S1367
potentially represents a new minimally invasive restrictive-type of endoscopic weight loss option. It
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Abstracts
Intestinal enterobiasis is a common cause of morbidity and disease, affecting as much as 11% to 61%
appears to be an effective and safe procedure that offers the potential advantages of efficiency, low techni-
cal complexity and no surgical complications. Further studies are needed.
2456
Paralysis Due to Thiamine and Copper Deficiencies Following Sleeve Gastrectomy Complicated by
Oral Intolerance With Recurrent Pancreatitis
Catherine Tridico Hudson, MD, MPH1, Vaniolky Losada, MD2, Emily Alker, RD3, Michael Cook, MD4.
1. LSU School of Medicine, New Orleans, LA; 2. LSU School of Medicine, River Ridge, LA; 3. UMCNO
Bariatrics and Nutrition, Mandeville, LA; 4. Louisiana State University, New Orleans, LA
Worsening obesity and widespread availability of laparoscopic surgery has led to an increase in bariatric
weight loss procedures with long term consequences including nutritional deficiencies more common
after malabsorptive procedures such as gastric bypass and biliopancreatic diversion. This is a case of a
restrictive procedure that led to unexpected nutritional deficiencies with lasting disability. A 30 year old
woman with a history of vertical sleeve gastrectomy 16 months prior had complications of oral intolerance
due to several bouts of pancreatitis with prolonged hospitalization and total parenteral nutrition (TPN).
Five weeks after surgery she developed ascending numbness and tingling of the feet leading to falls and
inability to walk. She was treated for multiple vitamin deficiencies including Dry Beriberi and had several
balloon dilations of her sleeve eventually tolerating enteral feeding again. She was improving with physi-
cal therapy but recurrence of oral intolerance led to progression of numbness, tingling, and weakness to
include her face, hands, and abdomen causing her to present to the ED. Labs revealed deficiencies of
copper and riboflavin with borderline thiamine levels as well as toxic levels of pyridoxine. Exam revealed
motor and sensory polyneuropathies with an escutcheon sign to the umbilicus and weakness of lower
extremities with loss of vibration and proprioception. Nystagmus and memory loss were consistent with
Wernicke’s Encephalopathy as well. Endoscopy was unrevealing and gastrointestinal symptoms resolved
prior to discharge six days later with improvement of the neuropathy of the hands and face after IV and
oral thiamine and copper supplementation. Although not often associated with sleeve gastrectomy, copper
deficiency is associated with zinc supplementation and use of TPN as in this case. Currently, the ASMBS
(American Society of Metabolic and Bariatric Surgery) only recommends checking levels in patients with
suggestive symptoms who have had malabsorptive procedures, but not in restrictive. But in 2017, a small
retrospective study of patients with gastric sleeves showed those with neuropathy displayed a pattern of
low thiamine, copper, and riboflavin with toxic levels of pyridoxine which also causes neuropathy. Perhaps
copper levels should be routine post-operatively in restrictive bariatric procedures. Consistent vitamin
toxicities also speaks to the need for reevaluation of vitamin supplementation regimens.
2457
Diagnostic Dilemma: Perforated Gastric Ulcer in the Excluded Stomach After Roux-en-Y
Gastric Bypass
Megan Frank, MPAS, PA-C, David Deysher, DO, Iryna S. Hepburn, MD, FACG, FACP. WellSpan Health,
Lebanon, PA
Bariatric surgery has become an important therapeutic option for the treatment of severe obesity. There are
multiple procedures to choose from, each with its own risks and benefits. Complications can occur such
as micronutrient deficiency, dumping syndrome, and marginal ulceration. We report a case of perforated
gastric ulcer occurring in the excluded stomach 15 years after Roux-en-Y gastric bypass highlighting the
diagnostic challenge these patients can pose. A 44 y/o female with history of Roux -en-Y gastric bypass
for weight loss 15 years ago presented with worsening RUQ and epigastric pain present for 3 weeks. She
had no fever, melena, or hematemesis. There was no NSAID, alcohol, tobacco or drug use. She denied
any past history of PUD or diabetes. P.E.: blood pressure 116/58, HR 71, RR 18, T 37C, the abdomen
was soft, nondistended with normal bowel sounds. Tenderness was noted in the right upper quadrant
and epigastrium, but no rebound. Stool hemoccult was positive. Laboratory studies showed WBC count
8800, hgb 15.7. Liver enzymes, bilirubin, lipase, and creatinine were normal. On day 1 of admission, a CT
demonstrated normal liver, gallbladder and biliary system, and pancreas, a normal gastric remnant and no
leak or free air was found. On day 2, an EGD revealed no ulcer or erosion and normal efferent limb. On day
3, the patient continued to have pain. WBC became elevated despite IV antibiotics. On day 4, abdominal
ultrasound of the liver and gallbladder was normal but a CCK HIDA scan revealed a gallbladder ejection
fraction of 7%. On day 5, a laparoscopic cholecystectomy was attempted. On insertion of the scope pus was
noted throughout the abdominal cavity. After conversion to an open procedure a perforation was found in
her native excluded stomach. This was repaired with an omental Graham patch and a cholecystectomy was
performed. Culture grew pseudomonas. The patient improved and was discharged 5 days later. Conclu-
sion: Patients with bariatric surgery can pose a diagnostic challenge. This case underscores the need for
thorough pre-operative evaluation including exclusion of H.pylori. Post operatively many complications
may occur. As seen here, disease in the excluded stomach, bowel, biliary tree and pancreas may be difficult
to detect and treat and may only be directly visualized with difficulty with enteroscopy of the Roux limb.
Am J Gastroenterol 2018;113:S1367–S1368; doi:10.1038/ajg.2018.316
ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—PEDIATRICS
2458
Pinworms: The Missing Link Between Vitamin B12 Deficiency and Tissue Eosinophilia
David Wilhoite, BS1, Alexandria Boley, DO2, Patrick Costello, MD2, Anjali Malkani, MBBS2. 1. East
Tennessee State University, Quillen College of Medicine, Johnson City, TN; 2. East Tennessee State
University, Johnson City, TN
The American Journal of GASTROENTEROLOGY
of children worldwide. While Enterobius Vermicularis has been associated with decreased serum levels
of zinc, copper and magnesium, studies have disagreed on the association between serum Vitamin B12
levels and Enterobius Vermicularis infestation. We present a case of Vitamin B12 deficiency secondary to
intestinal Enterobius Vermicularis.
A 7-year-old female patient was referred to pediatric gastroenterology for abdominal pain and acropara-
sthesias. Extensive lab studies performed revealed elevated absolute eosinophil count (750 cells/microL),
positive ANA (1:320 speckled pattern), and low Vitamin B12 (299 pg/mL). Upper endoscopy and colo-
noscopy biopsies revealed 5-10 eosinophils/hpf in mid and distal esophagus and eosinophilia in termi-
nal ileum and colon. Stool ova and parasite examination was negative. She was started on omeprazole,
mesalamine 50 mg/kg/day and Vitamin B12 injections (100 mcg for 10 days).Genetics, neurology, and
rheumatology referrals were unable to identify an etiology for acroparasthesias, including negative testing
for Fabry’s Disease, heavy metals, porphyria, and inborn errors of metabolism. At follow-up colonoscopy,
a pinworm was identified at the hepatic flexure. Biopsies showed persistent elevation of eosinophils in the
terminal ileum and a pinworm ova on the surface of the epithelium. The patient and family were treated
with albendazole with increasing serum B12 levels and resolution of her symptoms.
Pinworm infestation as a cause of tissue eosinophilia and Vitamin B12 deficiency would have been undi-
agnosed if the worm and ova had not been found on follow-up colonoscopy. Due to the low sensitivity
of stool ova and parasite testing, B12 deficiency of undetermined etiology associated with tissue eosino-
philia may warrant endoscopic evaluation, as pinworm infestation may be the missing link between the
two findings.
Additionally, more studies may be needed to evaluate if empiric antiparasitic treatment of children with
B12 deficiency of undetermined etiology may be of benefit prior to the initiation of an expensive multi-
specialty workup.
2459
Johanson-Blizzard Syndrome: Report of One Case
Narmer F. Galeano, MD, Rivera-Penera Maria Teresa, MD, Nishith Bhattacharyya, MD, Roberto
Nachajon, MD, Punita Gupta, MD. St. Joseph’s Medical Center, Paterson, NJ
Genetic causes of exocrine pancreatic insufficiency (EPI) are rare and commonly associated with Cystic
fibrosis (CF) or Shwachman Diamond syndrome. Herein we describe a child affected with Johansson Bliz-
ard syndrome (JBS), another rare cause of EPI. JBS is an autosomal recessive condition due to mutations
in the Ubiquin 3 ligase gene (UBR1). Findings of JBS include craniofacial malformations, EPI, failure to
thrive (FTT), hearing loss, developmental delay and anal, genitourinary and other malformations. Case:
Our patient was born at 38 weeks via repeat C-section to a 24 year old G2 P1 mother. Pregnancy was com-
plicated by polyhydramnios, hydronephrosis and dilated rectum detected at the 20 week prenatal ultra-
sound. Growth parameters at birth were normal. She was found to have abdominal distention, imperforate
anus, perianal fistula, micro colon, inspissated meconium, persistent cloacae and mild facial dysmorphism
. She underwent surgery and had placement of end ileostomy. Testing for CF was negative but steator-
rhea was present in the ileostomy effluent. She was started on pancreatic enzymes (Creon 6000 units per
feeding), vitamin ADEK and Alimentum formula. At 6 months she had cloacae repair and 2 months later
closure of ileostomy. There had been no weight gain till that point and height was at the 3rd percentile. At
19 months, both weight and height were below the 3rdpercentile. She was lost for follow up for one year
and was seen again at 31 months of age. Mother reported that the child had been fitted with a cochlear
implant and that Creon had been discontinued. Patient continued to have FTT and delayed developmental
milestones. She had hypoalbuminemia, anemia, steatorrhea and low fecal pancreatic elastase of < 50 ug/g.
Physical exam was significant for plagiocephaly, flat face, elevated palate, up slanting of palpebral fissures
and hypoplastic alae nasai. Findings were considered to be consistent with JBS. A baseline genetic evalua-
tion revealed a normal female karyotype and a normal SNP microarray. Preauthorization for UBR1 gene
sequencing was obtained and sample sent. A hypercaloric diet and pancreatic enzymes were prescribed as
well as iron and vitamin supplementations. At 33 months she had some weight gain but at 36 months her
height and weight remained below the 3rd percentile. Hypoalbuminemia has been corrected and hemoglo-
bin levels have improved. Creon supplements were readjusted. Genetic testing for JBS is pending.
2460
Benign Colonic Schwann Cell Hamartoma in a Pediatric Patient with PTEN Hamartoma Tumor
Syndrome (PHTS)
Naser Tolaymat, MD, Adam Paul, DO. Children Hospital’s at Lehigh Valley Health Network,
Allentown, PA
Schwannomas are tumors histologically derived from Schwann cells that form the neural sheath. They
occur in the head, neck, arms and limbs. Gastrointestinal Schwannoma is a rare stromal tumor of the
gastrointestinal tract reported in adult and it has not been reported in children. This is a case report of 12
year old male who presented with painless rectal bleeding. His EGD revealed no abnormality. His colo-
noscopy revealed a large number of colonic polyps. Several polyps were large, pedunculated and numerus
polyps were small and sessile. Seven polyps were removed. He had a second colonoscopy 11 days later
after presenting to the ER with significant rectal bleeding. Another 8 polyps were removed. Histology
was consistent with juvenile polyposis. Barium small bowel fluoroscopy was negative. He underwent a
genetic evaluation and he had negative SMAD4 and BMPR1 gene mutations. Subsequent testing revealed
a pathogenic mutation in the PTEN gene. He was diagnosed with PTEN hamartoma, possible Bannaya
Riley Ruvalcaba Syndrome (BRRS) given penile hamartoma. He had another colonoscopy 7 months
later. Seven small polyps were removed. These small polyps were indistinguishable visually and were sent
together to the pathology department. One polyp was described as colonic mucosa with spindle cell pro-
liferation, positive with immunohistochemical panel (S-100 protein), and compatible with Schwannoma.
This is possibly the youngest reported patient with colonic schwannoma in the literature. It is unclear
whether the benign Schwann cell hamartoma in our patient is part of a newly described histological
presentation of PHTS, or whether it is an isolated finding.
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