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INFLIXIMAB IN THE THERAPY OF SOLITARY RECTALULCER SYNDROMEAnand Madan, M.D., Sailaja M. Cheruku, M.D. and John J. O’Brien,M.D.*. Gastroenterology, S.I.U. School of Medicine, Springfield, IL.

Purpose: The development of solitary rectal syndrome (SRUS) is pre-sumed to be the result of excessive straining during defecation causingtrauma to the mucosa. Treatment of SRUS has been directed towardavoidance of straining to defecate. In addition to bulking agents, anti–inflammatory drugs (salicylates, corticosteroids and sucralfate) have alsobeen used with varying degrees of success. We report our preliminaryexperience using biologic therapy (infliximab) in the management of a 78year old weightlifter with SRUS.Methods: This 78 year old white male had been treated with radiationtherapy (XRT) for a prostate cancer almost ten years earlier at the MAYOClinic. Although he had had some transient diarrhea with the XRT heotherwise was asymptomatic until approximately 2 years ago. He subse-quently developed diarrhea, tenesmus, fecal incontinence, rectal discomfortand passage of blood per rectum. An outside physician performed aproctosigmoidoscopy demonstrating rectal erythema. The patient had beentreated with mesalamine, corticosteroids and sucralfate without benefit fora presumed diagnosis of late onset IBD. The patient subsequently sought asecond opinion at the University. Our repeat colonoscopy demonstrated asolitary rectal ulcer (biopsy results were consistent with SRUS).Results: The patient was placed on infliximab every 8–10 weeks withresolution of his symptoms and endoscopic findings.Conclusions: The treatment of SRUS had been unsatisfactory in thispatient until infliximab was introduced. This case may represent a subset ofpatients with SRUS who have an inflammatory component of the mucosathat may improve with biologic (i.e., anti–TNF) therapy.

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A RARE COMBINATION OF MIRIZZI’S SYNDROME ANDPANCREATITIS, EVOLVING INTO ACHOLECYSTODUODENAL FISTULAM. Raza Anees, M.D.*, Vikas Khurana, M.D. and Kenneth Manas, M.D.Department of Internal Medicine, Overton Brooks VAMC, Shreveport,LA and Department of Internal Medicine, Louisiana State UniversityHealth Science Center, Shreveport, LA.

Purpose: The Mirizzi’s syndrome refers to common hepatic duct obstruc-tion caused by an extrinsic compression from an impacted stone in thecystic duct. Pancreatitis secondary to gallstone is a well–known entity. Wepresent a rare combination of Mirizzi’s syndrome and acute pancreatitis,which later evolve into a cholecystoduodenal fistula.Case Report: A 71–year–old gentleman with history of recurrent pancre-atitis presented with severe vomiting, nausea, and abdominal pain, whichworsened with movements. Abdominal examination revealed diffuse ten-derness with rebound and guarding. Lab studies revealed AST 302, ALT204, T Bili 1.9, Amylase 1191 and Lipase of 5482. Ultrasound failed toreveal gallstones, bile duct was 8 mm. A diagnosis of pancreatitis wasmade. CT scan of the abdomen revealed edematous pancreas with peripan-creatic edema and fluid collection anterior to the pancreas. Multiple gall-stones were also identified this time. A HIDA scan showed incompletefilling of gall bladder at 4 hrs. Two days later his abdominal pain haddecreased significantly and his LFTs and amylase had normalized. AnERCP was performed after 2 weeks, which showed normal CBD, PD, intrahepatic ducts and distended GB with multiple large stones. Purulent ma-terial was noted in the stomach at entry, and at the withdrawal of theduodenoscope a submucosal mound was noted in the bulb with purulentexudate on top. A forward viewing endoscopic examination revealed afistula in the duodenal bulb with purulent discharge. A catheter wasintroduced via fistula and contrast was injected. Contrast was seen going upto the cystic duct and filled an abscess cavity. Purulent material wasaspirated which grew klebsiella pneumonia.

Discussion: This case is clinically challenging as it has multiple twists inits presentation. During initial clinical presentations a link between pan-creatitis and gallstones was not made because none of the imaging studiesreveal gallstones. We hypothesized that dilated bile duct and abnormalLFTs were secondary to Mirizzi’s syndrome, as evident from CT finding,which later resolved as cholecystoduodenal fistula. We will present theendoscopic pictures of duodenal fistula and fluoroscopic images of fistulawith contrast injection.Conclusion: Our case represents a rare combination of acute pancreatitis,Mirizzi’s syndrome and cholecystoduodenal fistula. We believe that acutepancreatitis facilitated the formation of the cholecystoduodenal fistula.

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AN UNUSUAL ETIOLOGY OF IRON DEFICIENCY ANEMIADIAGNOSED BY UPPER ENDOSCOPYAldo A. Garza, M.D.*, Jaime R. Zuniga, M.D. and Hector J.Maldonado, M.D. Internal Medicine / Gastroenterology, UniversidadAutonoma de Nuevo Leon / Hospital Universitario, Monterrey, NuevoLeon, Mexico.

Introduction: Endoscopy of the gastrointestinal tract is part of thework–up of iron deficiency anemia in adults. We describe the clinical andendoscopic findings of a patient with an endemic parasitic disease thatcauses microcytic anemia in developing countries of the Western hemi-sphere.Case Report: A previously healthy 22 year–old Mexican male farmerpresented to our institution complaining of two months of progressivefatigue, malaise, headaches, and mild dyspnea. He denied the use ofmedications. His family history was negative. On physical examination, thepatient appeared pale and presented marked glossitis and spoon–shapednails (Koilonychia). His bloodwork revealed a hemoglobin of 2.9 g/dl, anMCV of 58.9 fl, and normal white blood cells and platelets. Serum iron waslow (15 mg/dl). His serum chemistry and liver function tests were unre-markable. An upper endoscopy was performed, revealing the presence ofmultiple hookworms in the duodenum at the level of the bulb, second andthird portions. The duodenal mucosa appeared chronically inflammed andfriable. Multiple organisms were retrieved using suction through the scope.Biopsies were also obtained. Microscopic and histologic examinations ofthe parasites confirmed the hookworm to be Necator americanus species.The patient received blood transfusions, and was treated with albendazoleand iron supplement therapy. He was discharged in good condition.Conclusion: The diagnosis of infection by Necator americanus is usuallymade by examination of the stools for ova. Ocassionally, such as in thiscase, a specific etiologic diagnosis can be made by finding the actualparasites and identifying the exact species by retrieval of the organismsthrough endoscopy.

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DORMANT TUMORS METASTATIC TO THEGASTROINTESTINAL TRACT: AN UNUSUAL CAUSE OFUPPER GI BLEEDINGAldo A. Garza, M.D.*, Jaime R. Zuniga, M.D., Hector J. Maldonado,M.D. and Francisco J. Bosques, M.D. Internal Medicine /Gastroenterology, Universidad Autonoma de Nuevo Leon / HospitalUniversitario, Monterrey, Nuevo Leon, Mexico.

Introduction: Submucosal tumors of the gastrointestinal wall are usuallyprimary, but metastatic tumors can also occur in patients with history ofmalignant disease. We describe a patient with a recurrent tumor involvingthe UGI tract presenting with bleeding long after the initial diagnosis.Case Report: A 67 year–old diabetic woman was hospitalized with epi-gastric pain and hematemesis. Her medical history included a left nephrec-tomy for renal cell carcinoma 27 years earlier. Interestingly, 19 years aftersurgery she had a partial thyroidectomy for a thyroid mass; histology of thetumor showed recurrent metastatic renal cell Ca. The patient had noevidence of residual disease on follow–up. Five years prior to admission

S197AJG – September, Suppl., 2002 Abstracts