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Overt-obscure GI bleeding from an unusual small bowel lesion in a HIV patient previously treated for Kaposi’s sarcoma
S112
Abstracts
digestive system; a recorder which receives and records the transmitted data. After examination, data are transferred to a computer workstation for interpretation. Between January and May 2001 we evaluated with this system ten patients (7 men, 3 women, aged between 18 – 61 years) with obscure and recurrent bleeding in the gastrointestinal tract in whom previous upper and lower endoscopies were normal. Push enteroscopy was performed prior to capsule examination in all patients except in one. Two patients were diagnosed to have jejunal AVMs, only partly responsive to enteroscopic treatment. In the remaining patients push enteroscopy was normal. The bowel was prepared with a 24 hours fluid diet. An oral purge (polyethylene glycol-based solution and sulfate purge) was additionally given to six patients the day before of the capsule endoscopy. The patients swallowed the capsule after signing an informed consent form and under continuous medical supervision. Two gastroenterologists with experience of enteroscopy viewed all of the capsule videos. Results: The capsule was secreted naturally in all patients and no complications occurred throughout the study. The capsule remained in the stomach for an average of 64 minutes (8 –240). The average small bowel transit time was 204 minutes (125–320). The images of the small bowel obtained were of good quality, especially in patients who took an oral purge. A small bowel bleeding site was found in 7 of 10 patients: ileal ulcers (1), AVMs (1), varices (1), Crohn’s disease (1), active ileal bleeding (1), ileal lymphoma (1), traces of blood clots in the jejunum (1). In this last patient a subsequent push enteroscopy identified a jejunal tumor which was missed by the capsule. Capsule endoscopy found a distal source of bleeding in 5 of 7 patients with normal push enteroscopic exams. Findings at capsule endoscopy led to changes in medical regimen in 5 patients, and to surgical therapy in 2. Conclusions: The Given diagnostic imaging system is able to acquire satisfactory images and to identify pathologies in parts of the small bowel which are beyond the reach of conventional enteroscopy. The information provided was helpful in directing further diagnostic and treatment options in our patients with small bowel bleeding.
351 Endoscopic placement of feeding tubes in 856 consecutive cancer patients— our clinical experience Mohandas KM MD, DNB TM*, Yogesh M Shastri MD TM, Prasanna S Shah MD TM, Shaestha Mehta MD, DNB TM, Sandeep Gopal DNB, DNB TM, Rajesh Sainani MD TM and Vinay Dhir MD, DNB TM. 1Div. Digestive Diseases & Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharastra, India. Purpose: Enteral feeding is physiologiclly a safe means of nutritional support. Oral feeding may be difficult in cancer patients due to the distorted upper gastro-intestinal tract anatomy following surgery or due to obstruction caused by the tumor and often neccessitates tube feeding. For the same reasons we took up the study to determine the indications, technical success and safety of endoscopic feeding tube placement in a large consecutive sample of cancer patients Methods: Between January 1996 and December 2000,856 consecutive patients underwent 922 procedures for endoscopic placement of feeding tubes. The procedures attempted included naso-gastric tube[NGT] placement in 810,naso-enteral tube[NET]in 37 and percutaneous endoscopic gastrostomy [PEG]in 75 patients. The NGT and NJT were placed by passing a stiff shaft guide wire deep into the stomach or jejunum and by threading the poly vinyl chloride or polyurathane feeding tube over it using the Seldinger technique similar to placment of a naso biliary drain. Tight strictures were dilated with Savary-Gilliard dilators to facilitate passasge of 14Fr tubes. Modified techniques[K.M.Mohandas et al. Endoscopy 1995]were used in some patients with tight and tortuous strictures such as recurrent cancers after surgery or post chemoradiation. Fluoroscopy was used in 166 patients for safe positioning of guide wire and subsequent placement of feeding tubes. All PEG procedures were done by pull-through technique using either indigenously made PEG tubes or commercial tubes.
AJG – Vol. 96, No. 9, Suppl., 2001
Results: Technical success of placing a feeding tube was achieved initially in 824 patients[96.2%]. Out of 810 NGT placed,153 needed fluoroscopy.143 were successful[93.4%]. Of 37 NJT placed, 12 needed fluoroscopy.10 were successful[83%].[97%] and [88%] were successful without fluoroscopy respectively. In repeat fluoroscopy 94.9% and 100% was the success for NGT and NJT respectively. There were 42 complications,5 major complications requiring intervention and 37 minor requiring no intervention. There was 1 death due to tube placement. Immediate complications were seen in 11.4% with fluoroscopy and 2.5% of procedures without fluoroscopy. The success of tube placement done by fellows was similar to that done by the attending consultant. However, services of the attending consultants were required in more difficult tube placement Conclusions: Enteral access can be established in almost all cancer patients using a combination of techniques. The concomitant use of fluroscopy increases the success rate. Care is required to avoid an occasional serious complication.
352 Obesity and weight gain secondary to antipsychotic medications— A retrospective study Vinit K. Shah. M.D. NYS OMH BPC 425 Robinson St., Binghamton, NY. Purpose: Obesity is a threat to health and longevity and practices causing major weight gain deserve careful attention. Moreover, schizophrenic individuals appear to be at increased risk for DM II and Heart Disease. Historically, the EPS of antipsychotics outweighed any of the non EPS side effects. With the advent of newer “atypical” antipsychotics, EPS side effects are becoming less of a problem and weight gain and its associated comorbidities have become more prevalent. Methods: A retrospective study on two samples of patients on a ward was done. The patients were classified into two groups—A: those who gained weight during the previous year (14 pts.) and B: those who did not gain or lost weight (11 pts.). Further analysis was done based on type of antipsychotic meds, number of meds, gender and BMI. The results were confirmed by Null hypothesis and Mann-Whitney U rankings. Results/Conclusions: (1) 14/25 patients gained weight over a twelve month period. These patients were overweight by 24 – 68 lbs. and all had a BMI of more than 27; 71% had a BMI of ⬎30. (2) Weight gain was most likely associated with Clozapine, Olanzapine, Seroquel and Risperidone among the atypicals and Lithium, Depakote and Haldol among the older drugs. (3) Among 14 patients who gained weight, 65% were on three or more antipsychotics suggesting that additive use of these meds may cause more weight gain than individual drugs. (4) 71% of pts. who gained weight were female vs 73% of pts. who did not gain weight were male suggesting that female pts. are more likely to gain weight. (5) Pts. who started off with a higher BMI were more likely to gain weight. (6) Weight gain in these pts. is multi-factorial and the detailed mechanism is not clear. Factors such as Serotonin blockade, Dopamine (D2) and noradrenergic (Alpha I) blockade and influence on histamine (5HT1) sites has been implicated.
353 Overt-obscure GI bleeding from an unusual small bowel lesion in a HIV patient previously treated for Kaposi’s sarcoma Nadeem Ullah MD, David Lucas MD, Robert Yeh MD, Jamil Akhras MD, Murray Ehrinpreis MD* and Parasad Kulkarni MD, 1Internal medicine/GI, Wayne State University, Detroit, MI, United States. Purpose: Since the introduction of highly active anti reteroviral therapy (HAART), patients with HIV infection live longer and have less frequent GI menifestations of HIV infection or other associated conditions. However, new pathological lesions are emerging either as a result of treatment or because of prolonged survival. We present a patient with HIV on HAART who presented with overt-obscure GI bleeding from an unusual lesion of small bowel which has not been previously described.
AJG – September, Suppl., 2001
Methods: A 38 year old Caucasian male with HIV infection on antireteroviral therapy for last 5 years was admitted with intermittent maroon colored stools for 3 days and hemoglobin decrease from 15.5 g/dl to 6.5 g/dl. He was treated for Kaposi’s sarcoma involving skin and stomach 5 years ago with complete remission. He had two similar episodes of GI bleed 2 years ago but the GI work-up including upper and lower GI endoscopy, enteroscopy, small bowel barium x-ray, abdominal CT scan and Meckel’s scan failed to localize the bleeding site. His recent CD4 count was 340 and viral load ⬍1000. He never had any other opportunistic infections. On admission, he was orthostatic and pale otherwise rest of the examination was unremarkable. A repeat colonoscopy revealed maroon blood throughout the colon. Small bowel enteroscopy upto mid small bowel did not reveal any bleeding site. An RBC tagged scan showed evidence of active bleeding from small bowel but abdominal angiogram did not detect the bleeding site or abnormal vasculature. On laparotomy, ten areas of submucosal sponginess with bluish discoloration were noted in the distal ileum from about 3 feet proximal to the ileocecal valve down to 5 cm from it. About 3 feet of the involved ileum was resected. Patient had an uneventful recovery without recurrence of GI bleed. Histopathological examination of these lesions revealed band like zones of fibrosis near submucosal lymphoid tissue along with increased number of congested submucosal vessels of various calibers, focally extending through muscularis mucosa into lamina propria. Special stains for organisms (AFB & GMS) were negative. Precise etiology of this nonneoplastic fibroinflammatory process remains unclear. Conclusions: To our knowledge, this unique nonneoplastic fibroinflammatory lesion of the small bowel presenting as overt GI bleeding in a patient with HIV who was previously treated for KS has not been reported so far. Although the exact etiopathogenesis of this lesion remains conjectural, it may be related to immune status of the patient and/or secondary to the therapy.
354 Role of endoscopic ultrasound in definitive diagnosis and staging of lung adenocarcinoma localized to superior mediastinum Shiro Urayama*. 1Internal Medicine, University of California Davis, Sacramento, CA, United States. Purpose: We describe a particular role of endoscopic ultrasound in diagnosis and staging of mass located in superior mediastinal region. Methods: Retrospective case review of a patient presented as having a unknown primary adenocarcinoma with mediastinal lymphadenopathy. Results: A 67y/o male presented with complaints of refractory nausea, vomitting and significant weight loss of 3 months duration. Upper endoscopic evaluation revealed linear ulcerations in esophagus consistent with recurrent reflux symptoms, but no evidence of gross malignancy. CT scan evaluation of abdomen and chest showed paraesophageal & pretracheal/ subcarinal adenopathies without an evidence of primary tumor. Mediastinoscopic biopsies of the lymph nodes showed evidence of adenocarcinoma. The patient’s symptoms had significantly improved after high dose protonpump inhibitor treatment was initiated. We repeated upper endoscopy to evaluate for any evidence of primary upper GI tract malignancy. We also performed endoscopic ultrasonography during the second endoscopy to evaluate periluminal region. Mucosal examination showed healed esophageal ulcers and rest of the upper GI tract to second portions were normal. EUS, however, showed 3cm mass lesion in the left superior mediastinum located just above the aortic arch, adjacent to esophagus, vertebral body, and left pulmonary field. Several paraesophageal adenopathies were also noted. More importantly, left adrenal gland was identified transgastrically and showed a focally enlarged appearance. Pancreas was normal. EUSguided fine needle aspiration was completed of the superior mediastinal mass as well as the left adrenal gland. Both of these lesions showed adenocarcinoma and similar cellular appearance from the paratracheal lymph node lesion obtained at the time of mediastinoscopy. Thus, the final
Abstracts
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diagnosis and the staging was primary lung adenocarcinoma with stage IV with metastasis to left adrenal gland. Conclusions: This case illustrates the utility of endoscopic ultrasound in evaluation of mediastinal adenopathy with unknown primary malignancy as well as evaluation of superior mediastinal lesions in providing both diagnosis and staging of lung cancer. EUS provided not only the identification of primary malignancy but also accurately identified the advanced stage with positive metastatic cellular aspirate of the left adrenal gland during one session. 355 Software assisted detection of abnormalities of the GI tract for wireless capsule endoscopy Ofra Zinaty, M.Sc., Harold Jacob, M.D., Daphna Levy, M.Sc., Reuven Shreiber, M.D. and Arkady Glukhovsky, D.Sc.*. Yoqneam, Israel. Purpose: An ingestible wireless video capsule enables visualization of the small intestine beyond the reach of the endoscope. Detection of pathology is performed by a physician reviewing the recorded images. An algorithm for automatic detection of bleeding will assist the reviewer, thereby increasing the efficiency of the review process. Methods: A small bowel enteroscopy was performed using the Given® Diagnostic Imaging System. The blood detection algorithm automatically indicates suspicious images of the small bowel consistent with bleeding. The findings are presented to the reviewer as indicators on the time bar synchronized to the displayed video stream. The algorithm is based on detection of colorimetric abnormalities from an expected spectrum derived from spectral analysis of the video images. Each sample is compared to a reference representing blood, and to a reference representing healthy tissue of the patient. Each area of the image is assigned a value indicating the probability of the image to be a suspicious bleeding site. The probability indication function is based on a relative difference between the examined image sample and a reference sample of blood and healthy tissue. The reference of a healthy tissue is constructed using an adaptive approach. The blood detection algorithm is applied off-line, during the data processing phase. Results: The blood detection algorithm was verified by comparing results to 25 small bowel capsule enteroscopies that were interpreted by physicians. Based on this interpretation the following classification was made: 11 cases of bleeding, 6 cases of miscellaneous pathology, 4 cases with no diagnosed pathology, and 4 healthy volunteers. The automatic blood detection algorithm showed no false negative results with all known bleeding sites detected, and showed acceptably small amount of false positive results. Conclusions: The automatic detection algorithm may be of value in assissting the diagnostic procedure by prompting the physician to examine the sites of possible bleeding. This method may also be applicable to other pathologies. 356 “Atypical presentations” of celiac disease (CD) are the most common presentations Robert D. Zipser M.D., FACG1*, Sunil Patel, Donald W. Baisch2 and Elaine Monarch2. 1Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States; and 2Celiac Disease Foundation, Studio City, CA, United States. Purpose: The classic presentation of CD is childhood steatorrhea, weight loss and failure to thrive. In contrast, there is now increasing recognition that CD frequently has an adult onset without classic symptoms. Methods: To determine the most common presentations, officers of a large support group, Celiac Disease Foundation, did member surveys. All CD patients (n ⫽ 1032) had diagnosis confirmed by small bowel biopsy. Results: At diagnoses, the median age was 46 years (n ⫽ 968), and 14 patients were over age 80 years. Only 12% were diagnosed before the age of 10 years. The median body mass index (BMI) was 20 indicating that
Abstracts
digestive system; a recorder which receives and records the transmitted data. After examination, data are transferred to a computer workstation for interpretation. Between January and May 2001 we evaluated with this system ten patients (7 men, 3 women, aged between 18 – 61 years) with obscure and recurrent bleeding in the gastrointestinal tract in whom previous upper and lower endoscopies were normal. Push enteroscopy was performed prior to capsule examination in all patients except in one. Two patients were diagnosed to have jejunal AVMs, only partly responsive to enteroscopic treatment. In the remaining patients push enteroscopy was normal. The bowel was prepared with a 24 hours fluid diet. An oral purge (polyethylene glycol-based solution and sulfate purge) was additionally given to six patients the day before of the capsule endoscopy. The patients swallowed the capsule after signing an informed consent form and under continuous medical supervision. Two gastroenterologists with experience of enteroscopy viewed all of the capsule videos. Results: The capsule was secreted naturally in all patients and no complications occurred throughout the study. The capsule remained in the stomach for an average of 64 minutes (8 –240). The average small bowel transit time was 204 minutes (125–320). The images of the small bowel obtained were of good quality, especially in patients who took an oral purge. A small bowel bleeding site was found in 7 of 10 patients: ileal ulcers (1), AVMs (1), varices (1), Crohn’s disease (1), active ileal bleeding (1), ileal lymphoma (1), traces of blood clots in the jejunum (1). In this last patient a subsequent push enteroscopy identified a jejunal tumor which was missed by the capsule. Capsule endoscopy found a distal source of bleeding in 5 of 7 patients with normal push enteroscopic exams. Findings at capsule endoscopy led to changes in medical regimen in 5 patients, and to surgical therapy in 2. Conclusions: The Given diagnostic imaging system is able to acquire satisfactory images and to identify pathologies in parts of the small bowel which are beyond the reach of conventional enteroscopy. The information provided was helpful in directing further diagnostic and treatment options in our patients with small bowel bleeding.
351 Endoscopic placement of feeding tubes in 856 consecutive cancer patients— our clinical experience Mohandas KM MD, DNB TM*, Yogesh M Shastri MD TM, Prasanna S Shah MD TM, Shaestha Mehta MD, DNB TM, Sandeep Gopal DNB, DNB TM, Rajesh Sainani MD TM and Vinay Dhir MD, DNB TM. 1Div. Digestive Diseases & Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharastra, India. Purpose: Enteral feeding is physiologiclly a safe means of nutritional support. Oral feeding may be difficult in cancer patients due to the distorted upper gastro-intestinal tract anatomy following surgery or due to obstruction caused by the tumor and often neccessitates tube feeding. For the same reasons we took up the study to determine the indications, technical success and safety of endoscopic feeding tube placement in a large consecutive sample of cancer patients Methods: Between January 1996 and December 2000,856 consecutive patients underwent 922 procedures for endoscopic placement of feeding tubes. The procedures attempted included naso-gastric tube[NGT] placement in 810,naso-enteral tube[NET]in 37 and percutaneous endoscopic gastrostomy [PEG]in 75 patients. The NGT and NJT were placed by passing a stiff shaft guide wire deep into the stomach or jejunum and by threading the poly vinyl chloride or polyurathane feeding tube over it using the Seldinger technique similar to placment of a naso biliary drain. Tight strictures were dilated with Savary-Gilliard dilators to facilitate passasge of 14Fr tubes. Modified techniques[K.M.Mohandas et al. Endoscopy 1995]were used in some patients with tight and tortuous strictures such as recurrent cancers after surgery or post chemoradiation. Fluoroscopy was used in 166 patients for safe positioning of guide wire and subsequent placement of feeding tubes. All PEG procedures were done by pull-through technique using either indigenously made PEG tubes or commercial tubes.
AJG – Vol. 96, No. 9, Suppl., 2001
Results: Technical success of placing a feeding tube was achieved initially in 824 patients[96.2%]. Out of 810 NGT placed,153 needed fluoroscopy.143 were successful[93.4%]. Of 37 NJT placed, 12 needed fluoroscopy.10 were successful[83%].[97%] and [88%] were successful without fluoroscopy respectively. In repeat fluoroscopy 94.9% and 100% was the success for NGT and NJT respectively. There were 42 complications,5 major complications requiring intervention and 37 minor requiring no intervention. There was 1 death due to tube placement. Immediate complications were seen in 11.4% with fluoroscopy and 2.5% of procedures without fluoroscopy. The success of tube placement done by fellows was similar to that done by the attending consultant. However, services of the attending consultants were required in more difficult tube placement Conclusions: Enteral access can be established in almost all cancer patients using a combination of techniques. The concomitant use of fluroscopy increases the success rate. Care is required to avoid an occasional serious complication.
352 Obesity and weight gain secondary to antipsychotic medications— A retrospective study Vinit K. Shah. M.D. NYS OMH BPC 425 Robinson St., Binghamton, NY. Purpose: Obesity is a threat to health and longevity and practices causing major weight gain deserve careful attention. Moreover, schizophrenic individuals appear to be at increased risk for DM II and Heart Disease. Historically, the EPS of antipsychotics outweighed any of the non EPS side effects. With the advent of newer “atypical” antipsychotics, EPS side effects are becoming less of a problem and weight gain and its associated comorbidities have become more prevalent. Methods: A retrospective study on two samples of patients on a ward was done. The patients were classified into two groups—A: those who gained weight during the previous year (14 pts.) and B: those who did not gain or lost weight (11 pts.). Further analysis was done based on type of antipsychotic meds, number of meds, gender and BMI. The results were confirmed by Null hypothesis and Mann-Whitney U rankings. Results/Conclusions: (1) 14/25 patients gained weight over a twelve month period. These patients were overweight by 24 – 68 lbs. and all had a BMI of more than 27; 71% had a BMI of ⬎30. (2) Weight gain was most likely associated with Clozapine, Olanzapine, Seroquel and Risperidone among the atypicals and Lithium, Depakote and Haldol among the older drugs. (3) Among 14 patients who gained weight, 65% were on three or more antipsychotics suggesting that additive use of these meds may cause more weight gain than individual drugs. (4) 71% of pts. who gained weight were female vs 73% of pts. who did not gain weight were male suggesting that female pts. are more likely to gain weight. (5) Pts. who started off with a higher BMI were more likely to gain weight. (6) Weight gain in these pts. is multi-factorial and the detailed mechanism is not clear. Factors such as Serotonin blockade, Dopamine (D2) and noradrenergic (Alpha I) blockade and influence on histamine (5HT1) sites has been implicated.
353 Overt-obscure GI bleeding from an unusual small bowel lesion in a HIV patient previously treated for Kaposi’s sarcoma Nadeem Ullah MD, David Lucas MD, Robert Yeh MD, Jamil Akhras MD, Murray Ehrinpreis MD* and Parasad Kulkarni MD, 1Internal medicine/GI, Wayne State University, Detroit, MI, United States. Purpose: Since the introduction of highly active anti reteroviral therapy (HAART), patients with HIV infection live longer and have less frequent GI menifestations of HIV infection or other associated conditions. However, new pathological lesions are emerging either as a result of treatment or because of prolonged survival. We present a patient with HIV on HAART who presented with overt-obscure GI bleeding from an unusual lesion of small bowel which has not been previously described.
AJG – September, Suppl., 2001
Methods: A 38 year old Caucasian male with HIV infection on antireteroviral therapy for last 5 years was admitted with intermittent maroon colored stools for 3 days and hemoglobin decrease from 15.5 g/dl to 6.5 g/dl. He was treated for Kaposi’s sarcoma involving skin and stomach 5 years ago with complete remission. He had two similar episodes of GI bleed 2 years ago but the GI work-up including upper and lower GI endoscopy, enteroscopy, small bowel barium x-ray, abdominal CT scan and Meckel’s scan failed to localize the bleeding site. His recent CD4 count was 340 and viral load ⬍1000. He never had any other opportunistic infections. On admission, he was orthostatic and pale otherwise rest of the examination was unremarkable. A repeat colonoscopy revealed maroon blood throughout the colon. Small bowel enteroscopy upto mid small bowel did not reveal any bleeding site. An RBC tagged scan showed evidence of active bleeding from small bowel but abdominal angiogram did not detect the bleeding site or abnormal vasculature. On laparotomy, ten areas of submucosal sponginess with bluish discoloration were noted in the distal ileum from about 3 feet proximal to the ileocecal valve down to 5 cm from it. About 3 feet of the involved ileum was resected. Patient had an uneventful recovery without recurrence of GI bleed. Histopathological examination of these lesions revealed band like zones of fibrosis near submucosal lymphoid tissue along with increased number of congested submucosal vessels of various calibers, focally extending through muscularis mucosa into lamina propria. Special stains for organisms (AFB & GMS) were negative. Precise etiology of this nonneoplastic fibroinflammatory process remains unclear. Conclusions: To our knowledge, this unique nonneoplastic fibroinflammatory lesion of the small bowel presenting as overt GI bleeding in a patient with HIV who was previously treated for KS has not been reported so far. Although the exact etiopathogenesis of this lesion remains conjectural, it may be related to immune status of the patient and/or secondary to the therapy.
354 Role of endoscopic ultrasound in definitive diagnosis and staging of lung adenocarcinoma localized to superior mediastinum Shiro Urayama*. 1Internal Medicine, University of California Davis, Sacramento, CA, United States. Purpose: We describe a particular role of endoscopic ultrasound in diagnosis and staging of mass located in superior mediastinal region. Methods: Retrospective case review of a patient presented as having a unknown primary adenocarcinoma with mediastinal lymphadenopathy. Results: A 67y/o male presented with complaints of refractory nausea, vomitting and significant weight loss of 3 months duration. Upper endoscopic evaluation revealed linear ulcerations in esophagus consistent with recurrent reflux symptoms, but no evidence of gross malignancy. CT scan evaluation of abdomen and chest showed paraesophageal & pretracheal/ subcarinal adenopathies without an evidence of primary tumor. Mediastinoscopic biopsies of the lymph nodes showed evidence of adenocarcinoma. The patient’s symptoms had significantly improved after high dose protonpump inhibitor treatment was initiated. We repeated upper endoscopy to evaluate for any evidence of primary upper GI tract malignancy. We also performed endoscopic ultrasonography during the second endoscopy to evaluate periluminal region. Mucosal examination showed healed esophageal ulcers and rest of the upper GI tract to second portions were normal. EUS, however, showed 3cm mass lesion in the left superior mediastinum located just above the aortic arch, adjacent to esophagus, vertebral body, and left pulmonary field. Several paraesophageal adenopathies were also noted. More importantly, left adrenal gland was identified transgastrically and showed a focally enlarged appearance. Pancreas was normal. EUSguided fine needle aspiration was completed of the superior mediastinal mass as well as the left adrenal gland. Both of these lesions showed adenocarcinoma and similar cellular appearance from the paratracheal lymph node lesion obtained at the time of mediastinoscopy. Thus, the final
Abstracts
S113
diagnosis and the staging was primary lung adenocarcinoma with stage IV with metastasis to left adrenal gland. Conclusions: This case illustrates the utility of endoscopic ultrasound in evaluation of mediastinal adenopathy with unknown primary malignancy as well as evaluation of superior mediastinal lesions in providing both diagnosis and staging of lung cancer. EUS provided not only the identification of primary malignancy but also accurately identified the advanced stage with positive metastatic cellular aspirate of the left adrenal gland during one session. 355 Software assisted detection of abnormalities of the GI tract for wireless capsule endoscopy Ofra Zinaty, M.Sc., Harold Jacob, M.D., Daphna Levy, M.Sc., Reuven Shreiber, M.D. and Arkady Glukhovsky, D.Sc.*. Yoqneam, Israel. Purpose: An ingestible wireless video capsule enables visualization of the small intestine beyond the reach of the endoscope. Detection of pathology is performed by a physician reviewing the recorded images. An algorithm for automatic detection of bleeding will assist the reviewer, thereby increasing the efficiency of the review process. Methods: A small bowel enteroscopy was performed using the Given® Diagnostic Imaging System. The blood detection algorithm automatically indicates suspicious images of the small bowel consistent with bleeding. The findings are presented to the reviewer as indicators on the time bar synchronized to the displayed video stream. The algorithm is based on detection of colorimetric abnormalities from an expected spectrum derived from spectral analysis of the video images. Each sample is compared to a reference representing blood, and to a reference representing healthy tissue of the patient. Each area of the image is assigned a value indicating the probability of the image to be a suspicious bleeding site. The probability indication function is based on a relative difference between the examined image sample and a reference sample of blood and healthy tissue. The reference of a healthy tissue is constructed using an adaptive approach. The blood detection algorithm is applied off-line, during the data processing phase. Results: The blood detection algorithm was verified by comparing results to 25 small bowel capsule enteroscopies that were interpreted by physicians. Based on this interpretation the following classification was made: 11 cases of bleeding, 6 cases of miscellaneous pathology, 4 cases with no diagnosed pathology, and 4 healthy volunteers. The automatic blood detection algorithm showed no false negative results with all known bleeding sites detected, and showed acceptably small amount of false positive results. Conclusions: The automatic detection algorithm may be of value in assissting the diagnostic procedure by prompting the physician to examine the sites of possible bleeding. This method may also be applicable to other pathologies. 356 “Atypical presentations” of celiac disease (CD) are the most common presentations Robert D. Zipser M.D., FACG1*, Sunil Patel, Donald W. Baisch2 and Elaine Monarch2. 1Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States; and 2Celiac Disease Foundation, Studio City, CA, United States. Purpose: The classic presentation of CD is childhood steatorrhea, weight loss and failure to thrive. In contrast, there is now increasing recognition that CD frequently has an adult onset without classic symptoms. Methods: To determine the most common presentations, officers of a large support group, Celiac Disease Foundation, did member surveys. All CD patients (n ⫽ 1032) had diagnosis confirmed by small bowel biopsy. Results: At diagnoses, the median age was 46 years (n ⫽ 968), and 14 patients were over age 80 years. Only 12% were diagnosed before the age of 10 years. The median body mass index (BMI) was 20 indicating that