His chest exam revealed bilateral crackles; heart examination revealed tachycardia. Abdominal exam was remarkable for diffusely decreased bowel sounds. He was intubated because of worsening shortness of breath, hypoxemia and acidosis. Chest x–ray revealed diffuse infilterates. He underwent an uneventful bronchoscopy. Both his blood cultures and endotracheal washings grew Corynebacterium jeikeium. Vancomycin was added, but he kept spiking fevers. He developed tense distention of his abdomen, with decreased bowel sounds and tympany on percussion unrelieved by intermittent suction. An abdominal x–ray revealed increased air in the transverse colon and cecum without evidence of obstruction. Abdominal computed tomographic scan with contrast confirmed the results. Supportive treatment with IV fluids and colonic decom-