Ischaemic colitis in a young adult male-infection v/s idiopathic
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pancreatitis was diagnosed each time. He did not drink alcohol and previ- ous work-up, including RUQ ultrasound, did not reveal an etiology for the pancreatitis. Physical examination was unremarkable. On admission, the lipase was 38,000 U/l and the amylase was 1565 U/l. Abdominal CT revealed a normal pancreas and a 1.5 cm 3 2.5 cm thick-walled hypoden- sity to the right of the pancreas, thought to represent a non-opacified loop of bowel. ERCP demonstrated a large (4 –5 cm) smooth submucosal pedunculated mass arising in the vicinity of the Ampulla of Vater. This mass was torsed around its short stalk and was partially intussuscepting into the third portion of the duodenum. Initially, the ampullary orifice could not be visualized. On palpation with a standard ERCP catheter the mass was soft and easily compressible, with a positive “pillow sign”. This manipu- lation detorsed the mass and revealed the ampullary orifice at the base of its peduncle. The pancreatic duct was cannulated and found to be normal. Attempted cannulation of the common bile duct was unsuccessful. MRCP demonstrated a cystic 3 cm 3 4 cm structure adjacent to the wall of the second portion of the duodenum with a prominent T2 weighted signal. The pancreatic and common bile ducts were normal and not in continuity with the cystic structure, which was felt to be most consistent with a duodenal duplication cyst. The patient underwent a laparotomy and duodenotomy, at which time the ampullary orifice was identified and the cyst was resected. Histologic examination of the wall of the cyst revealed it to contain the normal layers of the duodenum, that confirming the diagnosis of a dupli- cation cyst. Conclusion: This case demonstrates a rare cause of recurrent pancreatitis due to a duodenal duplication cyst causing torsion of the ampullary orifice. Although the endoscopic appearance of the cyst is suggestive of the diagnosis, MRCP can provide additional information to help confirm the diagnosis. 514 Ischaemic colitis in a young adult male-infection v/s idiopathic Vijay Arya*, Prag Gupta, Davinder Sohal, Yashpal Arya, Shyam Goyal, Manish Singhal, Shailaja Daminini. Wyckoff Heights Medical Center, Brooklyn, NY. Purpose: Ischaemic colitis,while a well recognised entity in older patients, is very rare in young males. An extesive literature review also suggests that the etiological investigation of ischeamic colitis is usually negative in young patients. Methods: The patient is a 30 year old white male who started complaining of abdominal cramps and bloody diarrhoea about 8 –10 hours after eating restaurant food. On physical examination he was dehydrated with low grade fever. The abdomen was diffusely tender with hyperactive bowel sounds. The hemoglobin level was 11.5, WBC-14300 with left shift. Colonscopy revealed well demarcated segmental splenic flexure involve- ment, with mucosal denudation and ulceration. The microscopic examina- tion was consistent with ischaemic colitis. The patient had fast recovery on oral cipro and flagyl. Conclusions: We report, a case of typical ischaemic colitis in a young male. He had no known risk factors. The most likely etiology is infectious colitis. 515 Esophagocolonic fistula presenting as feculent emesis in a pediatric patient post diaphragmatic hernia repair Thomas M Attard, Kathleen B Schwarz, Carmen Cuffari*. The Johns Hopkins Hospital Children’s Center, Baltimore, MD. Purpose: Background: The spectrum of acquired esophageal fistulae in- clude tracheoesophageal, esophago-pleural and esophagoaortic fistulae. Herein, we report the first case of an esophagocolonic fistula in a child status post diaphragmatic hernia repair who presented with feculent emesis. Methods: Case History: A 16 year old African American female with static encephalopathy from perinatal asphyxia presented to The Johns Hopkins Hospital with feculent emesis and mild abdominal distension. Her past medical history was significant for long-standing gastroesophageal reflux disease refractory to medical therapy that required a Nissen Fundoplication. The patient has had a long history of post-operative complications, includ- ing empyema, several episodes of small bowel obstruction secondary to adhesions, and a slipped Nissan that required multiple revisions. The most recent revision was performed at age 11 years of age. During that surgery, a diaphragmatic hernia was repaired using Marlex mesh. Results: Clinical course: On admission, the patient was noted to have increased irritability, mild abdominal distension, and normal bowel sounds. A chest roentgenogram showed the reappearance of the diaphragmatic hernia 5 years post surgical repair. An upper gastrointestinal series with contrast injected through the gastrostomy tube showed normal gastric emptying, and no radiological signs of small bowel obstruction nor gas- troesophageal reflux. Thereafter, the child underwent an elective esopha- gogastroduodenoscopy that showed a communication between the mid esophagus and the transverse colon. The upper GI series was then repeated through a nasoesophageal feeding tube identifying the esophagocolonic fistula. Corrective Surgery was discussed with the patient’s caregivers but was declined in view of the associated risks. The patient was discharged on continuous gastrostomy tube feeds. Conclusions: Esophagocolonic fistula is an uncommon complication post diaphragmatic hernia repair. An esophagocolonic fistula should be consid- ered in the differential diagnosis of children presenting with feculent vomiting, and may be overlooked in radiological studies with barium administered through either nasogastric or gastrostomy feeding tubes. 516 Heterotopic gastric mucosal polyps in the duodenum causing recurrent pancreatitis Thomas M Attard, Anthony Kalloo, Susan C Abraham, Carmen Cuffari*. The Johns Hopkins Hospital, Baltimore, MD. Purpose: Background: Tumorous heterotopic gastric mucosa is a rare congenital abnormality that has been previously described in the small intestine and rectum. Lesions have been associated with intestinal intus- susception and hemorrhage, or in the absence of symptoms, an incidental finding as polyps on radiological studies. Herein, we report the first pedi- atric case of recurrent pancreatitis secondary to obstructive heterotopic duodenal polyps near the ampulla of Vater. Methods: Case History: An 18 year old caucasian male presented to The Johns Hopkins Hospital with a clinical history of paroxysmal, post-pran- dial, epigastric abdominal pain. Marked elevation of serum amylase (4 3 Normal) and lipase (3 3 Normal) levels raised concerns for acute pancre- atitis. His past medical history was significant for two similar episodes in the past 2 years. In each, he was diagnosed with idiopathic pancreatitis based on the measurement of elevated serum amylase and lipase levels. Incidental findings include an abnormal upper gastrointestinal contrast study that showed two filling defects in the second portion of the duodenum. On endoscopy, the two filling defects were identified as large pedunculated polyps distal to the Ampulla of Vater. Biopsy specimens showed hetero- topic gastric mucosa without signs of ulceration nor enterochromaffin cell hyperplasia. The patient had a normal biochemistry panel, including serum calcium and triglyceride levels. Results: Clinical course: During this admission, serum lipase and amylase levels normalized rapidly three days into the hospitalization. An abdominal CT confirmed the presence of the large polyps within the second portion of the duodenum. The pancreas and liver appeared normal. An ERCP showed normal pancreatic ductal anatomy and no dilatation of the hepatobiliary ducts. On endoscopy, three large polypoid lesions, the largest measuring 4 cms was identified 3 cms from the papilla. The papilla was draining bile and appeared normal. Endoscopic biopsies showed oxyntic type gastric mucosa with foveolar hyperplasia, chronic inflammation and marked re- active epithelial changes. Polypectomy was discussed with the patient’s family, but was declined. 2561 AJG – September, 2000 Abstracts
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Transcript of Ischaemic colitis in a young adult male-infection v/s idiopathic
pancreatitis was diagnosed each time. He did not drink alcohol and previ-ous work-up, including RUQ ultrasound, did not reveal an etiology for thepancreatitis. Physical examination was unremarkable. On admission, thelipase was 38,000 U/l and the amylase was 1565 U/l. Abdominal CTrevealed a normal pancreas and a 1.5 cm3 2.5 cm thick-walled hypoden-sity to the right of the pancreas, thought to represent a non-opacified loopof bowel. ERCP demonstrated a large (4–5 cm) smooth submucosalpedunculated mass arising in the vicinity of the Ampulla of Vater. Thismass was torsed around its short stalk and was partially intussuscepting intothe third portion of the duodenum. Initially, the ampullary orifice could notbe visualized. On palpation with a standard ERCP catheter the mass wassoft and easily compressible, with a positive “pillow sign”. This manipu-lation detorsed the mass and revealed the ampullary orifice at the base ofits peduncle. The pancreatic duct was cannulated and found to be normal.Attempted cannulation of the common bile duct was unsuccessful. MRCPdemonstrated a cystic 3 cm3 4 cm structure adjacent to the wall of thesecond portion of the duodenum with a prominent T2 weighted signal. Thepancreatic and common bile ducts were normal and not in continuity withthe cystic structure, which was felt to be most consistent with a duodenalduplication cyst. The patient underwent a laparotomy and duodenotomy, atwhich time the ampullary orifice was identified and the cyst was resected.Histologic examination of the wall of the cyst revealed it to contain thenormal layers of the duodenum, that confirming the diagnosis of a dupli-cation cyst.Conclusion: This case demonstrates a rare cause of recurrent pancreatitisdue to a duodenal duplication cyst causing torsion of the ampullary orifice.Although the endoscopic appearance of the cyst is suggestive of thediagnosis, MRCP can provide additional information to help confirm thediagnosis.
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Ischaemic colitis in a young adult male-infection v/s idiopathicVijay Arya*, Prag Gupta, Davinder Sohal, Yashpal Arya, Shyam Goyal,Manish Singhal, Shailaja Daminini. Wyckoff Heights Medical Center,Brooklyn, NY.
Purpose:Ischaemic colitis,while a well recognised entity in older patients,is very rare in young males. An extesive literature review also suggests thatthe etiological investigation of ischeamic colitis is usually negative inyoung patients.Methods: The patient is a 30 year old white male who started complainingof abdominal cramps and bloody diarrhoea about 8–10 hours after eatingrestaurant food. On physical examination he was dehydrated with lowgrade fever. The abdomen was diffusely tender with hyperactive bowelsounds. The hemoglobin level was 11.5, WBC-14300 with left shift.Colonscopy revealed well demarcated segmental splenic flexure involve-ment, with mucosal denudation and ulceration. The microscopic examina-tion was consistent with ischaemic colitis. The patient had fast recovery onoral cipro and flagyl.Conclusions: We report, a case of typical ischaemic colitis in a youngmale. He had no known risk factors. The most likely etiology is infectiouscolitis.
515
Esophagocolonic fistula presenting as feculent emesis in a pediatricpatient post diaphragmatic hernia repairThomas M Attard, Kathleen B Schwarz, Carmen Cuffari*. The JohnsHopkins Hospital Children’s Center, Baltimore, MD.
Purpose: Background: The spectrum of acquired esophageal fistulae in-clude tracheoesophageal, esophago-pleural and esophagoaortic fistulae.Herein, we report the first case of an esophagocolonic fistula in a childstatus post diaphragmatic hernia repair who presented with feculent emesis.Methods: Case History: A 16 year old African American female with staticencephalopathy from perinatal asphyxia presented to The Johns Hopkins
Hospital with feculent emesis and mild abdominal distension. Her pastmedical history was significant for long-standing gastroesophageal refluxdisease refractory to medical therapy that required a Nissen Fundoplication.The patient has had a long history of post-operative complications, includ-ing empyema, several episodes of small bowel obstruction secondary toadhesions, and a slipped Nissan that required multiple revisions. The mostrecent revision was performed at age 11 years of age. During that surgery,a diaphragmatic hernia was repaired using Marlex mesh.Results: Clinical course: On admission, the patient was noted to haveincreased irritability, mild abdominal distension, and normal bowel sounds.A chest roentgenogram showed the reappearance of the diaphragmatichernia 5 years post surgical repair. An upper gastrointestinal series withcontrast injected through the gastrostomy tube showed normal gastricemptying, and no radiological signs of small bowel obstruction nor gas-troesophageal reflux. Thereafter, the child underwent an elective esopha-gogastroduodenoscopy that showed a communication between the midesophagus and the transverse colon. The upper GI series was then repeatedthrough a nasoesophageal feeding tube identifying the esophagocolonicfistula. Corrective Surgery was discussed with the patient’s caregivers butwas declined in view of the associated risks. The patient was discharged oncontinuous gastrostomy tube feeds.Conclusions:Esophagocolonic fistula is an uncommon complication postdiaphragmatic hernia repair. An esophagocolonic fistula should be consid-ered in the differential diagnosis of children presenting with feculentvomiting, and may be overlooked in radiological studies with bariumadministered through either nasogastric or gastrostomy feeding tubes.
516
Heterotopic gastric mucosal polyps in the duodenum causingrecurrent pancreatitisThomas M Attard, Anthony Kalloo, Susan C Abraham, Carmen Cuffari*.The Johns Hopkins Hospital, Baltimore, MD.
Purpose: Background: Tumorous heterotopic gastric mucosa is a rarecongenital abnormality that has been previously described in the smallintestine and rectum. Lesions have been associated with intestinal intus-susception and hemorrhage, or in the absence of symptoms, an incidentalfinding as polyps on radiological studies. Herein, we report the first pedi-atric case of recurrent pancreatitis secondary to obstructive heterotopicduodenal polyps near the ampulla of Vater.Methods: Case History: An 18 year old caucasian male presented to TheJohns Hopkins Hospital with a clinical history of paroxysmal, post-pran-dial, epigastric abdominal pain. Marked elevation of serum amylase (43Normal) and lipase (33 Normal) levels raised concerns for acute pancre-atitis.
His past medical history was significant for two similar episodes in thepast 2 years. In each, he was diagnosed with idiopathic pancreatitis basedon the measurement of elevated serum amylase and lipase levels. Incidentalfindings include an abnormal upper gastrointestinal contrast study thatshowed two filling defects in the second portion of the duodenum. Onendoscopy, the two filling defects were identified as large pedunculatedpolyps distal to the Ampulla of Vater. Biopsy specimens showed hetero-topic gastric mucosa without signs of ulceration nor enterochromaffin cellhyperplasia. The patient had a normal biochemistry panel, including serumcalcium and triglyceride levels.Results:Clinical course: During this admission, serum lipase and amylaselevels normalized rapidly three days into the hospitalization. An abdominalCT confirmed the presence of the large polyps within the second portion ofthe duodenum. The pancreas and liver appeared normal. An ERCP showednormal pancreatic ductal anatomy and no dilatation of the hepatobiliaryducts. On endoscopy, three large polypoid lesions, the largest measuring 4cms was identified 3 cms from the papilla. The papilla was draining bileand appeared normal. Endoscopic biopsies showed oxyntic type gastricmucosa with foveolar hyperplasia, chronic inflammation and marked re-active epithelial changes. Polypectomy was discussed with the patient’sfamily, but was declined.
2561AJG – September, 2000 Abstracts
