respiratory depression, most often in older patients. Slowintravenous injection through a large-diameter vein orthrough the intravenous tubing will minimize the hazardsfrom this complication.

Analysis of the 5 fatal cases stresses the importance ofprompt surgical drainage when ductal obstruction is demon­strated. Because of this and because ERCP is a stressful proce­dure, it should be performed on only those patients who areacceptable surgical candidates.

ERCP has proven to be an exciting new diagnostic proce­dure in the evaluation of a variety of pancreatic and biliarytract diseases. In properly selected patients, it is capable ofproviding unique diagnostic information with reasonable riskto the patient. Serious complications following ERCP can beminimized by careful attention to detail, as well as by anappreciation of the hazards associated with ductal obstruc­tion.

ACKNOWLEDGEMENTSThe authors would like to acknowledge the secretarial assistance provided by

the Clinical Investigation Center, Naval Regional Medical Center, San Diego,Cal iforn ia.

REFERENCES1. KATZ D: Morbidity and mortality in standard and flexible gastrointestinal

endoscopy. Gastrointestinal Endoscopy 15:134, 19692. BACKWOOD WB, VENNES jA, SILVIS SE: Post-endoscopy pancreatitis and

hyperamylasuria. Gastrointestinal Endoscopy 20:56, 19733. GOTHLIN j, TRANBERG KG: Complications of percutaneous trans- hepatic

cholangiograph (PTC). Am j. Roentgenal 117:426, 19734. AMMANN RW, DEYHLE P, BUTIKOFER E: Fatal necrotizing pancreatitis after

peroral cholangiopancreatography. Gastroenterology 64:320, 19735. OKUDA K, SOMEYA N, GOTO A. KUNISAKI T, EMURA T, YASUMOTO M,

SHIMOKAWA Y: Endoscopic pancreatocholangiography: A preliminaryreport on technique and diagnostic significance. Am j Roentgenol 117:437,1973

6. RUPPIN H, AMON R, EnL W, CLASSEN M, DEMLING l: Acute pancreatitisafter endoscopic I radiological pancreatography (ERCP). Endoscopy 6:94,1974

7. BLUMGART lH, SALMON PR, COnON PB: Endoscopy and retrogradecholedochopancreatography in the diagnosis of the patient with iuandice.Surg Gynecol Obstet 138:575, 1974

8. VENNES jA, jCOBSON jR, SILVIS SE: Endoscopic cholangiography for biliarysystem diagnosis. An Int Med 80:61,1974

9. SILVIS SE, NEBEL OT, ROGERS G, SUGAWA C, MANDELSTAM P:Endoscopic complications: results of the 1974 American Society for Gas­trointestinal Endoscopy (NS/G/E) Survey. JAMA, in press, 1975

10. KEDDIE N, NARDI Gl: Pancreatography: a safe and effective technique. Amj Surg 110:863, 1965

11. SILVIS SE, BLOCK jA: The role of glucagon in pancreatocholangiography.Gastrointestinal Endoscopy, in press, 1975

12. KASUGAI T. KUNO N, K,zu M: Mamometric endoscopic retrogradepancreatocholangiography: technique, significance, and ev.aluation. Am jDig Dis 19:485, 1974

13. VENNES lA, JACOBSON jR, SILVIS SE: Endoscopic cholangiography forbiliary system diagnosis. Am Int Med 80:61,1974

14. COTTON PB, SALMON PR, BLUMGART lH, PIERCE jW, SALMON PR,BURWooD Rj, lAWRIE BW, READ AE: Cannulation of the papilla of Vatervia fiber-duodenography; assessment of ERCP in 60 patients. Lancet 1:53,1972

36

of specialnoteEndoscopic diagnosis of malignant melanomametastatic to the duodenum

Michael V. Sivak, Jr., MDB. H. Sullivan Jr, MD*

Department of GastroenterologyThe Cleveland Clinic Foundation

and the Cleveland Clinic Educational FoundationCleveland, Ohio

Malignant melanoma is prominent among those tumors thatmetastasize to the gastrointestinal tract by methods other thancontiguous spread.',2 The liver is the intraabdominal organmost often invaded by metastatic melanoma,3 although thefrequency of metastasis to the small intestine closely ap­proaches that for hepatic involvement.3-S Metastasis can occurin the small intestine without spread to the liver. 6 Gastricmetastasis is less frequent at necropsy than involvement of thesmall bowel, the pancreas, or the spleen.'

Metastatic disease in the liver is often appreciated cI inically,but its presence in the gastrointestinal tract proper is often notrecognized during life. Earlier case surveys included mainlythe findings at postmortem examination.' Recent reviewsstress the clinical diagnosis of metastatic gastrointestinalmelanoma, since in many instances operative treatment hasprovided prolonged periods of palliation in symptomaticpatients.3.6,8,9

Endoscopy has not been afforded an important role in re­ported cases. There were only 3 instances of endoscopicinvestigation in Booth' s'o review of 51 patients with metastaticmelanoma in the stomach, and in no case was the diagnosisconfirmed by biopsy. In some cases endoscopic examinationhas been negative." Reed et al. 12 were first to obtain proof ofmetastatic gastric melanoma by biopsy, and endoscopic find­ings in the stomach only have also been reported by Richter etal.,13 Stalder,S and Backman and Davidsson. 14

CASE REPORT A malignant melanoma was removed by wideexcision from the skin of the back of a 35 year old man 18months previous to endoscopic examination. Six months latera radical dissection of the right axilla was performed becauseof metastasis, and this was followed in 3 months by excision ofa similar lesion of the right upper arm. Epigastric pain unre­lated to eating and with no associated nausea or vomitingbegan 10 days before admission. Melena, but not hema­temesis, appeared 5 days later.

Many subcutaneous nodules of 1 cm average diameter werefound on examination of the arms, axillae, neck, and lowerabdominal wall. There was no hepatomegaly or palpable

·abdominal masses.There was a hypochromic microcytic anemia with a hemo­

globin of 7 g. The leukocyte, differential, and platelet countswere normal, as were liver function tests and a liver scan. Apercutaneous needle biopsy of the liver revealed nonspecificmild chronic portal triaditis, The brain scan, colon and skull

"Reprint requests: B. H. Sullivan, Jr., MD, Department of Gastroenterology, TheCleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44106.

GASTROINTESTINAL ENDOSCOPY

roentgenograms, bone survey, and bone marrow biopsy wereall normal. Radiographs of the esophagus, stomach, andduodenum were interpreted as normal although those of thesmall bowel suggested several areas of indentation in theterminal ileum (Figure 1). A chest radiograph disclosed nu­merous nodular densities of varying size throughout both lungfields.

Endoscopic examination was performed with an OlympusGIF-D2 instrument. The esophagus and stomach were normalexcept for 2 nonpigmented nodules measuring 2 mm to 3mmin the mucosa near the pylorus. No abnormalities were en­countered in the duodenal bulb, but the descendingduodenum contained 6 tumor nodules of various sizes andstages of ulceration (Figure 2). The smallest was 3 mm and thelargest 1.5 to 2 cm in diameter. All were pigmented (Figure

2b), and 2 of the larger lesions were ulcerated (Figure 2c). Noactive bleeding was noted. Biopsy specimens from the lesionsrevealed malignant melanoma in an enteric segment.

Subsequent management included chemotherapy, bloodtransfusion, bland diet, and antacid therapy. The abdominalpain subsided over the next 2 weeks, but melena persisted.The patient was thereafter lost to follow-up.COMMENT Gastrointestinal metastasis may become evidentmany years after discovery of aprimary melanoma. Symptomshave commenced as long as 11 years after diagnosis of aninitial lesion." Metastasis in the gastrointestinal tract appearedan average of 3 years after discovery of a primary lesion formale patients and 3.8 years for females in Backman's3 reviewof 18 cases.

Symptoms may include nonspecific abdominal discomfort,pain suggestive of peptic ulcer disease, nausea, or vomiting.General features of malignancy such as weight loss, malaise,and anorexia may be present. Ulcerated mucosal lesions arefrequently associated with intra-enteric blood loss. A gradualdevelopment of anemia is more typical than massive hemor­rhage. Acute small bowel obstruction, a frequent mode ofpresentation, is usually the result of intussusception. Annularlesions are rare." Perforations of the stomach' °and intestine"have occurred. A malabsorption syndrome, attributed to ex­tensive involvement of the small intestine by tumor with as­sociated bacterial overgrowth, has been reported in 1patient.'6 It is unusual to palpate a tumor mass.3

Radiographic contrast studies are frequently negative. 1S Inthe stomach, a filling defect with a large central collection ofbarium in relation to the diameter of the defect ("bull's eyelesion") is characteristic.17 The demonstration of a similarradiographic finding in the small intestine is unusual,3 al­though it has been reported.'"

Figure 1. Radiography of stomach and small intestine.

Lesions in the stomach or small intestine may be eithersingle or multiple. Gastric lesions are thought to occur mainlyon the greater curvature aspect of the body and funduss,lo,13although metastasis to the lesser curvature has beendescribed." Harris" believes that lesions are encounteredwith decreasing frequency from proximal to distal in the smallbowel, but no other author has called attention to such apattern,

Metastases may be polypoid or sessile masses or infiltrativeulcerating mucosal deposits, They are most often polypoid inthe small intestine,·'" Willbanks and Fogelman" dividedmetastatic small intestinal melanoma into 2 clinicopathologicgroups. The larger group consists of those patients who havepolypoid lesions, Polypoid lesions were likely to be multiple,nonpigmented, and associated with intussusception, The sec­ond group consists of those with ulcerating mucosal tumors.These tumors were more likely to be solitary, pigmented, andassociated with blood loss. In their series, patients with sol itaryulcerating metastases appeared to have a better prognosis.

Figure 2. Endoscopic photo­graphs of (a) ulcerated tumornodule in medial wall of descend­ing duodenum, (b) pigmentedtumor nodule in duodenal mu­cosa, and (e) large ulceratedmetastatic melanoma involvingduodenal mucosa.

VOLUME 22, NO.1, 1975 37

DasGupta and Brasfield 's in a series of 100 autopsy caseswere unable to correlate gastrointestinal metastatic diseasewith any particular primary cutaneous site. In many instances,a primary lesion apart from the gastrointestinal tract was notfound:'· and this has led to speculation that malignantmelanoma may occur as a primary tumor in the boweL",20Most reviewers regard the tumor as secondary in the gastroin­testinal tract, despite the fact that in some cases extraabdomi­nal primary tumor cannot be demonstrated.J.6SUMMARY The diagnosis of metastatic malignant melanomanot demonstrated roentgenographically in the duodenum wasmade by endoscopy in a patient with epigastric pain andmelena. Endoscopic biopsy confirmed the diagnosis. Metas­tasis in the gastrointetinal tract can appear long after treatmentof a primary extraabdominal tumor, and is not necessarilyassociated with metastases elsewhere. In selected, sympto­matic patients, operative treatment may provide prolongedperiods of palliation. Endoscopic examination is clearly indi­cated in the evaluation of patients with metastatic malignantmelanoma.

© ....

REFERENCES1. FARMER RG, HAWK WA: Metastatic tumors of the small bowel.

Gastroenterology 47 :496, 19642. DECASTRO CA, DOCKERTY MB, MAYO CWo Metastatic tumors of the

small intestine. Surg Gynecol Obstet 105:159, 19573. BACKMAN j: Metastases of malignant melanoma in the gastrointestinal tract.

Geriatrics 24:112, 19694. DASGUPTA T, BRASFIELD R: Metastatic melanoma; a clinicopathologic

study. Cancer 17:1323, 19645. STALDER GA: Malignant melanoma of the stomach. Gastrointestinal Endos­

copy 16:30, 19696. MACBETH WAAG, GWYNNE Fj, JAMIESON MG: Metastatic melanoma in

the small bowel. Aust NZ 1 Surg 38:309, 19697. HERBUT PA, MANGES WE: Melanoma of the small intestine. Arch Pathol

39:22, 19458. WILLBANKS Ol, FOGELMAN Mj: Gastrointestinal melanosarcoma. Am 1

Surg 120:602, 19709. RICHIE RE, REYNOLDS VH, SAWYERS jl: Tumor metastasis to the small

bowel from extra-abdominal sites. South Med 1 66: 1383, 197310. BOOTH j B: Malignant melanoma of the stomach; report of a case presenting

as an acute perforation and review of the literature. Br 1Surg 52:262, 196511. HARRIS MN: Massive gastrointestinal hemorrhage due to metastatic malig­

nant melanoma of small intestine. Arch Surg 88: 1049, 196412. REED PI, RASKIN HF, GRAFF PW: Malignant melanoma of the stomach.

lAMA 182:298, 196213. RICHTER R, PANISH j, BERCI G: Endoscopic findings in melanoma metasta­

tic to the stomach. Gastrointestinal Endoscopy 18:172, 197214. BACKMAN H, DAVIDSSON l: Metastases of malignant melanoma in the

stomach and small intestine. Acta Med Scand 178:329, 196515. OASGUPTA TK, BRASFIELD RO: Metastatic melanoma of the gastrointesti­

naltract. Arch Surg 88:969, 196416. BENISCH BM, ABRAMSON S, PRESENT DH: Malabsorption and metastatic

melanoma. Mt Sinai I Med NY 39:474, 197217. POTCHEN Ej, KHUNG Cl, YATSUHASHI M: X-ray diagnosis of gastric

melanoma. N Engl 1 Med 271 :133, 196418. REEDER MM, CAVANAGH RC: "Bull's Eye" lesions; solitary or multiple

nodules in the gastrointestinal Iract with large central ulceration. lAMA229:825, 1974

19. CHANDLER AB, JONES GF: Malignant melanoma of the gastrointestinaltract; a case report. Am Surg 17:719, 1951.

20. BIERNE MF: Malignant melanoma of the small intestine. Radiology 65:749,1955

38

Parotid gland swelling developingduring peroral endoscopy

Robert l. Slaughter, MD*Gastroenterology Service

Veterans Administration HospitalBirmingham, Alabama

Swelling of the submaxillary salivary glands developingduring peroral endoscopy has been previously described. I

•2

These swellings were noted to develop during the course of anupper gastrointestinal endoscopic examination, were com­pletely painless, and resolved slowly over a period of a fewhours. This communication reports a similar swelling of theparotid gland developing during peroral endoscopy, an ob­servation not previously recorded.

Figure 1. A, Patient's normal appearance (photograph taken afterswelling had subsided). B, Marked swelling of left parotid glandimmediately after peroral endoscopy.

CASE REPORT A 49 year old man with a history of recurrentpancreatitis was hospitalized at the Birmingham VA Hospitalbecause of abdominal pain and rectal bleeding of 5 days'duration. He had no history of parotid gland swelling orsymptoms. Admission physical examination revealed atachycardia of 124 per minute, pallor, a systolic ejectionmurmur, and bright blood within the rectum that was comingfrom above the reach of the sigmoidoscope. His hematocritwas 23%. He was transfused with 5 units of blood. Uppergastrointestinal radiographs revealed a gastric diverticulum.

Upper gastrointestinal endoscopy was scheduled as afurther part of his evaluation for gastrointestinal bleeding.After an overnight fast, he was given meperidine 75 mg anddiazepam 7.5 mg intravenously, and his throat was anes­thetized topically with 1% dyclonine. The ACMI Panendo­scope was introduced with the patient in the left lateraldecubitus position. The examination of the entire upper gas­trointestinal tract took 15 minutes and was an easy examina­tion. A benign gastric ulcer, in addition to the previouslydemonstrated gastric diverticulum, was found. Immediatelyupon completion of the examination, the patient was noted tohave marked swelling in the region of the left parotid gland, aswelling that had not been present before the examination(Figure 1).

"Reprint requests: Robert l. Slaughter, MD, Gastroenterology Service, VAHospital, Birmingham, Alabama 35233.

GASTROINTESTINAL ENDOSCOPY