Ectopic pancreatic adenocarcinoma presenting as gastric outlet obstruction
Descrição do Produto
2578
Abstracts
mass on the greater curvature adjacent pancreas that could represent a leiomyoma. There was no obvious local invasion. EGD/EUS were performed and showed no mucosal lesions, a complex partially cystic mass measuring 5⫻6 cm, which appeared to be located deep to the muscularis propria and not involving the gastric wall. He was referred to surgery and underwent exploratory celiotomy, partial gastrectomy and resection of the juxtagastric mass with a wedge of full thickness posterior gastric wall. All adjacent structures were unremarkable. Pathology showed organizing hematoma without necrosis, normal stomach and benign nodes. He did well post-operatively. This was an unusual case of organizing hematoma due to the absence of any significant history of precipitating factors and the presentation as an abdominal mass which resembled gastric leiomyoma on imaging studies. 572 Hiatal hernia with gastrobronchial fistula Hammod R. MD, Leichus L., MD, Lambert J., MD, Desai M., MD, Deeb A., MD. Tallahassee Community Hospital, Tallahassee, Florida. Although hiatal hernia itself rarely causes symptoms directly (e.g., Incarceration with pain and peptic ulceration with bleeding), it is the anatomic companion of gastroesophageal reflux. Fortunately, proper medical therapy controls reflux-related symptoms sufficiently well that surgical intervention is needed in fewer than 5% of patients. We report a rare case of hiatal hernia in a 55-year female who presented to the ER with increase shortness of breath and dysphagia for solids. A Chest X ray showed increase density in the retrosternal area. A CT scan of the chest showed dilated esophagus with fluid level, hiatal hernia and possible perforation with abscess formation. Barium study showed filling of the medial basal R lower bronchus with contrast. Upper endoscopy confirmed the presence of a large hiatal hernia and a possible fistula formation. Patient failed to respond to medical treatment (NPO, TPN, IV antibiotics). Through a thoraco-abdominal approach, the patient was found to have severe chronic inflammatory changes of the proximal stomach and distal esophagus with gastrobronchial fistula. Patient tolerated esophagogastrectomy with lobectomy and pyloroplasty. Conclusion: This is a rare complication of hiatal hernia. Medline search revealed few reported cases of gastrobronchial fistula complicating surgical repair of hiatal hernia. This is an extremely rare complication of denovo fistula between hiatal hernia sac and the bronchial tree. 573 Ileo-colic intussusception secondary to severe cecal diverticulosis Hammod R., MD, Leichus L., MD, Desai M., MD. Tallahassee Community Hospital, Tallahassee, Florida. A 68-year man with a history of hypertension and atrial fibrillation, was admitted with rectal bleeding, abdominal pain and anemia (Hb 7.1 gm). After resuscitation, the patient had colonoscpy that showed a mass with irregular surface and central umbilication just above the cecum. There were few diverticulae in the area. A decision was made not to remove the lesion endoscopically because of its obscure appearance and to avoid perforation in the presence of diverticular disease. After discussing the differential diagnosis with the patient and for fear of missing a malignant lesion, the patient had laparotomy and right hemicolectomy. Gross pathology showed prominent ileocecal valve with ileal mucosa extending up to 2.2 cm above the valve area with gross thickening of the terminal ileum secondary to serve diverticulitis. Multiple sections confirmed diverticulosis with diverticulitis. No tumor identified. Unfortunately the patient died of post-operative cardio-pulmonary complications. Conclusion: Intussusception is rare in adults. Pediatric intussuscepion is mostly idiopathic. However in adults a causative factor can be identified in more than 90% of cases. This is a rare case of ileo-colic intussesception induced by diverticulitis.
AJG – Vol. 95, No. 9, 2000
Extreme caution should be exercised in dealing with mass lesion at the ileo-cecal valve area. 574 Local control of hepatocellular carcinoma with proton beam therapy followed by curative liver transplantation Hillebrand Donald J, Bush David A, Concepcion Waldo, Hu Ke-Qin, Ojogho Okechukwu, Slatter Jerry D, Slater James A. Loma Linda University Medical Center, Loma Linda, California, United States. Purpose: To report the first patient in the U.S. with cirrhosis and localized hepatocellular carcinoma treated with proton beam therapy followed by curative liver transplantation Methods: A 54 years old male with hepatitis C virus Child-Pugh Class B (Child-Turcotte-Pugh 9) cirrhosis complicated by ascites, hepatic encephalopathy, and variceal bleeding was noted to have a 3.5 ⫻ 5.7 cm right liver lobe nodule on CT performed during transplant evaluation. Alpha fetoprotein was 289.0 ng/mL and biopsy confirmed hepatocellular carcinoma. Chest CT and bone scan were negative. The tumor was staged at Stage III (T3N0M0) of the modified TNM classification of the American Liver Tumor Study Group. The patient was listed United Network for Organ Sharing (UNOS) status 2B for liver transplantation. Proton beam therapy was performed with 63 Gy delivered to the radiographic extent of the tumor and a surrounding 1.0 –2.0 cm of non-cancerous liver (15 daily 4.2 Gy sessions). Results: The patient tolerated proton therapy well without significant changes in Karnoffsky Performance Status, quality of life index, weight, Child-Turcotte-Pugh Score, or overall clinical condition. Serial abdominal/ chest CT scans and bone scans demonstrated a complete response to therapy without visible tumor. AFP decreased to 5.5 ng/mL. Abdominal MRI failed to demonstrate the tumor. Liver transplantation was performed 296 days after initial listing (190 days after completing proton therapy). The explant revealed a 1.7 cm nodule that was 40% necrotic with only a peripheral rim of apparently viable tumor and no vascular invasion. No adjuvant chemotherapy was given intra- or postoperatively. Immunosuppression initially involved tacrolimus, mycophenolate mofetil, and prednisone but was rapidly tapered to tacrolimus monotherapy by 6 months after transplant. On follow up 238 days after transplantation he is clinically well with AFP 4.6 ng/mL and abdominal/chest CT scan and bone scan without evident tumor. Minimal recurrent hepatitis C is evident based on liver enzymes, HCV RNA level, and liver histology. Conclusions: Proton beam therapy of a large localized hepatocellular carcinoma in the setting of advanced decompensated cirrhosis was well tolerated and achieved local tumor control maintained over the 9 months on the UNOS waiting list. Curative liver transplantation was then performed in this patient without adjuvant chemotherapy which may accelerate recurrent post-transplant vital hepatitis. This is the first report of the curative combination of proton beam therapy and liver transplantation for hepatocellular carcinoma. 575 Ectopic pancreatic adenocarcinoma presenting as gastric outlet obstruction Hussain Ayub, MD, Goldstein Jeffrey A, MD, Shah Ashok, MD, Potter Gregory, MD, Chey William MD, Bessey Palmer MD. University of Rochester, School of Medicine, Rochester, NY, USA. A 63 year-old white male with no significant past medical history, presented with a three week history of postprandial nausea, vomiting, bloating and early satiety. He was admitted with a diagnosis of gastric outlet obstruction and underwent an esophagogastroduodenoscopy, which revealed a prepyloric gastric ulcer (jumbo well biopsies were negative for malignancy). At this point he was aggresively treated for peptic ulcer disease and H-pylori and his symptoms improved. The abdominal CT scan revealed moderate gastric distension and no evidence of a mass at the gastric outlet. The patient initially improved only to return 6 weeks later
AJG – September, 2000
with symptoms of gastric outlet obstruction. He underwent two successive upper endoscopies, which revealed grade IV esophagitis, residual amount of food in the stomach and antral stenosis, which was dilated with a 16mm hydrostatic balloon dilator. Despite this, his symptoms persisted. He had a repeat abdominal CT scan which revealed an intramural gastric mass /thickening in the antrum of the stomach measuring 5.5⫻6.2⫻6.0cm suspicious for primary gastric neoplasm, without any lymphadenopathy or liver lesion. The patient underwent gastric surgical resection. He recovered well after surgery. The pathology report revealed ectopic well-differentiated pancreatic type adenocarcinoma involving the entire gastric wall, with margins of resection free of carcinoma. Postoperatively he is doing well. There were 10 perigastric lymph nodes without evidence of metastases. We report a case of ectopic pancreatic adenocarcinoma presenting as gastric outlet obstruction. 576 Rapid weight loss causing the superior mesenteric artery (SMA) syndrome in a patient with chronic diarrhea Hussain Hamid, Vlodov Jane, Tenner Scott*. Maimonides Medical Center, Brooklyn, NY, United States. Purpose: We report a 24 year old Hispanic male who presented with nausea, vomiting, intermittent upper abdominal pain, and diarrhea for two years, and a 40 lbs. weight loss in the last six months. A prior evaluation included a normal stool C & S, O & P, normal colonoscopy and negative HIV serology. On examination he appeared asthenic and uncomfortable, abdominal examination was normal, his stool for hemoccult was negative. Electrolytes and CBC were normal, stool for culture and sensitivity, ova and parasite was negative. His abdominal X-ray showed a dilated stomach with air- fluid level in stomach and duodenum ‘Double Bubble sign’ consistent with high small bowel obstruction. An upper endoscopy revealed a dilated stomach with food residue, and antral mucosal erythema. The proximal duodenum was dilated and contained bilious fluid. An upper GI series showed a markedly dilated stomach with some thickening of the folds. The duodenal bulb and duodenal sweep to the level of the distal third portion were markedly dilated with an extrinsic pressure effect at the level of the transverse duodenum. The more distal small bowel was normal. An abdominal CT showed massive gastric distension and proximal duodenal dilatation. Clonoscopy was performed to evaluate the diarrhea and was normal. The presumptive diagnosis of Superior Mesenteric Artery Syndrome was made. The patient failed to improve with NGT suction and parenteral nutrition. On surgical exploration the stomach was dilated, duodenum was mobilized by extensive Kocher maneuver; the duodenum was markedly dilated up to the third portion. There was narrowing of duodenum where the superior mesenteric artery crosses distal to the third portion of duodenum. Duodeno-jejunostomy had done by using endo-GIA stapler. The patient did well post operatively. We present a young male with rapid weight loss due to chronic diarrhea that developed distal duodenal obstruction due to superior mesenteric artery compression. Since the Superior Mesenteric Artery Syndrome can occur in patient who lose weight rapidly due to loss of mesenteric fat and more acute angulation of the SMA. It should be considered in individuals with weight loss due to chronic diarrhea that develops high small bowel obstruction. Duodeno-jejunal bypass rather than gastro-jejunal bypass is the recommended treatment. 577 A novel and simple methodology to remove small stones and fragments from the dilated common bile duct after sphincterotomy Indrakrishnan Bhuvanendram, MD, FACG. Atlanta Gastroenterology Associates, Atlanta, Georgia, United States. Purpose: It is not uncommon to experience technical difficulties in clearing the common bile duct of small stones, fragments and other debris, particularly when the common bile duct is dilated. Small particles may escape
Abstracts
2579
from the balloon extraction and may not be retrievable by the basket. We describe a unique, but simple technique to remove the small stones and other organized debris, particularly in the setting of a dilated common bile duct after sphincterotomy. An eighty-year-old woman underwent an ERCP for choledocholithiasis and ascending cholangitis. The cholangiogram revealed a dilated common bile duct containing multiple gallstones at least twelve in number, measuring from 3–15 mm in diameter. Repeated attempts to extract the stones by Dormia basket and balloon catheter were only partially successful in fragmenting the stones and removing part of them after sphincterotomy. A repeat cholangiogram still revealed multiple small stones and fragments within the common bile duct in spite of an adequate sphincterotomy. At this juncture, a heater probe catheter (Olympus/ HPU) was passed directly into the proximal common bile duct through the sphinterotomized papilla. Continuous forceful water irrigation was used for 5–10 seconds to flush the stones and fragments out of the common bile duct. The small stones and the fragments were seen coming through the orifice with the water flow. The repeat cholangiogram showed no evidence of residual stones. The patient underwent an uneventful laparoscopic cholecystectomy later and was discharged home in good health. Forceful saline and sterile water irrigation is being used to remove the stones and fragments during the perioperative period directly through the choledochoscope or via T-tube. However, using forceful dynamic water irrigation with a heater probe to clear the common bile duct stones during the ERCP is not reported in the literature, to our knowledge. The heater probe catheter is very flexible through the scope and it is not larger than the balloon catheter or basket. It is readily available in the endoscopy units and it does not add much cost to the entire procedure. We believe that our technique is a time saving and efficacious alternative when difficulties are encountered in removing the small stones, fragments and debris from a dilated common bile duct after a sphincterotomy and may be safely applied under compatible circumstances.
578 Acute esophageal necrosis with spontaneous esophageal perforation in a patient with heat stroke Ismail Mohammad K, Johnson Lawrence W, Werkman Robert,* Smith Lacey. University of Tennessee, Memphis, TN, United States. Purpose: Acute esophageal necrosis (AEN) is an uncommon cause of esophageal perforation. Most cases have no etiology, although it mostly affects elderly patients with grave conditions such as neoplasm, renal failure, infection or recent surgery. Heat stroke causing AEN with spontaneous esophageal perforation, to our knowledge, has never been reported in literature. We report a case of AEN with spontaneous esophageal perforation in an elderly patient following heat stroke. Methods: Case Report: This 74-year-old male was admitted to ICU with heat stroke in a hot summer day, with a core temperature of 107 °F. Patient was intubated and was treated for heat stroke, with subsequent complications of rhabdomyolysis and aspiration pneumonia. He transiently improved but on the tenth ICU day, he developed upper gastrointestinal bleeding, including hematemesis and melena. At that time, he had a hemoglobin of 10 gm/dl, WBC count of 18000, creatinine of 2.3 mg/dl, and a normal prothrombin time. An upper endoscopy was performed. EGD demonstrated a rim of normal mucosa in the most proximal esophagus, but rest of the mucosa distally down to GE junction was black, friable with diffuse circumferential ulceration. There was also a concern of possible spontaneous perforation in the distal esophagus at 30 cm from incisors. Endoscopist decided to continue the procedure due to the presence of fresh blood in stomach. Multiple ulcers were noted in the stomach and duodenum with mild inflammation of the mucosa (no diffuse necrosis). One 2 cm duodenal ulcer had active oozing that required endoscopic therapy. Emergent surgery, for the endoscopic finding of AEN and esophageal perforation, confirmed ischemic changes with necrosis in the esophagus, and free perforation in the distal esophagus (with bilateral pleural effusion). Another perforation was noted in the duodenum. A diverting cervical end esophagostomy with duodenal perforation repair and vagotomy was performed,
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