bright red blood and clots from an ulcer and sclerotherapy was unsuccess-ful. Surgery revealed a necrotic area in the pancreas within which was afistula from the pancreatic tumor into the stomach and major retroperitonealvessels. The bleeding from the major retroperitoneal vessels, through thepancreatic fistula was controlled with balloon tamponade using a Foleycatheter. The patient had a complicated post-operative course and died ofmultiple organ failure five days later.Discussion: Order et al. recently developed a technique to inject a radio-active isotope of phosphorus, colloidal 32P, directly into pancreatic tumor.Our patient underwent this therapy after failure of chemoradiation. Shedeveloped pancreatic necrosis with fistula formation possibly as a result ofthe irradiation. Improved local tumor control is claimed to be due to thehighly concentrated therapy by this technique. However, due to the con-centrated form of therapy, untoward events could occur and may haveresulted in a vascular pancreatic gastric fistula. Ninety-seven other patientstreated to date by S.O with similar high doses by infusional brachytherapy,have not had this complication.Conclusion Further reporting of the side effects and complications willsubsequently define the recommendations for the judicious use of Colloidal32P Injection for nonresectable pancreatic cancer.

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Toxic methemoglobinemia induced by topical benzocaine applicationduring endoscopyAli S Karakurum, MD, FACG, C Hadjiyane, MD, FACG, G Garramone,MD, I. Zaffer, MD, A. Shehata, MD, C Pellecchia, MD, FACG. NassauUniversity Medical Center, East Meadow, New York.

Introduction: Topically applied anesthetics are commonly used as part ofpremedication for endoscopic procedures. We describe a rare case of toxicmethemoglobinemia that resulted from a standard dose of topical benzo-caine spray use. Methemoglobin is a potentially fatal complication, whichcan occur in people with no predisposing factorsCase: A 37 year-old white female with severe reflux symptoms presentedfor outpatient upper endoscopy. Procedure started after two short topicalsprays of 20% benzocaine, 2mg Versed and 50mg Demerol administration.Standard monitoring utilizing pulse oxymetry, pulse and blood pressurewas done. Ten minutes following the completion of the procedure O2saturation gradually dropped to 81% despite 100% O2 via facemask, BPand pulse remained stable. Patient was become cyanotic and was veryanxious. Methemoglobinemia was suspected, arterial blood gases wereobtained, pH 7.59, PAO2-367 mmHg, PaCO2-23. Methemoglobin levelwas 37.6%. 100 mg Methylene blue 1% solution over 5 minutes wasadministered and the patient responded. O2 saturation improved to 96%.Patient was admitted to ICU, monitored overnight hospital course wasunevenful and patient was discharged the next day.Discussion: Methemoglobin is formed when ferrous iron in hemoglobin isoxidized to ferric iron which unable hemoglobin from carrying oxygen.Cyanosis may appear with levels of 15%, asymptomatic below 20%,lethargy, lightheadedness and anxiety develops with 30%, coma 50-70%and lethal if levels are 70% or more. Methemoglobin increases the affinityof normalhemoglobin to oxygen, thereby hindering oxygen release to thetissue. Anesthetics are implicated as a causative factor for methemoglo-binemia. This reaction may be dose related or it may be sporadic. A bedsidetest that can be helpful is blood containing high concentrations of methe-moglobin appears chocolate brown. Once recognized, can easily be treatedwith intravenous methylene blue.

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Liver transplantation in autoimmune cholangitisGuilherme Macedo, M.D., FACG, Susana Lopes, M.D., Costa Maia,M.D., Abilio Gomes, M.D., Fatima Carneiro, M.D., PhD, Tome Ribeiro,M.D., PhD. Gastroenterology Unit, Hosp. S. Joao, Porto, Portugal.

Autoimmune cholangitis is a clinical entity characterized by clinical andbiochemical cholestasis, classic histologic features of primary biliary cir-

rhosis, absence of antimitochondrial antibodies (using standard immuno-fluorescence), with predominant cytolysis or cholestasis depending on itsstage of evolution. It has been recognized that some patients are refractoryto steroids and/orursodeoxycholic acid, but only a few have been reportedto be treated with liver transplantation. (OLT).

We present the clinical and immunological features of 2 female patients,transplanted at the age of 43 and 52 years old, because of portal hyper-tension, jaundice and intractable pruritus. Both were submitted to tripleimmunossupressive induction therapy, which included mycophenolatemofetil. One of the patients had an acute cellular rejection, promptlyresolved with steroid bolus. Both patients underlined an overnight disap-pearance of pruritus, after transplantation. The graft function is excelent, 21and 42 months after OLT. Both patients reassumed normal lives.

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Giant duodenal bulb villotubular adenoma evaluated by endoscopicultrasound and removed endoscopicallyN. S. Mann, M.D., FACG, P. I. Sheykhzadeh, M.D., S. K. Mann, M.D.,FACG, I. Meadows, M.D., and J. W. Leung, M.D., FACG. VANCHCSMartinez, CA and Univ of Calif, Davis, School of Medicine, Davis,California.

Introduction: Giant polyps localized to the duodenal bulb are uncommon,although small nodules of heterotopic gastric mucosa in the duodenal bulbare not uncommon. We describe a case of a giant duodenal bulb polypwhich was evaluated by upper GI endoscopic ultrasound (EUS) and suc-cessfully removed by endoscopic polypectomy.Case Report: A 37 year old male patient presented with history ofepigastric discomfort and occasional nausea but no vomiting for 3 months.He also had heartburn for many years off and on. The patient deniedhematemesis, melena, hematochezia or weight loss. Physical exam androutine laboratory tests were normal. EGD showed mild reflux esophagitis,and normal stomach. In the duodenal bulb there was a 4.5 cm � 4.0 cmmultilobed, soft mass on a short stalk; it intermittently prolapsed into thestomach through the pylorus (Fig 1). On EUS it appeared as a heterogenousmultilobed mass (Fig 2 arrow) localized to the mucosa. EUS findingsemboldened us to remove the polyp piece meal by snare polypectomy. Eachtime after the polyp was snared, 0.5 mg I. V. glucagons was given toabolish duodenal motility to prevent it being washed down the duodenum.To our knowledge this is the first time glucagons has been used for thispurpose. After the polyp was cut, it was retrieved by using foreign bodybasket. There were no complications and one month after the procedure thepatient was asymptomatic.Conclusion: A giant duodenal bulb polyp was removed endoscopicallyafter EUS which assured us that the lesion was entirely mucosal in location.Thus a laparotomy was avoided.

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Isolated cecal diverticulosisN. S. Mann, M.D., FACG, P. I. Sheykhzadeh, M.D., S. K. Mann, M.D.,FACG, J. W. Leung, M.D., FACG. VANCHCS Martinez, CA, and Univof Calif, Davis, School of Medicine, Davis, California.

Introduction: Diverticula localized to the cecum when there are no diver-ticula in the rest of the colon are uncommon (Dis Colon Rectum 1984;27:454). Diverticula in the rest of the colon do not include all the layers of

S257AJG – September, Suppl., 2001 Abstracts