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Small bowel ileus following colonoscopy
AJG – September, Suppl., 2002
ciated colitis remain very uncommon. However, such episodes may be severe, possibly life threatening, and there may be a delay in establishing the correct diagnosis. A frail 74 –year old woman with Parkinson’s disease underwent open cholecystectomy at another hospital and was then transferred to this institution for rehabilitation prior to discharge locally. During the first hospitalization she received broad–spectrum antimicrobial therapy. At transfer she had slurred speech and right–sided limb weakness, followed by left– sided pleuritic chest pain and hypoxia thought to represent pneumonia. Further parenteral broad–spectrum anti–microbial therapy was given, and she was anti– coagulated with heparin. Generalised abdominal pain and increasing frequency of liquid, but non– bloody stools developed. Initial stool cultures were negative, in particular for Clostridium difficile (C. difficile) toxins A and B, but MRSA was cultured in large amounts from stool. Flexible sigmoidoscopy demonstrated mucosal edema and granularity, together with cnumerous adherent, pale yellow plaques throughout the left colon. Biopsies taken from multiple sites revealed changes consistent with pseudomembranous colitis. However, given the presence of such large amounts of MRSA in stool, and the absence of both C. difficile toxins, MRSA colitis was considered the working diagnosis. Existing treatment with metronidazole was supplemented with oral vancomycin 125mg, qds, and given for a total of 17 days. Recovery was slow but sustained; more than 30 months later she remains alive and without recurrence. Given that MRSA – associated colitis can occur in the same clinical setting as C. difficile colitis, and shares similar sigmoidoscopic and histologic features to that condition, a low threshold for consideration of this diagnosis should be retained. Oral vancomycin therapy appears both effective, and well tolerated. Furthermore, it can be started whilst waiting for stool culture and colonic biopsy results.
607 SMALL BOWEL ILEUS FOLLOWING COLONOSCOPY Deborah Bernasconi, Mark Gehring and Praveen K. Roy, M.D.*. Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA; Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA and Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA. Purpose: Small bowel ileus is a rare complication of colonoscopy. Less than 5 cases have been reported in the literature in the last two decades. Predisposing factors for this complication are not known. We report a patient who developed small bowel ileus following colonoscopy. Case Report: A 61–year– old male underwent colonoscopy for evaluation of heme–positve stools. He denied any gastrointestinal symptoms. His past medical history consisted of multiple sclerosis which was in remission. He had no prior history of abdominal surgery. On colonoscopy few small sessile polyps were seen and these were resected. Two hours after the procedure he had an episode of vomiting. The following day his vomiting worsened and he also complained of abdominal pain and abdominal distension. On examination he was afebrile and dehydrated. Abdominal examination revealed distended abdomen with absent bowel sounds and an empty rectum. Errect chest and plain radiographs showed no free air. Distended loops of small bowel were seen with no air in the colon. Abdominal CT scan revealed similar findings. Serum electrolytes were within normal limits. White blood cell count was normal. He was treated conservatively with nasogastric tube decompression and the small bowel ileus resolved over the next 7 days. Discussion: Small bowel ileus is a rare complication of gastrointestinal endoscopy. It has been reported following both upper and lower endoscopy. Many mechanisms have been susgested as contributing to small bowel ileus following colonoscopy. Reported factors include sympathetic overactivity casued by the high pressure required to distend the bowel wall. air insufflation through an incompetent ileo– cecal valve with distension and subsequent entrapment of the small bowel with adhesions. Our patient did not have any history suggestive of abdominal adhesions. Gastroenterologists should be aware of the possibility of small bowel
Abstracts
S199
ileus after colonoscopy and should consider this diagnosis in patients presenting with abdominal distension and vomiting after the procedure.
608 MECKEL’S DIVERTICULUM AS A SOURCE OF OBSCURE GI BLEEDING Stacie A. Friesen, M.D. and Darwin L. Conwell, M.D.*. Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH. Purpose: Meckel’s diverticulum is an uncommon congenital anomaly that usually remains asymptomatic in adults. We present a case of a Meckel’s diverticulum in a patient with a three–year history of chronic microcytic anemia. The patient is a 44 –year– old woman who began having symptoms of fatigue and abdominal pain in 1998. The pain was diffuse and crampy, occasionally exacerbated by meals. In addition, she was found to have a microcytic anemia and was given iron supplementation. The anemia persisted with hemoglobin levels as low as 7.4 gm/dL. In 2001 patient had heme positive stools which prompted an extensive evaluation including CT scan, upper and lower endoscopy, and push enteroscopy at an outside institution. No etiology for her anemia was found, and she continued to have heme positive stools. She was referred to our institution for work up of her chronic microcytic anemia and obscure GI bleeding. Past medical history was significant for hypertension. Past surgical history was unremarkable. Medications included hydroclorothiazide and verapamil, and she had no known drug allergies. Family history included lung cancer in grandmother and hypertension in mother. She she denied tobacco or alcohol use. On physical exam, patient was an obese female, well appearing. Pulse was 118 bpm and blood pressure was 133/84 mmHg. Cardiopulmonary exam was normal. Stool was hemoccult positive. CBC showed hemoglobin of 12 gm/dL and MCV of 74 fL. Ferritin was 3.5 ng/mL and TIBC 507 ug/dL. Transferrin saturation was 6%. Basic metabolic panel was normal. Due to the obscure nature of the GI bleeding, the patient underwent a small bowel enteroclysis. An ulcerated apple core lesion was seen 10 –15 cm from the terminal ileum. A primary small bowel neoplasm was suspected, and she was referred to surgery. At laparotomy an ulcerated Meckel’s diverticulum was found approximately 2 feet from the ileocecal valve with a small nodule at the base. The diverticulum was resected. Pathology confirmed a Meckel’s diverticulum consisting of small bowel mucosa with an ulcer and acute and chronic inflammation. No pancreatic or gastric mucosa was identified. The nodule was benign. At post–surgical follow up, the anemia had resolved. Meckel’s diverticulum is the most common congenital anomaly of the GI tract, but can be difficult to diagnose. Symptoms are rare in the adult, however in a young patient with otherwise unexplained occult GI bleeding, a Meckel’s diverticulum should be considered in the differential diagnosis.
609 MESO–ATRIAL SHUNT FOR BUDD–CHIARI SYNDROME (BCS) IN THE CONTEXT OF ANTIPHOSPHOLIPID SYNDROME (APS). A POSSIBLE SAFE AND GOOD OUTCOME RELATED TREATMENT. CASE REPORT Mario C. Pelaez–Luna, M.D., Aurora Loaeza–Del Castillo, M.D. and Marco A. Olivera, M.D.*. Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico. Background: BCS is a rare cause of liver disease, characterized by obstruction to hepatic venous outflow anywhere above the level of the hepatic venulae. Several etiologies have been implicated and recently APS has been considered as a major etiologic factor. Case Report: A 23 year– old man with a 2 year history of recurrent deep lower limbs vein thrombosis, developed sudden right upper abdominal
ciated colitis remain very uncommon. However, such episodes may be severe, possibly life threatening, and there may be a delay in establishing the correct diagnosis. A frail 74 –year old woman with Parkinson’s disease underwent open cholecystectomy at another hospital and was then transferred to this institution for rehabilitation prior to discharge locally. During the first hospitalization she received broad–spectrum antimicrobial therapy. At transfer she had slurred speech and right–sided limb weakness, followed by left– sided pleuritic chest pain and hypoxia thought to represent pneumonia. Further parenteral broad–spectrum anti–microbial therapy was given, and she was anti– coagulated with heparin. Generalised abdominal pain and increasing frequency of liquid, but non– bloody stools developed. Initial stool cultures were negative, in particular for Clostridium difficile (C. difficile) toxins A and B, but MRSA was cultured in large amounts from stool. Flexible sigmoidoscopy demonstrated mucosal edema and granularity, together with cnumerous adherent, pale yellow plaques throughout the left colon. Biopsies taken from multiple sites revealed changes consistent with pseudomembranous colitis. However, given the presence of such large amounts of MRSA in stool, and the absence of both C. difficile toxins, MRSA colitis was considered the working diagnosis. Existing treatment with metronidazole was supplemented with oral vancomycin 125mg, qds, and given for a total of 17 days. Recovery was slow but sustained; more than 30 months later she remains alive and without recurrence. Given that MRSA – associated colitis can occur in the same clinical setting as C. difficile colitis, and shares similar sigmoidoscopic and histologic features to that condition, a low threshold for consideration of this diagnosis should be retained. Oral vancomycin therapy appears both effective, and well tolerated. Furthermore, it can be started whilst waiting for stool culture and colonic biopsy results.
607 SMALL BOWEL ILEUS FOLLOWING COLONOSCOPY Deborah Bernasconi, Mark Gehring and Praveen K. Roy, M.D.*. Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA; Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA and Section of Gastroenterology, Jonathan Wainwright VA Medical Center, Walla Walla, WA. Purpose: Small bowel ileus is a rare complication of colonoscopy. Less than 5 cases have been reported in the literature in the last two decades. Predisposing factors for this complication are not known. We report a patient who developed small bowel ileus following colonoscopy. Case Report: A 61–year– old male underwent colonoscopy for evaluation of heme–positve stools. He denied any gastrointestinal symptoms. His past medical history consisted of multiple sclerosis which was in remission. He had no prior history of abdominal surgery. On colonoscopy few small sessile polyps were seen and these were resected. Two hours after the procedure he had an episode of vomiting. The following day his vomiting worsened and he also complained of abdominal pain and abdominal distension. On examination he was afebrile and dehydrated. Abdominal examination revealed distended abdomen with absent bowel sounds and an empty rectum. Errect chest and plain radiographs showed no free air. Distended loops of small bowel were seen with no air in the colon. Abdominal CT scan revealed similar findings. Serum electrolytes were within normal limits. White blood cell count was normal. He was treated conservatively with nasogastric tube decompression and the small bowel ileus resolved over the next 7 days. Discussion: Small bowel ileus is a rare complication of gastrointestinal endoscopy. It has been reported following both upper and lower endoscopy. Many mechanisms have been susgested as contributing to small bowel ileus following colonoscopy. Reported factors include sympathetic overactivity casued by the high pressure required to distend the bowel wall. air insufflation through an incompetent ileo– cecal valve with distension and subsequent entrapment of the small bowel with adhesions. Our patient did not have any history suggestive of abdominal adhesions. Gastroenterologists should be aware of the possibility of small bowel
Abstracts
S199
ileus after colonoscopy and should consider this diagnosis in patients presenting with abdominal distension and vomiting after the procedure.
608 MECKEL’S DIVERTICULUM AS A SOURCE OF OBSCURE GI BLEEDING Stacie A. Friesen, M.D. and Darwin L. Conwell, M.D.*. Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH. Purpose: Meckel’s diverticulum is an uncommon congenital anomaly that usually remains asymptomatic in adults. We present a case of a Meckel’s diverticulum in a patient with a three–year history of chronic microcytic anemia. The patient is a 44 –year– old woman who began having symptoms of fatigue and abdominal pain in 1998. The pain was diffuse and crampy, occasionally exacerbated by meals. In addition, she was found to have a microcytic anemia and was given iron supplementation. The anemia persisted with hemoglobin levels as low as 7.4 gm/dL. In 2001 patient had heme positive stools which prompted an extensive evaluation including CT scan, upper and lower endoscopy, and push enteroscopy at an outside institution. No etiology for her anemia was found, and she continued to have heme positive stools. She was referred to our institution for work up of her chronic microcytic anemia and obscure GI bleeding. Past medical history was significant for hypertension. Past surgical history was unremarkable. Medications included hydroclorothiazide and verapamil, and she had no known drug allergies. Family history included lung cancer in grandmother and hypertension in mother. She she denied tobacco or alcohol use. On physical exam, patient was an obese female, well appearing. Pulse was 118 bpm and blood pressure was 133/84 mmHg. Cardiopulmonary exam was normal. Stool was hemoccult positive. CBC showed hemoglobin of 12 gm/dL and MCV of 74 fL. Ferritin was 3.5 ng/mL and TIBC 507 ug/dL. Transferrin saturation was 6%. Basic metabolic panel was normal. Due to the obscure nature of the GI bleeding, the patient underwent a small bowel enteroclysis. An ulcerated apple core lesion was seen 10 –15 cm from the terminal ileum. A primary small bowel neoplasm was suspected, and she was referred to surgery. At laparotomy an ulcerated Meckel’s diverticulum was found approximately 2 feet from the ileocecal valve with a small nodule at the base. The diverticulum was resected. Pathology confirmed a Meckel’s diverticulum consisting of small bowel mucosa with an ulcer and acute and chronic inflammation. No pancreatic or gastric mucosa was identified. The nodule was benign. At post–surgical follow up, the anemia had resolved. Meckel’s diverticulum is the most common congenital anomaly of the GI tract, but can be difficult to diagnose. Symptoms are rare in the adult, however in a young patient with otherwise unexplained occult GI bleeding, a Meckel’s diverticulum should be considered in the differential diagnosis.
609 MESO–ATRIAL SHUNT FOR BUDD–CHIARI SYNDROME (BCS) IN THE CONTEXT OF ANTIPHOSPHOLIPID SYNDROME (APS). A POSSIBLE SAFE AND GOOD OUTCOME RELATED TREATMENT. CASE REPORT Mario C. Pelaez–Luna, M.D., Aurora Loaeza–Del Castillo, M.D. and Marco A. Olivera, M.D.*. Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico. Background: BCS is a rare cause of liver disease, characterized by obstruction to hepatic venous outflow anywhere above the level of the hepatic venulae. Several etiologies have been implicated and recently APS has been considered as a major etiologic factor. Case Report: A 23 year– old man with a 2 year history of recurrent deep lower limbs vein thrombosis, developed sudden right upper abdominal