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Rumination documented by combined multichannel intraluminal impedance and manometry—case report
AJG – September, Suppl., 2003
palpation in the right upper quadrant with mild distension and no rebound. Rectal examination revealed maroon stool. Laboratory data revealed hemoglobin 8.5 g/dL (normal 14.0) and ALT 82 U/L (normal ⬍72). Nasogastric lavage was clear and in vivo nuclear red blood cell scan was negative. CT scan of the abdomen revealed retroperitoneal air and fluid in proximity to the duodenum. Upper GI series confirmed a duodenal perforation with a fistula from the retroperitoneum to the hepatic flexure. Exploratory laparotomy confirmed the transected duodenum and perforated colon. He underwent resection of a portion of his duodenum with a roux-en-Y gastrojejunostomy reconstruction and right partial colectomy with anastomosis of the ileum and transverse colon. His required emergent surgery six weeks later for perforation of the gastrojejunal anastomosis, and died three weeks later from multisystem organ failure secondary to sepsis. Conclusion: RFA of retroperitoneal tumors can cause adjacent tissue necrosis, in our patient’s case duodenal and colonic perforation, and caution should be exercised when ablating tumors in the proximity of the gastrointestinal tract. 506 ETHYLENE GLYCOL TOXICITY ASSOCIATED WITH ISCHEMIA, PERFORATION, AND COLONIC OXALATE CRYSTAL DEPOSITION Timothy B. Gardner, M.D., Harold L. Manning, M.D., Andrew Beelen, M.D., Robert J. Cimis, M.D., Justin M.M. Cates, M.D., Lionel D. Lewis, M.D.* Dartmouth-Hitchcock Medical Center, Lebanon, NH. Ethylene glycol is a volatile alcohol whose accessibility and sweet taste have made it a frequent culprit in poisonings. Previously reported gastrointestinal side effects of ethylene glycol toxicity were limited to nausea, vomiting, hematemesis, cramping, non-specific abdominal pain and focal hemorrhages in the gastric mucosa. We report a case of ethylene glycol toxicity associated with the delayed sequelae of ischemic colitis, perforation and colonic oxalate crystal deposition. Case Report: Twelve weeks before the current admission, a 54 yr-old male presented with acute ethylene glycol intoxication. With intravenous ethanol and hemodialysis treatments his condition slowly improved. During this hospitalization, however, he complained of intermittent diarrhea and mild abdominal pain but was discharged 54 days after admission without work-up for these symptoms. He re-presented to the emergency room four weeks after discharge with a narcotic overdose and concomitant aspiration pneumonia. He improved with Nalaxone and broad-spectrum intravenous antibiotic treatment until the 6th hospital day, when he complained of intermittent, severe, crampy lower abdominal pain. An abdominal CT scan demonstrated a 6cm stricture along the splenic flexure of the colon with a dilated terminal ileum. Emergent colonoscopy showed a non-circumferential nearly obstructing mass with high grade stenosis located 50 cm from the anus. Laparotomy revealed a stricture in the splenic flexure and a small associated mass extending into the distal transverse colon accompanied by colonic ischemia and two transverse colon perforations. The patient underwent subtotal colectomy with ileosigmoid anastomosis. Pathologic examination revealed an inflammatory mass and microscopic exam of the ulcerated bowel revealed translucent, polyhedral crystals highly suggestive of oxalate deposition. Since his discharge, the patient has had no recurrence of his abdominal symptoms. Conclusion: Previously described gastrointestinal sequelae of ethylene glycol intoxication have been mostly constitutional. This case indicates that ethylene glycol poisoning can be associated with both acute and delayed ischemic injury to the colon. Clinicians should be aware of the potential for intestinal ischemia in the setting of ethylene glycol overdose. 507 TENSION PNEUMOTHORAX AS A COMPLICATION OF COLONOSCOPY Rajinder Parmar, M.D., Muhammad Abdullah, M.D., Mitchell Cappell, M.D.*, Irwin Grosman, M.D., Jose O. Mejia. Woodhull Medical Center, Brooklyn, NY.
Abstracts
S171
We present the case of a patient who developed acute respiratory failure due to tension pneumothorax precipitated by colonic perforation during diagnostic colonoscopy. Fewer than ten such cases have been described in the literature. A 76 year-old woman with a history of hypertension and uterine myomectomy presented for outpatient colonoscopy to evaluate fecal occult blood. Under intravenous sedation with fentanyl 100 mcg and versed 2 mg, colonoscopy was performed with little difficulty up to the cecum using a Pentax colonoscope. There was no evidence of diverticulosis or polyps. While the colonoscope was being withdrawn into the transverse colon, the patient passed flatus forcibly several times, started coughing and reported severe dyspnea. The colonoscope was quickly withdrawn. The patient was noted to be apneic with a drop in oxygen saturation to less than 60% and a heart rate of 30 to 40 per minute. The blood pressure was 100/60 mm Hg. Resuscitation was started using ACLS protocol. Atropine, naloxone and flumazenil were given intravenously. Endotracheal intubation was needed for respiratory support. High peak pressures were noted with intermittent oxygen desaturation to 50% on 100% FiO2. A stat chest x-ray after intubation revealed a right-sided tension pneumothorax and air under the diaphragm. The patient was transferred to the medical intensive care unit where emergent needle decompression of the pneumothorax was performed followed by chest tube insertion. Marked clinical improvement was noted. The patient underwent laparotomy that revealed a 1.5 cm perforation on the anti-mesenteric border of the mid-sigmoid colon. The diaphragm appeared intact. Repair of the perforation and primary closure of the laparotomy wound was done. The patient was extubated on the second postoperative day and the chest tube was removed on the third postoperative day. The patient recovered well postoperatively and was discharged home after ten days. Colon perforation can lead to gas tracking into the retroperitoneal space and the mediastinum causing pneumomediastinum, pneumothorax, pneumopericardium and subcutaneous emphysema. Pneumoperitoneum, pneumoretroperitoneum, pneumoscrotum, and pneumatosis cystoides coli can also occur as a result of colonic perforation. The very rare complication of tension pneumothorax should be kept in mind if a patient develops acute respiratory decompensation during or after colonoscopy, especially if perforation is suspected. 508 RUMINATION DOCUMENTED BY COMBINED MULTICHANNEL INTRALUMINAL IMPEDANCE AND MANOMETRY—CASE REPORT Radu Tutuian, M.D., Donald O. Castell, M.D., M.A.C.G.* Medical University of South Carolina, Charleston, SC. The clinical diagnosis of rumination is established from patient’s history of frequent regurgitation of stomach content into the mouth predominantly in the post-prandial period. Once the food buffered intragastric acidity returns to low pH values ruminators usually stop this involuntary learned behavior due to the unpleasant taste of acid refluxate. To date no clinical test has been established to demonstrate this phenomenon and its mechanism. Clinical presentation: The case is a 26 year-old male complaining of long history of frequent regurgitation and re-swallowing (approximately every minute) especially in the post-prandial periods that decreased in frequency and intensity 2-hours after meals. Upper endoscopy, esophageal manometry, pH testing were normal. On several occasions his supervisor sent him home from his job in the steel factory as he could not keep the regurgitated material in his mouth and was vomiting at the work place. Combined MII-EM testing for rumination: A 9-channel combined MII-EM probe was placed transnasally with the distal pressure sensor in the stomach and pressure sensors and impedance measuring segments in the LES and at 5cm intervals in the esophageal body. The patient was monitored during one post-prandial hour and asked to indicate whenever he felt the regurgitation reaching his mouth. During the 1-hour post-prandial testing period all 31 episodes or regurgitation noted by the patient were preceded by an increase in intragastric pressure, a retrograde bolus appearance in the esophagus followed by at least one clearing swallow. Event sequence is presented in the figure below and considered suggestive for rumination.
S172
Abstracts
Clinical course: One week after this test the patient called asking for a note stating that he could return to part-time, light work and another week later asked for another note stating that he can return to full-time work. He admitted still having some regurgitation but was able to control it. Combined MII-EM should be considered for documenting and assisting behavioral therapy in patients with rumination. 509 ALL “POST-PRANDIAL PRESYNCOPE” IS NOT DUMPING SYNDROME–AN INTERESTING CASE OF DEGLUTITION SYNCOPE Jonathan Gonenne, M.D., Thomas Mangan, M.D.* Mayo Clinic, Rochester, MN. Case Presentation: An 81 year-old male presented with dizziness and nausea brought on immediately with eating or drinking small amounts. He felt as if he was going to “pass out,” and a recent episode culminated with a syncopal spell requiring hospital admission. His symptoms had not responded to a “dumping diet.” The local physician was specifically concerned about dumping syndrome and referred him for further investigation. Physical exam was remarkable for orthostasis. Our evaluation included normal vestibular evaluation, MRI brain, ECG, echo, and 24 Holter monitor (during which he experienced symptoms). An autonomic reflex screen with tilt table testing was performed, during which he was instructed to drink water. This showed evidence of cardiovagal and adrenergic impairment, with a 60-mmHg blood pressure drop induced by drinking. The patient was diagnosed with deglutition syncope and orthostatic hypotension. Recommendations included avoidance of cold drinks, never drinking while standing or driving, and to wear tight compressive stockings. His presyncopal symptoms have resolved following these recommendations. Discussion: Deglutition syncope is a dysautonomic syndrome associated with intense vagal afferent activation due to esophageal stimulation. It is thought these pathways are mediated through local mechanoreceptors in the esophagus. Stimuli trigger sympathetic inhibition with vagal efferent activation, which in turn may cause peripheral vasodilatation, bradycardia and/or hypotension. As a result, cerebral hypoperfusion and syncope occurs. Cold beverages have been noted to induce deglutition syncope. In addition, achalasia and esophageal cancer may predispose patients to this swallowing reflex. In diagnosing this syndrome, it is crucial to obtain an accurate history. ECG and blood pressure monitoring/tilt table testing while the patient swallows ice water may then reveal bradycardia or profound drops in blood pressure. Avoiding aggravating stimuli or in refractory cases, cardiac pacemaker placement treats the syndrome. 510 A “HIDDEN TREASURE” CAUSING MICROCYTIC HYPOCHROMIC ANEMIA Luis J. Lopez, M.D., Charmaine Perez, M.D., Carlos Ramos, M.D., Maria I. Dueno, M.D., Doris H. Toro, M.D.* San Juan VA Medical Center, San Juan, Puerto Rico.
AJG – Vol. 98, No. 9, Suppl., 2003
A 62 years old man with history of schizophrenia was admitted with symptomatic microcytic hypochromic anemia associated to a mild vague abdominal discomfort. Physical exam disclosed a non-tender, soft and depressible abdomen with an associated irregular fullness in the left lower quadrant. Initial work up revealed hemoglobin of 4 g/dl without obvious evidence of gastrointestinal bleeding. An abdominal x-ray showed a conglomerate of multiple radiopaque foreign bodies in the lower abdomen that measured in aggregate 19 cm ⫻ 19.5 cm.These foreign bodies were presumed to be localized in an inferiorly displaced stomach. Upon confronting the patient, he stated that he had been “hiding a personal treasure” for the past 16 months. Upper endoscopy confirmed the presence of a large amount of coins, batteries, stones, screws, spark plugs and mechanical tool parts lying in and markedly displacing the gastric greater curvature. Severe ulcerative esophagitis, a dilated esophagus, and a large gastric ulceration were observed. A surgical gastrotomy was performed, removing approximately 3.5 kg of diverse foreign bodies. Our case is interesting not only because of the enormous amount of foreign bodies ingested but also for its clinical presentation. The formation of an intertwined mass in the stomach prevented the passage of the objects beyond the pylorus, thus avoiding expected serious complications such as perforation or obstruction, which may have resulted in an earlier clinical presentation. The longstanding damage to the gastric mucosa by the chronic ingestion of large foreign bodies resulted in the unusual presentation of severe microcytic hypochromic anemia observed in this case.
palpation in the right upper quadrant with mild distension and no rebound. Rectal examination revealed maroon stool. Laboratory data revealed hemoglobin 8.5 g/dL (normal 14.0) and ALT 82 U/L (normal ⬍72). Nasogastric lavage was clear and in vivo nuclear red blood cell scan was negative. CT scan of the abdomen revealed retroperitoneal air and fluid in proximity to the duodenum. Upper GI series confirmed a duodenal perforation with a fistula from the retroperitoneum to the hepatic flexure. Exploratory laparotomy confirmed the transected duodenum and perforated colon. He underwent resection of a portion of his duodenum with a roux-en-Y gastrojejunostomy reconstruction and right partial colectomy with anastomosis of the ileum and transverse colon. His required emergent surgery six weeks later for perforation of the gastrojejunal anastomosis, and died three weeks later from multisystem organ failure secondary to sepsis. Conclusion: RFA of retroperitoneal tumors can cause adjacent tissue necrosis, in our patient’s case duodenal and colonic perforation, and caution should be exercised when ablating tumors in the proximity of the gastrointestinal tract. 506 ETHYLENE GLYCOL TOXICITY ASSOCIATED WITH ISCHEMIA, PERFORATION, AND COLONIC OXALATE CRYSTAL DEPOSITION Timothy B. Gardner, M.D., Harold L. Manning, M.D., Andrew Beelen, M.D., Robert J. Cimis, M.D., Justin M.M. Cates, M.D., Lionel D. Lewis, M.D.* Dartmouth-Hitchcock Medical Center, Lebanon, NH. Ethylene glycol is a volatile alcohol whose accessibility and sweet taste have made it a frequent culprit in poisonings. Previously reported gastrointestinal side effects of ethylene glycol toxicity were limited to nausea, vomiting, hematemesis, cramping, non-specific abdominal pain and focal hemorrhages in the gastric mucosa. We report a case of ethylene glycol toxicity associated with the delayed sequelae of ischemic colitis, perforation and colonic oxalate crystal deposition. Case Report: Twelve weeks before the current admission, a 54 yr-old male presented with acute ethylene glycol intoxication. With intravenous ethanol and hemodialysis treatments his condition slowly improved. During this hospitalization, however, he complained of intermittent diarrhea and mild abdominal pain but was discharged 54 days after admission without work-up for these symptoms. He re-presented to the emergency room four weeks after discharge with a narcotic overdose and concomitant aspiration pneumonia. He improved with Nalaxone and broad-spectrum intravenous antibiotic treatment until the 6th hospital day, when he complained of intermittent, severe, crampy lower abdominal pain. An abdominal CT scan demonstrated a 6cm stricture along the splenic flexure of the colon with a dilated terminal ileum. Emergent colonoscopy showed a non-circumferential nearly obstructing mass with high grade stenosis located 50 cm from the anus. Laparotomy revealed a stricture in the splenic flexure and a small associated mass extending into the distal transverse colon accompanied by colonic ischemia and two transverse colon perforations. The patient underwent subtotal colectomy with ileosigmoid anastomosis. Pathologic examination revealed an inflammatory mass and microscopic exam of the ulcerated bowel revealed translucent, polyhedral crystals highly suggestive of oxalate deposition. Since his discharge, the patient has had no recurrence of his abdominal symptoms. Conclusion: Previously described gastrointestinal sequelae of ethylene glycol intoxication have been mostly constitutional. This case indicates that ethylene glycol poisoning can be associated with both acute and delayed ischemic injury to the colon. Clinicians should be aware of the potential for intestinal ischemia in the setting of ethylene glycol overdose. 507 TENSION PNEUMOTHORAX AS A COMPLICATION OF COLONOSCOPY Rajinder Parmar, M.D., Muhammad Abdullah, M.D., Mitchell Cappell, M.D.*, Irwin Grosman, M.D., Jose O. Mejia. Woodhull Medical Center, Brooklyn, NY.
Abstracts
S171
We present the case of a patient who developed acute respiratory failure due to tension pneumothorax precipitated by colonic perforation during diagnostic colonoscopy. Fewer than ten such cases have been described in the literature. A 76 year-old woman with a history of hypertension and uterine myomectomy presented for outpatient colonoscopy to evaluate fecal occult blood. Under intravenous sedation with fentanyl 100 mcg and versed 2 mg, colonoscopy was performed with little difficulty up to the cecum using a Pentax colonoscope. There was no evidence of diverticulosis or polyps. While the colonoscope was being withdrawn into the transverse colon, the patient passed flatus forcibly several times, started coughing and reported severe dyspnea. The colonoscope was quickly withdrawn. The patient was noted to be apneic with a drop in oxygen saturation to less than 60% and a heart rate of 30 to 40 per minute. The blood pressure was 100/60 mm Hg. Resuscitation was started using ACLS protocol. Atropine, naloxone and flumazenil were given intravenously. Endotracheal intubation was needed for respiratory support. High peak pressures were noted with intermittent oxygen desaturation to 50% on 100% FiO2. A stat chest x-ray after intubation revealed a right-sided tension pneumothorax and air under the diaphragm. The patient was transferred to the medical intensive care unit where emergent needle decompression of the pneumothorax was performed followed by chest tube insertion. Marked clinical improvement was noted. The patient underwent laparotomy that revealed a 1.5 cm perforation on the anti-mesenteric border of the mid-sigmoid colon. The diaphragm appeared intact. Repair of the perforation and primary closure of the laparotomy wound was done. The patient was extubated on the second postoperative day and the chest tube was removed on the third postoperative day. The patient recovered well postoperatively and was discharged home after ten days. Colon perforation can lead to gas tracking into the retroperitoneal space and the mediastinum causing pneumomediastinum, pneumothorax, pneumopericardium and subcutaneous emphysema. Pneumoperitoneum, pneumoretroperitoneum, pneumoscrotum, and pneumatosis cystoides coli can also occur as a result of colonic perforation. The very rare complication of tension pneumothorax should be kept in mind if a patient develops acute respiratory decompensation during or after colonoscopy, especially if perforation is suspected. 508 RUMINATION DOCUMENTED BY COMBINED MULTICHANNEL INTRALUMINAL IMPEDANCE AND MANOMETRY—CASE REPORT Radu Tutuian, M.D., Donald O. Castell, M.D., M.A.C.G.* Medical University of South Carolina, Charleston, SC. The clinical diagnosis of rumination is established from patient’s history of frequent regurgitation of stomach content into the mouth predominantly in the post-prandial period. Once the food buffered intragastric acidity returns to low pH values ruminators usually stop this involuntary learned behavior due to the unpleasant taste of acid refluxate. To date no clinical test has been established to demonstrate this phenomenon and its mechanism. Clinical presentation: The case is a 26 year-old male complaining of long history of frequent regurgitation and re-swallowing (approximately every minute) especially in the post-prandial periods that decreased in frequency and intensity 2-hours after meals. Upper endoscopy, esophageal manometry, pH testing were normal. On several occasions his supervisor sent him home from his job in the steel factory as he could not keep the regurgitated material in his mouth and was vomiting at the work place. Combined MII-EM testing for rumination: A 9-channel combined MII-EM probe was placed transnasally with the distal pressure sensor in the stomach and pressure sensors and impedance measuring segments in the LES and at 5cm intervals in the esophageal body. The patient was monitored during one post-prandial hour and asked to indicate whenever he felt the regurgitation reaching his mouth. During the 1-hour post-prandial testing period all 31 episodes or regurgitation noted by the patient were preceded by an increase in intragastric pressure, a retrograde bolus appearance in the esophagus followed by at least one clearing swallow. Event sequence is presented in the figure below and considered suggestive for rumination.
S172
Abstracts
Clinical course: One week after this test the patient called asking for a note stating that he could return to part-time, light work and another week later asked for another note stating that he can return to full-time work. He admitted still having some regurgitation but was able to control it. Combined MII-EM should be considered for documenting and assisting behavioral therapy in patients with rumination. 509 ALL “POST-PRANDIAL PRESYNCOPE” IS NOT DUMPING SYNDROME–AN INTERESTING CASE OF DEGLUTITION SYNCOPE Jonathan Gonenne, M.D., Thomas Mangan, M.D.* Mayo Clinic, Rochester, MN. Case Presentation: An 81 year-old male presented with dizziness and nausea brought on immediately with eating or drinking small amounts. He felt as if he was going to “pass out,” and a recent episode culminated with a syncopal spell requiring hospital admission. His symptoms had not responded to a “dumping diet.” The local physician was specifically concerned about dumping syndrome and referred him for further investigation. Physical exam was remarkable for orthostasis. Our evaluation included normal vestibular evaluation, MRI brain, ECG, echo, and 24 Holter monitor (during which he experienced symptoms). An autonomic reflex screen with tilt table testing was performed, during which he was instructed to drink water. This showed evidence of cardiovagal and adrenergic impairment, with a 60-mmHg blood pressure drop induced by drinking. The patient was diagnosed with deglutition syncope and orthostatic hypotension. Recommendations included avoidance of cold drinks, never drinking while standing or driving, and to wear tight compressive stockings. His presyncopal symptoms have resolved following these recommendations. Discussion: Deglutition syncope is a dysautonomic syndrome associated with intense vagal afferent activation due to esophageal stimulation. It is thought these pathways are mediated through local mechanoreceptors in the esophagus. Stimuli trigger sympathetic inhibition with vagal efferent activation, which in turn may cause peripheral vasodilatation, bradycardia and/or hypotension. As a result, cerebral hypoperfusion and syncope occurs. Cold beverages have been noted to induce deglutition syncope. In addition, achalasia and esophageal cancer may predispose patients to this swallowing reflex. In diagnosing this syndrome, it is crucial to obtain an accurate history. ECG and blood pressure monitoring/tilt table testing while the patient swallows ice water may then reveal bradycardia or profound drops in blood pressure. Avoiding aggravating stimuli or in refractory cases, cardiac pacemaker placement treats the syndrome. 510 A “HIDDEN TREASURE” CAUSING MICROCYTIC HYPOCHROMIC ANEMIA Luis J. Lopez, M.D., Charmaine Perez, M.D., Carlos Ramos, M.D., Maria I. Dueno, M.D., Doris H. Toro, M.D.* San Juan VA Medical Center, San Juan, Puerto Rico.
AJG – Vol. 98, No. 9, Suppl., 2003
A 62 years old man with history of schizophrenia was admitted with symptomatic microcytic hypochromic anemia associated to a mild vague abdominal discomfort. Physical exam disclosed a non-tender, soft and depressible abdomen with an associated irregular fullness in the left lower quadrant. Initial work up revealed hemoglobin of 4 g/dl without obvious evidence of gastrointestinal bleeding. An abdominal x-ray showed a conglomerate of multiple radiopaque foreign bodies in the lower abdomen that measured in aggregate 19 cm ⫻ 19.5 cm.These foreign bodies were presumed to be localized in an inferiorly displaced stomach. Upon confronting the patient, he stated that he had been “hiding a personal treasure” for the past 16 months. Upper endoscopy confirmed the presence of a large amount of coins, batteries, stones, screws, spark plugs and mechanical tool parts lying in and markedly displacing the gastric greater curvature. Severe ulcerative esophagitis, a dilated esophagus, and a large gastric ulceration were observed. A surgical gastrotomy was performed, removing approximately 3.5 kg of diverse foreign bodies. Our case is interesting not only because of the enormous amount of foreign bodies ingested but also for its clinical presentation. The formation of an intertwined mass in the stomach prevented the passage of the objects beyond the pylorus, thus avoiding expected serious complications such as perforation or obstruction, which may have resulted in an earlier clinical presentation. The longstanding damage to the gastric mucosa by the chronic ingestion of large foreign bodies resulted in the unusual presentation of severe microcytic hypochromic anemia observed in this case.