A 20-year-old male without medical history presented with a 4 monthhistory of progressive epigastric pain with associated non-bloody emesis,anorexia and a 25-pound weight loss.

Physical exam revealed a soft, non-distended abdomen with epigastrictenderness without guarding, rebound or organomegaly. Stool was hemoc-cult negative. Remarkable laboratory studies included: WBC 4,400; Hct36%, MCV 77, AST 63 U/L (normal, 0–35), ALT 45 U/L (normal, 0–35),Alkaline phoshatase 180 U/L (normal, 30–130) and total bilirubin 0.7mg/dl.

Abdominal CT showed scattered hypodensities in the liver, splenomeg-aly, mesenteric lymphadenopathy and diffuse gastric wall thickening (Fig-ure 1A). Upper endoscopy revealed diffusely nodular gastric mucosa withantral narrowing and ulceration (Figure 1B). Biopsies showed multiplenoncaseating granulomas (Figure 1C). Acid fast bacilli (AFB) and fungalstains were negative. Liver biospy showed large noncaseating granulomasin portal areas and within the lobules (Figure 1D, top), while an omentallymph node excision revealed granulomatous inflammation with focalfibrinoid necrosis (Figure 1D, bottom). Stains for fungal and AFB organ-isms were negative.

Serology for rheumatoid factor, antineutrophil cytoplasmic antibodies,VDRL, hepatitis A, B, C, cytomegalovirus, Epstein-Barr virus were neg-ative. Angiotensin-converting enzyme level was normal. A protein-purifiedderivative skin test was nonreactive, with a normal anergy panel response.Colonoscopy, small bowel series, chest CT and gallium scan were normal.The patient was begun on oral prednisone. After only 4 days steroidtherapy, he was symptom-free and was discharged. There are only fewanectodal reports of corticosteroid efficacy in isolated gastohepatic sar-coidosis. Our case further suggests that acute abdominal pain due toprimary gastrohepatic disease can be successfully treated with oral corti-costeroids.

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MEDIASTINAL ABSCESS AS A COMPLICATION OF A FISHBONE IN THE ESOPHAGUSBlanche Y. Fung, M.D., Lawrence J. Brandt, M.D., M.A.C.G.*.Montefiore Medical Center, Bronx, NY.

Swallowing a fish bone is usually an innocuous event. These two casesillustrate mediastinal abscess as a complication, and remind us to excludethis condition when patients have persistent symptoms.Case 1: D.R. is a 34 y.o. man who presented to the ED with pain in his leftneck after swallowing a fish bone. Physical examination was negative.

Cervical radiographs revealed no foreign body or soft tissue abnormality.The patient was discharged home. The next day, he returned now com-plaining of dysphagia and odynophagia. Endoscopy revealed a superficial,3cm linear abrasion in the mid-esophagus. A CT scan of the neck wasnormal. Once again, he was discharged home. One week later, he returnedto the ED with increasing left-sided neck pain and decreased neck motility.Cervical films now showed prevertebral soft tissue swelling with locules ofair. A CT scan showed a hypopharyngeal abscess extending into thesubsternal space. The abscess was incised and drained. He was treated withIV antibiotics and discharged two weeks later. He has done well sincedischarge.Case 2: C.S. is a 73 y.o woman who came to our ED after swallowing afish bone. Upper endoscopy demonstrated the fish bone in the cervicalesophagus, spanning the lumen with both ends embedded in the esophagealwall. A biopsy forceps was used to remove the bone. The patient saw herprimary doctor a week later and complained of dysphagia and odynopha-gia. He attributed her symptoms to esophageal abrasions, and prescribedsucralfate. The patient had slight symptomatic improvement.

Two weeks later, she continued to have dysphagia, odynophagia, andnow back pain. She went to the hospital, where a CT scan showedesophageal perforation. The day after admission, she developed fever andshortness of breath. A repeat CT scan showed bilateral lobar pneumoniaand a 5cm density partially compressing the trachea. She was intubated andstarted on imipenem, metronidazole, and TPN. Blood cultures grew Bac-teroides spp. Three days after admission, she went to the OR for drainage.Mediastinal cultures also grew Bacteroides spp. Subsequently, the patientimproved and was extubated on post-op day 5.

Esophageal foreign bodies are a common reason for GI consultation, butall physicians should have a heightened sense of concern for esophagealperforation and mediastinal abscess formation especially when the foreignbody is sharp, like a fish bone. Persistence of symptoms should prompt aCT scan to exclude these complications. Even if it is normal, close fol-low-up of the patient is advised.

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41 YEAR-OLD FEMALE WITH FAILURE TO THRIVE ANDABDOMINAL PAINYogesh Patel, D.O., Mani Mahdavian, M.D.*. Lutheran GeneralHospital, Park Ridge, IL.

A 41 year old female was seen for persistent sharp intermittent pelvic painassociated with a change in bowel pattern. She also complained of earlysatiety, bloating, and a seventeen pound weight loss over the last twomonths. She adhered to a low fat diet and had no complaints of mal-absorption or steatorrhea. She had a negative workup including a pelvicultrasound and a laparoscopy . A colonoscopy by a non-gastroenterologistwas not revealing due to inadequacy of prep despite her completing of theprep.

She was a long distance runner until a recent diagnosis of bronchiectasis.Past medical history is significant for a seven-year history of asthma.Family history and social history were noncontributory.

Physical exam was significant for thin build, short stature, and mildrespiratory distress with persistent cough. Pulmonary exam demonstrateddiffuse bilateral crackles. Clubbing was also noted on patient’s fingernails.

A CT scan of the abdomen and pelvis was recommended which revealedcomplete atrophy of the pancreas with fatty replacement (see figure 1). Adiagnosis of cystic fibrosis was entertained and confirmed by geneticstudies revealing a homozygous Delta F508 mutation. She had been re-ferred to a local cystic fibrosis center and has been relatively symptom freefrom the GI and pulmonary standpoints.

S136 Abstracts AJG – Vol. 98, No. 9, Suppl., 2003

In the U.S. the median age of diagnosis of cystic fibrosis is at six months,with greater than 90% of patients being diagnosed by the age of eight. Ourpatient adds to a growing list of cystic fibrosis patients diagnosed inadulthood. Marked phenotypic differences in clinical severity of cysticfibrosis ranging from mild impairment to end stage disease in early adult-hood have been demonstrated in patients with the same genotype. Thepatient described in this case adds to a growing database of adult diagnosedcystic fibrosis, confirming that longevity is possible with cystic fibrosis.Gastroenterologists should consider cystic fibrosis in adult patients withlongstanding abdominal pain, mal-absorption, idiopathic chronic pancre-atitis, and/or intestinal obstruction.

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NEPHROTIC SYNDROME DURING TREATMENT WITHPEGYLATED INTERFERON ALFA AND RIBAVIRIN. A CASEREPORTGiancarlo Spinzi, M.D.*, Paolo Grillo, M.D., Natalia Terreni, M.D.,Giovanna Mandelli, M.D., Alessandra Beltrame, M.D.,Carlo Grillo, M.D., Giorgio Minoli, M.D. Valduce Hospital, Como,Italy and S.Anna Hospital, Como, Italy.

This 41-year-old male nurse was referred, in November 2001, to theEmergency Department for asthenia, hypotension and anasarca. In 1983 hehad presented high transaminases and was HBsAg positive; liver biopsyhad found persistent chronic hepatitis. In 1992 he was found positive forHCV, with evidence of HCV-RNA in his serum (PCR). On 9 november2001, in view of the persistently high transaminases, heavy viral load andgenotype 1b, the patient started treatment with Peg Interferon alfa 2b (1.5mcg/ Kg/ week) and Ribavirin (800 mg/day). He was positive for HBsAgand antiHBe, anti-Delta negative (HBV-DNA PCR �700 copies/ml), IgManti HBc 0.06, anti-HIV negative. Pre-treatment renal function was normal.On 20 November four days after the second injection of Peg IFN, thepatient was admitted to hospital for anasarca. Biochemistry gave serumcreatinine 0.95 mg/dl (vn 0.6–1.3), albumin 0.92 g/dl (vn 3.4–5.0). Pro-teinuria was 16.9 g/ 24h. Immunological tests were all negative. A renalbiopsy was taken. Ultrastructural examination showed a normal basementmembrane in the capillary loops. The endotelia showed focal areas ofactivation with tubule reticular structures. A form of minimal changeglomerular disease was diagnosed, and bolus steroids were started. Theproteinuria gradually dropped and the protein profile improved. In this casethere appear to be a close link between the nephrotic syndrome and Peg IFNand/or ribavirin, considering the lack of any other detectable causes ofnephropathy, systemic diseases or evident infection, the fact that the patientused no other medications besides acetaminophen and the time profile ofthe events.No renal toxicity has been reported during Ribavirin mono-therapy. The electron microscopic finding of tubule reticular structuresstrengthens the correlation with IFN. These inclusions are anastomizedtubular structures, with a periodicity of 24 nm, internal vacuole 8 nm andmaximum size 100 nm, found inside the rough endoplasmic reticulum,

chemically made up of phospholipids and acid glycoproteins, probablycorrelated with endothelial exposure to IFN. Renal damage during Peg IFNis infrequent and impredictable, but close observation is called for in patientbeing treated for chronic hepatitis.

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SPLENIC ARTERY PSEUDOANEURYSM IN A YOUNG MANWITH CHRONIC PANCREATITISLisa Motavalli, M.D. Ira Merkel, M.D., FACG* UMDNJ–Robert WoodJohnson University Hospital, New Brunswick, NJ.

A 36 year-old man with a two-year history of alcohol induced chronicpancreatitis presented to the emergency room after being found unrespon-sive at home. Two years earlier he underwent a pancreatic cyst-enterostomyfor pain from pseudocysts. Three weeks prior to this evaluation he had aone-week hospitalization for abdominal pain, fever and Klebsiella bacte-remia. Abdominal CT scan did not reveal a source of infection. Constipa-tion was his only complaint after discharge. Emergency medical servicesfound the patient unresponsive with pulseless electrical activity and resus-citation was initiated. On arrival, physical exam revealed an intubatedmale, with no palpable distal pulses and cold extremities. Abdominal examwas normal and there was no stool in the rectal vault. A nasogastric tuberevealed bilious fluid. Hemoglobin was 5.6 g/dl.

CT of the abdomen demonstrated a 12 7.5 cm hematoma in the upperabdomen and retroperitoneum, with a tubular structure suggesting a splenicartery pseudoaneurysm. The addition of intravenous contrast revealed activeextravasation of blood into the hematoma. Angiography revealed a 4.5 cmpseudoaneurysm of the proximal splenic artery. Embolization with coiling wasattempted but was unsuccessful secondary to anatomic limitations. Subse-quently, an exploratory laparotomy, splenic artery ligation and splenectomywere performed. Despite a complicated post-operative course, the patient wasdischarged in stable condition on the forty-sixth hospital day.

Splenic artery pseudoaneurysm is a complication of pancreatitis causedby enzymatic degradation of the arterial wall, or from erosion of a pseudo-cyst into a location that contains an artery.1 The mortality rate withhemorrhage can be as high as 60%.1 The differential diagnosis of pancre-atitis-associated gastrointestinal bleeding includes Mallory-Weiss tear, gas-tritis, peptic ulcer disease, portal or splenic vein thrombosis, pancreaticinflammation and pseudoaneurysms.2 This case reinforces the need toconsider the latter diagnosis when presented with pancreatitis-associatedhemorrhage because it is a serious complication that can rapidly becomelife threatening.

1. Forsmark C, Wilcox C, Grendell J. Endoscopy- negative upper gas-trointestinal bleeding in a patient with chronic pancreatitis. Gastro-enterology 1992;102:230–239.

2. de Perrot M, Berney T, Buhler L, et al. Management of bleedingpseudoaneurysms in patients with pancreatitis. British Journal ofSurgery 1999;86:29–32.

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ACUTE SEVERE UPPER GASTROINTESTINAL BLEEDINGFROM EROSION OF THE SPLENIC ARTERY ANEURYSM, ACASE REPORTAndrew D. Guidroz, M.D. Subbaramiah Sridhar, F.R.C.P.(Edin)*Vinayasekhara Reddy, M.D. Urooj Ahmed, M.D. Urias Cuartas, M.D.Vernon Spaulding, M.D. Ayaz Chudhary, M.D. Samuel Mietling, M.D.Medical College of Georgia, Augusta, GA.

Background: Visceral artery aneurysms occasionally rupture and causecatastrophic bleeding which carry high morbidity and mortality. UpperGastrointestinal bleeding in the setting of acute pancreatitis is common butbleeding from ruptured visceral aneurysms is a rare entity. We report apatient who developed an acute major upper GI bleeding from an erodingsplenic artery aneurysm.Patient: A 44-yr-old patient was admitted to a peripheral hospital formanagement of acute severe pancreatitis. On day 12 the patient developed

S137AJG – September, Suppl., 2003 Abstracts