S236 Abstracts
risk for intraabdominal vascular complications including thrombosis of the 654
mesenteric veins and arteries. Microvascular thrombosis of the splanchnic
vessels has been reported as a cause of recurrent episodes of abdominal pain
and mucosal ulceration; its pathogenesis is thought to be multifactorial and
may be secondary to complement activation, increased platelet aggrega-
tion, enhanced expression of tissue factor, and impaired fibrinolysis. MALS
Downloaded from http://journals.lww.com/ajg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWn
results from extrinsic compression of the CA by the median arcuate liga-
ment, a fibrous band bordering the aortic hiatus anteriorly. MALS is char-
acterized by chronic postprandial abdominal pain, weight loss, and imaging
studies demonstrating extrinsic compression of the CA. Chronic compres-
sion of the CA may induce hyperplasia of the tunica media resulting in
stenosis of the artery and probably explain the non-universal efficacy of sur-
YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 09/16/2023
gical release of the ligament. Acute intestinal ischemia is a rare complication
of PNH and has never been reported in association with MALS. Although
histological confirmation was not possible in our patient, we hypothesize
that acute ischemia resulted from a synergistic combination of pathogenic
factors associated with these two diseases: anemia, severe compression of
the CA causing tissue hypoxia and increased complement activation, and
perhaps microvascular thrombosis of the bowel. The clinical improvement
after treatment with anticoagulation and red cell transfusions corroborates
our hypothesis.
653
Unusual Case of Obscure Overt Gastrointestinal Bleeding Diagnosed with
Spirus Enteroscopy in Patient with Tuberous Sclerosis
Soukayna Rkaine, MD, Ali Nawras, MD. Internal Medicine, University of
Toledo Medical Center, Toledo, OH.
Purpose: Tuberous sclerosis complex (TSC) is an autosomal dominant dis-
order characterized by the development of benign neoplasms of the skin and
internal organs. It involves the neurological system in most cases, in addition
to the skin, the kidneys and the lungs. The Involvement of gastrointestinal
system is uncommon and not well described in literature. This involvement
varies from benign angiomyolipomas, neuroendocrine tumors, hamarto-
mas polyps and stromal tumors to invasive rectal adenocarcinoma. Here we
report a patient known to have TSC, presented with recurrent obscure overt
gastrointestinal bleeding due to a large Jejunal submucosal undifferentiated
tumor diagnosed by Spirus enteroscope. A 39- year- old Caucasian female,
known to have TSC with multi-organ involvement including kidney, lung
and liver, presented to our hospital with a complaint of melena for three
days. She denied any abdominal pain, nausea, vomiting hematemesis or
hematochezia. On physical examination, she had normal vital signs. The
abdomen was soft, nontender with positive bowel sounds. Her blood test
revealed hemoglobin of 6.7 g/dl. Prior to this episode the patient had recur-
rent episodes of obscure overt GI bleeding in the form of melena over the
course of one year. She had two previous upper endoscopies revealing mul-
tiple small polyps in the stomach and duodenum. None of the polyps had
stigmata of bleeding. She also had two negative colonoscopies. The patient
was admitted to the hospital, received blood transfusion and underwent
upper gastrointestinal endoscopy which revealed again multiple small non
bleeding sessile polyps in the stomach and duodenum. The colonoscopy was
unremarkable. Capsule endoscopy was done and revealed fresh blood in the
jejunum without identifying the source. Enteroscopy was then performed
using spirus enteroscope, which showed large submucosal, umbilicated and
ulcerated mass at the proximal jejunum. The mass was biopsied and the
biopsy was unremarkable. Surgical resection of the mass was performed. The
gross pathology revealed well circumscribed submucosal gray-white mass.
The immunostains were negative. The pathological diagnosis of the mass was
reported as undifferentiated malignant neoplasm. Up to date (three months
post surgical resection) the patient had no further episodes of GI bleeding
and her Hemoglobin level stayed normal. To our knowledge, our patient
is the first reported patient with TSC and large undifferentiated malignant
neoplasm of the jejunum causing significant recurrent obscure overt GI
bleeding and the first to be diagnosed by using Spirus enteroscope and then
successfully treated surgically.
The American Journal of GASTROENTEROLOGY
Management of Gastrointestinal Bleeding with Heparin - A Paradoxical
Treatment
Mylan Satchi, MD, Kenneth Strachan, MD, Elizabeth Smith, MD, David
Robbins, MD. Lenox Hill Hospital, New York, NY.
Purpose: A 57-year-old Caucasian male with history of a pulmonary embo-
lism presented with a two-day history of melena and dizziness. He denied
hematemesis, hemoptysis, BRBPR, chest or abdominal pain, palpitation,
dyspnea. On admission, he appeared pale, but in no distress. His vitals were
stable and exam was benign except for black, guaiac positive stool in the rec-
tal vault. Hemoglobin on admission was 7.6 mg/dl. In the ED, he received two
units of pRBCs. Despite an appropriate increase in hematocrit, melena per-
sisted. An EGD, performed in the ICU, revealed mild gastritis and duodenitis
with no evidence of active bleeding. However, a small amount of old blood
was seen in the 3rd portion of the duodenum. Repeat EGD the next day
revealed a small nodule in the 2nd portion of the duodenum with an oozing
mildly ulcerated tip, where an endoclip was placed, and thickened duodenal
folds, which were biopsied. A follow-up small bowel capsule study revealed
blood in distal duodenum/proximal jejunum. At this time, the patient also
complained of left leg swelling and imaging discovered a DVT. Because of
persistent melena, an IVC filter was placed and a colonoscopy and EGD
were performed. The colonoscopy revealed no abnormalities and the EGD
revealed a clot in the antrum, with no identifiable source of bleeding. In the
3rd portion of the duodenum a small adherent thrombin clot was noted at the
previously clipped lesion. Endoclips were placed with adequate hemostasis.
On further inspection a region of dilated vessels in the 2nd and 3rd portions
of duodenum were visualized, suspicious for duodenal varices. To further
investigate the duodenal varices, a CT scan of the abdomen revealed an ill-
defined area of low density in the uncinate process of the pancreas without
ductal dilation, and mild splenomegaly. The superior mesenteric vein did
not opacify which led to suspicion for an SMV thrombus. An incidental PE
was also found on CT scan. An endoscopic ultrasound was performed which
confirmed an 2.5 x 3 cm well-circumscribed conglomeration of small blood
vessels in the uncinate process verified by observation of Doppler flow in the
region. We postulated that the SMV thrombus caused the duodenal varices
which led to gastrointestinal bleeding. Given the CT findings, the thrombus
was thought to be due to a hypercoagulable state stemming from a malig-
nancy; however an extensive workup was negative. A hypercoagulable work
up was within normal limits as well. With evidence of new DVT, PE and SMV
thrombus, the patient was started on unfractionated heparin as a bridge to
warfarin therapy. His melena resolved, Hb stabilized, and patient was dis-
charged on hospital day 18.
655
A Case of a Patient with a Benign Cyst Presenting as a Submucosal Small
Bowel Mass on Wireless Capsule Endoscopy Prompting Double Balloon
Endoscopy
Valley Dreisbach, MD, Asad Ullah, MD, Ashok Shah, MD, MACG. University
of Rochester Medical Center, Rochester, NY.
Purpose: An 82-year-old female with a one year history of iron deficiency ane-
mia. She underwent an EGD and colonoscopy by an outside gastroenterologist
which revealed erythema throughout the stomach and a healing ulcer. Colo-
noscopy revealed a non-bleeding cecal AVM. Twice daily proton pump inhibi-
tor was continued, but one month later, the patient was admitted to an outside
hospital with syncope and a hematocrit of 26 requiring blood transfusion. Her
aspirin was held. A follow-up EGD was unremarkable. Subsequently, a wire-
less capsule enteroscopy found a submucosal mass in the mid-small bowel. She
was referred to our institution for consideration of double balloon endoscopy.
She reported a good appetite without pyrosis or nausea and a 20 lb weight loss
earlier in the year, but a stable weight within the past few months. She denied
any visible blood in her stools or black stools. Her hematocrit had stabilized at
37. A double-balloon endoscopy was performed from oral route under general
VOLUME 105 | SUPPLEMENT 1 | OCTOBER 2010 www.amjgastro.com