been reported in the world literature between the years 1950 and 1988, and granulomas were found in biopsy specimens in only 12 cases. 5 In our patient, an epithelioid granuloma was found only after several deep biopsies were taken during the second upper gastrointestinal endoscopy. The low incidence of granulomas in biopsy specimens has been explained by the patchy nature of the lesions and the superficiality of endoscopic esophageal biopsies. 1, 4, 5 ACKNOWLEDGMENT
Authors are indebted to Mrs. Dolores MacFarland for valuable assistance. Figure 2. Biopsy specimen from the area of the esophagus shown in Figure 1 showing an epithelioid granuloma surrounded by chronic inflammation (H & E, original magnification x400).
disease in patients with esophageal involvement,3 as occurred in our patient. Endoscopic findings of early Crohn's disease include multiple erosions, discoid ulcers with elevated margins, and shallow ulcers surrounded by erythema. 3-5 Only 53 cases of esophageal Crohn's disease have
Late presentation of metastatic renal cell carcinoma as a bleeding ampullary mass Glen S. Robertson, MD Stanford L. Gertler, MD
Malignant lesions of the ampulla of Vater are an infrequent cause of gastrointestinal bleeding. Bleeding metastatic lesions to the ampulla are distinctly uncommon. We present a case of renal cell carcinoma with late metastasis to the ampulla and pancreas which presented with upper gastrointestinal bleeding. CASE REPORT
A 70-year-old man was admitted in November 1988 with a 3-day history of weakness and melena. In 1976, he underwent a left nephrectomy for a renal cell carcinoma. At that time, there was evidence of renal vein invasion and perirenal capsular invasion. In August 1988, he underwent an elective total hip replacement for osteoarthritis. His post-operative course was From the Departments of Medicine, University of California, Irvine, California and Southern California Permanente Medical Group, Anaheim, California. Reprint requests: Stanford L. Gertler, MD, 411 Lakeview Avenue, Anaheim, California 92807.
304
REFERENCES 1. Gelfand BW, Krone CL. Dysphagia and esophageal ulceration in Crohn's disease. Gastroenterology 1968;55:510-3. 2. Huchzermeyer H, Paul F, Seifert E, Frohlich H, Rasmussen ChW. Endoscopic results in five patients with Crohn's disease of the esophagus. Endoscopy 1976;8:75-81. 3. Degryse HR, De Schepper AM. Apthoid esophageal ulcers in Crohn's disease of ileum and colon. Gastrointestinal Radiol 1984;9:197-201. 4. Geboes K, Janssens J, Rutgeerts P, Vantrappen G. Crohn's disease of the esophagus. J Clin GastroenteroI1986;8:31-7. 5. Kuboi H, Yashiro K, Shindou H, Hayashi N, Nagasako K. Crohn's disease in the esophagus. Report of a case. Endoscopy 1988;20:118-21.
complicated by a deep venous thrombosis and he was discharged home on Coumadin® anticoagulation therapy. In November 1988, while still receiving Coumadin,® he presented with weakness, melena, and a microcytic anemia. Upper gastrointestinal endoscopy with an end-viewing Olympus OES XQI0 endoscope revealed a bleeding 2-cm ampullary mass with ulceration. The side-viewing Olympus JFlTID endoscope was then passed for better viewing of the lesion (Fig. 1), and multiple biopsies were obtained using an Olympus FB-26N forceps. These initial specimens revealed only granulation tissue. An attempt at ERCP was made, but despite deep cannulization into the mass there was no filling of the pancreatic or biliary ducts. A subsequent abdominal CT scan demonstrated a mass involving the ampulla as well as the neck and head of the pancreas (Fig. 2). The patient had a second bleeding episode while off Coumadin® and 'awaiting semielective surgery. Repeat endoscopy confirmed that the ampullary mass was the site of bleeding. The patient was then taken to surgery where a Whipple procedure was performed. Review of the pathology specimens demonstrated invasion of the ampulla and pancreas by focal areas of moderately well-differentiated adenocarcinoma of the clear cell type. Comparison of these specimens with the original nephrectomy specimens confirmed a similar morphological appearance consistent with the diagnosis of metastatic renal cell carcinoma. Post-operatively the patient has done well except for the recurrence GASTROINTESTINAL ENDOSCOPY
Endoscopic appearance of bleeding ampullary mass measuring approximately 2 em.
Figure 1.
Figure 2. Abdominal CT scan demonstrating a mass involving the second portion of the duodenum (arrow) and the pancreas.
of deep venous thrombosis necessitating further anticoagulation therapy.
DISCUSSION
Metastatic disease can present 10 or more years after the initial diagnosis of renal cell carcinoma. The most common sites of metastasis are the lungs, lymph nodes, and liver. 1 The pancreas is a rare site of metastatic spread among patients with any malignancy. Pancreatic metastases have been found in 3% of patients with a malignancy.2 In patients with renal cell VOLUME 36, NO.3, 1990
carcinoma who develop metastatic disease, 1 to 3% have been shown to develop pancreatic metastases, accounting for 1 to 2% of all patients with pancreatic metastases. 3 - 5 The most common presentation of these patients is with gastrointestinal bleeding which has been reported in more than 60% ofpatients. 3 The timing of diagnosis has varied from a synchronous presentation to as long as 17 years later. 5-7 Renal cell carcinoma metastasizes to the small intestine in 4% of patients. 8 Among locations in the small intestine, the duodenum is the least frequent site of metastasis. Duodenal metastases from renal cell carcinoma have rarely been reported to cause massive gastrointestinal bleeding.9 Moreover, metastatic involvement of the ampulla of Vater is infrequent. Among the more common tumors which have been reported to metastasize to the ampulla are lymphomas and melanomas. lO There has been only one other recent case report of metastatic renal cell carcinoma to the ampulla. l l That case presented with malabsorption and no evidence of gastrointestinal bleeding. Obtaining diagnostic biopsies of ampullary masses is often difficult. The false negative rate of biopsies of the surface of an ampullary lesion using standard techniques has been reported as high as 50%.12 To improve the diagnostic yield, various modifications have been described including snare excision biopsy of the papilla, biopsies taken with the use of jumbo forceps, biopsies taken with the ampulla under fluoroscopic control and after sphincterotomyy·14 The technique of biopsy following sphincterotomy in one study lowered the false negative rate to less than 13%.14 Prior to the advent of endoscopy, gastrointestinal bleeding in patients receiving anticoagulants was frequently attributed to mucosal leakage from overanticoagluation. 15. 16 Patients receiving anticoagulants, who develop gastrointestinal bleeding, have subsequently been shown to have a high frequency of significant pathology. One recent prospective study demonstrated upper gastrointestinal sources of bleeding in over 80% of anticoagulated patients with gastrointestinal bleeding, over 40% of whom were found to have peptic ulcers. 17 In our case, the use of Coumadin® probably intensified the bleeding and hastened the discovery of the underlying metastatic lesion.
REFERENCES 1. Ritchie AWS, Chisholm GD. The natural history of renal
carcinoma. Semin Oncol 1983;10:390-400. 2. Willis RA. The spread of tumours in the human body. 3rd ed. London: Butterworths, 1973;216-7. 3. Tongio J, Peruta 0, Wenger JJ, Warter P. Metastases duodenales et pancreatiques dti nephro-epitheliome. A propos de quatre observations. Ann RadioI1977;20:641-7. 4. Klugo RC, Detmers M, Stiles RE, Talley RW, Cerny JC. Aggressive versus conservative management of stage IV renal cell carcinoma. J Urol 1977;118:244-6. 305
5. Strijk SP. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointest Radiol 1989;14:123-6. 6. Whittington R, Moylan DJ, Dobelbower RR, Kramer S. Pancreatic tumours in patients with previous malignancy. Clin Radiol 1982;33:297-9. 7. Rumancik WM, Megibow AJ, Bosniak MA, Hilton S. Metastatic disease to the pancreas: evaluation by computed tomography. J Comp Assist Tomogr 1984;8:829-34. 8. Grahm AP. Malignancy of the kidney, survey of 195 cases. J UroI1947;58:10. 9. Lynch-Nyhan A, Fishman E, Kadir S. Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma. J UroI1987;138:611-3. 10. Venu RP, Geenen JE. Diagnosis and treatment of diseases of the papilla. Clin GastroenteroI1986;15:439-56. 11. McKenna JI, Kozarek RA. Metastatic hypernephroma to the ampulla of Vater: an unusual cause of malabsorption diagnosed at endoscopic sphincterotomy. Am J GastroenteroI1989;84:813.
Splenic injury following colonoscopy Don C. Rockey, John R. Weber, Teresa L. Wright, Susan D. Wall,
MD MD MD MD
Splenic injury is an uncommon event after colonoscopy, with only nine cases reported in the English literature. 1- 15 We report two patients who developed splenic injury associated with colonoscopy, in whom the clinical diagnosis was confirmed by computed tomography, and who were managed non-operatively. CASE REPORTS Case 1
A 90-year-old man with a history of adenomatous polyps, iron deficiency anemia, and peptic ulcer disease status postpartial gastrectomy and Billroth II anastomosis underwent colonoscopy. The examination was performed with the Olympus CF VIOL colonoscope and was uneventful. A diminutive polyp in the descending colon was biopsied a single time. Hemodynamics and oxygen saturation were normal throughout the procedure. Because a significant lesion was not identified (to explain the iron deficiency anemia) at colonoscopy, upper endoscopy was performed and also was uneventful, revealing only erythema and edema in the gastric remnant. Six hours after the colonoscopy, the patient complained of diffuse abdominal pain and his blood pressure dropped from 148/90 to 82/35 mm Hg. There had been no interval trauma, left shoulder pain, or blood per rectum. Abdominal examination revealed diffuse tenderness but no peritoneal findings. After a 250-ml intravenous bolus of normal saline From the Division of Gastroenterology and Departments of Medicine and Radiology, University of California, San Francisco, California. Reprint requests: Don C. Rockey, MD, UCSF Liver Center Laboratory, San Francisco General Hospital, Building 40 Room 4102, San Francisco, California 94110. 306
12. Walsh DB, Eckhauser FE, Cronenwett JL, Turcotte JG, Lindenauer SM. Adenocarcinoma of the ampulla of Vater: diagnosis and treatment. Ann Surg 1982;195:152-7. 13. Nakao NL, Siegel JH, Stenger RJ, Gelb AM. Tumors of the ampulla of Vater: early diagnosis by intraampullary biopsy during endoscopic cannulation. Gastroenterology 1982;83:45964. 14. Safrany L. Duodenoscopy and biopsy. In: Classen M, Geenen J, Kawai K. The papilla of Vater and its diseases. Baden-Baden; Gerhard Wirtzstrock, 1979:66. 15. Zweifler AJ. Relation of prothrombin concentration to bleeding during oral anticoagulant therapy. N Engl J Med 1962;267:2835.
16. Peyman MA. The significance of hemorrhage during the treatment of patients with coumarin anticoagulants. Acta Med Scand 1958;162(suppI339):1-62. 17. Tabibian N. Acute gastrointestinal bleeding in anticoagulated patients: a prospective evaluation. Am J Gastroenterol 1989;84:10-2.
and 0.4 mg of Narcan, his blood pressure increased to 110/ 40 mm Hg. Twelve hours later his hematocrit was noted to fall from 30.2% to 20.0%. He received 2 units of packed red blood cells and the hematocrit rose to 31.4%. He continued to complain of abdominal discomfort, at this time localizing to the left upper quadrant. Examination 36 hours after colonoscopy revealed distension and left upper quadrant tenderness, but still no peritoneal findings. Repeat hematocrit was 25.6%. He was transfused an additional 2 units of packed red cells, and the hematocrit increased to 33.8%. Computed tomography of the abdomen (Fig. lA) showed a large subcapsular splenic hematoma with free intraperitoneal blood. Surgical consultation was obtained and given his stable clinical status, it was decided to manage the patient nonoperatively. His left upper quadrant pain diminished over the next 2 weeks, and his hematocrit remained stable throughout this time. A repeat CT scan (Fig. IB) of the abdomen 3 weeks after the colonoscopy demonstrated partial resolution of the subcapsular fluid collection. Case 2
A 74-year-old woman with a history of hypertension, Raynauds phenomenon, and Hemoccult-positive stools underwent colonoscopy. Complete evaluation of the colon using the Olympus CF VIOL was normal. Although there was mild colonic spasm which was reversed with intravenous glucagon, the examination was performed without difficulty. The morning following the colonoscopy, the patient noted left upper quadrant abdominal discomfort and left shoulder pain which were aggravated by deep inspiration. She was seen by her primary physician who felt the symptoms were musculoskeletal in origin. The symptoms persisted, and 8 days after the colonoscopy she presented to the emergency department for further evaluation. There was no history of trauma or rectal bleeding. Physical examination revealed normal vital signs, decreased breath sounds over the left lung base, normal bowel sounds, and moderate left upper quadrant abdominal discomfort on palpation but without rebound tenderness. Hemoglobin was 11.6 g/dl (14.8 g/dl GASTROINTESTINAL ENDOSCOPY
Authors are indebted to Mrs. Dolores MacFarland for valuable assistance. Figure 2. Biopsy specimen from the area of the esophagus shown in Figure 1 showing an epithelioid granuloma surrounded by chronic inflammation (H & E, original magnification x400).
disease in patients with esophageal involvement,3 as occurred in our patient. Endoscopic findings of early Crohn's disease include multiple erosions, discoid ulcers with elevated margins, and shallow ulcers surrounded by erythema. 3-5 Only 53 cases of esophageal Crohn's disease have
Late presentation of metastatic renal cell carcinoma as a bleeding ampullary mass Glen S. Robertson, MD Stanford L. Gertler, MD
Malignant lesions of the ampulla of Vater are an infrequent cause of gastrointestinal bleeding. Bleeding metastatic lesions to the ampulla are distinctly uncommon. We present a case of renal cell carcinoma with late metastasis to the ampulla and pancreas which presented with upper gastrointestinal bleeding. CASE REPORT
A 70-year-old man was admitted in November 1988 with a 3-day history of weakness and melena. In 1976, he underwent a left nephrectomy for a renal cell carcinoma. At that time, there was evidence of renal vein invasion and perirenal capsular invasion. In August 1988, he underwent an elective total hip replacement for osteoarthritis. His post-operative course was From the Departments of Medicine, University of California, Irvine, California and Southern California Permanente Medical Group, Anaheim, California. Reprint requests: Stanford L. Gertler, MD, 411 Lakeview Avenue, Anaheim, California 92807.
304
REFERENCES 1. Gelfand BW, Krone CL. Dysphagia and esophageal ulceration in Crohn's disease. Gastroenterology 1968;55:510-3. 2. Huchzermeyer H, Paul F, Seifert E, Frohlich H, Rasmussen ChW. Endoscopic results in five patients with Crohn's disease of the esophagus. Endoscopy 1976;8:75-81. 3. Degryse HR, De Schepper AM. Apthoid esophageal ulcers in Crohn's disease of ileum and colon. Gastrointestinal Radiol 1984;9:197-201. 4. Geboes K, Janssens J, Rutgeerts P, Vantrappen G. Crohn's disease of the esophagus. J Clin GastroenteroI1986;8:31-7. 5. Kuboi H, Yashiro K, Shindou H, Hayashi N, Nagasako K. Crohn's disease in the esophagus. Report of a case. Endoscopy 1988;20:118-21.
complicated by a deep venous thrombosis and he was discharged home on Coumadin® anticoagulation therapy. In November 1988, while still receiving Coumadin,® he presented with weakness, melena, and a microcytic anemia. Upper gastrointestinal endoscopy with an end-viewing Olympus OES XQI0 endoscope revealed a bleeding 2-cm ampullary mass with ulceration. The side-viewing Olympus JFlTID endoscope was then passed for better viewing of the lesion (Fig. 1), and multiple biopsies were obtained using an Olympus FB-26N forceps. These initial specimens revealed only granulation tissue. An attempt at ERCP was made, but despite deep cannulization into the mass there was no filling of the pancreatic or biliary ducts. A subsequent abdominal CT scan demonstrated a mass involving the ampulla as well as the neck and head of the pancreas (Fig. 2). The patient had a second bleeding episode while off Coumadin® and 'awaiting semielective surgery. Repeat endoscopy confirmed that the ampullary mass was the site of bleeding. The patient was then taken to surgery where a Whipple procedure was performed. Review of the pathology specimens demonstrated invasion of the ampulla and pancreas by focal areas of moderately well-differentiated adenocarcinoma of the clear cell type. Comparison of these specimens with the original nephrectomy specimens confirmed a similar morphological appearance consistent with the diagnosis of metastatic renal cell carcinoma. Post-operatively the patient has done well except for the recurrence GASTROINTESTINAL ENDOSCOPY
Endoscopic appearance of bleeding ampullary mass measuring approximately 2 em.
Figure 1.
Figure 2. Abdominal CT scan demonstrating a mass involving the second portion of the duodenum (arrow) and the pancreas.
of deep venous thrombosis necessitating further anticoagulation therapy.
DISCUSSION
Metastatic disease can present 10 or more years after the initial diagnosis of renal cell carcinoma. The most common sites of metastasis are the lungs, lymph nodes, and liver. 1 The pancreas is a rare site of metastatic spread among patients with any malignancy. Pancreatic metastases have been found in 3% of patients with a malignancy.2 In patients with renal cell VOLUME 36, NO.3, 1990
carcinoma who develop metastatic disease, 1 to 3% have been shown to develop pancreatic metastases, accounting for 1 to 2% of all patients with pancreatic metastases. 3 - 5 The most common presentation of these patients is with gastrointestinal bleeding which has been reported in more than 60% ofpatients. 3 The timing of diagnosis has varied from a synchronous presentation to as long as 17 years later. 5-7 Renal cell carcinoma metastasizes to the small intestine in 4% of patients. 8 Among locations in the small intestine, the duodenum is the least frequent site of metastasis. Duodenal metastases from renal cell carcinoma have rarely been reported to cause massive gastrointestinal bleeding.9 Moreover, metastatic involvement of the ampulla of Vater is infrequent. Among the more common tumors which have been reported to metastasize to the ampulla are lymphomas and melanomas. lO There has been only one other recent case report of metastatic renal cell carcinoma to the ampulla. l l That case presented with malabsorption and no evidence of gastrointestinal bleeding. Obtaining diagnostic biopsies of ampullary masses is often difficult. The false negative rate of biopsies of the surface of an ampullary lesion using standard techniques has been reported as high as 50%.12 To improve the diagnostic yield, various modifications have been described including snare excision biopsy of the papilla, biopsies taken with the use of jumbo forceps, biopsies taken with the ampulla under fluoroscopic control and after sphincterotomyy·14 The technique of biopsy following sphincterotomy in one study lowered the false negative rate to less than 13%.14 Prior to the advent of endoscopy, gastrointestinal bleeding in patients receiving anticoagulants was frequently attributed to mucosal leakage from overanticoagluation. 15. 16 Patients receiving anticoagulants, who develop gastrointestinal bleeding, have subsequently been shown to have a high frequency of significant pathology. One recent prospective study demonstrated upper gastrointestinal sources of bleeding in over 80% of anticoagulated patients with gastrointestinal bleeding, over 40% of whom were found to have peptic ulcers. 17 In our case, the use of Coumadin® probably intensified the bleeding and hastened the discovery of the underlying metastatic lesion.
REFERENCES 1. Ritchie AWS, Chisholm GD. The natural history of renal
carcinoma. Semin Oncol 1983;10:390-400. 2. Willis RA. The spread of tumours in the human body. 3rd ed. London: Butterworths, 1973;216-7. 3. Tongio J, Peruta 0, Wenger JJ, Warter P. Metastases duodenales et pancreatiques dti nephro-epitheliome. A propos de quatre observations. Ann RadioI1977;20:641-7. 4. Klugo RC, Detmers M, Stiles RE, Talley RW, Cerny JC. Aggressive versus conservative management of stage IV renal cell carcinoma. J Urol 1977;118:244-6. 305
5. Strijk SP. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointest Radiol 1989;14:123-6. 6. Whittington R, Moylan DJ, Dobelbower RR, Kramer S. Pancreatic tumours in patients with previous malignancy. Clin Radiol 1982;33:297-9. 7. Rumancik WM, Megibow AJ, Bosniak MA, Hilton S. Metastatic disease to the pancreas: evaluation by computed tomography. J Comp Assist Tomogr 1984;8:829-34. 8. Grahm AP. Malignancy of the kidney, survey of 195 cases. J UroI1947;58:10. 9. Lynch-Nyhan A, Fishman E, Kadir S. Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma. J UroI1987;138:611-3. 10. Venu RP, Geenen JE. Diagnosis and treatment of diseases of the papilla. Clin GastroenteroI1986;15:439-56. 11. McKenna JI, Kozarek RA. Metastatic hypernephroma to the ampulla of Vater: an unusual cause of malabsorption diagnosed at endoscopic sphincterotomy. Am J GastroenteroI1989;84:813.
Splenic injury following colonoscopy Don C. Rockey, John R. Weber, Teresa L. Wright, Susan D. Wall,
MD MD MD MD
Splenic injury is an uncommon event after colonoscopy, with only nine cases reported in the English literature. 1- 15 We report two patients who developed splenic injury associated with colonoscopy, in whom the clinical diagnosis was confirmed by computed tomography, and who were managed non-operatively. CASE REPORTS Case 1
A 90-year-old man with a history of adenomatous polyps, iron deficiency anemia, and peptic ulcer disease status postpartial gastrectomy and Billroth II anastomosis underwent colonoscopy. The examination was performed with the Olympus CF VIOL colonoscope and was uneventful. A diminutive polyp in the descending colon was biopsied a single time. Hemodynamics and oxygen saturation were normal throughout the procedure. Because a significant lesion was not identified (to explain the iron deficiency anemia) at colonoscopy, upper endoscopy was performed and also was uneventful, revealing only erythema and edema in the gastric remnant. Six hours after the colonoscopy, the patient complained of diffuse abdominal pain and his blood pressure dropped from 148/90 to 82/35 mm Hg. There had been no interval trauma, left shoulder pain, or blood per rectum. Abdominal examination revealed diffuse tenderness but no peritoneal findings. After a 250-ml intravenous bolus of normal saline From the Division of Gastroenterology and Departments of Medicine and Radiology, University of California, San Francisco, California. Reprint requests: Don C. Rockey, MD, UCSF Liver Center Laboratory, San Francisco General Hospital, Building 40 Room 4102, San Francisco, California 94110. 306
12. Walsh DB, Eckhauser FE, Cronenwett JL, Turcotte JG, Lindenauer SM. Adenocarcinoma of the ampulla of Vater: diagnosis and treatment. Ann Surg 1982;195:152-7. 13. Nakao NL, Siegel JH, Stenger RJ, Gelb AM. Tumors of the ampulla of Vater: early diagnosis by intraampullary biopsy during endoscopic cannulation. Gastroenterology 1982;83:45964. 14. Safrany L. Duodenoscopy and biopsy. In: Classen M, Geenen J, Kawai K. The papilla of Vater and its diseases. Baden-Baden; Gerhard Wirtzstrock, 1979:66. 15. Zweifler AJ. Relation of prothrombin concentration to bleeding during oral anticoagulant therapy. N Engl J Med 1962;267:2835.
16. Peyman MA. The significance of hemorrhage during the treatment of patients with coumarin anticoagulants. Acta Med Scand 1958;162(suppI339):1-62. 17. Tabibian N. Acute gastrointestinal bleeding in anticoagulated patients: a prospective evaluation. Am J Gastroenterol 1989;84:10-2.
and 0.4 mg of Narcan, his blood pressure increased to 110/ 40 mm Hg. Twelve hours later his hematocrit was noted to fall from 30.2% to 20.0%. He received 2 units of packed red blood cells and the hematocrit rose to 31.4%. He continued to complain of abdominal discomfort, at this time localizing to the left upper quadrant. Examination 36 hours after colonoscopy revealed distension and left upper quadrant tenderness, but still no peritoneal findings. Repeat hematocrit was 25.6%. He was transfused an additional 2 units of packed red cells, and the hematocrit increased to 33.8%. Computed tomography of the abdomen (Fig. lA) showed a large subcapsular splenic hematoma with free intraperitoneal blood. Surgical consultation was obtained and given his stable clinical status, it was decided to manage the patient nonoperatively. His left upper quadrant pain diminished over the next 2 weeks, and his hematocrit remained stable throughout this time. A repeat CT scan (Fig. IB) of the abdomen 3 weeks after the colonoscopy demonstrated partial resolution of the subcapsular fluid collection. Case 2
A 74-year-old woman with a history of hypertension, Raynauds phenomenon, and Hemoccult-positive stools underwent colonoscopy. Complete evaluation of the colon using the Olympus CF VIOL was normal. Although there was mild colonic spasm which was reversed with intravenous glucagon, the examination was performed without difficulty. The morning following the colonoscopy, the patient noted left upper quadrant abdominal discomfort and left shoulder pain which were aggravated by deep inspiration. She was seen by her primary physician who felt the symptoms were musculoskeletal in origin. The symptoms persisted, and 8 days after the colonoscopy she presented to the emergency department for further evaluation. There was no history of trauma or rectal bleeding. Physical examination revealed normal vital signs, decreased breath sounds over the left lung base, normal bowel sounds, and moderate left upper quadrant abdominal discomfort on palpation but without rebound tenderness. Hemoglobin was 11.6 g/dl (14.8 g/dl GASTROINTESTINAL ENDOSCOPY
