Mario A. Vitale

A “vanishing” cause of upper gastrointestinal haemorrhage

A 57-year-old man presented with melaena of 2 days duration. He was haemodynamically stable and his haemoglobin level was 10 g/dl. An urgent oesophagogastroduodenoscopy revealed a solitary polyp with a long stalk prolapsing from the bulb into the third duodenum. The stalk consisted of a large, …

7148 Two young patients with a primary form of pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of submucosal or subserosal gas-filled cysts within the bowel wall. From 1985, we have observed five cases of PCI; we present two of these cases, that can be considered atypical in some way. In the first patient, a 20-year-old white male, disease was localized to the right colon. He had a history of chronic abdominal pain, with no findings at physical examination. A colonoscopy showed the presence of multiple rounded bluish masses in the right colon; puncture of these polypoid lesions with an endoscopic injection needle caused them to collapse, so confirming the diagnosis.A barium enema was then performed, with final definition of the case. An accurate evaluation excluded any associated condition and patient received no specific therapy. Three months later, follow-up endoscopy documented a complete resolution of the lesions. The second patient, a 23- year-old female, presented a disease localized to the left colon. She was referred for a recent history of abdominal pain and change in bowel habits; for this reason, patient underwent a colonscopy showing the presence of multiple typical lesions of PCI in the descending-sigmoid colon. Again, no associated condition was found. Follow-up endoscopy, performed after four months, revealed disappearance of gas collections without specific treatment. We conclude that the peculiarity of these two cases of PCI consists in the following aspects: 1)appearance in young patients; 2)absence of associated conditions (primary or idiopathic form); 3)differential diagnosis with inflammatory bowel disease; 4)spontaneous and rapid resolution of lesions.

7139 Severe haematemesis from a gastric arteriovenous malformation.

A 38 year old lady was admitted in S.Giovanni Addolorata Hospital in Rome for a massive haematemesis.Vital parameters showed marked hypotension and tachycardia; severe anemia (haemoglobin 5,8 g/dL) was detected. No relevant past medical history was recorded, the day before the patient had taken an aspirin tablet for a headache. After blood transfusions and an improvement of vital signs an urgent upper gastrointestinal endoscopy was performed. No lesions were found in oesophagus and duodenum, in the stomach a large amount of blood clots not adherent to the gastric walls were present, in the fundus a plexus of veins, 3 cm in diameter, 5 mm in mean calibre, was seen one of them was oozing. An abdominal ultrasound showed no portal hypertension and no thrombosis of the splenic vein. A surgical solution was chosen. The bleeding vessel was excised. Histologic evaluation of the surgical specimen showed an arterovenous malformation with big calibre vessels in proximity to gastric mucosa. A doppler ultrasound of the celiac trunk and of the superior mesenteric artery resulted to be normal. Angiography of the celiac trunk and of the superior mesenteric artery did not show splenic vein thrombosis, but tortuous arterial vessels, anastomised, which arose from the splenic and the left gastric artery. Patient gradually recovered and was discharged after ten days uneventfully. Gastric arteriovenous malformations are a rare cause of massive bleeding, may be misdiagnosed with gastric varices, but the absence of portal hypertension, of thrombosis of splenic vein and no alterations on angiography and Doppler ultrasound may be indicative

7140 Cough-induced mallory-weiss syndrome with multiple tears and severe persistent bleeding endoscopically treated.

A 31-year-old white male, A.A, presented to our hospital with severe hematemesis. He referred a history of several coughing spells prior to the admission, but no vomiting. During the first hours in the hospital, he had repeated episodes of hematemesis. An accurate history confirmed the previous occurrence of several violent coughing spells for the last few days, but excluded any prior vomiting. Patient was hemodynamically unstable, with hypotension, sinus tachycardia and postural changes. The laboratory data revealed a severe anemic condition (hemoglobin level: 6.0 g/dL), that required three blood transfusions. Chest X-ray was normal. The upper gastrointestinal (GI) endoscopy, performed after transfusions (12 hours after the admission), showed four longitudinal tears (maximum lenght: 20 mm): one of these tears was actively bleeding (“oozing”). Therefore, injection therapy for the active bleeding was performed, using a combined treatment strategy (polidocanol 0.5% and epinephrine 1:10000, total amount: 10 mL), with subsequent hemostasis. Afterwards, a medical therapy with omeprazole i.v. (40 mg bid) was started. Patient recovered uneventfully and at the follow-up endoscopy, performed two days later, tears showed a clean base. We present a case of severe persistent upper GI hemorrhage, precipitated by coughing, with endoscopic evidence of multiple tears at the gastroesophageal junction and in the lower esophagus. In our opinion, the severity and persistence of bleeding event, its apparent etiology (coughing), and the number of tears (four) make this case of Mallory Weiss syndrome an intesting one.

Acute intestinal ischemia in a young patient with cocaine abuse and polycythemia

A 29-year-old patient was admitted to our hospi tal with hematemesis, hematochezia and abdominal pain. He was affected by polycythemia (basal hemoglobin level: 18.5 g/dL) and referred cocaine abuse. Physical examination showed mild diffuse abdominal tenderness, hypotension, tachycardia and postural changes. Laboratory data documented a severe anemic condition (hemoglobin: lO g/dL). Therefore, an upper gastrointestinal endoscopy was performed showing blood clots in the fundic area and a gastric ulcer with non bleeding visible vessel, undergone to injection therapy (epinephrine 1:10000, total amount 8 ml); in addition, mucosa of the distal duodenum appeared frankly ischemic. A colonoscopy was negative for mucosal lesions but revealed the presence of red blood. Subsequently, an arteriogram of mesenteric vessels documented occlusion of the superior mesenteric artery. Therefore, patient underwent surgical intervention with extensive jejunal and limited ileal resection. We present a case of acute intestinal ischemia in a young man with polycytemia and cocaine abuse. The combination of the above conditions is rare. Nevertheless, mesenteric ischemia should be considered in the differential diagnosis of abdominal pain syndrome in patients with cocaine abuse.