sidered early in any patient after OLT who presents with the symptomcomplex of unexplained fever, skin rash, cytopenia and diarrhea.

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TIPS: A TREATMENT FOR REFRACTORY HYPOXEMIA IN AYOUNG PATIENT WITH HEPATOPULMONARY SYNDROMEBashar M. Attar, M.D.,FACG*, Priti Pandya, M.D., Archana Verma,M.D. and Frida Abrahamian, M.D. Division of Gastroenterology, CookCounty Hospital, Chicago, IL.

Purpose: Hepatopulmonary syndrome (HPS) can be seen in up to 47% ofpatients with advanced liver disease and is characterized by a triad of liverdisease, hypoxia and intrapulmonary vascular dilation (IPVD). We reportthe youngest patient with hepatopulmonary syndrome who was ventilator–dependent and had remarkable post TIPS recovery.

A 27–yr–old male with significant history of alcohol abuse was admittedwith hematemesis and melena.

At admission the patient was hypotensive and hypoxic with O2 satura-tion of 88% on room air. He was icteric, but had no other stigmata ofchronic liver disease. NG tube showed active bleeding. Patient was intu-bated and started on octreotide. EGD showed actively bleeding grade 4varices and the bleeding was controlled with band ligation.

Initial labs were suggestive of decompensated liver disease: Albumin 3.1gm%, INR 1.8, Bilirubin 3.5gm%, no ascites/encephalopathy, no hepato-renal syndrome, Creatinine 0.5gm% ALT44, AST63, Cholesterol 198,normocytic anemia with hemoglobin 8.9 gm%, thrombocytopenia 94.Workup for other causes of liver disease was negative. Patient continued tohave high FIO2 requirements. Chest X–ray showed bilateral small pleuraleffusions and infiltrate. Pleural and ascitic fluid were tapped and wereidentical transudates. Patient was treated with antibiotics with no improve-ment and a subsequent bronchoscopy was normal.

A bubble echo was negative for an intracardiac shunting. However,Tc99m–labeled albumin scan demonstrated uptake in the kidneys and brainsuggestive of intrapulmonary vascular dilation and consistent with thediagnosis of hepatopulmonary syndrome.

Patient underwent TIPS because of refractory hypoxemia. HPVG was 19mm of Hg that decreased to 9 mm of Hg subsequently. Patient wasextubated 2 days post TIPS placement and discharged home within 5 daysof placement. Discharge ABG on room air showed PaO2 of 63 mm of Hgcompared to an initial PaO2 of 56 at FIO2 of 80%.Discussion: Impaired oxygenation is a hallmark of HPS and this is man-ifested by dyspnea, platypnea and orthodexia. IPVDs, which are the de-fining feature of HPS, are thought to cause severe hypoxemia. Thus, TIPSmay act as a bridge to liver transplantation in patients with HPS byimproving the renal blood flow, increasing systemic vascular resistance,decreasing the intrapulmonary shunt, and improving oxygenation.

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ENDOSCOPIC ULTRASOUND AND EARLY DETECTION OFPANCREATIC ACINAR CELL CARCINOMAThomas A. Capozza, M.D., Walter J. Coyle, M.D.* and William R.Schindler, D.O. Division of Gastroenterology, Naval Medical CenterSan Diego, San Diego, CA.

Introduction: Acinar cell carcinoma (ACC) of the pancreas accounts for1% of pancreatic exocrine tumors. This rare cancer typically presentsduring the 5th and 6th decades of life with non–specific abdominal symp-toms. In prior reports, 50% of patients present with metastatic disease andan average tumor size of �10cm. Another 23% of patients will developmetastases to the regional lymph nodes and liver soon after diagnosis.Several case reports have shown FNA with imaging guidance to be anaccurate and rapid method of diagnosis in ACC and islet cell tumors whenused in conjunction with immunocytochemical staining.Case Report: A 79 y.o. female presented to our institution with intermit-tant right upper quadrant and mid–epigastric pain. The patient denied anynausea, vomitting, anorexia, weight loss or post–prandial discomfort. A

previous laboratory evaluation showed a mild normocytic anemia withnormal hepatic synthetic function and liver associated enzymes. A RUQultrasound showed a 1.3 x 1.9 x 1.3 cm well–circumscribed, hypoechoicmass in the body of the pancreas. Endoscopic ultrasound with FNA wasperformed. The EUS confirmed the presence of a 1.3 x 1.3 cm homoge-nous, solid mass in the body of the pancreas adjacent to but not invadingthe main pancreatic duct or splenic vein. The aspirate revealed PASpositive cells forming ribbons and trabeculae consistent with an acinar celltumor. Immunocytochemistry was positive for alpha–1–antitrypsin andnegative for neuron–specific enolase, chromogranin and synaptophysin.Serum alpha–fetoprotein, insulin, glucagon and gastrin were all withinnormal limits. The patient underwent en–bloc resection via distal pancre-atectomy with splenectomy. Pathologic review confirmed the presence ofa well–circumscribed, 1.5cm, poorly differentiated acinar cell carcinomawith clear margins and 6 of 6 benign lymph nodes. The patient has enjoyeda full recovery to date.Conclusions: This represents the smallest known acinar cell carcinomareported in the medical literature. Our case lends support to the use ofendoscopic ultrasound with FNA and selective immunocytochemical stain-ing for the evaluation and diagnosis of atypical pancreatic lesions. Therewill continue to be an increasing demand for such specialized proceduresas imaging technology and sensitivity improve.

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TRAUMATIC ABDOMINAL PAIN AND NORMAL CA 19–9CONCEALING PANCREATIC ADENOCARCINOMAApril Lee, M.D., Nicholas Inverso, M.D., Michael Komar, M.D.*, AlexRusynyk, D.O. and Matthew Grundfast, D.O. Department ofGastroenterology and Nutrition, Geisinger Medical Center, Danville,PA.

Background: CA 19–9 mAb was developed in 1979 from a humancolorectal cancer cell line. Though derived from a colorectal cancer, CA19–9 is most sensitive for the detection of pancreatic carcinoma. Sensi-tivities range from 69% to 89%, and up to 75% of patients with tumorspread beyond the pancreatic bed will have a CA 19–9 of greater than 40U/ml at presentation. Despite the promising sensitivities reported for CA19–9, especially in the setting of metastatic disease, a normal value is nota reliable marker for exclusion of the presence of pancreatic cancer,localized or widespread.Case Report: A 48 year old male without significant previous medicalhistory presented to an outside hospital with complaints of severe, persis-tent abdominal pain that began immediately after a 12 to 14 foot fall. MRIof the abdomen upon initial presentation revealed mild enlargement of thepancreatic head. Laboratory analysis revealed a mildly elevated serumlipase level and a CA 19–9 level of 26.2 U/ml (normal). The patient wasdiagnosed with traumatic pancreatitis and discharged. Two weeks later, thepatient presented to the same hospital with unrelenting abdominal pain. CA19–9 was once again normal at 22.6 U/ml. Approximately 1 month afterinitial presentation, he presented to the ED with right lower extremity DVTand unchanged abdominal pain. MRI of abdomen was repeated at that timeand revealed a 6cm by 6cm mass in the head of the pancreas with multipleliver metastases and para–aortic lymphadenopathy. Pancreatic cancer wasconfirmed at Geisinger Medical Center by fine needle aspiration of thepancreatic and liver lesions. CA 19–9 at that time found again to be normalat 20.3 U/ml.Conclusion: Many clinicians persist in utilizing CA 19–9 as a screeningtool and a basis of exclusion for pancreatic cancer. Up to 75% of patientswith pancreatic cancer, including those with malignancy confined to thepancreatic bed, will present with elevated CA 19–9; however, that obvi-ously leaves a clinically significant percentage of patients who will presentwith pancreatic cancer (even metastatic disease, as in the patient presentedabove) and a “negative” or normal CA 19–9. It must be reinforced toclinicians that CA 19–9 is more reliably utilized as a marker for recurrenceof known disease, and though many promising new cancer markers mayexist on the horizon, there is no substitute for sound clinical judgment.

S186 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002