A CASE OF HEMOPTYSIS FOLLOWING PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY. S. Chebrolu 1 , J. Addagatla 1 , F. Ali 1 ; 1 St. Francis Hospital, Evanston, IL LEARNING OBJECTIVES: 1) Recognize the occurrence of bleeding complications including pulmonary alveolar hemorrhage following the use of Group IIb-IIIa receptor inhibitors in acute coronary syndromes. 2) Diagnose and manage pulmonary alveolar hemorrhage. CASE INFORMATION: A 68 year-old woman with a past medical history of diabetes mellitus and hypertension presented to the emergency room with chest pain. She was a non-smoker and had no known lung disease. Physical examination was normal. EKG showed an acute anteroseptal myocardial infarction. Emergent angiogram revealed a 100% proximal left anterior descending artery lesion. Percutaneous transluminal coronary angioplasty with placement of a multilink stent of the left anterior descending artery lesion was done. During the procedure, she was given 10,000U of heparin and 0.25 mg/kg of abciximab boluses followed by infusion of heparin at 700U/hr and abciximab at 0.125 mcg/kg/min after the procedure. An intra-aortic balloon pump was also placed. One hour later, she had hematemesis and hemoptysis and developed respiratory distress with hypoxia. Heparin and abciximab were discontinued and emergent intubation was done. A copious amount of blood was aspirated from the endotracheal tube. CXR revealed diffuse bilateral interstitial infiltrates. Hemoglobin dropped from 12.6g/dl to 10g/dl. A diagnosis of pulmonary alveolar hemorrhage was made. Bright red blood was suctioned from the endotracheal tube for a few hours. Hypoxemia improved rapidly with complete clearing of the CXR over the next two days. She was extubated on day three and was discharged home on day seven on aspirin, clopidogrel, metprolol and ramipril. She received two units of packed red blood corpuscles during her hospital course. DISCUSSION: Pulmonary alveolar hemorrhage is an infrequent and rarely reported hemorrhagic complication of the use of Group IIb-IIIa receptor inhibitors in acute coronary syndromes. It should be considered in the differential diagnosis of a patient who receives these agents and presents with respiratory distress, pulmonary infiltrates and a drop in hemoglobin, with or without hemoptysis. It is usually seen in older patients and in those with increased pulmonary capillary wedge pressure and evidence of pulmonary edema. Management is mainly supportive with discontinuation of all anticoagulants and with transfusions of packed red blood corpuscles and platelets as needed. An 82 year-old man was admitted with complaints of dysphagia and constipation for one week. It was associated with anorexia and significant weight loss over one month duration. He denied any history of abdominal pain, hematemesis or melena. Past medical history included COPD and coronary artery disease. Past surgical history included CABG, appendectomy and bilateral inguinal hernia repair. Abdominal examination was benign but he was found to be fecal occult blood positive. Laboratory work up revealed evidence of iron deficiency anemia and a gastrointestinal malignancy was suspected. He underwent gastroduodenoscopy that revealed hiatal hernia and a colonoscopy was planned. A few hours after the procedure, he complained of severe lower abdominal pain when he was noticed to have right lower quadrant tenderness and fullness but with no guarding or rigidity. CT scan of the abdomen was done which revealed a mass in the terminal ileum and a 5-cm mass in the left lobe of liver. It also revealed superior MVT with ischemic changes in the small bowel. He underwent emergent angiography that confirmed the presence of MVT and was given local t-PA for dissolution of the MVT. Following this, his abdominal pain worsened with development of peritoneal signs and he underwent exploratory laparotomy with the resection of terminal ileum, right hemicolectomy and biopsy of the liver mass. Histopathology of the mass and liver biopsy revealed malignant carcinoid tumor with mesenteric node and liver involvement. DISCUSSION: MVT is characterized by pain out of proportion to physical findings, nausea, vomiting, constipation and occasional bloody diarrhea. Previous abdominal surgery, hypercoagulable states, cirrhosis and gastrointestinal malignancies are the most common conditions associated with MVT. Abdominal distention, though nonspecific, is the most frequent sign. Leukocytosis may be found in half of the patients but laboratory tests are not helpful in the diagnosis. CT is the diagnostic test of choice and demonstrates thrombus in the superior mesenteric vein with evidence of bowel ischemia. Anticoagulation with heparin followed by warfarin in the absence of contraindications is the mainstay of medical management. All patients with localized or diffuse peritonitis should undergo immediate exploratory laparotomy with resection of nonviable bowel. MVT has not been reported previously as a presenting feature of malignant carcinoid tumor as seen in our patient here.