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Recurrent portosystemic encephalopathy despite medical therapy
S202
Abstracts
AJG – Vol. 98, No. 9, Suppl., 2003
of the liver with smaller satellite areas of low attenuation scattered throughout the more anterior aspect of the right lobe highly suggestive of hepatic infarction. Steroids and heparin were started. Additional labs included a positive lupus anticoagulant and an elevated anticardiolipin IgM antibody. She was discharged home on warfarin after attaining therapeutic INR levels. Follow-up CT scan done a month later showed resolution of the infarction. Discussion: The liver is a very vascular organ, with a dual blood supply from both hepatic and portal circulation. As such, hepatic infarction is rare. Patients diagnosed with the antiphospholipid syndrome are at increased risk for thromboembolic phenomena, both in the venous and arterial systems thus requiring long term anticoagulation. Antiphospholipid syndrome is a rare cause of hepatic infarction. As illustrated in this case, this syndrome should be entertained in the differential diagnosis of hepatic infarction.
607 RECURRENT PORTOSYSTEMIC ENCEPHALOPATHY DESPITE MEDICAL THERAPY Christian M. Mendez, M.D.*, Luis S. Marsano, M.D., Craig J. McClain, M.D., Aronson Brian, M.D. University of Louisville School of Medicine, Louisville, KY. A 60 year-old white male presents with a 2 month history of recurrent episodes of innapropiate behavior and disorientation. Past medical history included ulcerative colitis in remission and abnormal liver tests. An ERCP and percutaneous liver biopsy were performed as part of the work up for abnormal liver tests. ERCP showed sclerosis of the secondary and tertiary biliary ducts and no strictures. The liver biopsy showed mild portal fibrosis and positive PAS staining consistent with alpha 1 antitrypsin deficiency. Phenotype PiMZ. Physical exam revealed an obese male with asterixis and no stigmata of chronic liver disease. Work-up performed showed mild anemia, normal platelet count, ALT 156, AST 116, total bilirrubin 2.3, albumin 4.1, PT 11, INR 1.0. Ammonia level was elevated in 95. HCV and HBV serologies were negative. CSF exam and CT and MRI of the head were normal. Patient had received treatment for hepatic encephalopathy with metronidazol/lactulose with recurrence of symptoms. Further work-up included a hepatic doppler ultrasound that was normal and an arteriovenous phase CT of the abdomen that showed an intrahepatic arteriovenous shunt located in the right hepatic lobe. A mesenteric angiography did confirm the diagnosis and allowed the successful embolization and closure of the shunt using steel coils. Resolution of the symptoms was noted and there were no more episodes of confusion during follow-up. Learning points: recurrent episodes of encephalopathy despite medical therapy and no precipitating factors may be secondary to portosystemic shunts; and vascular complications of liver biopsy are rare events and are amenable to angiographic therapy.
608 MASSIVE GASTRIC BLEEDING AS INITIAL PRESENTATION OF PANCREATIC CANCER Ziad Salem, M.D., Walid Baddoura, M.D., Michael Martino, M.D., Ralph Demaio, M.D.*. Seton Hall University School of Medical Education, South Orange, NJ and Saint Joseph’s Regional Medical Center, Paterson, NJ. Introduction: Neoplasm as a cause of massive upper gastrointestinal bleeding is uncommon. It is mostly caused by gastric cancer; it is also well established that pancreatic cancer can directly invade the duodenum and present as bleeding. Case Report: A 79 year-old man with history of coronary artery bypass, congestive heart failure, hypertriglyceridemia, cardiovascular accident and prostate cancer was hospitalized with peri-umbilical pain, lightheadedness and two episodes of melena. He denied back pain or weight loss. His medications included metoprolol, furosemide and gemfibrozil. His physical examination was only remarkable for mid-abdominal tenderness. Nasogastric tube revealed a coffee-ground return. Laboratory findings on admission were significant for Hgb 9.1 with an MCV of 96. Upper endoscopy showed a large amount of coffee-ground material and pre-pyloric erosions with no demonstrable active bleeding site; the proximal duodenum was clear. The patient was treated with a proton pump inhibitor for presumptive ulcer disease. Due to a two-gram drop in Hgb, a repeat endoscopic examination was performed; frank bleeding was noted in the fundic area which could not be controlled. This prompted an emergency laparotomy which showed a pancreatic mass invading the proximal stomach wall; bleeding vessels were ligated as the tumor was found to be unresectable. Pathological analysis revealed a well differentiated mucin-producing pancreatic adenocarcinoma with metastasis to the small bowel mesentery. The post operative course was complicated by a transient coagulopathy and a change in mental status. Palliative therapy was subsequently initiated. Conclusion: Although pancreatic cancer is known to impinge on adjacent structures such as the duodenum and the stomach, it seldom presents with active upper gastrointestinal bleeding; massive gastric bleeding is exceedingly rare. Our case illustrates such a rare presentation of locally invasive pancreatic cancer.
609 DOUBLE DUCT SIGN DUE TO PANCREATIC LYMPHOMA IN AIDS Joanne M. Silvia, Graham Gardner, M.D., Samir A. Shah, M.D., FACG, Edward R. Feller, M.D., FACG*. Brown Medical School, Providence, RI and Beth Israel Deaconess Medical Center, Boston, MA. Pancreatic lymphoma is a rare cause of biliary obstruction. We report a case of obstructive jaundice due to large-cell, non-Hodgkin’s lymphoma to alert
Abstracts
AJG – Vol. 98, No. 9, Suppl., 2003
of the liver with smaller satellite areas of low attenuation scattered throughout the more anterior aspect of the right lobe highly suggestive of hepatic infarction. Steroids and heparin were started. Additional labs included a positive lupus anticoagulant and an elevated anticardiolipin IgM antibody. She was discharged home on warfarin after attaining therapeutic INR levels. Follow-up CT scan done a month later showed resolution of the infarction. Discussion: The liver is a very vascular organ, with a dual blood supply from both hepatic and portal circulation. As such, hepatic infarction is rare. Patients diagnosed with the antiphospholipid syndrome are at increased risk for thromboembolic phenomena, both in the venous and arterial systems thus requiring long term anticoagulation. Antiphospholipid syndrome is a rare cause of hepatic infarction. As illustrated in this case, this syndrome should be entertained in the differential diagnosis of hepatic infarction.
607 RECURRENT PORTOSYSTEMIC ENCEPHALOPATHY DESPITE MEDICAL THERAPY Christian M. Mendez, M.D.*, Luis S. Marsano, M.D., Craig J. McClain, M.D., Aronson Brian, M.D. University of Louisville School of Medicine, Louisville, KY. A 60 year-old white male presents with a 2 month history of recurrent episodes of innapropiate behavior and disorientation. Past medical history included ulcerative colitis in remission and abnormal liver tests. An ERCP and percutaneous liver biopsy were performed as part of the work up for abnormal liver tests. ERCP showed sclerosis of the secondary and tertiary biliary ducts and no strictures. The liver biopsy showed mild portal fibrosis and positive PAS staining consistent with alpha 1 antitrypsin deficiency. Phenotype PiMZ. Physical exam revealed an obese male with asterixis and no stigmata of chronic liver disease. Work-up performed showed mild anemia, normal platelet count, ALT 156, AST 116, total bilirrubin 2.3, albumin 4.1, PT 11, INR 1.0. Ammonia level was elevated in 95. HCV and HBV serologies were negative. CSF exam and CT and MRI of the head were normal. Patient had received treatment for hepatic encephalopathy with metronidazol/lactulose with recurrence of symptoms. Further work-up included a hepatic doppler ultrasound that was normal and an arteriovenous phase CT of the abdomen that showed an intrahepatic arteriovenous shunt located in the right hepatic lobe. A mesenteric angiography did confirm the diagnosis and allowed the successful embolization and closure of the shunt using steel coils. Resolution of the symptoms was noted and there were no more episodes of confusion during follow-up. Learning points: recurrent episodes of encephalopathy despite medical therapy and no precipitating factors may be secondary to portosystemic shunts; and vascular complications of liver biopsy are rare events and are amenable to angiographic therapy.
608 MASSIVE GASTRIC BLEEDING AS INITIAL PRESENTATION OF PANCREATIC CANCER Ziad Salem, M.D., Walid Baddoura, M.D., Michael Martino, M.D., Ralph Demaio, M.D.*. Seton Hall University School of Medical Education, South Orange, NJ and Saint Joseph’s Regional Medical Center, Paterson, NJ. Introduction: Neoplasm as a cause of massive upper gastrointestinal bleeding is uncommon. It is mostly caused by gastric cancer; it is also well established that pancreatic cancer can directly invade the duodenum and present as bleeding. Case Report: A 79 year-old man with history of coronary artery bypass, congestive heart failure, hypertriglyceridemia, cardiovascular accident and prostate cancer was hospitalized with peri-umbilical pain, lightheadedness and two episodes of melena. He denied back pain or weight loss. His medications included metoprolol, furosemide and gemfibrozil. His physical examination was only remarkable for mid-abdominal tenderness. Nasogastric tube revealed a coffee-ground return. Laboratory findings on admission were significant for Hgb 9.1 with an MCV of 96. Upper endoscopy showed a large amount of coffee-ground material and pre-pyloric erosions with no demonstrable active bleeding site; the proximal duodenum was clear. The patient was treated with a proton pump inhibitor for presumptive ulcer disease. Due to a two-gram drop in Hgb, a repeat endoscopic examination was performed; frank bleeding was noted in the fundic area which could not be controlled. This prompted an emergency laparotomy which showed a pancreatic mass invading the proximal stomach wall; bleeding vessels were ligated as the tumor was found to be unresectable. Pathological analysis revealed a well differentiated mucin-producing pancreatic adenocarcinoma with metastasis to the small bowel mesentery. The post operative course was complicated by a transient coagulopathy and a change in mental status. Palliative therapy was subsequently initiated. Conclusion: Although pancreatic cancer is known to impinge on adjacent structures such as the duodenum and the stomach, it seldom presents with active upper gastrointestinal bleeding; massive gastric bleeding is exceedingly rare. Our case illustrates such a rare presentation of locally invasive pancreatic cancer.
609 DOUBLE DUCT SIGN DUE TO PANCREATIC LYMPHOMA IN AIDS Joanne M. Silvia, Graham Gardner, M.D., Samir A. Shah, M.D., FACG, Edward R. Feller, M.D., FACG*. Brown Medical School, Providence, RI and Beth Israel Deaconess Medical Center, Boston, MA. Pancreatic lymphoma is a rare cause of biliary obstruction. We report a case of obstructive jaundice due to large-cell, non-Hodgkin’s lymphoma to alert