that lymphocytic duodenitis is part of the celiac disease spectrum. Whetherthe metabolic abnormalities seen in this study are related to the increasedIEL or to other mechanisms remains to be evaluated.

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CAPSULE ENDOSCOPY: 18 MONTH EXPERIENCE INPRIVATE PRACTICESteven P. Lawrence, M.D., FACG*, David E. Adams, M.D.,Bahri M. Bilir, M.D., Nuray Bilir, M.D., David L. Carpenter, M.P.A.S.,Richard N. Hansen, M.D., FACG, Andrzej T. Triebling, M.D. ArapahoeGastroenterology, Littleton, CO.

Background: Wireless videocapsule endoscopy has been developed toacquire serial photographic images of the small bowel. The GIVEN M2Acapsule endoscopy system was used for all patients.Methods: A retrospective review of 31 capsule endoscopies done in thefirst 18 months of service in a private gastroenterology practice.Results: A total of 30 patients received 31 capsule endoscopies (1 patientunable to swallow capsule, two patients with 2 capsule endoscopies). Of the31 capsule endoscopies, 21 were for GI Bleed (both repeat capsule endos-copies for GI bleed), 6 for abdominal pain, 2 for carcinoid syndrome, 1 forGardner’s syndrome, and one self-referral for halitosis. Yield was 18/21(65%) for GI bleed, 0/6 (0%) for abdominal pain, 0/2 for Carcinoid (0%),1/1 (100%) for Gardener’s, and 0/1 (0%) for halitosis. Complicationsincluded 1 capsule failure at two hours, 1 patient unable to swallow thecapsule, and 2 cases of partial bowel obstruction that spontaneously re-solved. Of the 18 patients diagnosed with GI bleed interventions were madein 10 (56%). These included 3 surgeries, 1 embolization, 1 estrogentherapy, 3 bicap procedure, 1 polypectomy, and 1 dextran therapy. Six arebeing followed as their lesions were deemed not to be amenable to therapyor had excessive risk. One patient expired awaiting treatment and one waslost to follow up. In over 50% of the cases where a lesion was discovered,information led to change in treatment and outcomes.Conclusions: Wireless capsule endoscopy shows good sensitivity for oc-cult GI bleed. It shows poor sensitivity for other processes such as abdom-inal pain. It also showed good sensitivity for small bowel polyps inGardener’s syndrome in the one case studied. Capsule endoscopy has beenpositively accepted and proves to be a valuable adjunct in the privatesetting.

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BROWN BOWEL SYNDROME AS A COMPLICATION OFREFRACTORY SPRUEBharat Pothuri, M.D., Panna S. Mahadevia, M.D.,Lawrence J. Brandt, M.D., M.A.C.G.*. Montefiore Medical Center,Albert Einstein College of Medicine, Bronx, NY.

Purpose: A 64 year-old Irish man presented with severe epigastric pain ofone-week’s duration. His past medical history was significant for celiacsprue and his only mediations were multivitamins. Physical examinationand laboratory data were unremarkable. An endoscopy revealed multiplewhite plaques and ulcers in the descending duodenum, along with a flatmucosal pattern. Biopsies revealed a focal acute ulcer with absence of villi.He was started on prednisolone. One month later he developed peritonealsigns and hypotension and an emergent exploratory laparotomy was per-formed. This revealed multiple jejunal ulcerations and an area of perfora-tion. Oversewing was performed and a full-thickness biopsy revealed totalvillous atrophy, areas of deeply penetrating ulcers with macro and mi-croperforations. The muscle wall was deeply pigmented with lipofuscin.This was consistent with the “brown bowel syndrome.” There was also 15�m of subepithelial collagen deposition. He was started on TPN, whichwas later supplemented with vitamin E. He was still complaining of severeabdominal pain and was started on intravenous azathioprine in addition tosteroids. Due to wasting and continued severe abdominal pain, cyclospor-ine was added. His abdominal symptoms improved dramatically and thesteroids were discontinued. He was subsequently transferred to a rehabil-itation facility on oral cyclosporine. He developed recurrent symptoms on

cyclosporine and was started on tacrolimus as salvage therapy but unfor-tunately expired secondary to purulent peritonitis as a result of multipleperforations.

The brown bowel syndrome is a rare entity where accumulation oflipofuscin occurs inside smooth muscle cells of the bowel wall. Lipofuscindeposition is found in association with disorders that present with malab-sorption and vitamin E deficiency. Vitamin E is found inside mitochondriawhere it functions as a powerful antioxidant. In vitamin E deficiency thefree radicals produced during oxidative phosphorylation are not oxidizedby vitamin E but by the phospholipid component of the mitochondria. Thisresults in degradation of mitochondrial membranes, and lipofuscin isformed. The loss of energy supply within the smooth muscle may result ina dilated atonic bowel similar to a smooth muscle mitochondrial myopathy.Only 80 cases of the brown bowel syndrome have been documented in theliterature. This is the first reported case associated with the sprue syn-dromes.

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CONCURRENT INFLAMMATORY BOWEL DISEASE (IBD)AND CELIAC DISEASE (CeD): AN AGGRESSIVE FORM OF IBD?Muhammad Alam, M.D., Bo Shen, M.D.*, Jean-Paul Achkar, M.D.,Mansour Parsi, M.D., Jason Connor, M.S., Indra Patel,Jhony Doumit, M.D., Michael Zuschin, Charles Bevins, M.D.,Aaron Brzezinski, M.D., Bret Lashner, M.D. The Cleveland ClinicFoundation, Cleveland, OH.

Purpose: The availability of serology tests for CeD has made this diseaseincreasingly recognized. There are scattered case reports of coexistentIBD�CeD. Pts with concurrent IBD�CeD may have a more aggressivedisease course than either of them alone. But this notion has not beenexplored. Aim: To characterize clinical features of pts with coexistent ofIBD and CeD.Methods: We searched the database of lab tests for CeD and ICD-9 codesfor IBD (N�6908) and CeD (N�512) between 1998 and 2002 and iden-tified 18 pts with IBD�CeD. Crohn’s disease (CD), ulcerative colitis (UC),or indeterminate colitis (IC) were diagnosed based on endoscopy, radiog-raphy, and histology. CeD was defined as the presence of characteristicsmall bowel histology and positive serology (� 2 folds more than the upperlimits of normal values in 2 out of 4 markers. Controls were consecutiveage-, disease-location- and disease-duration matched IBD pts with negativeceliac serology, and age- matched pts with CeD.

IBD�CeD(N�18)

IBD Only(N�24)

CeD(N�20) P-value

Age (SD) 46.6 �17.6 43.5 � 11.8 49.1 � 15.3 0.43Gender (female, %) 14 (78%) 22 (91%) 17 (82%) 0.20CD/UC/IC, cases 10/6/2 14/10/0 N/A 0.34Diz location:Upper GI/Sm

bowel/pancolon/left colon2/7/16/2 1/13/16/3 N/A 0.65

IBD duration(mon, SD) 108.8�115.7 117.8�83.7 N/A 0.63Smoker (n, %) 6 (33%) 7 (29%) 5 (25%) 0.85Family hx IBD (n, %) 8 (44%) 6 (25%) 1 (5%) 0.018*Family hx CeD (n, %) 1 (6%) 0 1 (5%) 0.52Microcytic anemia (n, %) 5 (28%) 4 (20%) 2 (10%) 0.35Extraintestinal manifestations

(n, %)7 (38%) 3 (12.5%) 1 (5%) 0.017**

3 of IBDSteroid-dependent orimmunosuppressive agents-related surgeries (SD)

14 (78%) 13 (54%) 1 (5%) �0.0001***

# of IBD sugeries (SD) 1.3�1.7 0.8�0.8 4.3�1.9 0.20Daily stool frequency (SD) 6.4�3.5 3.7�2.0 4.3�1.9 0.02****Frequent bloody stool (n, %) 11 (61%) 15 (63%) 1 (5%) 0.0001*****

*,**, *** IIBD�CeD vs. CeD, p � 0.01;**** IBD�CeD vs IBD, p�0.02;***** IBD�CeD vs. CeD, p�0.0002

Conclusions: 1) Concurrent IBD and CeD mainly affected female pts; 2)Extraintestinal manifestations were more common in IBD�CeD than inIBD or CeD; 3) Concurrent IBD�CeD had a trend towards more aggres-

S80 Abstracts AJG – Vol. 98, No. 9, Suppl., 2003

sive disease (ie. steroid-dependency, symptoms, and IBD-related surger-ies). IBD pts who have a refractory course should be checked for CeD.

235

PREVALANCE OF LOW BONE MASS IN A COMMUNITYPOPULATION OF PATIENTS WITH KNOWN CELIACDISEASE AND THE RELATIONSHIP OFNONPHARMACOLOGICAL MEASURES (GLUTEN FREE DIET)WITH BONE DENSIY IN THIS POPULATIONGhazaleh Bigdeli, M.D., Kelly Krohn, M.D., David Limauro, M.D.*,David Glorioso, M.D., Anthony Colatrella, M.D. Mercy Hospital ofPittsburgh, Pittsburgh, PA.

Purpose: Osteopenia and osteoporosis are well–recognized complicationsof celiac disease. The objectives of this study were to evaluate the preva-lence of low bone mass in a community population of patients with knownceliac disease and to analyze the relationship between low bone mass andclinical data of patients.Methods: We studied 37 patients with a well-established diagnosis ofceliac disease. All patients had a retrospective historical review by fillingout a questionnaire and survey. All patients underwent bone mineraldensity measurement by Accu Dexa bone scan of the middle finger of thenon- prominent hand. Bone mineral density was determined by T scorescalculated from the normative database of the manufacture.Results: Among celiacs, 10 patients (F�7 and M�3) (27%) had low bonedensity with a T score �-1 measured by the accu dexa scan. Patients hada mean age of 67.7 years. Control studies show that the distribution ofosteoporosis cases by age in men and women is about 22% and 25%respectively (CCJM 70 :( 245–253) March 2003).

The mean duration of the disease in this group was 46.6 months and theywere on a self-reported gluten diet for mean of 40.6 months. None of thepatients were on chronic steroids and 7/10 (70%) were taking calciumsupplements. Four patients were on treatment for osteoporois. One patienthad a fracture due to osteoporosis.Conclusions: This study showed that patients with celiac disease have ahigh prevalence of low bone density. The main associated variables of lowBMD were age and postmenopausal status (women). Our results show thatnonpharmacologic measures such as gluten free diet are not sufficient.There has been no studies to show significant improvement in adult patientswho have been on a gluten-free diet (Guidelines for osteoporosis in celiacdisease and IBD, Gut. 46 Suppl 1:i1–8, 2000 Jan). Early diagnosis andeffective treatment of celiac disease are the most relevant measures toprotect patients from bone disease.

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CLINICAL SIGNIFICANCE OF ENDOSCOPICALLY OBTAINEDSMALL BOWEL MUCOSAL BIOPSIESShaily Jain, M.B.B.S., John O’Brien, M.D.*. Siu School of Medicine,Springfield, IL.

Purpose: Small bowel biopsies (SBB) are routinely performed duringesophagogastroduodenoscopy (EGD). Although SBB may help in diagnos-ing specific diseases, often the indications for SBB are unclear. The aim ofthe present study is to determine the yield of SBB and its impact onpatient(pt)’s management.Methods: So far, data is collected on 123 consecutive patients (pts) whohad SBB done at a tertiary medical center. Clinical indications were:anemia 73 (59 %); diarrhea 17 (14%); abdominal pain 14 (11%); gross GIbleed 6; dysphagia 5; weight loss 3; dyspepsia 3; portal hypertension 1;celiac sprue(CS) 1. SBB histologies were compared with EGD findings andclinical indications.Results: 24 (19.5%) of 123 pts biopsied had abnormal EGD findings :duodenal ulcer 5; duodenitis 5; nodular mucosa 3; reduced duodenal folds2; atrophic mucosa 2, granular mucosa 1; duodenal plaque 1; duodenalangiodysplasia 1; duodenal nodule 1; friable mucosa 1; duodenal polyp 1;thickened duodenum 1. Histologic results were: duodenitis 10(42%); CS 2;gastric metaplasia 2; Crohn’s disease(CD) 1; MAI 1. Of interest, histologic

interpretations from 8 biopsies with positive EGD findings were normal.On other hand, 4 pts with normal EGD had positive SBB histology(duo-denitis). The 2 pts with CS on biopsy had clinical manifestations (malab-sorption and anemia) and endoscopic findings (presence of scalloped mu-cosa and reduced duodenal folds) suggestive of CS. The pts with CD andMAI had histories consistent with CD and AIDS respectively.Conclusions: With few exceptions, the histologic results of SBB seldomprovide additional information that was not known from pts’ clinicalhistory and EGD that leads to change in pt’s management. Even the smallnumber of pts with CS and CD had history and EGD findings suggestiveof their diagnosis. False negative histologic interpretations were seen in 8pts with EGD findings. Standard biopsy forceps rarely traverse the mucosallayer so the histology may be normal in pts with submucosal lesions.Though it was not the case in our study, there are documented cases ofclinically significant bleeding with SBB. Also, the total charge to pt forSBB is at least $400 (endoscopist and pathologist fee and technical pa-thology). Therefore a strong case for obtaining SBB routinely on EGDcannot be made unless specific clinical indications are present or endo-scopic appearance suggests a specific etiology that would change the pt’scourse of management.

LIVER

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LIVER FUNCTION TESTS AND CLINICAL SEVERITY OFDENGUE INFECTION IN ADULT PATIENTSSombat Treeprasertsuk, M.D., Chatporn Kittitrakul, M.D.,Udomsak Silachamroon, M.D., Weerapong Phumratanaprapin, M.D.,Srivicha Krudsood, M.D., Polrat Wilairatana, M.D., FACG*,Sornchai Looareesuwan, M.D. Faculty of Tropical Medicine, Rajvithi,Bangkok, Thailand.

Purpose: This study aims to describe the clinical manifestations of dengueinfection in adult patients and to compare their severity between the groupof dengue infection with and without abnormal liver function tests in adultpatients.Methods: A retro and prospective study of 127 cases of Dengue infectionin adult ( age � 15 years ) admitted at Hospital for Tropical Diseases from2000 to 2002 and diagnosed by WHO clinical criteria with serological testsconfirmed by using ELISA test or Rapid Immunochromatographic test wasreviewed.Results: Males and female were 1:1. The mean age of the patients was26.4 � 11.5 years. Classification of Dengue infection by WHO criteriawere DF 3.1% , DHF gr.I 25.2% , DHF gr.II 65.4% and DHF gr.III 6.3%.Mean duration of fever clearance time was 6.0�1.9 days but the fever lastlonger in cases of abnormal liver function tests (ALT� 10 times). Thecommon presenting symptoms and signs were nausea and vomiting(87.7%) , tourniquet test positive (77.2%), abdominal pain (42.7%), hep-atomegaly (34.6%), bleeding (35.1%), skin rash (29.9%) and diarrhea(14.5%). Thirty six patients ( 28.3% ) had platelet count less than 20,000cell/mm3. Abnormal AST. and ALT. were found in 88.2% and 69.3% ofpatients, respectively . The mean level of serum ALT was 129.3�169.8 U/lin DF / DHF gr.I and 161.6�230.6 U/l in DHF gr.II / DHF gr.III (p �0.05). The ratio of AST and ALT, especially in the first 7 days of fever was1.8:1. Ten fold greater than the normal limit of AST and ALT occured in11.0% and 7.0% , respectively. The dengue infected patients who hadelevated ALT of greater than 4 times of upper normal limit present withlower white blood cells count, lower platelets count on admission than thepatients who had elevated ALT of lower than 4 times (p � 0.05). However,their clinical severities, especially the bleeding tendency,were not signifi-cantly different in both group.Conclusions: The clinical manifestations of dengue infection in adultpatients were different from those in children in the aspect of the lessprevalence of bleeding tendency, the more common of abnormal liverfunction tests. There was no any significant difference in their clinicalseverity between the group of normal and abnormal liver function tests inadult patients.

S81AJG – September, Suppl., 2003 Abstracts