Intestinal spirochetosis: is it a commensal or a pathogen?
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Conclusions: Gastroenterologists have been assisting Otolaryngologists in the management of patients with head and neck cancer by placing PEG tubes. This fruitful collaboration may be extended to the placement of TEPs, as the endoscopic placement of TEP is simple, convenient, and easily accomplished. In addition one could avoid the need for general anesthesia. 645 EUS assisted gastric pacemaker (neurostimulator) implantation for gastroparesis G.S. Raju, MD, I. Sarosiek, MD, J. Forster, MD, S. Rosenthal, MD, Z. Lin MS, R. McCallum, MD. Department of Medicine, Radiology, and Surgery. Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Gastric neurostimulator implantation is one of the recent advances in the management of refractory gastroparesis. During the pro- cedure electrodes are inserted into the muscular layer of the stomach. Care is taken to avoid penetration of the mucosa. Endoscopy and intra-operative surface ultrasound confirm positioning of the electrode. The former needs distension of the stomach, which interferes with the closure of abdomen from distended bowel loops, and, the latter produces an unsatisfactory image from reverberation artifacts. Endoscopic ultrasound overcomes both these problems as it provides excellent imaging of the layers of the stomach wall along with clear visualization of the mucosal aspect of the stomach. We describe the use of EUS to confirm the gastric pacemaker electrode placement. Materials and Methods: A 38-year-old woman with gastroparesis refrac- tory to medical management was referred for gastric pacemaker implan- tation. A radial echo-endoscope was passed into the stomach under general anesthesia. Pacemaker wires were implanted into the stomach wall, avoid- ing mucosal puncture. The placement of the gastric pacemaker wires into the central muscular coat was confirmed by EUS. Endoscopic visualization of the area was also done to exclude mucosal penetration by the pacemaker wires. Once the positioning of the electrode was confirmed by endoscopy and also by the EUS, the wires were secured in the serosal layer. A total of 12 patients underwent gastric pacemaker implantation at our site. The last 5 underwent EUS assisted gastric pacemaker implantation. During the follow-up (3–12 mo), no problems were noted. Conclusions: EUS is useful to confirm the placement of the gastric neuro- stimulator (now approved to treat refractory gastroparesis) and is superior to imaging with intra-operative surface ultrasound. High frequency ultra- sound probe may provide further improvement in the imaging. 646 Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome G. S. Raju, MD, Greg Crawford, RN, Brad Peck, RN, G. Cox, MD, E. Seigel, MD, B. Trasher, MD. Department of Medicine, Radiology and Urology, Kansas Univ. Medical Ctr. Kansas City, KS. Introduction: Open cholecystectomy is the treatment of choice for Mirizzi syndrome; laparoscopic cholecystectomy is not only unsuccessful in re- moving the burrowed stones in the cystic duct, but is also associated with a high risk of complications. Using a combination of ESWL & a novel endoscopic method, we were able to clear an impacted (burrowed) stone from the bile duct in a patient with Mirizzi syndrome following laparo- scopic cholecystectomy. Materials and Methods: A 26 year-old-woman, with Mirizzi syndrome, underwent laparoscopic cholecystectomy & placement of a catheter into the cystic duct after a failed laparoscopic clearance of an impacted (burrowed) CBD stone at the cystic duct insertion. Even after multiple endoscopic & interventional radiological attempts, including mono-octanoin infusion in the hospital for 5 days, removal of the stone was unsuccessful. At this stage, she was referred to our center for another endoscopic attempt, as she refused surgery. After ESWL of the CBD stone, an ERCP was attempted to remove the stone. There was narrowing of the distal CBD, a low insertion of cystic duct, and the stone was in the common hepatic duct. With a balloon sweep, the stone moved down & got stuck in the narrow distal CBD. Repeat attempts to cannulate the CBD, even with a wire, were unsuccessful. A Jagwire was passed down the cystic duct through the cystic duct tract into the duodenum, & was brought out through the endoscope biopsy port. A balloon catheter was passed over the wire, from the ab- dominal wall, through the tract into the cystic duct. The balloon was inflated just above the stone in the CBD. After placing a clamp on the Jagwire, behind the balloon catheter & using a push & pull technique, the stone was removed from the CBD successfully. Half of the circumference of the stone was covered with ductal tissue indicating that the stone was burrowed in the wall of the duct. The patient tolerated the procedure well with out any complications. Conclusions: A combination of ESWL and a novel endoscopic technique helped to solve the issue. A collaborative effort (with radiologists & urologists) is useful in the management of difficult biliary stone disease. 647 Intestinal Spirochetosis: Is it a commensal or a pathogen? Q. Tawfik, MD, Ph.D., G.S. Raju, MD. Department of Medicine & Pathology. Kansas University Medical Center, Kansas City, KS. Introduction: Intestinal Spirochetosis: Is it a commensal or a pathogen in the HIV infected men? That is the question. We present a case of chronic diarrhea and intestinal spirochetosis in a patient with HIV infection. Erad- ication of infection lead to the resolution of diarrhea, thereby confirming the pathogenic role of this organism. Materials and Methods: A 39-year-old man with HIV infection, without AIDS, presented with eight weeks of chronic non-bloody diarrhea. He denied rectal or esophageal symptoms, constitutional symptoms, abdomi- nal pain and weight loss. There was no history of laxative or antacid use. He has not been put on any new medications prior to the onset of diarrhea. There was no change in his dietary habits. His other medical problems include chronic hepatitis C with cirrhosis, ascites, hiatal hernia and cerebral aneurysm. His colonoscopic examination, including the biopsies, was nor- mal four years prior to this presentation. He was on spironolactone, dap- sone, zerit, acyclovir, epivir, and viracept. Examination was remarkable for mild hepatomegaly and minimal ascites. The colonic mucosa was normal on colonoscopy. Colonic biopsies with H & E stains showed luminal organisms consistent with intestinal spirochetosis, with moderate chronic inflammation of the lamina propria and mild eosinophilia. PAS and War- thin-Starry Silver strains confirmed intestinal spirochetosis. His diarrhea completely resolved after a two-week course of metronidazole 500 mg three times a day. Eradication of intestinal spirochetosis was confirmed by repeat colonoscopic examination with multiple biopsies. He did not have any recurrence of symptoms on follow-up (6 months). Conclusions: Documentation of intestinal spirochetosis in this patient with chronic diarrhea, quick resolution of the diarrhea with the eradication of infection, and no further recurrence of diarrhea on follow-up argues in favor of a pathogenic role rather than an innocent bystander (commensal). 648 Laparoscopy assisted endoscopy (LAE) to define the lower extent of obstructive hypopharyngeal cancer M. Moncure, MD, G.S.G.S. Raju, MD, I. Ahmed, MBBS, G. Crawford, RN, J. Hershberger, RN, T. Tsue, MD, A. Merati, MD. Department of Medicine, Surgery & Otolaryngology, University of Kansas Medical Center, Kansas City, KS. Introduction: Diagnosis of the pharyngo-esophageal cancer & its extent is relatively straightforward. In some patients, with near complete obstruction at the pharyngo-esophageal junction, it is impossible to define the lower extent of the hypopharyngeal cancer with conventional endoscopy. Ap- proaching the lesion from below, with laparoscopic assisted endoscopy, may be useful in defining the lower extent of the disease in patients with 2599 AJG – September, 2000 Abstracts
Transcript of Intestinal spirochetosis: is it a commensal or a pathogen?
Conclusions:Gastroenterologists have been assisting Otolaryngologists inthe management of patients with head and neck cancer by placing PEGtubes. This fruitful collaboration may be extended to the placement ofTEPs, as the endoscopic placement of TEP is simple, convenient, and easilyaccomplished. In addition one could avoid the need for general anesthesia.
645
EUS assisted gastric pacemaker (neurostimulator) implantation forgastroparesisG.S. Raju, MD, I. Sarosiek, MD, J. Forster, MD, S. Rosenthal, MD, Z.Lin MS, R. McCallum, MD. Department of Medicine, Radiology, andSurgery. Kansas Univ. Medical Ctr. Kansas City, KS.
Introduction: Gastric neurostimulator implantation is one of the recentadvances in the management of refractory gastroparesis. During the pro-cedure electrodes are inserted into the muscular layer of the stomach. Careis taken to avoid penetration of the mucosa. Endoscopy and intra-operativesurface ultrasound confirm positioning of the electrode. The former needsdistension of the stomach, which interferes with the closure of abdomenfrom distended bowel loops, and, the latter produces an unsatisfactoryimage from reverberation artifacts. Endoscopic ultrasound overcomes boththese problems as it provides excellent imaging of the layers of the stomachwall along with clear visualization of the mucosal aspect of the stomach.We describe the use of EUS to confirm the gastric pacemaker electrodeplacement.Materials and Methods: A 38-year-old woman with gastroparesis refrac-tory to medical management was referred for gastric pacemaker implan-tation. A radial echo-endoscope was passed into the stomach under generalanesthesia. Pacemaker wires were implanted into the stomach wall, avoid-ing mucosal puncture. The placement of the gastric pacemaker wires intothe central muscular coat was confirmed by EUS. Endoscopic visualizationof the area was also done to exclude mucosal penetration by the pacemakerwires. Once the positioning of the electrode was confirmed by endoscopyand also by the EUS, the wires were secured in the serosal layer. A total of12 patients underwent gastric pacemaker implantation at our site. The last5 underwent EUS assisted gastric pacemaker implantation. During thefollow-up (3–12 mo), no problems were noted.Conclusions:EUS is useful to confirm the placement of the gastric neuro-stimulator (now approved to treat refractory gastroparesis) and is superiorto imaging with intra-operative surface ultrasound. High frequency ultra-sound probe may provide further improvement in the imaging.
646
Extra-corporeal shock wave lithotripsy (ESWL) plus a novel methodof removal of a burrowed CBD stone in a patient with MirizzisyndromeG. S. Raju, MD, Greg Crawford, RN, Brad Peck, RN, G. Cox, MD, E.Seigel, MD, B. Trasher, MD. Department of Medicine, Radiology andUrology, Kansas Univ. Medical Ctr. Kansas City, KS.
Introduction: Open cholecystectomy is the treatment of choice for Mirizzisyndrome; laparoscopic cholecystectomy is not only unsuccessful in re-moving the burrowed stones in the cystic duct, but is also associated witha high risk of complications. Using a combination of ESWL & a novelendoscopic method, we were able to clear an impacted (burrowed) stonefrom the bile duct in a patient with Mirizzi syndrome following laparo-scopic cholecystectomy.Materials and Methods: A 26 year-old-woman, with Mirizzi syndrome,underwent laparoscopic cholecystectomy & placement of a catheter into thecystic duct after a failed laparoscopic clearance of an impacted (burrowed)CBD stone at the cystic duct insertion. Even after multiple endoscopic &interventional radiological attempts, including mono-octanoin infusion inthe hospital for 5 days, removal of the stone was unsuccessful. At this stage,she was referred to our center for another endoscopic attempt, as sherefused surgery. After ESWL of the CBD stone, an ERCP was attemptedto remove the stone. There was narrowing of the distal CBD, a low
insertion of cystic duct, and the stone was in the common hepatic duct.With a balloon sweep, the stone moved down & got stuck in the narrowdistal CBD. Repeat attempts to cannulate the CBD, even with a wire, wereunsuccessful. A Jagwire was passed down the cystic duct through the cysticduct tract into the duodenum, & was brought out through the endoscopebiopsy port. A balloon catheter was passed over the wire, from the ab-dominal wall, through the tract into the cystic duct. The balloon wasinflated just above the stone in the CBD. After placing a clamp on theJagwire, behind the balloon catheter & using a push & pull technique, thestone was removed from the CBD successfully. Half of the circumferenceof the stone was covered with ductal tissue indicating that the stone wasburrowed in the wall of the duct. The patient tolerated the procedure wellwith out any complications.Conclusions:A combination of ESWL and a novel endoscopic techniquehelped to solve the issue. A collaborative effort (with radiologists &urologists) is useful in the management of difficult biliary stone disease.
647
Intestinal Spirochetosis: Is it a commensal or a pathogen?Q. Tawfik, MD, Ph.D., G.S. Raju, MD. Department of Medicine &Pathology. Kansas University Medical Center, Kansas City, KS.
Introduction: Intestinal Spirochetosis: Is it a commensal or a pathogen inthe HIV infected men? That is the question. We present a case of chronicdiarrhea and intestinal spirochetosis in a patient with HIV infection. Erad-ication of infection lead to the resolution of diarrhea, thereby confirmingthe pathogenic role of this organism.Materials and Methods: A 39-year-old man with HIV infection, withoutAIDS, presented with eight weeks of chronic non-bloody diarrhea. Hedenied rectal or esophageal symptoms, constitutional symptoms, abdomi-nal pain and weight loss. There was no history of laxative or antacid use.He has not been put on any new medications prior to the onset of diarrhea.There was no change in his dietary habits. His other medical problemsinclude chronic hepatitis C with cirrhosis, ascites, hiatal hernia and cerebralaneurysm. His colonoscopic examination, including the biopsies, was nor-mal four years prior to this presentation. He was on spironolactone, dap-sone, zerit, acyclovir, epivir, and viracept. Examination was remarkable formild hepatomegaly and minimal ascites. The colonic mucosa was normalon colonoscopy. Colonic biopsies with H & E stains showed luminalorganisms consistent with intestinal spirochetosis, with moderate chronicinflammation of the lamina propria and mild eosinophilia. PAS and War-thin-Starry Silver strains confirmed intestinal spirochetosis. His diarrheacompletely resolved after a two-week course of metronidazole 500 mgthree times a day. Eradication of intestinal spirochetosis was confirmed byrepeat colonoscopic examination with multiple biopsies. He did not haveany recurrence of symptoms on follow-up (6 months).Conclusions:Documentation of intestinal spirochetosis in this patient withchronic diarrhea, quick resolution of the diarrhea with the eradication ofinfection, and no further recurrence of diarrhea on follow-up argues infavor of a pathogenic role rather than an innocent bystander (commensal).
648
Laparoscopy assisted endoscopy (LAE) to define the lower extent ofobstructive hypopharyngeal cancerM. Moncure, MD, G.S.G.S. Raju, MD, I. Ahmed, MBBS, G. Crawford,RN, J. Hershberger, RN, T. Tsue, MD, A. Merati, MD. Department ofMedicine, Surgery & Otolaryngology, University of Kansas MedicalCenter, Kansas City, KS.
Introduction: Diagnosis of the pharyngo-esophageal cancer & its extent isrelatively straightforward. In some patients, with near complete obstructionat the pharyngo-esophageal junction, it is impossible to define the lowerextent of the hypopharyngeal cancer with conventional endoscopy. Ap-proaching the lesion from below, with laparoscopic assisted endoscopy,may be useful in defining the lower extent of the disease in patients with
2599AJG – September, 2000 Abstracts
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