& very rarely reported. Foreign bodies in the esophagus may cause esoph-ageal perforation and their removal with a rigid esophagoscope is consid-ered relatively safe, however, may cause severe morbidity and mortality.

A 37–yr. white male patient was seen in a primary hospital for esoph-ageal meat bolus impaction. Rigid esophagoscope was inserted with dif-ficulty. During the procedure the patient developed chest pain and dyspnea.Chest X–ray revealed pneumomediastinum. The patient was transferred toThe Medical College of Georgia for management. Upon arrival, the pa-tient’s respiratory rate was 24/min., the heart rate was 90/min., & a normalbody temp. Subcutaneous emphysema was noted in the neck. Lab param-eters revealed Hb. 11.4g%, WBC 15800 with predominant polymorphs.Gastrograffin swallow identified a small perforation at the level of thecricopharyngeus. The patient was intubated & ventilated. Therapeuticupper endoscope was passed to the level of cricopharyngeus and advancedto 38cms to identify blind pouch. No foreign body was found. Severalwashings did not reveal an opening in to the stomach. The endoscope waswithdrawn which identified an induration at the level of cricopharyngeus.Air insufflation revealed the true esophageal lumen. The endoscope wasthen advanced through the esophagus into the stomach & the duodenum.No foreign body was discovered. A naso–duodenal feeding tube wasplaced with aid of the endoscope. CT scan of the chest demonstrated air inthe mediastinum, peritoneum & in the retroperitoneal space. The patientwas managed with IV antibiotics, enteral feedings and monitored forinfection. Repeat CT scans, contrast swallows & endoscopies at 1, 2 & 3weeks confirmed progressive healing of the esophageal dissection andresorption of mediastinal & retroperitoneal air. The patient was dischargedhome & followed frequently. He remains healthy without any complica-tions.Conclusions: Unlike in the past, the above patient was safely managedconservatively. Although rigid esophagoscopy is considered safe, is notwithout complications even in the hands of experienced clinicians. There-fore, flexible therapeutic endoscopes should be used as a first choice in themanagement of foreign bodies in the esophagus. Additionally, non–opera-tive management for esophageal dissection should be considered in someinstances.

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INTESTINAL PERFORATION IN A PARASTOMAL HERNIA BYA MIGRATED PLASTIC BILIARY STENTSandeep N. Patel, D.O. and John M. Levey, M.D.*. Gastroenterology,University of Massachusetts, Worcester, MA and Gastroenterology,Worcester Medical Center/Fallon Clinic, Worcester, MA.

Purpose: Organ perforation is a well–described complication of plasticbiliary stent placement. Most commonly, a stent will cause duodenalperforation while still in the area of the biliary system. Less frequently, aperforation occurs as a result of stent migration into the distal luminal GItract. We describe the first reported case of a plastic bilary stent causingperforation inside a parastomal hernia.Methods: An 81 year–old male was admitted to the hospital with left lowerabdominal pain and swelling around his colostomy site. His past medicalhistory was significant for coronary artery bypass, nephrectomy for renalcancer, severe COPD and colostomy for diverticulitis. Two weeks prior tothis admission the patient had developed cholangitis for which he under-went an ERCP at that time revealing a large ovoid filling defect in thecommon bile duct. Owing to patient instability, an 8.5 French 7cm plasticbiliary stent was placed for drainage. On admission, physical exam wasremarkable for swelling, redness, and tenderness around the colostomy site.Pertinent laboratory data revealed white blood cell count of 17,500 uL, totalbilirubin 6.7 mg/dl, alkaline phosphatase 563 U/dl, ALT 52 U/L, AST 38U/L, and a normal amylase. The patient was taken for ERCP with thepresumed diagnosis of stent occlusion. The scout film revealed migrationof the stent into the left lower quadrant with no evidence of free air. Thecommon duct stone was extracted uneventfully. Over the next day, thepatient’s left lower quadrant pain persisted with increased swelling and

tenderness around the colostomy site. He was taken to the operating roomfor colostomy revision.Results: Operative findings included incarcerated small bowel in a paras-tomal hernia. The biliary stent was at the site of perforation in the segmentof bowel inside the hernia sac. A segmental resection of small bowel wasperformed and the parastomal hernia was repaired. The patient was dis-charged on post–op day seven, and has been without symptoms after threemonths of follow–up.Conclusions: Intestinal perforation in the setting of stent migration isfortunately an uncommon occurrence. In our review, there have been 19such reported cases with a majority occurring in the duodenum. Wedescribe the first case of a plastic biliary stent causing perforation of bowelinside a parastomal hernia.

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GASTRIC VARICEAL BLEED DUE TO A “WANDERINGSPLEEN”Khiem D. Nguyen, M.D., Manish Dhawan, M.D., Sumir Patel, M.D.,Sangeeta K. Gulati, M.D., Michael Scheidler, M.D., Radheshyam M.Agrawal, M.D.* and Andrew Thomas, M.D. Department ofGastroenterology, Allegheny General Hospital, Pittsburgh, PA andDepartment of Surgery, Allegheny General Hospital, Pittsburgh, PA.

Case Report: A 24–year–old white female with prior left congenitalposterolateral diaphragmatic hernia repair was admitted for anemia. Sherecently required a C–section due to acute pancreatitis and gestationalthrombocytopenia. Her admission H/H and platelets were 6.1/18.5 and287K respectively. Despite transfusing 5 units of PRBC’s, her H/H con-tinued to decline.

Detailed hematological work–up, LFT, amylase and lipase were normal.An abdominal CT showed an inferiorly placed spleen and dilated LUQvenous system.

An EGD revealed thickened gastric folds suspicious for gastric variceswithout active bleeding in the fundus. An abdominal MRI demonstratedfundic varices without a splenic vein thrombosis. A liver–spleen scanshowed an abnormally placed spleen with normal colloid shift. Later, thepatient developed hematochezia. Repeat EGD confirmed fundic variceswith stigmata of recent bleed. At laparotomy, splenectomy was performedfor a chronically twisted splenic hilum and scarred splenic vessels. 4 weekslater, an EGD showed complete resolution of the gastric varices.Discussion: To our knowledge, this is the first case report of bleedinggastric varices due to a wandering spleen. Esophagogastric varices are aconsequence of portal hypertension. However, isolated gastric varices tendto result from left portal hypertension due to splenic vein obstruction.

A wandering spleen is a rare clinical diagnosis. Evidence suggests anembryological error of the spleen’s primary supporting ligaments.

Due to ligament laxity during pregnancy, the spleen often “wanders” ina young, often multiparous, woman during child–bearing years. Spleno-megaly from malarial infection or neoplastic process can cause lengtheningof the splenic pedicle and allow the spleen to be mobile. Prior studiespostulated that the congenital type of wandering spleen is due to a longpedicle, and the acquired type is from splenic enlargement and a laxabdominal wall.

Most wandering spleens are asymptomatic and treated conservatively.The most common symptomatic presentation is an acute abdomen fromsplenic torsion or infarct.

Abdominal ultrasound, CT and MRI are excellent means of diagnosingthis clinical entity. When isolated gastric variceal bleeding is associatedwith a wandering spleen, splenopexy or splenectomy is a definitive treat-ment.

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A CASE OF OBSCURE GASTROINTESTINAL BLEEDINGAmit Rastogi, M.D. and Miguel Regueiro, M.D.*. Gastroenterology,Hepatology and Nutrition, University of Pittsburgh Medical Center,Pittsburgh, PA.

S150 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002

Introduction: Obscure gastrointestinal bleeding (GIB) refers to bleedingof unknown origin that persists or recurs after initial endoscopy (upperendoscopy and / or colonoscopy). It can be occult or overt. The small bowelis the most likely source of bleeding when upper and lower endoscopy arenegative and there is continuing blood loss. We present a case of obscureGIB that turned out to be due to a Gastrointestinal stromal tumor (GIST)in the third portion of duodenum. This is an uncommon site and presen-tation of GIST.Case Report: A 79 years old male with past medical history of polycy-themia vera, hypertension, atrial fibrillation and cerebrovascular diseasewas admitted with the history of passing melenic stools and low hematocrit.He had been having similar episodes over the last three years and repeatedupper endoscopy and colonoscopy were unrevealing. He also gave historyof coffee ground emesis. On exam, his conjunctiva was pale, abdomenrevealed splenomegaly and rectal exam showed melenic stools. An en-teroscopy was performed. There was a 2 cm submucosal mass with centralumblication and active oozing of blood , seen in the third portion of theduodenum. The patient was referred for surgery. Preoperative enteroscopydone to exactly localize the lesion, revealed another area of abnormalnodular mucosa in the proximal jejunum about 6–7 cms distal to theduodenal mass. Resection of both the lesions was performed. Histopathol-ogy and immunophenotyping of the duodenal mass showed that it was aGIST. The jejunal lesion proved to be a lymphoma. The patient is doingwell 8 months post surgery.Discussion: GISTs are nonepithelial mesenchymal tumors arising from thegastrointestinal tract. They are most commonly seen in the stomach andsmall intestine. Immunophenotyping is used to differentiate GIST fromother mesenchymal tumors. GISTs express CD117 Ag ( part of C–kitreceptor) and are negative for muscle cell markers (desmin, actin). Theycan present with abdominal pain, intestinal obstruction, intestinal perfora-tion, bleeding or more commonly may remain asymptomatic. Treatment issurgical resection. Malignant cells in GIST overexpress the product ofc–kit protooncogene which is a tyrosine kinase called KIT. For unresect-able or metastatic GIST– STI 571 (Glivac), which is a tyrosine kinaseinhibitor, has been found to be effective.

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MESENTERIC VARICES: AN UNUSUAL SOURCE OFGASTROINTESTINAL BLEEDINGThomas J. Birdas, M.D., Raye J. Budway, M.D., Pavlos K. Papasavas,M.D., Deborah Evers, B.S.N. and Philip F. Caushaj, M.D.*.Department of Surgery, The Western Pensylvannia Hospital – TempleUniversity School of Medicine Western Clinical Campus, Pittsburgh,PA.

Purpose: Mesenteric varices represent an unusual source of lower GIbleeding in patients with portal hypertension. Only sporadic cases andsmall series have been reported, mainly in the non–English literature. Wereport the case of a 62 y/o female with alcoholic cirrhosis, hematocheziaand previous abdominal surgery. Endoscopic evaluation (EGD/ colonos-copy) failed to identify the source of bleeding, while a tagged RBC scanlocalized it to the right lower quadrant. Localized mesenteric varices werenoted during the venous phase of mesenteric angiography, without activeextravasation. The patient underwent a laparotomy, during which thevarices were seen on a distal ileal loop as well as on the adhesions formedbetween this loop and the abdominal wall – a result of the prevouslaparotomy. A resection with primary anastomosis was performed. Post-operatively the patient had no evidence of further bleeding but developedliver and multi–organ system failure, which eventually led to her death.Mesenteric varices should be included in the diagnosis of patients withportal hypertension and lower gastrointestinal bleeding, particularly in theface of prior abdominal surgery.

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OCCULT PERINEAL ENDOMETRIOSIS AND THE USE OFTRANSANAL ULTRASOUND: 2 CASE REPORTSRobert Akbari, M.D., Deborah Evers, B.S.N., Daniel Gagne, M.D.,Bradford Sklow, M.D., Thomas Read, M.D. and Philip Caushaj, M.D.*.Department of Surgery, The Western Pennsylvania Hospital, Pittsburgh,PA and School of Medicine, Clinical Campus, Temple University,Pittsburgh, PA.

Introduction: Perineal endometriosis is a rare clinical entity, which typi-cally presents as cyclic perineal pain in women with a history of priorepisiotomy. Transanal ultrasound can be used to localize the lesion anddefine its relation to surrounding structures, facilitating diagnosis andtreatment. In order to better understand this condition and emphasize theutility of transanal ultrasound in this setting, two recent cases of perinealendometriosis are presented.Methods: Chart review; including review of histology, ultrasonographicimages, and intraoperative photographs.Results: The two cases of perineal endometriosis presented in the typicalfashion. The lesions were localized to the perineum and defined in relationto surrounding structures with the help of transanal ultrasound. The lesionswere excised successfully with histologic confirmation of the diagnoses.Both patients had relief of symptoms postoperatively.Discussion & Conclusions: Perineal endometriosis is a rare condition,which is being diagnosed more frequently. The pathogenesis is likelyrelated to the transplantation of shed zona basilis cells from the endometriallining of the uterus to a recent episiotomy incision. Both patients hadtypical presentations and transanal ultrasonography revealed anechoic le-sions and displayed their size and position. This facilitated curative exci-sion in both cases. These cases illustrate the utility of transanal ultrasoundin this clinical setting.

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RESOLUTION OF INTRACTABLE DIARRHEA ANDABDOMINAL PAIN IN A PATIENT WITH SHORT–BOWELSYNDROME USING OCTREOTIDE LONG ACTING RELEASEFOLLOWING FAILED OCTREOTIDE THERAPYAsif Qadri, Anil Singh, Robin Midian–Singh, Ronald Crock and MichaelGurney*. Internal Medicine Department, Affiliated Hospitals at Canton,Canton, OH.

Purpose: Short–bowel syndrome (SBS) represents a state of malabsorp-tion, malnutrition, and weight loss occurring after extensive resection of thesmall–bowel. With SBS, total parental nutrition (TPN) is initiated to allowhealing of anastomoses and to assess basal losses of water and electrolytes.In general, patients with jejunal length of less than 100 cm cannot maintainadequate nutrient absorption on oral feeding and will require long–termparenteral nutrition. The nutritional goal is to resume enteral feedings onthe premise that bowel adaptation takes place throughout the residualintestine.

A 41–year–old Caucasian male with a history of Hepatitis C, drug abuse,tobacco abuse was brought to the emergency room after receiving multiplegunshot wounds to the abdomen. He underwent surgery and was noted tohave injury to the small–bowel, with subsequent resection of approxi-mately 45 cm of both jejunum and distal ileum. Two days later, hedeveloped severe abdominal pain and was taken back for exploratorysurgery revealing extensive small bowel necrosis secondary to mesentericinfarction. Approximately 195 cm of small–bowel were removed. Theduodenal length was estimated to be slightly more than 12 inches. Thesurgeon, utilizing the remaining 18 inches of small bowel past the ligamentof Treitz, created a functional enteroenteric to ileocolic anastomosis. TPNwas begun with enteral feedings resumed. Small Bowel Follow Throughshowed bowel length of 70 cm. The patient complained of frequent loosestools and was started on octreotide 50 micrograms bid. The patient wasable to tolerate a normal diet but diarrhea and pain persisted. The patientrequired numerous hospitalizations secondary to this. During last hospital-

S151AJG – September, Suppl., 2002 Abstracts