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A BLEEDING DUODENAL LIPOMAEmad H. Elbadawy, M.D., Marina S. Marcu, M.D., Khaled Issa, M.D.and Michael Springer, M.D.*. Internal Medicine, Fairview Hospital,Cleveland, OH.

Introduction: Duodenal lipomas are very rare source of acute uppergastrointestinal bleeding that could be diagnostically challenging. Wedescribe a case of massive melena caused by a 2 cm pedunculated duodenallipoma in a patient receiving warfarin for atrial fibrillation.Case: A 64–year old male presented with history of dizziness and passageof 4 tarry bowel movements for 1 day. Past medical history was significantfor paroxysmal atrial fibrillation and hemicolectomy for diverticulitis.Home medications included warfarin, digoxin and nadolol. Physical ex-amination demonstrated systolic pressure of 102 mmHg, irregular pulse of96 with no orthostatic changes. The abdomen was soft with normal bowelsounds. Laboratory investigations on admission revealed: hematocrit of37%, hemoglobin of 12.6 g/dL, INR 6.5 and prothrombin time 32.6.Warfarin was stopped and patient received two units of fresh frozen plasmato correct his coagulopathy. After 6 hours, hematocrit and hemoglobindropped to 30.9 and 10.5 respectively and repeated INR was 2.4. Initialesophagogastroduodenoscopy revealed fresh blood in the duodenum distalto the ampulla with no evidence of active bleeding and no lesion wasidentified. Repeated endoscopy of the upper gastrointestinal tract was donewith the ERCP scope and showed 2 cm pedunculated mass with centralumbilication inferior to the ampullary area with no signs of active bleeding.Endoscopic electrosurgical snare polypectomy was performed and the masswas removed. The polypoid mass measured 2.0 x 1.1 x 1.1 cm andpathological diagnosis was submucosal lipoma.Discussion: Lipomas have been described in all parts of the gastrointestinaltract with the majority found in the colon (65–75%). Duodenal lipomas arerare and they are usually located in the second portion of the duodenumwhere they arise from the submucosal adipose tissue. Acute upper gastro-intestinal hemorrhage presenting with severe melena is a very rare com-plication with few cases reported in the English literature. Most commonpresentations are chronic iron deficiency anemia due superficial ulcerationsand recurrent bleeding, epigastric pain and intussusception. Snare polypec-tomy can be easily performed on pedunculated tumors but surgical extir-pation is indicated in sessile duodenal lipomas because of the high risk ofduodenal perforation.

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GASTROCOLIC FISTULA: CASE REPORT AND REVIEW OFLITERATUREEmad H. Elbadawy, M.D., Marina S. Marcu, M.D., Aymen Atallah,M.D., Rakesh Bhalla, M.D. and Michael Springer, M.D.*. InternalMedicine, Fairview Hospital, Cleveland, OH.

Introduction: Gastrocolic fistula was first described by Haller in 1775 andwas most frequently reported as a complication of prior surgery for pepticulcer disease and malignancy of the stomach or the colon. We describe acase of gastrocolic fistula as a complication of recurrent gastric ulcer.Case: A 39 years old female presented with 5–week history of diarrhea and10 lbs weight loss. Patient complained of nausea and abdominal pain butdenied any vomiting, hematemesis or hematochezia. Past medical historywas significant for benign gastric ulcer complicated by gastric perforationin 1994 that was surgically repaired.

On examination, she weighed 100 pounds and stood 5 foot and 6 inch,with signs of malnutrition and guaiac negative stool. Initial laboratoryevaluation showed: iron deficiency anemia, hypokalemia, hyponatremiaand hypoalbuminemia. Stool examination was negative for ova, parasites,occult blood and cultures were negative for enteric pathogens. Colono-scopic evaluation was unremarkable. Esophagogastroduodenoscopy re-vealed fecal residue in the stomach with 5 cm deep penetrating gastric ulcerwith fistulous opening in the antral area and gastroscope was passed easilythrough that opening into the colon. Upper gastrointestinal radiographsdemonstrated contrast filling of the colon within 6 minutes of oral admin-

istration. Surgical excision of the fistulous tract was performed with va-gotomy, hemigastrectomy, Billroth II anastomosis and transverse colec-tomy. Pathological examination showed no evidence of malignancy.Discussion: Gastrocolic fistula was a well recognized complication ofprevious gastric surgery and malignancies of the colon and the stomach.Recent reports indicate that 50% to 75% of cases are secondary to benigngastric ulcers. Uncommon causes of gastrocolic fistula include: inflamma-tory bowel disease, pancreatic carcinoma and chronic pancreatitis. Patientsusually present with abdominal pain, diarrhea, weight loss and vomiting.Unusual presentation with cold diarrhea after drinking ice tea or reddiarrhea after eating red gelatin had been reported. Surgical management isalways required though medical management with anti–ulcer therapy wassuccessful in some patients with high surgical risk. Gastrocolic fistulashould be considered in the differential diagnosis of patients presentingwith chronic diarrhea, malabsorption and weight loss.

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INTESTINAL TUBERCULOSIS MIMICKING AS CROHN’S:THE DILEMMA CONTINUESShailender Singh, M.D., Mohinish Chhabra, M.D. and StevenLichtenstein, D.O.*. Department of Medicine, Mercy Catholic MedicalCenter, Darby, PA and Chhabra Gastroenterology & Endoscopy Clinic,Chandigarh, India.

Purpose: A 30–year–old male presented with early satiety, vomiting andforty pound weight loss of 3 months duration. His past medical history wasunremarkable and he was not on any medications. The physical examina-tion along with the vital signs was within normal limits. Laboratoryfindings: CBC, basic chemistry panel and chest radiography was normal.EGD showed stomach distended with clear fluid, diffuse nodularity, ulcer-ation and stricturing involving the first and second part of duodenum. Noactive ulcer seen. Biopsy from stomach and duodenum revealed non–caseating granulomatous inflammation. The biopsy specimens were nega-tive for acid fast bacilli. There was no evidence of malignancy or lym-phoma. Colono–ileoscopy performed revealed multiple skip areas ofdiscrete superficial ulcers and pseudopolyps resembling crohn’s disease(CD). The Ileo–caecal valve was edematous, ulcerated, hyperemic andileum showed loss of vascular pattern with granularity. Based on endo-scopic findings CD was thought to be the most likely diagnosis withtuberculosis (TB) being the major differential diagnosis. CT scan of ab-domen was negative for abdominal lymphadenopathy. In view of highprevalence of tuberculosis in the developing countries the patient wascommenced on anti–tuberculous treatment which resulted in completeresolution of symptoms.Discussion: Intestinal TB and CD are chronic granulomatous disorders thatare at times difficult to differentiate and pose a major diagnostic problemfor the clinicians where these conditions coexist. Clinically and radiolog-ically, the diseases are often similar. The final diagnosis depends largely onhistopathology and the presence or absence of acid fast bacilli. However,our case also exemplifies the often non–specific nature of endoscopicbiopsies and radiology in the diagnostic work–up of tuberculosis. It isessential to differentiate between the two conditions since treatment forcrohn’s with steroids or tumor necrosis factor can lead to worsening of thesymptoms if the underlying cause is tuberculosis. Duodenal strictures andcolonic skip lesions as seen in our patient suggest CD, they being extremelyuncommon in tuberculosis. In developing countries CD is uncommon andremains largely a diagnosis of exclusion. In such areas intestinal TB shouldbe suspected and a trial of anti–tuberculous treatment is warranted despitenegative histology, smear or culture results.

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PANCREATICO–PLEURAL FISTULA: AN UNUSUAL CAUSEFOR RECURRENT RIGHT–SIDED PLEURAL EFFUSIONShailender Singh, M.D., Mohinish Chhabra, M.D., Amandeep Gill, M.D.and Steven Lichtenstein, D.O.*. Department of Medicine, MercyCatholic Medical Center, Darby, PA and Chhabra Gastroenterology &Endoscopy Clinic, Chandigarh, India.

S131AJG – September, Suppl., 2002 Abstracts