Wednesday, March 11, 7:30 PM
Convention Center Auditorium
University of Arkansas for Medical Sciences, Little Rock, AR
In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose.
RHONDA K. YANTISS, Weill Medical College of Cornell University, New York, NY
GALEN CORTINA, University of California, Los Angeles, CA
MARIE ROBERT, Yale University School of Medicine, New Haven, CT
AMY NOFFSINGER, University of Chicago Medical Center, Chicago, IL
JOEL K. GREENSON, University of Michigan, Ann Arbor, MI
Clinical Histories and Still Images are displayed below.
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Submitted by: Rhonda K. Yantiss - Weill Medical College of Cornell University, New York, NY
The patient is a 45 year-old HIV-positive male who presented to the emergency room with severe dehydration following several months of profuse watery diarrhea, 10-15 bowel movements per day, and a 30-pound weight loss. The patient had a 9-year history of HIV infection, but maintained stable CD4 counts (730) on anti-retroviral therapy, and had no known opportunistic infections. He carried a diagnosis of ulcerative colitis that was made 12 months prior to presentation, based upon clinical symptoms of increased stool frequency (6-8 non-bloody bowel movements/day), endoscopic evidence of pancolitis, and colonic mucosal biopsies that showed "non-specific" colitis. His symptoms initially improved with asacol and prednisone, but he continued to have intermittent diarrheal episodes, the most recent of which occurred three months prior to presentation. At that time, he developed severe diarrhea following a 5-day trip to Peru and was empirically treated for amebiasis. He received a four-week course of metronidazole and, although his diarrheal symptoms initially abated, they recurred following cessation of antibiotic therapy. At the time of admission, the patient appeared thin and wasted, but had no localizing symptoms. Laboratory findings included a normal hematocrit, normal white blood cell count with a slight eosinophilia, and normal blood chemistries. Other pertinent studies included a negative C. difficile toxin assay and stool cultures with rare white cells. Endoscopic examination of the upper and lower gastrointestinal tract revealed a slightly irregular Z-line, but no other abnormalities. Mucosal biopsy samples were obtained from the jejunum, duodenum, stomach, esophagus, ileum, and colon. The images provided depict the jejunal findings.
Submitted by: Galen Cortina - University of California, Los Angeles, CA
The patient was a Persian-American female (Iranian -Jewish origin) who first presented at age 6 years. She had complaints of constipation and abdominal distention for over three years. She occasionally needed mineral oil and enemas to relieve the constipation. The abdominal distention significantly affected her ability to eat and drink. She began to fall off her growth curve. Physical examination showed a non -tender, distended soft abdomen, positive bowel sounds, no palpable mass, and no hepatosplenomegaly. Barium enema failed to demonstrate a stricture. The upper GI radiographic study showed marked delay in the small bowel transit time and a questionable stricture at the terminal ileum.
Laboratory tests: Negative for cystic fibrosis (including a DNA analysis). Evaluation for nutritional status: albumin 3.9 gm/dL [3.7-4.8], vitamin A level 0.3 mg/L [0.3-0.9], vitamin E level 4.8 mg/L [5.6-22], normal electrolytes.
It was decided that the possible stricture might be contributing to the distention and resultant reduced caloric intake. It was decided for her to undergo surgery to examine her distal small bowel and adjacent right colon and to possibly resect it. Diagnostic laparoscopy revealed hypermotility throughout the bowel. Exploratory laparotomy revealed a segment of bowel with thick inspissated luminal contents in the distal ileum but no mechanical obstruction. After consulting a pediatric gastroenterologist, it was decided to proceed with the resection of the terminal ileum and right colon in hopes of alleviating this 'partial obstruction'.
The resection specimen was submitted to surgical pathology with clinical diagnosis of 'pseudo-obstruction' (despite the lack of supporting data). The specimen had a smooth and shiny serosal surface and no obvious stricture. Upon opening, the specimen was found to contain thick stool in the distal small bowel, but did not demonstrate a mechanical obstruction. The mucosa appeared normal. At the ileocecal valve, the mucosal and mural folds were exaggerated. No gross photos were taken. Photomicrographs are shown in figures 1-4.
After the surgery the patient no longer had abdominal distension. The patient had one to two loose stools a day but no diarrhea. One year after surgery, she had gained weight but had not shown any catch-up in weight (5th to 10th percentile) or height (3rd percentile). She started growth hormone therapy at 9 years.
When she was 15-years old, she was evaluated for hypocalcemia of unknown cause, and she was found to have low levels of fat soluble vitamins despite vitamin supplements. Zinc levels were borderline low as well. EGD with biopsy was done to rule out a malabsorptive disorder. Photomicrographs are show in figures 5-10. Colonoscopy revealed retained stool, no lesions, and no biopsies were taken.
In light of the more recent histologic and immunohistochemical findings, immunostains were also performed in the resection specimen from nine years prior. A photomicrograph is shown in figure 11.
Submitted by: Marie Robert - Yale University School of Medicine, New Haven, CT
A 45 year old woman complained of vague abdominal discomfort without chest pain. An upper endoscopy revealed thickened gastric body folds. Biopsies were positive for Helicobacter pylori associated gastritis and a diffuse atypical lymphocytic proliferation, diagnostic of low grade B-cell MALT lymphoma. The patient was rebiopsied 4 months after H. pylori eradication. The endoscopic examination was now normal. Biopsies were taken from the area of previous lymphoma.
Submitted by: Amy Noffsinger - University of Chicago Medical Center, Chicago, IL
The patient is an 81 year old woman with a history of progressively worsening dysphagia. Endoscopic examination demonstrated a 10 cm polypoid mass located at the gastroesophageal junction.
Submitted by: Joel K. Greenson - University of Michigan, Ann Arbor, MI
A 74 year-old man presented with abdominal pain and symptoms of acute intestinal obstruction. Imaging studies showed a mass in the small intestinal. A segmental resection of the mid-jejunum was performed.
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