s Submitted for the 68th Annual Scientific Meeting of the American College of Gastroenterology October 10-15, 2003, Baltimore, Maryland: SMALL INTESTINE/UNCLASSIFIED: PDF Only

A case of an ulcerated gastric wall mass ultimately found to be splenosis is presented in which the index patient had endoscopic and endoscopic ultrasonographic evaluation prior to resection. Although no visual features identified this mass as a splenic implant preoperatively, the lesion appeared to be atypical for leiomyoma, which led to surgical intervention. The role of endoscopic ultrasonography in assessing isolated gastric masses is discussed.

A 76-year-old man underwent evaluation for a 2-week history of decreased stool frequency, intermittent mild abdominal pain, and occasional nausea and vomiting. He denied weight loss, hematochezia, fever, or change in urinary function. Physical examination revealed normal bowel sounds without hepatosplenomegaly. Mild suprapubic tenderness was present. By digital rectal examination, a large mass was palpable in the rectal vault that was fixed both anteriorly and posteriorly. Colonoscopy revealed an annular, firm, and friable mass, 5 cm in length, beginning at 16 cm above the exterior anal verge. The mass appeared to be intrinsic to the bowel wall by visual inspection, with prominent central ulceration (Fig. 1). The remainder of the examination was unremarkable except for several small diverticula in the transverse colon. Preliminary pathologic review suggested a poorly differentiated adenocarcinoma of rectal origin. EUS was done for local staging to determine the need for neoadjuvant therapy. A radial scanning echoendoscope (GFUM-20; Olympus America, Inc., Melville, N.Y.) was used with a water-filled balloon and instillation of water into the rectum. Ultrasound scanning was performed at 7.5 MHZ to 9, 6, and 4 cm depths. EUS revealed a 6 × 4 cm hypoechoic mass extrinsic to the bowel wall. The tumor was noted to penetrate the four outermost ultrasonographic layers of the rectal wall, including the hypoechoic muscularis mucosa. The innermost hyperechoic layer, representing the balloon-mucosa interface, remained intact for the majority of the length of the tumor, although this layer was deformed by the underlying mass (Fig. 2). Approximately one half of the prostate gland was replaced with an irregular, echopoor lesion that obliterated and extended beyond the external capsular border. A hypoechoic tongue of tumor arising from the prostate communicated with the extrinsic bowel wall mass (Fig. 3). Multiple hypoechoic lymph nodes larger than 1 cm in diameter were seen above the tumor mass. These findings suggested a primary prostate carcinoma, with bowel wall invasion and local nodal metastases, mimicking a rectal neoplasm. Histopathologic study confirmed the prostatic origin of the tumor. Hematoxylin and eosin–stained sections of the rectal biopsy revealed a poorly differentiated tumor infiltrating the submucosa and muscularis mucosae. The mucicarmine stain was negative for mucin. Immunohistochemical stains revealed intracytoplasmic staining of the neoplastic cells with prostate specific antigen. Hormonal therapy with flutamide and leuprolide was initiated, with good response.

EUS is an increasingly important tool which requires cognizance of difficult anatomic relationships.The Visible Human Project at the University of Colorado Health Sciences Center offers a unique data base through which high resolution anatomical images can be obtained in any plane of reference.This facilitates comparative study of endosonographic and sectional anatomy.Methods: Using a combination of sagittal, coronal and transverse images from the Visible Human data base, an approximate pathway of an endoscope was defined through the upper digestive tract.Using programs to tilt images in nonconventional planes with feedback from real time EUS images, a theoretical curve was constructed to approximate the path of an endoscope from the gastroesophageal junction through the third portion of the duodenum.Perpendicular high resolution images centered on this curve were obtained at 1 mm intervals.This image pool was compared to real time EUS images of the normal stomach and duodenum generated by an Olympus GFUM20 EUS endoscope and captured by a Panasonic AG1970 video recorder on SVHS videotape.Individual, sequential, transverse EUS images were captured digitally.Extraluminal structures were identified on the visible human data base and correlative structures identified and labeled on the digitalized EUS images.Results: A series of high resolution anatomic images were obtained which correlated to real time radial scanning EUS.Specific structures, including the splenic vein, portal vein, hepatic veins, vena cava, aorta, biliary tree and solid organs were identified on both anatomic and EUS images.Complex anatomic relationships between these extraluminal structures were clearly defined.High quality photographs were obtained at each level, and the compilation of data allowed fly through imaging mimicking virtual echoendosonography.Conclusions: Correlation of EUS to images of the Visible Human Project provide an excellent tool for teaching and reviewing normal endosonographic anatomy.The current database will shorten the learning curve for EUS proficiency and enhance the skills of experienced endosonographers.In the future this database can be manipulated to simulate variant normal and abnormal EUS anatomy.

Thrombocytopenia associated with chronic liver disease presents a difficult management issue. Most reports conclude that portocaval and distal splenorenal shunts do not improve platelet counts in this setting. The response of thrombocytopenia after transjugular intrahepatic portosystemic shunt placement has not been studied. All platelet counts of 21 patients undergoing intrahepatic shunt placement were determined retrospectively to accumulate values at one month prior to procedure, weekly for the first month after the procedure, and monthly thereafter to six months. Comparison of pre- and postshunt platelet means showed a significant increase in counts in patients with a postshunt portal pressure gradient <12 mm Hg, with the increment evident by one week after the procedure. This response was not seen when preshunt thrombocytopenia was used as the lone variable. This study suggests that the transjugular intrahepatic portosystemic shunt may improve the thrombocytopenia associated with liver cirrhosis when these pressure gradients are attained.