- Email: [email protected]
Ventricular tachycardia after endoscopic injection of epinephrine for bleeding ulcer
2618
Abstracts
711 Symptomatic squamous papillomatosis of anus evaluated by endoscopic ultrasound Mann N.S. M.D., FACG, Sandford I.M. M.D., Mann S.K. M.D., FACG, Leung J.W. M.D., FACG. VA Medical Center, Martinez, University of California, Davis, CA. Squamous cell papillomatosis of the anus in immunocompetent patients is rare. Rarely massive anal bleeding and prolapse may occur (Eur J Surg 157:491, 1991). We present a case of squamous cell papillomatosis of anus, which was evaluated by endoscopic ultrasound (EUS). Case Report: 55-year-old white male presented with marked rectal pain and hematochezia and intermittent constipation. He had previous h/o hypertension, colonic diverticulosis, and benign colonic polyp and was previously treated for syphilis. On colonoscopy there was mild anal stenosis, extensive colonic diverticulosis. Just distal to the pectinate line there were multiple lobed lesion (Fig 1) which endoscopically looked like anal carcinoma. Endoscopic biopsies showed it to be composed of polypoid stratified squamous epithelium showing hydropic and ballooning changes. An EUS was done (Fig 2) which showed hyperechoic nodules localized to the mucosa; one small peri-rectal lymph node was seen. The patient underwent local excision of the lesion with relief of symptoms; histology of the resected specimen was similar to the endoscopic biopsy. Discussion: Squamous cell papillomatosis of the anus in immunocompetent patients in rare. In this symptomatic patient this lesion was evaluated by EUS which confirmed its mucosal location and non-invasive character.
712 Ventricular tachycardia after endoscopic injection of epinephrine for bleeding ulcer Abrahamian Frida M.D., Attar Bashar M. M.D., F.A.C.G., Pothamsetty Srikiran M.D. Division of Gastroenterology, Cook County Hospital and Rush Medical College, Chicago, IL. Endoscopic injection of epinephrine for management of bleeding peptic ulcer disease is simple, economical and effective. Although epinephrine injections produce a four to five fold increase in plasma levels of epinephrine, adverse cardiovascular events are rare. We report a case of ventricular tachycardia developing after endoscopic submucosal injection of epinephrine for a bleeding peptic ulcer. A 44 yr-old female presented with abdominal pain and melena. She had hypertension, diabetes, and newly diagnosed depression with psychotic features, and she was receiving fosinopril, furosemide, potassium supplementation, insulin, risperdal and sertraline. Her vital signs were normal. She had brown hemoccult positive stool. Her hemoglobin at admission was 11.5 g/dL. The day after admission, she had melanotic stools and her hemoglobin dropped to 8.5 g/dL. Endoscopy revealed a 3-cm posterior bulb ulcer with a clot and surrounding erythema and edema. The area immediately adjacent to the clot was treated with three 1-ml injections of 1:10,000 epinephrine. Before the injections the patient was in normal sinus rhythm with HR of 96 bpm. Ventricular tachycardia developed immediately after the injections, which spontaneously reverted back to sinus rhythm after about one minute. No more epinephrine was given and the area was treated with heater probe. Endoscopic submucosal injection of epinephrine is not known to cause cardiovascular complications because of a significant first-pass extraction by the liver. Topical anesthetics such as xylocaine used during endoscopic procedures have been reported to be absorbed in significant amounts, and
AJG – Vol. 95, No. 9, 2000
may contribute to the toxicity of epinephrine. This illustrates the need to monitor patients during and immediately after epinephrine injection. 713 Endoscopic band ligation of bleeding duodenal varices Al-Khatatneh Salim MD, Fares Joseph MD, Elfarra Hossam MD, Baddoura Walid MD. Seton Hall University, School of Graduate Medical Education, South Orange, NJ. St. Joseph’s Hospital & Medical Center, Paterson, NJ. Introduction: Bleeding from varices outside the gastroesophageal region is an uncommon complication of portal hypertension. These ectopic variceal bleedings, such as duodenal, are often massive and life threatening. Therefore, a prompt recognition of this condition with early intervention is imperative. Different modalities of treatment have been described. We report a case of duodenal variceal bleeding treated successfully by endoscopic band ligation. Case Report: This is a 34 year old female with a history of alcoholic liver disease and type II Diabetes Mellitus, who was hospitalized for multiple episodes of hematemesis and melena associated with dizziness and generalized fatigue. On physical exam, she had stable vital signs and no stigmata of liver disease. The examination was otherwise unremarkable. The initial hemoglobin was 6.7 gm/dl with a hematocrit of 20.2% and an MCV of 83. There was thrombocytopenia with a normal coagulation profile. The aminotransferases were normal, but marked hypoalbuminemia was noted. The viral hepatitis panel was negative. Rapid volume replacement was initiated and intravenous Octreotide and Famotidine were started. She also received multiple blood transfusions. An urgent esophagogastroduodenoscopy (EGD) demonstrated gastritis and erosive duodenitis with no evidence of gastroesophageal varices or stigmata of recent bleeding. On the second day of hospitalization, the patient again started having hematemesis. A second EGD was then performed which revealed a large varix in the second part of the duodenum, with a cherry red spot and some blood oozing. The varix was successfully band ligated. The patient had no subsequent bleeding episodes and her hemogram remained stable. Conclusion: Recognition of bleeding duodenal varices is critical given the potential of recurrent bleeding and its attendant risks. Endoscopic band ligation offers an effective modality of treatment and appears to be safe. 714 Chronic mesenteric ischemia with only mild abdominal pain and extreme weight loss Arora Kanwarjit M.D., Hoque Nazmul M.D., Attar Bashar M. M.D., FACG, Williams Anthony D. M.D., Siddiq Muhammed, Mehta Bhupar M.D. Division of Gastroenterology,Cook County Hospital and Rush Medical College, Chicago, IL. Chronic mesenteric ischemia, because of its highly variable and often nonspecific symptoms and signs, is an under-diagnosed and under-reported condition. It often takes high clinical suspicion to make a prompt diagnosis. A previously healthy 54 yr-old male smoker presented with a 5 month history of crampy lower abdominal pain that was mostly post-prandial, and associated with passage of 4 –5 small, greasy, non-bloody stools per day, nausea, occasional vomiting, and weight loss of 45 lbs. Physical exam was remarkable for extreme cachexia (height: 66 in; weight: 77 lbs), normal abdominal exam, and brown, occult blood positive stool. Laboratory studies showed a normal CBC, thyroid function tests, and CXR. Stool studies were negative for leukocytes, pathogens and fat. EGD with small bowel biopsy was normal. Colonoscopy showed areas of patchy erythema in the ascending colon and splenic flexure. Histopathology of these colonic biopsies showed nonspecific inflammation. Abdominal CT scan revealed a mural thrombus in the abdominal aorta, and a mesenteric angiogram revealed complete occlusion of the superior and inferior mesenteric arteries. The patient underwent successful mesenteric revascularization resulting in resolution of his symptoms and gain of weight.
Abstracts
711 Symptomatic squamous papillomatosis of anus evaluated by endoscopic ultrasound Mann N.S. M.D., FACG, Sandford I.M. M.D., Mann S.K. M.D., FACG, Leung J.W. M.D., FACG. VA Medical Center, Martinez, University of California, Davis, CA. Squamous cell papillomatosis of the anus in immunocompetent patients is rare. Rarely massive anal bleeding and prolapse may occur (Eur J Surg 157:491, 1991). We present a case of squamous cell papillomatosis of anus, which was evaluated by endoscopic ultrasound (EUS). Case Report: 55-year-old white male presented with marked rectal pain and hematochezia and intermittent constipation. He had previous h/o hypertension, colonic diverticulosis, and benign colonic polyp and was previously treated for syphilis. On colonoscopy there was mild anal stenosis, extensive colonic diverticulosis. Just distal to the pectinate line there were multiple lobed lesion (Fig 1) which endoscopically looked like anal carcinoma. Endoscopic biopsies showed it to be composed of polypoid stratified squamous epithelium showing hydropic and ballooning changes. An EUS was done (Fig 2) which showed hyperechoic nodules localized to the mucosa; one small peri-rectal lymph node was seen. The patient underwent local excision of the lesion with relief of symptoms; histology of the resected specimen was similar to the endoscopic biopsy. Discussion: Squamous cell papillomatosis of the anus in immunocompetent patients in rare. In this symptomatic patient this lesion was evaluated by EUS which confirmed its mucosal location and non-invasive character.
712 Ventricular tachycardia after endoscopic injection of epinephrine for bleeding ulcer Abrahamian Frida M.D., Attar Bashar M. M.D., F.A.C.G., Pothamsetty Srikiran M.D. Division of Gastroenterology, Cook County Hospital and Rush Medical College, Chicago, IL. Endoscopic injection of epinephrine for management of bleeding peptic ulcer disease is simple, economical and effective. Although epinephrine injections produce a four to five fold increase in plasma levels of epinephrine, adverse cardiovascular events are rare. We report a case of ventricular tachycardia developing after endoscopic submucosal injection of epinephrine for a bleeding peptic ulcer. A 44 yr-old female presented with abdominal pain and melena. She had hypertension, diabetes, and newly diagnosed depression with psychotic features, and she was receiving fosinopril, furosemide, potassium supplementation, insulin, risperdal and sertraline. Her vital signs were normal. She had brown hemoccult positive stool. Her hemoglobin at admission was 11.5 g/dL. The day after admission, she had melanotic stools and her hemoglobin dropped to 8.5 g/dL. Endoscopy revealed a 3-cm posterior bulb ulcer with a clot and surrounding erythema and edema. The area immediately adjacent to the clot was treated with three 1-ml injections of 1:10,000 epinephrine. Before the injections the patient was in normal sinus rhythm with HR of 96 bpm. Ventricular tachycardia developed immediately after the injections, which spontaneously reverted back to sinus rhythm after about one minute. No more epinephrine was given and the area was treated with heater probe. Endoscopic submucosal injection of epinephrine is not known to cause cardiovascular complications because of a significant first-pass extraction by the liver. Topical anesthetics such as xylocaine used during endoscopic procedures have been reported to be absorbed in significant amounts, and
AJG – Vol. 95, No. 9, 2000
may contribute to the toxicity of epinephrine. This illustrates the need to monitor patients during and immediately after epinephrine injection. 713 Endoscopic band ligation of bleeding duodenal varices Al-Khatatneh Salim MD, Fares Joseph MD, Elfarra Hossam MD, Baddoura Walid MD. Seton Hall University, School of Graduate Medical Education, South Orange, NJ. St. Joseph’s Hospital & Medical Center, Paterson, NJ. Introduction: Bleeding from varices outside the gastroesophageal region is an uncommon complication of portal hypertension. These ectopic variceal bleedings, such as duodenal, are often massive and life threatening. Therefore, a prompt recognition of this condition with early intervention is imperative. Different modalities of treatment have been described. We report a case of duodenal variceal bleeding treated successfully by endoscopic band ligation. Case Report: This is a 34 year old female with a history of alcoholic liver disease and type II Diabetes Mellitus, who was hospitalized for multiple episodes of hematemesis and melena associated with dizziness and generalized fatigue. On physical exam, she had stable vital signs and no stigmata of liver disease. The examination was otherwise unremarkable. The initial hemoglobin was 6.7 gm/dl with a hematocrit of 20.2% and an MCV of 83. There was thrombocytopenia with a normal coagulation profile. The aminotransferases were normal, but marked hypoalbuminemia was noted. The viral hepatitis panel was negative. Rapid volume replacement was initiated and intravenous Octreotide and Famotidine were started. She also received multiple blood transfusions. An urgent esophagogastroduodenoscopy (EGD) demonstrated gastritis and erosive duodenitis with no evidence of gastroesophageal varices or stigmata of recent bleeding. On the second day of hospitalization, the patient again started having hematemesis. A second EGD was then performed which revealed a large varix in the second part of the duodenum, with a cherry red spot and some blood oozing. The varix was successfully band ligated. The patient had no subsequent bleeding episodes and her hemogram remained stable. Conclusion: Recognition of bleeding duodenal varices is critical given the potential of recurrent bleeding and its attendant risks. Endoscopic band ligation offers an effective modality of treatment and appears to be safe. 714 Chronic mesenteric ischemia with only mild abdominal pain and extreme weight loss Arora Kanwarjit M.D., Hoque Nazmul M.D., Attar Bashar M. M.D., FACG, Williams Anthony D. M.D., Siddiq Muhammed, Mehta Bhupar M.D. Division of Gastroenterology,Cook County Hospital and Rush Medical College, Chicago, IL. Chronic mesenteric ischemia, because of its highly variable and often nonspecific symptoms and signs, is an under-diagnosed and under-reported condition. It often takes high clinical suspicion to make a prompt diagnosis. A previously healthy 54 yr-old male smoker presented with a 5 month history of crampy lower abdominal pain that was mostly post-prandial, and associated with passage of 4 –5 small, greasy, non-bloody stools per day, nausea, occasional vomiting, and weight loss of 45 lbs. Physical exam was remarkable for extreme cachexia (height: 66 in; weight: 77 lbs), normal abdominal exam, and brown, occult blood positive stool. Laboratory studies showed a normal CBC, thyroid function tests, and CXR. Stool studies were negative for leukocytes, pathogens and fat. EGD with small bowel biopsy was normal. Colonoscopy showed areas of patchy erythema in the ascending colon and splenic flexure. Histopathology of these colonic biopsies showed nonspecific inflammation. Abdominal CT scan revealed a mural thrombus in the abdominal aorta, and a mesenteric angiogram revealed complete occlusion of the superior and inferior mesenteric arteries. The patient underwent successful mesenteric revascularization resulting in resolution of his symptoms and gain of weight.