Patent ductus venosus in an adult presenting as pulmonary hypertension, right side heart failure and...

We present a case of DM in a patient with metastatic colorectal cancer inwhich the earliest symptom was hematochezia.Results: Case: A 51-year-old Hispanic male presented with a 4-monthhistory of hematochezia, which he ignored, followed by a 2-month historyof skin rash over the face and upper trunk, proximal muscle weakness, anddysphagia. The progressive weakness finally led him to seek medicalattention.

Physical examination revealed heliotrope rash of the eyelids, erythem-atous rash on the face and upper trunk, periungual erythema, and telang-ectasia of the nail folds. Proximal muscle strength was decreased.

Pertinent Labs: CK513266, ESR517.9, AST5133, AlkalinePhos5259, fecal occult blood positive. Patient underwent colonoscopy,which revealed a colonic mass, which was adenocarcinoma on biopsy.Abdominal CT showed hepatic metastasis. The patient died a few monthsafter diagnosis.Conclusions:DM is an autoimmune disorder characterized by inflamma-tory muscle and cutaneous disease. The diagnosis is based on classic skinfindings, proximal muscle weakness, elevated muscle enzymes, and can beconfirmed by muscle biopsy and/or electromyography. The most commonassociated malignancies are ovarian, lung, breast, stomach, pancreas, andurinary bladder, and colon cancer has also been associated with DM.Predictive signs of malignancy are cutaneous necrosis, elevated ESR(.40mm/hur), and age over 45. Malignancy evaluation in adults is war-ranted at the time of diagnosis and reevaluation for internal malignancyshould be considered every 6–12 months for the first 2 years after diag-nosis. The management of DM is topical and systemic steroid, azathioprineand the usual management for the type of cancer found. DM may or maynot improve with tumor removal. Death is usually related to metastaticdisease and not myopathy.

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Hepatic artery pseudoaneurysm presenting as right upper quadrantpain and massive upper gastrointestinal hemorrhageShen Bo M.D., Shay Steve M.D. FACG, Walsh Matthew M.D. TheCleveland Clinic Foundation, Cleveland, OH.

Hepatic artery pseudoaneurysms (HAPA) are rare and usually occurs aftertrauma or surgery. We present a patient with no apparent etiology success-fully treated with interventional radiology.Case Report:A 55 years old man presented at a local hospital with acuteonset of severe, intermittent right upper quadrant (RUQ) pain followed byseveral large volume hematemesis and melena. Initial upper endoscopy ata local hospital showed blood clots in the stomach and an extrinsiccompression at the distal antrum causing partial gastric outlet obstruction.No bleeding source was identified. Abdominal ultrasound revealed chole-lithiasis. He underwent laparotomy, gastrojejunostomy, and cholecystos-tomy. His RUQ pain persisted and he continued to have melena andhematemesis requiring more than 10 units of blood transfusions. Nine daysafter surgery, he was transferred to the Cleveland Clinic. Past historyrevealed chronic alcoholic Pancreatitis with common bile duct stricture andcholedochojejunostomy in 1978. On physical examination, BP was 110/50,pulse 98/min. The abdomen was tender at RUQ, and there was no mass,hepatosplenomegaly, or ascites. Laboratory tests were unremarkable excepthemoglobin 10.7. He received additional four units of blood transfusion.An emergent upper endoscopy showed blood clots coming from the affer-ent limb of gastrojejunostomy and extrinsic compression at the distalantrum. With difficulty, the pylorus was passed and the duodenum con-tained fresh blood clots. The bleeding site was identified as an atypical,superficial, focal ulceration at tip of an extrinsic lesion compressing theduodenal bulb. Endoscopic treatment was not considered feasible. Anemergent angiography revealed a large 5-cm right hepatic artery pseudo-aneurysm adjacent to the distal antrum and proximal duodenum. Though anoccluded portal vein was present, he did well after the pseudoaneurysm wassuccessfully embolized with coils. His RUQ pain resolved, and there wasno further gastrointestinal hemorrhage.

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Patent ductus venosus in an adult presenting as pulmonaryhypertension, right side heart failure and portosystemicencephalopathyShen B MD, Younossi Z MD, Dolmatch B MD, Newman J MD,Henderson M MD, Ong J MD, Gramlich T MD, Yamani M MD. TheCleveland Clinic, Cleveland, OH.

Introduction: Patent ductus venosus is persistence of the embryonic con-nection between the portal vein and the hepatic vein, which is rarely seenin adults.Case:A 50 year old man with a history of cardiomyopathy and heart failurewas referred for heart transplant evaluation. In the last 3 years, he has hadprogressive dyspnea and experienced multiple episodes of confusion withplasma ammonia levels between 80 to 160 umol/L suggestive of portosys-temic encephalopathy, and treated with lactulose. He had been sober for 11years. His physical examination was remarkable for a systolic murmur,hepatojugular reflux, hepatomegaly, and pedal edema. Laboratory datashowed albumin 3.4, bilirubin 2.0. normal AST and ALT, platelet 121K,hemoglobin 11.3, protime 15.2. An echocardiogram demonstrated normalleft ventricular function, dilated right ventricle with moderate systolicdysfunction and 31 tricuspid regurgitation. A right-sided cardiac cathe-terization revealed pulmonary arterial pressure of 75/40. A CT scan of chestincidentally identified a 4-cm diameter shunt between the left portal and lefthepatic veins. A transjugular liver biopsy showed mild sinosoidal fibrosiswithout cirrhosis. Transjugular hepatic venography confirmed a patentductus venosus. Transhepatic entry into the right portal vein system per-mitted coil embolization of the shunt with complete occlusion of flow. Themain portal vein pressure was 19 prior to shunt closure and 27 mmHgfollowing the procedure. The peri- and post- procedure course was un-eventful. The 3- and 6-hour plasma ammonia levels after a 60g protein mealwere 76 and 83 before embolization and 34 and 51 umol/L seven days afterembolization. His dyspnea has improved and no further episodes of por-tosystemic encephalopathy off lactulose has been reported.Conclusion:We report the first case of patent ductus venosus presenting asright-sided heart failure and portosystemic encephalopathy treated success-fully by coil embolization with early improvement in cardiovascular he-modynamics portosystemic encephalopathy.

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Use of physician assistant in gastroenterology in a communitypracticeShneidman Robert J*, Fossati Dale A. Kaiser Permanente Northwest,Portland, Oregon, United States.

Purpose: While 15% of major US academic centers have been usingphysician extenders to do flexible sigmoidoscopy, less than 4% have beenusing physician assistants to do more advanced procedures, e.g. upperendoscopy and colonoscopy. When physician extenders have been used, ithas been primarily in academic centers and not in the community. With theincreased demand for endoscopic procedures, and the anticipation ofscreening colonoscopy for colon cancer, there is a shortage of endoscopistsin the USA.

Aim: to train a physician extender for advanced procedures in a com-munity setting.

Demographics: 440,000 member HMO in the Pacific NorthwestMethods: This physician assistant was involved in a 4-year training periodfor advanced procedures, with final approval for practice by the OregonBoard of Medical Examiners, built on a base of.30,000 flexible sigmoid-oscopies. Training included a mentored program of reading, intensive staffsupervision in clinic and hospital, advanced procedures, and training andcredentialing in conscious sedation.Results: From January 1999 to April of 2000, the PA has done.1000diagnostic and theraputic colonoscopies, with complication rates similar tothe GI staff.

2607AJG – September, 2000 Abstracts