pseudocyst as a consequence of the previous pancreatitis. This was fol-lowed up with CT abdomen and found to be increasing in size. Shesubsequently developed epigastric discomfort, early satiety and weightloss. On MRCP, the cyst appeared complex, but the pancreatic duct wasnormal. An exploratory laparotomy was done which revealed a massoriginating from the posterior wall of the stomach which was adherent tothe tail of the pancreas. A sub-total gastrectomy, partial pancreatectomy,and splenectomy was performed. The pathological diagnosis was gastro-intestinal stromal sarcoma of the stomach.Conclusions: Pancreatic pseudocysts occur after acute pancreatitis in 5%of patients. Approximately 80% of acute pseudocysts �6 cm in size willresolve spontaneously, most within 6 weeks. This case illustrates that theappearance of a cyst of the pancreas may not always be a pseudo-cyst.Neoplastic cystic lesions of the pancreas and tumors arising from thestomach bed should also be ruled out.

798

Cytomegalovirus (CMV) infection documented in previouslyrefractory pouchitisCarlton W. Thomas, M.D.1 and Peter W. Carryer, M.D.2*. 1InternalMedicine, Mayo Foundation, Rochester, MN, United States; and2Gastroenterology and Hepatology, Mayo Foundation, Rochester, MN,United States.

Purpose: This clinical vignette demonstrates the importance of testing forCMV infection in patients with pouchitis refractory to conventional ther-apy.Methods: A 53-year-old male presented with recurrent diarrhea, abdomi-nal pain, a twenty-pound weight loss, and malaise. Eight years previouslyhe had a total colectomy with ileal pouch anal anastomosis for refractoryulcerative colitis. Recently his stool frequency had increased from a base-line of six stools per day to approximately twelve stools per day. Investi-gations by his local physician demonstrated severe ulceration in the ileo-anal pouch. He received courses of metronidazole, mesalamine, prednisoneand loperamide. However, he had an associated worsening of symptoms.He was referred to us for further evaluation. In addition to basic laboratoryinvestigations, he had stool studies, barium small bowel follow throughradiographs, and a pouch endoscopy.Results: Stool studies for parasitology and stool culture were negative. Hisbarium small bowel radiographs showed narrowing of the small bowelmucosa with mild proximal obstruction just above the ileoanal pouch. Thepouch endoscopy demonstrated diffuse erythema, friability, edema, andsuperficial and deep ulcerations in the ileoanal pouch as well as the terminalileum to forty centimeters from the anal verge. The inflammatory processwas continuous in the pouch with some skip areas in the neoterminal ileum.The biopsies revealed acute ileitis with multiple CMV inclusion bodies.Conclusions: The patient was diagnosed with CMV pouchitis and wasstarted on ganciclovir (five milligrams intravenously each twelve hours) forthree weeks. He was tapered off of his prednisone and other medications.The patient had a good response to ganciclovir therapy with a return tobaseline stool frequency, weight gain, and an improved quality of life. Thiscase clearly shows the importance of investigating for CMV infection inpatients with pouchitis refractory to conventional therapy.

799

Hepatic abscess in Crohn’s diseaseMiriam R. Thomas M.D “FACG” PH, Michael Piper M.D PH* and JayLevinson M.D. PH. 1Gastroenterology, Providence Hospital, Southfield,MI, United States.

Purpose: Liver abscess is one of the rare but serious complication ofCrohn’s disease. Although mild abnormalities of liver function tests arecommon in Crohn’s disease, severe hepatobiliary disease is infrequent.Intra-abdominal abscesses, fistulous disease, and metronidazole or steroidtherapy have all been reported to be predisposing factors in the pathogen-esis of the disease and the mortality has been reported to be high.

Methods: We report a case in a patient who developed liver abscess as acomplication of Crohn’s disease which was quiescent at presentation. A 50yr old physician with a history of Crohn’s disease localized to the terminalileum and controlled with Asacol therapy was hospitalized with right upperquadrant abdominal pain and chest pain worse on inspiration, chills andfever which developed 5 days prior to admission. He was found to havenormal laboratory data including liver function tests initially and chestX-ray showed a right pleural effusion. He was treated with antibiotics forpresumed pleuritis. He continued to be febrile with chills and persistentright upper quadrant pain and hence admitted to the hospital. Right lowerquadrant pain, diarrhea or anorexia was absent. On admission his temper-ature was 38.9 C and the only physical abnormality was marked hepatictenderness to direct palpation. There was no hepatomegaly, jaundice orright lower quadrant tenderness. Admission laboratory data included awhite count of 6.5 cells/mm3. Abnormal liver function tests included aserum alkaline phosphatase of 161 IU and a serum alanine aminotransferseof 66 IU. Computed tomographic (CT) scan of the abdomen revealed awell-demarcated spherical lesion in the right lobe of the liver. Bloodcultures were positive for Streptococcus and hence he was empiricallytreated with antibiotics but his symptoms did not resolve. He underwentCT-guided percutaneous aspiration of the abscess which yielded about 80cc of purulent fluid which grew Streptococcus miloeri. The patient wassubsequently treated with intravenous antibiotics for 8 weeks and follow upCT scan showed resolution of the abscess.Conclusions: This case report highlights the unusual features of Crohn’sdisease and stresses the importance of a high degree of suspicion for thediagnosis of liver abscess. Shaking chills, fever with or without leukocy-tosis and an elevated alkaline phosphatase are suggestive of a liver abscessand should prompt immediate radiological investigation. The rare pyogenicliver abscess are usually streptococcal, often multiple and frequently fatal.Catheter drainage with antibiotic therapy is effective and results in satis-factory healing if the liver abscess is diagnosed before extensive necrosishas occurred.

800

Malignant lymphoma in ulcerative colitisMiriam Thomas, F.A.C.G, M.D PH and Michael Piper, M.D PH*.1Gastroenterology, Providence Hospital, Southfield, MI, United States.

Purpose: Primary Malignant Lymphoma complicating Ulcerative colitis isencountered very rarely. They usually occur late in the course of the diseaseand its presentation is heralded by recent alteration in-patients symptoms,which do not respond adequately to medical treatment. Lymphoma canoccur anywhere in the colon but the rectum is the commonest site. Diffuselymphomas are indistinguishable clinically and radiological from Ulcer-ative colitis. Fever and night sweats are uncommon with primary gastro-intestinal lymphoma and usually suggest gastrointestinal involvement ofdiffuse lymphoma.Methods: A 60 year old white man with a history of ulcerative colitis ofthree years duration was admitted with rectal bleeding for which heunderwent colonoscopy. He did not have any fever, diarrhea or weight lossprior to the admission. He has a history of antiphosholipid syndrome forwhich he takes coumadin. He has also been taking prednisone and recentlyhe has been on Remeron. On physical examination the abdominal exami-nation was benign except for a 1cm palpable right inguinal lymph node.Colonoscopy showed necrotic, inflammatory mucosa with ulcerations inthe rectum with fairly diffuse erythema in the remaining colon. Subse-quently total protocolectomy and ileostomy was performed. The pathologyreport was “ Chronic active colitis, crypt abscess type, involving the entirecolon with evidence of diffuse large B cell lymphoma in the rectum 11/10.5cm, with extension focally through the muscularis propria. There was noevidence of malignancy within the resected pericolonic lymph nodes (0/18). The patient thereafter underwent systemic chemotherapy and toleratedit well.Conclusions: This report emphasizes a relatively rare condition compli-cating ulcerative colitis. Repeated episodes of lymphoid hyperplasia seen in

S250 Abstracts AJG – Vol. 96, No. 9, Suppl., 2001

chronic ulcerative colitis may result in the eventual development of lym-phoma. The prognosis is influenced by involvement of the regional nodesand adjacent structures. Radical surgical excision is done for localizedlymphoma associated with ulcerative colitis. Lymphomas arising in pa-tients with ulcerative colitis require a heightened index of suspicion.

801

Unusual manifestations of metastatic gastric cancerMiriam Thomas, FACG, M.D.PH and Michael Piper,M.D.PH*.1Gastroenterology, Providence Hospital, Southfield, MI, United States.

Purpose: Adenocarcinoma of the stomach is a difficult clinical problemand is associated with a dismal prognosis. The five year survival rate forpatients who had a potentially curative subtotal gastrectomy was 35%. Inthe late advanced gastric adenocarcinoma, upto 90% of the patients mayhave regional extension and 50% may have distant metastasis.Methods: A 73 year old male with a history of early gastric adenocarci-noma diagnosed by endoscopy and biopsy and status post partial gastrec-tomy presented two years later with anemia and occult blood in stools. Thepatient did not have recent weight loss, change in bowel habits or obviousgastrointestinal bleeding. He has no known metastasis of the gastric cancer.Family history was significant for gastrointestinal cancer in his mother andcolon cancer in his brother. Physical examination was only significant forconjunctival pallor and occult blood in stools. There was no evidence ofjaundice, hepatomegaly or lymphadenopathy. Laboratory data showed ahemoglobin of 11 gms/100ml. Chemical profile and liver enzyme studieswere normal. Colonoscopy showed erythematous and edematous mucosa at18-20 cm from the anal verge and biopsies revealed infiltrating adenocar-cinoma with features similar to the previous gastric carcinoma. Esophago-gastroduodenoscopy showed no evidence of reccurent stomach cancer.Computed Tomographic scan of the stomach and pelvis revealed no ab-normality. Subsequently partial colectomy was performed and showed 2submucosal masses in the area of the stricture in the rectosigmoid region.The pathology report was “ four sites of metastatic adenocarcinoma in-volving the bowel wall and the mesentry”. The pathology was identical tothe prior resected gastric adenocarcinoma. There was no evidence ofmalignancy in the margins of the resection or in the resected lymphnodes(0/8)Conclusions: Gastric cancer is a disease which is extremely aggressive andmost patients who have resectable disease have a high incidence of recur-rence. This appears to be one of the few published reports of sigmoid colonmetastasis from a primary gastric adenocarcinoma.

802

Aortoenteric fistula, eleven years after AAA repairGerard M Toso1, Kevin S Palumbo1 and Sonia Uchman1*.1Gastroenterology, Brown Medical School, Providence, RI, UnitedStates.

Introduction: An aortoenteric fistula is a rare cause of acute GI bleeding,in patients who have undergone abdominal aortic reconstructive surgery.Most bleeds occur three to five years after the aneurysm repair procedureand the diagnosis is rarely made at the time of endoscopy.Case: A 72 year old man with a past medical history of iron deficiencyanemia and abdominal aorta aneurysm repair with a left aorto-iliac bypassin 1981 complained of intermittent black stools. On presentation, thepatient was hemodynamically stable with a BP: 126/70 and HR: 80, and hisabdominal exam revealed a bruit at the umbilicus. He had dark stools,which were positive for occult blood. Initial lab data included Hgb: 8.3g/dL, MCV: 78 fL, platelets: 411,000/mm3, BUN: 33 mg/dL, creatinine:0.8 mg/dL, and normal liver function tests. A nondiagnostic EGD andcolonoscopy were followed by a push enteroscopy, which revealed a bilestained graft eroding through the fourth portion of the duodenum. Theaortoenteric fistula was repaired; however, the patient became septic postoperatively and expired.

Discussion: An aortoenteric fistula (AEF) usually between the aorta andduodenum may present itself as an acute upper GI bleed. A primary AEFusually occurs from the erosion of an enlarged aorta into the bowel.Secondary AEF develops in 0.5 to 2.4% of patients who have undergoneabdominal aortic reconstructive surgery, occurring on average three to fiveyears after surgery. The classic presentation is of a herald upper GIhemorrhage, which stops spontaneously and is later followed by a massivehemorrhage and exsanguination. Diagnosis is rarely made by upper endos-copy, and imaging studies such as arteriogram, MRI, or CT of the abdomenare sometimes useful. Surgical exploration is the gold standard to confirmor rule out an AEF. The treatment is surgical.Conclusions: Aortoenteric fistulas, although rare, are life threatening andshould always be suspected in a patient with aortic repair. This case isunusual in that it occurred eleven years after abdominal aorta aneurysmrepair and the graft (aortoenteric fistula) was seen at the time of endoscopy.

803

Budd-Chiari syndrome in a patient who is heterozygous for factor VLeidenGerard M Toso1, Kevin S Palumbo1 and Sonia Uchman1*.1Gastroenterology, Brown Medical School, Providence, RI, UnitedStates.

Introduction: Budd-Chiari syndrome is characterized by impedance ofhepatic venous outflow. This syndrome is rare in occurrence, varied inpresentation, and challenging in management.Case: A 21 year old woman with a past medical history of chronicidiopathic thrombocytopenic purpura developed severe right upper quad-rant pain. She was found to have abnormal liver function tests and under-went an open cholecystectomy. At the time of surgery her liver appearedcongested. Post cholecystectomy her abdominal pain persisted. She had nostigmata of chronic liver disease, but her abdominal exam revealed hepa-tomegaly. There was no splenomegaly or ascites. Initial lab data includedAST: 48 IU/mL, ALT: 60 IU/mL, Alk Phos: 127 IU/mL, Total bili: 1.0mg/dl, Hgb: 12.5 g/dL, platelets: 128,000/mm3, PT: 14.4 seconds, INR: 1.4,PTT: 62.8 seconds. An abdominal CT and MRI revealed hepatomegaly andleft and right hepatic venous thrombosis with narrowing of the IVC. Atransjugular hepatic venogram showed an elevated porto-atrial pressuregradient. A transjugular liver biopsy was consistent with distal venousoutflow obstruction, but no fibrosis. The labs showed that she was het-erozygous for Factor V Leiden, a positive lupus anticoagulant, and anti-cardiolipin antibodies. Balloon angioplasty of the stenosed IVC was un-successful. She underwent a meso-atrial shunt uneventfully and wasdischarged on anticoagulation.Discussion: Budd-Chiari syndrome (BCS) results from anatomic or phys-iological changes in the vasculature that lead to reduction of the hepaticvenous outflow. Histologically, it is characterized by acute central conges-tion, cell necrosis, hemorrhage, and eventual cirrhosis. BCS can be fulmi-nant, acute or chronic in presentation. Classically, it is the result of bloodclots in the hepatic veins and manifests with abdominal pain, ascites,hepatomegaly and liver failure. The diagnosis may be made by Dopplerultrasound, MRI or CT and confirmed by venography. The treatment variesbased on etiology, anatomy, and extent of liver disease at the time ofpresentation.Conclusions: Budd-Chiari syndrome is rare in occurrence, varied in pre-sentation, and often challenging to manage. This case highlights its pre-sentation and reviews the challenging management issues. The case pre-sented is unique because of its subacute presentation in the presence ofmultiple coagulation disorders.

804

Food impaction due to eosinophilic esophagitisAndrew Ukleja1, Kenneth R DeVault1* and Sami R. Achem1. 1Divisionof Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL,United States.

S251AJG – September, Suppl., 2001 Abstracts