A 60 year old woman with past medical history of diabetes and hyper-tension presented with a 3 day history of nausea and vomiting of coffee-ground material. She reported a 20lb weight loss in the previous 4 to 5months. She denied epigastric pain, dysphagia or history of NSAID use.The family history was notable for colon cancer in the patient’s father andbrother. Physical examination remarkable for temp of 38.6 C, conjunctivalpallor and mild epigastric tenderness. Labs: WBC14,300 with 73% PMNand 16% Bands. Hgb 8.9g/dl, MCV 79fl, RDW 18.4%. The chemistrieswere notable for a normal SMA-7 and LDH 392 U/I. Nasogastric tubelavage revealed coffee-ground material mixed with feculent material.CT scan of the abdomen showed a large necrotic mass at the splenicflexure of colon, contiguous with the posterior wall of the stomach.EGD revealed a 6cm malignant appearing mass in the body of stomachand a fistula connecting to the colon. Biopsies of the mass showedpoorly differentiated adenocarcinoma. The patient underwent an exten-sive surgical excision including subtotal gastrectomy, and transversecolectomy. Histopathology of the surgical specimen confirmed poorlydifferentiated mucin producing, signet ring cell adenocarcinoma of thetransverse colon. The patient had an uneventful post-operative recoveryand underwent chemotherapy and radiation therapy. Four months postsurgery the patient continues to do well.

698

A young vegetarian female with nausea, weight loss andsteatohepatitis: Anorexia nervosa or celiac sprue?Viramontes Blanca E., Thistle Johnson L.,* Batts Kenneth P. MayoClinic, Rochester, MN, United States.

Purpose: Background: Celiac disease is associated with a variety orextraintestinal manifestations, but steatohepatitis is rare. We present a caseof nonalcoholic steatohepatitis in a patient thought to have anorexia ner-vosa but subsequently found to have celiac sprue.Results: Case Report:A 22-year-old female presented with a six-monthhistory of nausea and weight loss. She had been a strict vegetarian for sixyears during which time her weight had been stable at 140 pounds. In thelast six months, however, she had lost 32 pounds. This coincided withdropping out of law school and swiching to a psychology doctorate pro-gram. She had always felt that she was overweight but denied intentionalefforts at weight loss. She complained of intermittent nausea and had notedirregular menses. She had no other abnormalities on history or physicalexamination. Laboratory tests two months prior to presentation revealed alow serum albumin of 2.57g/dl, elevated AST(63N) and ALT(33N).Studies for hepatitis A, B and C, Wilson’s disease and hemochromatosiswere negative. A liver biopsy demonstrated ‘severe macrocytic steatosis’.She denied any alcohol use, and there was no family history of liverdisease. It was concluded that she probably had anorexia nervosa withsecondary nutrititional deficits. On physical examination, her height was 64inches and weight 108 pounds, but no other abnormalities were detected.The following tests were abnormally low: hemoglobin 11.6g/dL (12.0–15.5g/dl), folate 1.1(NLÄ3.5mg/l), carotene 13(48–200mg/dl) and albu-min 2.7g/dl (3.5–5.0g/dl). To exclude celiac sprue, a small bowel biopsywas obtained and revealed subtotal villous atrophy with crypt hyperplasiaand intraepithelial lymphocytosis consistent with celiac sprue. Gliadin andendomysial antibodies were positive. Her aminotransferases again wereelevated (AST 53N, ALT 23N). Prothrombin time was 12.1s (8.4–12.0s).The liver biopsy was reviewed and the diagnosis of steatohepatitis wasconfirmed. A gluten-free diet led to complete resolution of her symptomsand return to her normal weight.Conclusions:This case illustrates another of the protean manifestations ofceliac disease. Celiac disease deserves to be considered in all cases ofunexplained hepatic dysfunction including steatohepatitis. A resolution ofsymptoms and hepatic abnormalities can usually be expected with adher-ence to a gluten-free diet.

699

Groove pancreatitis presenting with a double duct sign andmimicking pancreatic adenocarcinomaVlodov Jane, Terebelo Sima, Tenner Scott, Abdullah Muhammad, LapinSeth, Iswara Kadirawel.* Maimonides Medical Center, Brooklyn, NewYork, United States.

Purpose:The evaluation of a mass in the head of the pancreas can pose adiagnostic challenge. The presence of a dilated pancreatic and biliary ductis considered to be indicative of carcinoma (double duct sign). We desciribea patient who presented with a pancreatic mass and a double duct signsuspected as having an adenocarcinoma who was found to have a benigninflammatory mass: Groove Pancreatitis.

A 47yo male presented complaining of diffuse abdominal pain of 10days duration, associated with nausea, vomiting, weight loss, and inabilityto tolerate oral feeding. He denied alcohol abuse. Physical examinationrevealed mild icterus. Adominal exam revealed normal bowel sounds withmild RUQ tenderness without rebound or guarding. Laboratory analysisrevealed: WBC 4.2, Hg/Hct 15.8mg/dL/45.2, amylase 105 IU/mL, AST182 IU/mL, ALT 371 IU/mL, Alk Phos 533 IU/ml, bili t/d 3.6/2.2mg/dL,Alb 3.9mg/dL. On abdominal ultrasound there was distention of the gall-bladder without calculi and only mild ductal dilatation. The pancreas wasnot seen due to overlying gas. ERCP showed a mass protruding from theinferior wall of the bulb causing an outlet obstruction. Biopsies of the lesionshowed chronic inflammatory changes with edema. Abdominal MRI re-vealed moderate intra and extrahepatic biliary ductal dilatation. There wasalso dilatation of the pancreatic duct. EUS confirmed the finding of thedilated CBD and a mass in the head of the pancreas. There was no evidenceof portal vein invasion or celiac axis adenopathy. Given that the mass wassuspected to be carcinoma and ‘resectable‘ by EUS criteria, a curativeWhipple procedure was performed. Intraoperatively, the patient was foundto have severe inflammation with adhesions and a hard mass in the head ofthe pancreas. Microscopic evaluation of the mass revealed chronic pancre-atitis with extensive fibrosis. Groove pancreatitis is a distinct form ofsegmental chronic pancreatitis that causes scarring of the groove betweenthe duodenal sweep and the head of the pancreas. As this case demon-strates, a mass effect often mimicking pancreatic cancer can occur.

700

Watermelon herniopathy—a newly described variant of gastricantral vascular ectasia associated with Barrett’s esophagusWard Eric, Wolfsen Herbert C.* Mayo Clinic, Jacksonville, FL, UnitedStates.

Purpose:We report the case of a 68 year old Hispanic woman referred forevaluation of refractory heartburn in 1997.Methods: Case Report: Previous studies elsewhere had documented ane-mia and erosive esophagitis. She had no past history or family history ofdigestive diseases. Her past medical history was reviewed for patientdemographics, laboratory and endoscopic results.Results: Case Report: The physical examination was normal with nostigmata of chronic liver disease. Laboratory studies demonstrated irondeficiency anemia, elevated transaminase levels with positive anti-mito-chondrial antibody but normal hepatic synthetic function and negativechronic hepatitis testing. The diagnosis of early stage primary biliarycirrhosis was made and ursodeoxycholic acid treament was initiated. Thechest Xray, mammogram, contrast enhanced CT scan of chest and abdo-men, hepatobiliary sonogram and colonoscopy were normal. The upperendoscopy documented a non-dysplastic 2cm segment Barretts esophagusand 5cm hiatal hernia. In the antrum were raised longitudinal folds radi-ating to the pylorus characteristic of watermelon gastropathy (gastric antralvascular ectasia). Despite oral iron supplements, however, the anemiapersisted and required endoscopic treatment using the Argon Plasma Co-agulator (Erbe USA, Marrietta, Georgia) every 6–8 months thereafter. Atthe most recent study, vascular ectasias of watermelon gastropathy werenow present in the folds of the hiatal hernia as well as the antrum. No

2614 Abstracts AJG – Vol. 95, No. 9, 2000

Cameron lesions were found and the intervening mucosa appeared normal,with no evidence of portal hypertensive gastropathy. The mucosa of thehiatal hernia was treated with the Argon Plasma Coagulator in a similarmanner to the antrum with subsequent resolution of the anemia.Conclusions: 1) We report an unusual case of watermelon gastropathyassociated with Barretts esophagus and early stage primary biliary cirrho-sis. 2) Endoscopic therapy using the Argon Plasma Coagulator has effec-tively controlled the gastrointestinal bleeding and iron deficiency anemiarelated to the vascular ectasias. 3) Over time, the pattern of vascular ectasiahas extended to involve the folds of the hiatal hernia prompting thisdescription of a new disease variant—watermelon herniopathy.

701

Hepatitis B (HBV) reactivation after chemoembolizationWinters George R. III M.D., Cash Brooks D. M.D., Lane David M.D.,Holtzmuller Kent C. M.D. Departments of Gastroenterology andRadiology, Walter Reed Army Medical Center, Washington, D.C.

Backround: Reactivation of HBV is a well known complication in patientswith chronic HBV infection who receive systemic cytotoxic or immuno-suppressive therapy. To date, reactivation of HBV has not been describedwith localized therapies such as chemoembolization. We describe a case ofHBV reactivation after chemoembolization.Case Report: A 60 year old African American male with chronic HBVinfection underwent two courses of chemoembolization therapy for poorlydifferentiated hepatocellular carcinoma (HCC). His pre-treatment labswere: HBsAg Pos. HBeAg Neg, HBV DNA undetectable (,5.0 pg/ml),AFP 89,020, AST 130, ALT 57, Alk 102, tbili 0.8. Embolization therapyconsisted of 100mg Cisplatin, 50mg Adriamycin and 10mg Mitomycinfollowed by Gelfoam embolization. After the initial chemoembolization thepatient’s AFP decreased to 28,084. A second chemoembolization wasperformed six weeks later, with a further decrease in AFP to 5511. Sixweeks after the second chemoembolization the patient presented with newRUQ pain. Laboratory evaluation showed HBeAg Neg, HBV DNA 1547,AFP 74,941, AST 1408, ALT 513, Alk 288, tbili 9.3. Repeat CT Scanshowed interval increase in size of liver mass. The patient’s clinical coursedeteriorated and he died. The clinical course was most consistent with HCCrecurrence, however the positive HBV DNA represented evidence of HBVreactivation. HBV reactivation may have contributed to his decreasedhepatic function and his worsening clinical picture. The patient had notbeen placed on prophylactic lamivudine therapy prior to his chemoembo-lization.Conclusion: HBV reactivation can occur following localized chemoem-bolization therapy. Prophylactic lamivudine should be considered in pa-tients with HBV prior to chemoembolization.

702

Disseminated MAI as a cause of excruciating abdominal pain anddiffuse colonic wall thickeningYadav D. MD, Sachan P. MD, Rao PM MD, Corpuz M., MD, Hertan H.MD, FACG. Our Lady of Mercy Medical Center, Bronx, NY.

Disseminated MAI (Mycobacterium avium intracellulare) is a commonopportunistic infection in patients with advanced AIDS. A case of dissem-inated MAI with unusual clinical manifestations is reported.

A 40 year female with advanced AIDS (CD4 count,20/mm3) presentedwith high fever, excruciating abdominal pain for several days, diarrhea andnausea. Past history includes PCP and candida esophagitis. Exam revealeda young wasted female, moaning with pain. P-100, BP-100/80, RR-18, T-103°F, oral thrush present, Abdomen-distended, diffusely tender, 2 fingernon-tender hepatomegaly, no splenomegaly, bowel sounds present. Labs-WBC-5.1 (bands 35%), HCT 27.7, normal PT, PTT, amylase, lipase, LFT’snormal except Alb-2.5 gm/dl. CXR, FUA, abdominal sonogram, HIDAscan, gallium scan chest, multiple cultures, CMV titres and PPD werenegative. CT scan showed enlarged mesenteric and retroperitoneal lymphnodes. Bone marrow aspiration and biopsy were negative. No improvement

with broad spectrum antibiotics was noted. A laparotomy was done due tointractable abdominal pain, temperature of 103–106°F, severe tendernessand guarding. Laparotomy only showed multiple enlarged celiac and mes-enteric lymph nodes. Biopsies from lymph nodes and liver revealed poorlyformed granulomata with numerous AFB. Peritoneal swabs, sputum andstool cultures later showed MAI. She responded to MAI therapy and wasdischarged after 9 days.

On readmission 3 weeks later with weakness, abdominal pain anddiarrhea, she was afebrile, had mild abdominal tenderness and new onsetascites. She had stopped taking her medications after discharge. Labs-WBC-normal, Alb-2.2 gm/dl. Abdominal CT showed diffuse thickening ofthe entire colon and moderate ascites. Stool for C.difficile, CMV and otherorganisms was repeatedly negative. Sigmoidoscopy with multiple biopsieswere normal. With resumption of MAI therapy, she improved and wenthome after 10 days. A repeat CT scan showed resolution of colonic wallthickening and ascites.

Disseminated MAI should be considered in an AIDS patient presentingwith intractable abdominal pain and diffuse colonic wall thickening.

703

Role of lamivudine in the treatment of acute hepatitis B infectionassociated with polyarteritis nodosaYeh Robert MD, Ullah Nadeem MD, Ehrinpreis Murray MD FACG.Wayne State University, Detroit, MI.

Introduction: Clinical manifestation of PAN in the setting of acute HBVinfection has not been well characterized, and it remains unclear whethereradication of HBV is required to induce remission of acute HBV-relatedPAN.Case: A 24-year-old female admitted with right abdominal pain, fever,chills, nausea, vomiting, ankle pain, acholic stool. Physical exam was notedfor tender enlarged liver, and initial laboratory studies revealed abnormaltransaminases and alkaline phosphatase. Acute HBV infection was con-firmed by positive HBc IgM and HBsAg. HBV DNA was 4,058,000/ml.Hepatitis A and C serologies, HBsAb, and HBeAg were ?? negative.Vasculitis was confirmed by renal arteriograms showing small vesselocclusions and possible renal infarction. EMG and nerve conduction stud-ies showed findings consistent with neuropathy secondary to vasculitis inperoneal nerve. Percutaneous liver biopsy revealed morphologic featuresconsistent with acute HBV infection and positive HBc IgM immunostain-ing. Prednisone and plasma exchange for PAN was started and lamivudinefor acute HBV was also started. Lamivudine was continued after discharge.At 3 month follow-up, she was clinically stable and seroconversion wasdocumented by HBsAb. HBV DNA was undetechtable.Discussion: Adult patients with acute HBV infection typically do notrequire anti-viral therapy for seroconversion. However, in the case of PANrelated to acute HBV infection, patients may become immunosuppresseddue to treatment of PAN and may increase the risk of becoming carrier. Useof lamivudine in this setting may minimize conversion to HBV carrier.

704

Endoscopic diagnosis of tracheoesophageal fistula with directedmethylene blue instillation into esophagusYoon David K, M.D., Espada Rafael M.D., Gonzalez Jorge M, M.D.,Ergun Gulchin A, M.D.* Baylor College of Medicine, The MethodistHospital, Houston, Texas, United States.

Purpose: Tracheoesophageal (TE) fistulae may be devastating lesionswhich can lead to serious, even fatal, pulmonary complications. Today,acquired nonmalignant TE fistulae are mainly iatrogenic, occurring in thecourse of tracheal intubation or as a complication of endotracheal ortracheostomy tubes. Operative closure is necessary but demonstrating thesite of the fistula, which directs the selection of the surgical procedure, canbe difficult. This case illustrates the usefulness of methylene blue instilla-tion during sequential esophagosocpy and bronchoscopy to diagnose TEfistula.

2615AJG – September, 2000 Abstracts