bluuebunny/crossref_metadata_2025 huggingface dataset:
1974 Seeing Isn’t Always Believing! Recurrent Hematemesis Due to Factitious Disorder
Authors: Lakhoo Krutika , Enayati Pedram
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding is a common inpatient diagnosis with a cost >$5 billion in the US. Typically patients undergo endoscopic evaluation, capsule studies, CT imaging with/without embolization and in severe bleeding, surgical management may be pursued. We present a case of recurrent GI bleeding due to factitious disorder.

CASE DESCRIPTION/METHODS:

52-year-old female veterinary tech with a complex surgical history presented to the ER for acute recurrent hematemesis with bright blood seen in ER. In 2017, she developed recurrent upper GI bleeding. Previous EGD showed Dieulafoy lesions that were clipped and she underwent partial gastrectomy. Physical examination showed normal vitals and diffuse mild abdominal tenderness. Labs showed stable normocytic anemia (Hgb 9-10), normal iron stores, LFTs, INR, and platelets. She underwent extensive workup including angiogram, multiple endoscopies, and multiple CTA A/P with no identifiable source of bleeding. Given ongoing visualized bleeding and almost weekly hospitalizations she underwent remnant gastrectomy for definitive management and pathology confirmed Dieulafoy lesions. During the hospitalization, she was found to have 2 blood-filled syringes in her pillowcase. She had multiple concerning signs for a psychiatric disorder: "la belle indifference", no active bleeding on endoscopy, no melena, persistent bleeding despite gastrectomy, stable Hgb, female with medical training, and no further bleeding after sitter placed. Psychiatry team was consulted and discovered she had been ingesting blood drawn from a PICC line to stimulate bleeding. A diagnosis of Munchausen’s disorder was made.

DISCUSSION:

Munchausen’s disorder occurs when patients intentionally produce physical or psychiatric symptoms (usually of dramatic nature), allowing them to assume a sick role and gain medical attention. This is a difficult diagnosis and often results in the excessive use of medical resources. Risk factors include a serious illness/trauma during childhood, loss of a loved one, personality disorder, and being a healthcare worker. The motive is mainly to gain sympathy and attention. Physicians should confront patients with the diagnosis if a good therapeutic relationship has been established and patients benefit from psychotherapy and close medical and psychiatric follow up. Prognosis tends to be poor however, with most patients refusing psychiatric evaluation and leaving AMA. This case adds to literature suggesting factitious disorder with hematemesis is not as rare as expected.
1978 Picking up the Pieces: Surgical and Medical Management of Retained Shattered Glass in the Rectum
Authors: Klein Elliot , Bressler Moshe , Nadler Shmuel , Peysin Konstantin , Lapin Seth
Published: October 2019

INTRODUCTION:

Retained rectal foreign bodies are an increasingly common presentation requiring emergent surgery. The object can often be retrieved at bedside. However, in the setting of a retained foreign body, especially one complicated by bleeding, perforation, or peritonitis, open surgery or laparoscopic assisted transanal retrieval is often needed. Careful investigation and a high index of suspicion is required as patients are often reluctant to share the etiology of their presentations.

CASE DESCRIPTION/METHODS:

A 55-year-old male presented to the ED with complaints of rectal bleeding. He stated he had placed a glass bottle in his rectum. Upon removal he noticed the top half of the bottle was retained inside his rectum. He developed mild rectal pain and bright red blood per rectum. On exam, there were no peritoneal signs. DRE revealed no perianal lesions, sphincter lacerations, or palpable foreign bodies. Initial labs displayed hemoglobin and hematocrit at 11.7 and 34.1, respectively. CT showed multiple radiopaque foreign bodies in the distal rectosigmoid measuring up to 14 cm in length with presacral edema. Proctoscopy was performed in the OR. Glass which was readily removable via a transanal approach was retrieved, while larger perforating pieces were carefully mobilized proximally and retracted via laparotomy. Sigmoidoscopy confirmed complete removal with multiple deep lacerations and perforations in the rectal wall. On post-op day seven, large volume rectal and mucus fistula bleeding with severe hypotension, tachycardia, change in mental status and a drop in hemoglobin to 5.8 occured. MTP was activated with administration of a total of five units of PRBC and two units of FFP. Colonoscopy was performed in the OR. An ulcer containing a pulsating, protruding, visible vessel was actively bleeding. Two clips were placed over the vessel with no further episodes of bleeding. Three months postoperatively barium enema was performed showing no leaks leading to reversal of colostomy.

DISCUSSION:

A retained rectal foreign body is not commonly the cause of a surgical emergency. Post-op complications, such as rectal bleeding, are rare and are normally handled by a return to the OR to control the source. Colonoscopy after a perforating rectal injury may be considered to evaluate and stop the source of postoperative bleeding, thus avoiding additional surgery and decreasing recovery time. Additionally, DRE should be cautioned when suspecting sharp hazardous material at an undetermined height in the colorectal tract.
1982 The Plight of the Peptic Ulcer: Seconds From Exsanguination
Authors: Pasan Botheju Welathanthrige Savindu , Schieferdecker Nicola , Mehta Amit , Mukewar Saurabh , Wan David
Published: October 2019

INTRODUCTION:

Most peptic ulcer disease cases are often asymptomatic or present with dyspepsia. However, a small number present with complications such as bleeding, gastric outlet obstruction or perforation. Most of these complications can be treated with endoscopic interventions, while sometimes surgical intervention is required in cases with perforation or severe bleeding. Here we report a case of a man with a penetrating gastric body ulcer that led to massive bleeding requiring emergent surgery.

CASE DESCRIPTION/METHODS:

A 65-year old male with a history of hypertrophic obstructive cardiomyopathy presented with melena, dyspnea, and lightheadedness. Prior to the melena, he had abdominal pain and consumed ten tablets of Ibuprofen daily. On presentation, he was tachycardic, anemic with a Hb of 7.4 g/dL, BUN/Cr of 51 and was given a unit of blood. Electrolytes, creatinine and coagulation profile were unremarkable. A CT A/P showed a large, deep peptic ulcer (Figure 1). An EGD revealed a clean-based 5 cm non-bleeding, posterior wall gastric body ulcer with a biopsy positive for chronic active H.pylori gastritis. However, he continued to bleed and received several transfusions. A repeat EGD revealed the previous non-bleeding ulcer with a large, visible vessel (Forrest IIA) (Figure 1) with unsuccessful hemostasis and resultant active bleeding and hemodynamic instability. An emergent laparotomy and anterior gastrotomy revealed 2L of blood in the stomach. The ulcer had penetrated the retroperitoneal tissue and vessels and was resected carefully. He was started on quadruple therapy for H.pylori.

DISCUSSION:

The prevalence of peptic ulcer disease (PUD) has been declining since the 1990s and while H.pylori prevalence has reduced, more PUD cases are being attributed to the use of NSAIDs, aspirin and anticoagulants. Some cases precipitate into severe complications such as gastric outlet obstruction, perforation, bleeding or penetration. As in this case, posterior wall ulcers are associated with penetration and hemorrhage due to the close proximity to vessels such as the gastroduodenal artery and retroperitoneal vessels and pursuing endoscopic hemostasis must be considered a high-risk procedure in these patients. Caution must be applied in such cases where a large vessel is visualized, due to the risk of exsanguination. If imaging prior to endoscopic intervention shows close proximity to a large vessel, it may be prudent to defer endoscopic treatment and consider interventional radiology or surgical intervention instead.
1983 Hemospray® as Bridging Therapy in Acute Esophageal Bleeding Secondary to Varices and Post-Banding Ulcers
Authors: Sobani Zain A. , Saeidi Behtash , Sánchez-Luna Sergio A. , Paleti Swathi , Parasher Gulshan
Published: October 2019

INTRODUCTION:

Hemospray® is a noncontact, nontargeted inorganic powder for endoscopic hemostasis that forms a superficial mechanical barrier over bleeding sites. It is currently approved by the FDA for use in non variceal gastrointestinal bleeding (GIB). However it has been used for variceal bleeding. Here we present our initial experience of using hemospray as salvage therapy in patients with acute bleeding from esophageal varices and post banding ulcers refractory to endoscopic management.

CASE DESCRIPTION/METHODS:

Four patients with decompensated liver cirrhosis presented with acute upper GIB. The patients underwent emergent esophagogastroduodenoscopy (EGD) after initial resuscitation and medical management. On EGD the patients were found to have GIB secondary to esophageal varices and post banding ulcers. Given unsuccessful attempts at standard hemostatic procedures we opted to use Hemospray® to achieve hemostasis. [Figure 1] Their baseline characteristics and endoscopic findings are summarized in Table 1. Of the 4 patients 2 underwent definitive therapy with repeat EGD and banding 24 and 48 hours post initial procedure. One patient opted to undergo elective banding in 4 weeks and did not have further evidence of bleeding. One of the patient's with bleeding esophageal varices developed rebleeding 8 days after the index procedure; repeat EGD showed multiple clots overlying post banding ulcers without active bleeding. Two patient's died of multisystem organ failure on post procedure days 11 and 18, respectively. There were no Hemospray® related adverse events.

DISCUSSION:

In our experience Hemospray® seems to provide a safe endoscopic option for temporizing patients with GIB secondary to esophageal varices and post banding ulcers that are not amenable to endoscopic therapy and band ligation due to technical difficulties. It appears to serve as an effective bridge to definitive therapy in these patients.
1985 A Case of Spontaneous Hemoperitoneum in a Patient With Decompensated Alcoholic Cirrhosis
Authors: Williams Kathy N. , Kadosh David , Bhardwaj Richa , Ivanina Elena
Published: October 2019

INTRODUCTION:

Ascites is commonly seen in patients with decompensated cirrhosis. Hemorrhagic ascites is a rare, but a dangerous complication of cirrhosis. This case uniquely highlights an uncommon but important association between cirrhosis and spontaneous hemoperitoneum.

CASE DESCRIPTION/METHODS:

A 57-year-old female with a history of decompensated alcoholic cirrhosis with ascites presented with acute diffuse abdominal pain with hypotension. She denied hematemesis, hematochezia or melena. On exam she had scleral icterus with asterixis. Her abdomen was distended and diffusely tender with hypoactive bowel sounds. Her MELD-Na was 20. An abdominal CTA showed moderate to high density ascites suggestive of hemorrhagic ascites, without active bleeding (Figure 1). Paracentesis showed evidence of sanguineous fluid with 1.9 million RBC/u L. Following which she had a drop in her hemoglobin from 9 to 6.5 g/d L, with worsening of abdominal pain and distension. She underwent an exploratory laparotomy with evacuation of 7 liters of blood and diffuse oozing from visceral and peritoneal surfaces. The paracentesis tract was noted to be without hemorrhage. Labs showed platelets 43, fibrinogen < 80, PTT 131, suggestive of disseminated intravascular coagulation (DIC). She subsequently became hemodynamically unstable despite resuscitation and passed away from cardiopulmonary arrest.

DISCUSSION:

Spontaneous hemoperitoneum is rare and occurs in patients with decompensated cirrhosis with high MELD scores. In these patients, hemoperitoneum can be either related to trauma or spontaneous secondary to leakage of RBCs from the interstitial spaces of the liver or splanchnic bed or intra-abdominal bleeding from a small vessel portosystemic collateral or bleeding form HCC. The known coagulation disturbances associated with liver cirrhosis place these patients at increased risk for hemorrhage. The patient described in this case report is an example of spontaneous hemoperitoneum in the setting of a coagulation disturbance, which lead to hemorrhagic shock and highlights the importance of considering this diagnosis in patients who present with similar symptoms due to high rates of morbidity and mortality.
1988 Rectal Dieulafoy's Lesion: Hemorrhagic Shock Due to a Rare Cause of Acute Lower GI Bleeding
Authors: Mehta Sagar V. , Tayel Hussam , Duarte-Chavez Rodrigo , Martinez-Tapia Ana , Geme Berhanu
Published: October 2019

INTRODUCTION:

Dieulafoy's lesions account for 1–2% of acute GI bleeding and are characterized by dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of a primary ulcer. While the majority are found in the stomach (71%), they occur along other parts of the GI tract, however rectal sites are rare and only account for 1–2%. We present a case of massive LGIB due to a rectal Dieulafoy's lesion in a patient with intermittent hematochezia.

CASE DESCRIPTION/METHODS:

A 58-year-old female presenting with DKA had a hospital course complicated by necrotizing pneumonia requiring VATS and trach/PEG placement. Early in her admission she developed hematochezia with Hgb drop of 9.3 to 6.4 (baseline 12–13). EGD was unremarkable. Colonoscopy revealed a 1.5 cm clean based rectal ulcer that did not require intervention. 2 weeks later recurrent hematochezia presumably from rectal tube responded conservatively with TXA soaked Merocel packing. Hematochezia re-occurred 10 days later in the setting of a gradual drop in Hgb over the previous 2 weeks requiring 3u PRBCs(11.7 to 6.7 to 8.5). The following day she had large volume hematochezia with clots and was pale, diaphoretic, and less responsive with BP of 60/45, HR of 122 and Hgb of 5.8. Resuscitative efforts included IVF bolus, 4u PRBCs, 1u platelets, 2u FFP and pressor support. Patient continued to have active passage of multiple blood clots and after bedside evaluation we elected to proceed with emergent bedside EGD/colonoscopy after 1 tap water enema. Initially CTA was considered due to the rapidity of her bleed and significant hemodynamic compromise, however patient developed AKI and was too unstable for transport. EGD was normal and colonoscopy revealed large amounts of blood in rectum, sigmoid and descending colon with brown stool proximal to splenic flexure and normal TI. The colon was irrigated and revealed a large clot in distal rectum which was injected with Epi and then removed, revealing normal mucosa. Continued irrigation revealed blushing and after careful endoscopic inspection an actively spurting small vessel was seen protruding through rectal mucosa without surrounding ulcer suggestive of a Dieulafoy's lesion. Three clips deployed with good hemostasis and site tattooed. Hgb remained stable and no recurrence of bleeding during hospitalization.

DISCUSSION:

This case highlights the importance of vigilance in the evaluation of recurrent LGIB with timely resuscitative and endoscopic measures in identifying a rare source of massive LGIB.
2000 A Case of Gastric Intramural Hematoma Mimicking a Gastric Mass
Authors: Lee Edwin J. , Kothari Shivangi , Kothari Truptesh , Kaul Vivek
Published: October 2019

INTRODUCTION:

Intramural hematomas in the gastrointestinal tract are uncommon, and usually described in small bowel or esophagus. Occurrence in the stomach is extremely rare especially in the absence of any trauma or underlying coagulopathy. We describe a case of a vanishing “gastric mass” found on cross-sectional imaging caused by an intramural bleed from a gastric ulcer.

CASE DESCRIPTION/METHODS:

A 59-year-old female with history of type 2 diabetes mellitus presented to local urgent care with 6 days of progressive epigastric pain with nausea. She reported taking acetaminophen and ibuprofen. Blood count, basic metabolic panel and chest/abdominal x ray were unremarkable. She was discharged home with opioids. She presented to the primary care physician’s office three days later without improvement, with loss of appetite and 5 lb weight loss associated with some dark stools. She was started on PPI and CT abdomen performed that showed an infiltrating mass from gastric wall around pylorus (Figure 1) highly suspicious for gastric cancer. EGD revealed two clean based 5 mm ulcers in the antrum (Figure 2). Also, an extrinsic impression was seen in the stomach at the distal gastric body and no mucosal mass lesion was seen raising possibility that the mass seen on CT was intramural. EUS was then performed and between the left lobe of the liver and the pancreas there was an irregular hyperechoic mass, doppler negative, in the wall of the stomach suggestive of an intramural hematoma. PPI was continued and repeat CT abdomen in 4 weeks showed previous mass-like lesion to have resolved (Figure 3).

DISCUSSION:

Gastric intramural hematomas (GIH) are extremely rare. There are 47 cases described up to date, and most are usually related to underlying coagulopathy. The reports described in the past decade have mostly been related to surgeries and procedures, making hematomas caused by peptic ulcer disease or spontaneous in less than 12% of the cases. In the era of increased radiologic imaging, findings of masses or lesions often lead to increased psychological stress to providers and patients. Though uncommon, GIH can be a relatively benign and easily manageable cause of a possible mass-like gastrointestinal lesion. Thus, thorough investigation of any mass reported on imaging should be performed prior to declaring it to be a tumor since underlying pathology can be totally benign as seen in our case.
2005 Dieulafoy’s Lesion and Granulomatosis With Polyangitis
Authors: Kapadia Deena , Bhagavathula Anita
Published: October 2019

INTRODUCTION:

Commonly located in the proximal stomach, Dieulafoy’s lesions are a result of small vessel dilation that can result in GI hemorrhages. Granulomatosis with polyangiitis, a systemic small-vessel vasculitis, usually involves the respiratory tract, kidneys, skin, and joints. Although GI symptoms are uncommon, previous cases have shown an association between Dieulafoy’s lesions and other systemic vasculitides, including Buerger’s disease and HSP. This case suggests a possible link between Dieulafoy’s lesion and granulomatosis with polyangiitis.

CASE DESCRIPTION/METHODS:

A 69-year-old white female with history of nasal vestibulitis, sinusitis, and otitis media presented with generalized weakness and sharp, bilateral chest pain with associated shortness of breath and tachycardia. CTA was negative for pulmonary embolism. Labs revealed normal procalcitonin and lactic acid but elevated ESR, CRP, D-dimer, and WBC. Due to her high oxygen requirement, patient underwent a bronchoscopy that revealed multiple lung nodules. Biopsies revealed caseating granulomatous inflammation. Further workup confirmed the diagnosis of granulomatosis with polyangiitis, and she was started on Rituxan and solumedrol. Her condition was improving until she had acute onset of hematemesis, dropping her hemoglobin by 5 g/dL. She underwent an EGD that revealed hiatal hernia with erosions, a Dieulafoy vessel in the gastric body of the lesser curvature, and a large clot that obscured nearly two-thirds of the stomach. Once hemodynamically stable, EGD was repeated and revealed several small satellite ulcers around a large 1 cm ulcer with visible vessel in the greater curvature that was then cauterized and clipped. Hemoglobin remained stable for the remainder of the hospital course. Biopsies were negative for H. pylori. She was discharged to inpatient rehab, where she continued to receive Protonix, Rituxan, prednisone, Xopenex, and Pulmicort.

DISCUSSION:

Several case reports linking Dieulafoy’s lesions with vasculitides have been reported in recent times. In the case above, this abnormal lesion was found in a patient with active granulomatosis with polyangitis, a diagnosis primarily known to affect the respiratory and renal system. The presence of a Dieulafoy’s lesion can be life-threatening, as in this case. EGD is an important tool for diagnosis and treatment of these lesions in the upper GI tract. Awareness of this potential association can help physicians anticipate and prevent fatal outcomes while inducing remission of this disease.
2007 Post Transplant Lymphoproliferative Disorder: A Rare Cause of Gastrointestinal Blood Loss Anemia
Authors: Jayananda Sriraksha , Gollol Raju Narasimha Swamy , Muzaffar Mahvish
Published: October 2019

INTRODUCTION:

Post transplant lymphoproliferative disorder (PTLD) is a rare complication after solid organ or stem cell transplant. Gastrointestinal tract is a common site of PTLD proliferation but PTLD related GI bleeding is rare. WE here by present a young Caucasian male on chronic immunosuppression for disease donor kidney transplant who presented with severe iron deficiency anemia related to GI blood loss from PTLD.

CASE DESCRIPTION/METHODS:

A 33-year-old Caucasian male with H/O Alport syndrome with ESRD S/P kidney transplant in 2012 on chronic immunosuppression with azathioprine and tacrolimus presented with 3 months of abdominal pain and intermittent melena. Hb was 5.4 g/dl, iron 7 mg/dl, ferritin 5 ng/ml. CT abdomen with dilated ileal loop with wall thickening and lobular contour. After resuscitation, patient underwent EGD and colonoscopy. EGD was unremarkable and colonoscopy revealed normal colon but nodular pattern in the terminal ileum (Figure 1). Multiple biopsies were taken. Histopathology and immunohistochemical staining were noted as florid follicular hyperplasia and rare EBV-positive cells, compatible with non-destructive PTLD (Figure 2) and positive CD 20 and high KI-67 proliferation index (Figure 3). Patients was discharged with reduction of his immunosuppressant therapy along with weekly rituximab.

DISCUSSION:

Gastrointestinal tract is the most common extranodal location of PTLD. EBV is a risk factor for PTLD and is associated with more than 80% of cases. Uncontrolled proliferation of EBV transformed B cells in the setting of compromised T cell mediated immunity due to immune suppression is involved in the pathogenesis if PTLD. Gastrointestinal manifestations may include obstruction, perforation and, very rarely, bleeding. Endoscopic manifestation include ulcers or nodular lesions with or without central ulceration and histologically lymphoid hyperplasia to lymphoma with nearly 80% positive EBV staining. Management is reduction of immune suppression; R-CHOP is an alternative in high risk patients. Early diagnosis and prompt treatment is cornerstone of PTLD gastrointestinal involvement.
2010 Gastrointestinal Hemorrhage Due to Large B-Cell Lymphoma Treated With Hemospray
Authors: Sehmbey Gurbir , Kosa Dimas , Srinivasan Indu , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding (GIB) is a common cause of hospitalization and is associated with significant morbidity and mortality The most frequent causes of non-variceal upper GIB are peptic ulcers, erosions, Mallory-Weiss tears and malignancy. Current endoscopic hemostatic methods; including injections, thermal and mechanical modalities, have a 5-10% chance of recurrent bleeding. Hemospray (Cook Medical, USA) is a recently approved modality and can be helpful in treating tumor-related gastrointestinal bleeding.

CASE DESCRIPTION/METHODS:

A 57-year-old male with advanced diffuse large B-Cell lymphoma of the stomach with a contained perforation presented to the hospital with hematemesis. On exam, the patient had epigastric tenderness and dull bowel sounds. Labs revealed Hgb of 7.2 g/dL. CT of abdomen/pelvis revealed a gastric mass in the greater curvature of the stomach with a 3.1 cm perforation (Figure 1). EGD revealed a large blood clot attached to a giant ulcer in the great curvature of the fundus (Figure 2a). No active bleeding was noted, intravenous pantoprazole was initiated. Two days later, the patient developed recurrent hemorrhage with hemodynamic instability. Blood transfusion was initiated and repeat EGD showed large gastric perforation with evidence of recent bleed. The overlying clot was removed using a snare and Hemospray was deployed achieving hemostasis of the entire ulcer (Figure 2b). Post EGD, no immediate complications were seen. CT abdomen was performed which revealed a decreased amount of intraperitoneal free air without evidence of new perforation and no active bleeding. At this point, the patient was cleared to start chemotherapy. On follow-up EGD 2 months later, the contained perforation was seen nearly resolved (Figure 3).

DISCUSSION:

Tumor-related gastrointestinal bleeding is a challenging problem as it is difficult to control with conventional endoscopic hemostatic techniques. Hemospray is a newly FDA approved modality that can be helpful in controlling upper, lower and tumor-related GIB. Hemospray is an inorganic compound that when in contact with blood, absorbs water and adhesively forms a barrier over the bleeding site. Hemospray, unlike traditional therapies is a nonthermal, nontraumatic, and noncontact modality that doesn’t require precise targeting of other endoscopic devices. Hemospray is not absorbed by the body and usually passes through the lower GI tract within 72 hours. Overall the spray is 95% effective to achieve hemostasis in cases with upper and lower GIB.
2013 Thoracic Aortic Erosion Into the Esophagus With Aortoesophageal Fistula
Authors: Oldfield Edward C. , Arora Ipsa , Levitov Alexander , Parekh Parth J.
Published: October 2019

INTRODUCTION:

Aortoesophageal fistula is a rare but well described life-threatening cause of upper gastrointestinal bleeding. Primary aortoesophageal fistula is predominately caused by descending thoracic aortic aneurysms (52.4%), followed by foreign body ingestion and esophageal carcinoma.1–3 Secondary aortoesophageal fistula is an increasingly recognized complication of thoracic endovascular aortic repair (TEVAR), occurring in 1.7-1.9% of cases.4,5

CASE DESCRIPTION/METHODS:

A 76-year-old female with a past medical history of known 6cm thoracic aortic aneurysm was transferred to our facility for one day of hematemesis and hematochezia to undergo upper endoscopy. On arrival the patient had an emergent esophagogastroduodenoscopy which revealed a visible thoracic aorta through a large transmural defect adjacent to an aortoesophageal fistula in the middle esophagus (Figure 1). After the procedure, the patient underwent emergent CTA of the aorta, which revealed corresponding images to the endoscopic findings with an aortoesophageal fistula directly superior to an area of thoracic aorta protruding into the esophagus (Figure 2). The patient then had an emergent endovascular repair of the aortoesophageal fistula and thoracic aortic aneurysm with fluoroscopic images demonstrating successful graft deployment and fistula closure (Figure 3).

DISCUSSION:

Aortoesophageal fistula is a life-threatening condition that must be on a gastroenterologist’s differential for upper GI bleeding, in particular in patients with a known aortic aneurysm. Proper and rapid identification of the diagnosis is essential to allow for emergent vascular intervention and hemostatic control. Additionally, literature review highlights a paucity of evidence on the options for endoscopic intervention with esophageal stents. In this particular case, there was fortunately no active gastrointestinal bleeding at time of endoscopy and the patient had successful endovascular grafting; however, there are a number of case reports suggesting that esophageal stenting may be another therapeutic option if there is active esophageal hemorrhage, albeit more of a temporizing measure and one associated with a number of complications.3,6,7
2014 Over-the-Scope Clip as Salvage Therapy for Refractory Non-Variceal Upper Gastrointestinal Hemorrhage After Failed Conventional Management: A Case Series
Authors: Amarnath Shivantha , Philipose Jobin , Abergel Jeffrey , Khan Hafiz
Published: October 2019

INTRODUCTION:

Elderly patients with cardiovascular co-morbidities are of higher mortality risk from non-variceal upper gastrointestinal hemorrhage (NVUGIH). Traditional endoscopic interventions with through-the-scope-clips, electrocautery and epinephrine injections have a high failure rate at managing bleeding from large visible vessels, especially bleeding from posterior duodenal bulb ulcers. Over-the-scope-clips (OTSC) are preferred by endoscopists for their versatile role in repair of fistulas, bowel perforations and NVUGIH. We report two NVUGIH cases where traditional endoscopic and angiographic interventions failed and over the scope clip was used as salvage therapy.

CASE DESCRIPTION/METHODS:

85-year-old female with Pulmonary Hypertension and Atrial Fibrillation was admitted for hypovolemic shock from hematemesis. Endoscopy revealed a large posterior duodenal bulb ulcer with adherent clot for which epinephrine injection was used. The ulcer’s size and location prompted angiography and coil embolization of the gastroduodenal artery (GDA). Patient was in hypovolemic shock again due to a massive bleed. She was high risk for surgical intervention due to pulmonary hypertension, and repeat endoscopy was performed for hemostasis. An 11/6 T-type OTSC clip was successfully deployed at a large vessel oozing blood, after removal of a large adherent clot by snare. No further intervention was needed afterward. 76-year-old male with extensive cardiac history was admitted with burns and inhalation injury from a house fire, requiring tracheostomy and gastrostomy placement. During hospitalization, patient had multiple episodes of melena and required blood transfusion. Endoscopy revealed two large anterior and posterior duodenal bulb ulcers, with a visible vessel, managed by electrocautery. Due to persistent bleeding, he underwent coil embolization of the GDA. Two days later, patient had recurrent bleeding. Repeat endoscopy with OTSC was used for successful hemostasis of a large visible vessel in the posterior duodenal bulb.

DISCUSSION:

Traditional endoscopic management carries a 20% re-bleeding risk and successful secondary hemostasis drops from 90% to 75%. Anatomic variation in blood supply to the duodenal bulb, either from branches of celiac axis or superior mesenteric artery may be the reason why our patients failed angiographic coil embolization of the GDA. To our knowledge, we report the first two cases where OTSC was used for successful salvage of NVUGIH that failed initial endoscopic and angiographic interventions.
2019 Lower Gastrointestinal Bleeding Due to Sevelamer-Induced Colitis
Authors: Zeidan Joseph H. , Simmelink Andrew , Saboori Shadab , Ahrens William , Moshiree Baha
Published: October 2019

INTRODUCTION:

Acute lower gastrointestinal (GI) bleeding is uncommonly due to medication induced-colitis, reported in less than 6% of all lower GI bleeds. Identifying medications that may cause GI bleeding is particularly important in chronically ill patients at high risk for morbidity and mortality. A commonly used medication in patients with advanced renal disease is sevelamer, a phosphate binder in renal failure patients.

CASE DESCRIPTION/METHODS:

A 53-year-old female with end-stage renal disease presented with hematochezia for 2 days. She notes dark black stools for two weeks followed by rectal bleeding. Her past history is notable for a renal transplantation in 2008 with graft failure requiring hemodialysis. She has no history of NSAID use and her prior screening colonoscopy showed no evidence of colitis. Her medication list was extensive and included sevelamer and cinacalcet. The patient was hemodynamically stable. Initial labs showed a hemoglobin of 6.0 g/dl, baseline was 8.0-9.0 g/dl. She was resuscitated with intravenous fluids and received 2 units of blood. Next, the patient’s upper endoscopy showed gastric erythema only with no stigmata of recent bleeding. Her colonoscopy showed a macroscopically normal appearing colon however random biopsies revealed expansion of the lamina propria with significant population of increased eosinophils. Several crystals were embedded within the colonic mucosa and submucosa resembling sevelamer crystals. Based on the pathology, she was diagnosed with sevelamer-induced colitis and this medication was discontinued. Follow-up at 3 months showed the patient remained asymptomatic without further GI bleeding.

DISCUSSION:

Sevelamer is a common medication used in renal failure patients. It is a resin that binds and prevents absorption of phosphate within the GI tract and has been shown to cause GI issues such as nausea, vomiting and diarrhea. Rarely it can crystalize, become embedded in the GI tract and ulcerate and cause bleeding. A few case reports have described rectosigmoid ulceration and pseudotumor presentation of sevelamer induced colitis.1,2 Understanding and recognizing the potential for sevelamer-induced colitis is important with such a widely used medication.
2022 Beyond Skin Deep: Serious Gastrointestinal Complications Associated With Oral Chemotherapy for a Case of Basal Cell Carcinoma
Authors: Vasireddi Nikhil , Khakoo Nidah S. , Kasi Keerthana , Duggimpudi Arul Ruthwik , Vasireddi Neal , Doss Peter , Wirtshafter David , Minassian Haig , Vasireddi Srinivas S.
Published: October 2019

INTRODUCTION:

Oral chemotherapy with Vismodegib for locally advanced Basal Cell Carcinoma (BCC) is widely used by dermatologists. In several isolated case reports, rare hepatotoxicity has been reported, but no consumer safety notifications have been issued by the manufacturer or the FDA to date.

CASE DESCRIPTION/METHODS:

A 62-year-old Caucasian female presented to emergency room with profound jaundice of her skin and scleral icterus that began two weeks after completion of Vismodegib oral chemotherapy for BCC of the left lateral forehead (Figure 1). Her past medical history was only significant for hypertension and pyrosis. The patient reports that she did not take any prescription or over-the-counter medications, herbal supplements, and had no history of alcohol use. Admission labs revealed AST of 37, ALT of 287, alkaline phosphatase of 522, total bilirubin 11.2, direct bilirubin 6.9, and indirect bilirubin of 4.3. A prompt liver biopsy revealed findings consistent with drug-related injury, including bile ductular reaction associated with portal inflammation consisting of lymphocytes, eosinophils, and neutrophils (Figure 2). She was stabilized and discharged with a plan for weekly outpatient monitoring. However, she presented two weeks later with complaints of right upper quadrant pain and melanotic stools for two days. Admission labs revealed a hemoglobin of 8.4, decreased from 12.0 on previous discharge. She was transfused appropriately and an upper endoscopy (EGD) revealed bleeding from the papillary orifice, indicative of hemobilia (Figure 3), warranting selective angiography and coil embolization for successful hemostasis. Jaundice resolved fully in four weeks and hemoglobin and liver function tests (LFTs) normalized in two months at follow-up.

DISCUSSION:

As noted in our case, gastroenterologists are bound to see an array of iatrogenic life-threatening complications from outpatient oral therapy for cosmetic lesions. Our case involved not only the hepatotoxic effects from Vismodegib, but a rare iatrogenic complication from the biopsy with bleeding requiring further interventions. Fatalities have been reported with this drug. Therefore, heightened awareness in medical community and mandated patient safety notifications by the manufacturer and the FDA are necessary to improve outcomes.
2026 Successful Hemostasis in Acute Gastric Variceal Hemorrhage With Hemospray (Hemostatic Powder)
Authors: Gohar Hamza , Massey Harper , Carlson Brian , Sharma Vishvinder , Mukherjee Ranadev
Published: October 2019

INTRODUCTION:

Currently there are few effective therapies for acute gastric variceal hemorrhage: endoscopic variceal ligation (EVL), cyanoacrylate injection, and endoscopic sclerotherapy (ESL). For variceal hemorrhage that is not amenable to these therapies, Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon-occluded retrograde transvenous obliteration (BRTO) are recommended. For patients with contraindications to these procedures there is no effective treatment. Here we present a case of acute gastric variceal hemorrhage, in which hemostasis was successfully achieved with the use of Hemospray (hemostatic powder).

CASE DESCRIPTION/METHODS:

A 63-year-old hispanic man with PMH of HCV and alcoholic cirrhosis presented with coffee-ground emesis and melena. Admission vitals: T-37.7, HR-117, RR-20, BP-139/72, O2 sat-100% on RA. Physical exam was significant for only mild jaundice. Hemoglobin was 6.3. We started Protonix IV BID, Octreotide drip and Ceftriaxone QD. CT abdomen showed multiple metastatic appearing liver lesions, cirrhosis, varices, and cavernous transformation of the portal vein. Overnight his hemoglobin decreased to 4.5. During EGD, multiple gastric varices were noted including a large, actively hemorrhaging, GOV-2 varix. Unfortunately, we were unable to perform EVL due to the sheer volume of bleeding present. IR was consulted for emergent TIPS. However the patient was not a candidate for TIPS or BRTO due to the cavernous transformation of his portal vein. The decision was made to utilize Hemospray. EGD was repeated and the large GOV-2 gastric varix was seen actively hemorrhaging. A large, obstructing clot was removed and the site of bleeding was visualized. Hemospray was applied and hemostasis was quickly and effectively achieved. After application, the patient did not have recurrent bleeding.

DISCUSSION:

Hemostasis in the setting of acute gastric variceal hemorrhage can be very challenging to achieve. Hemospray should be considered when traditional therapies fail. It becomes cohesive and adhesive when it comes into contact with moisture, forming a stable mechanical barrier. Although there are few studies investigating its use in acute variceal hemorrhage, it was very effective in this case. Hemospray can also be useful for providing temporary hemostasis in an emergent situation; giving physicians more time to organize more definite treatments. Hemospray is a powerful endoscopic tool and should be considered when standard bleeding therapies are inadequate.
2027 Upper GI Bleeding With Black Esophagus: Case Report of Acute Esophageal Necrosis
Authors: Hammami Muhammad B. , Aboushaar Reem , Musmar Ahmad , Azhar Mishah , Miller Stephen M. , Salomon Peter
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis, a very rare cause of upper GI bleeding, is seen mainly in elderly men. We report a new case in an elderly woman.

CASE DESCRIPTION/METHODS:

A 90-year-old woman with a history of DM, HTN, and CHF presented with SOB and abdominal pain of 2-day duration. She didn’t vomit. Confusion, pallor, and large melanotic bowel movement were noted. Temperature was 36.1°C, BP 86/68 mmHg, HR 104 bpm, and RR 22 br/min. She had bilateral shallow coarse breath sounds and otherwise unremarkable abdominal and neurological exams. Urine ketones was negative, plasma glucose 98 mg/dL, WBC 40.8 K/mcL, hemoglobin 9.3 g/dL, platelet 437 K/mcL, GFR 18 mL/min/1.73 m2, lactate 15.5 mmol/L, and procalcitonin 1.49 ng/mL. Blood culture was negative. Chest CT showed small bilateral pleural effusions and ground glass opacities. Abdominal CT showed fecal impaction. Working diagnoses included septic/hypovolemic shock, pneumonia, encephalopathy, acute upper GI bleed, and acute hypoxic respiratory failure. Volume resuscitation, vasopressors (norepinephrine, phenylephrine, and vasopressin), mechanical ventilation, broad spectrum antibiotics (vancomycin, cefepime, and azithromycin), total parenteral nutrition, and proton pump inhibitor were started. EGD revealed friable, black, circumferential esophageal mucosal changes starting 25-30 cm from incisors and extending to GE junction without gastric outlet obstruction (Figure 1). Follow up EGD one week later showed slow healing with black and thin tissue, starting 4 cm proximal to GE junction without stricture (Figure 2). She continued to be encephalopathic, requiring mechanical ventilation and vasopressor support. She died upon intensive care withdrawal at family request.

DISCUSSION:

Our patient had endoscopic diagnosis of acute ischemic esophagitis, which was likely due to compromised esophageal perfusion secondary to septic/hypovolemic shock in the setting of chronic vascular compromise. Biopsy to differentiate ischemic esophageal necrosis from other etiologies, such as infection and malignancy, carries a high risk for perforation and was not performed. As seen in our patient, acute esophageal necrosis typically affects the relatively hypovascular distal esophagus down to GE junction and quickly resolves when blood flow is restored. Nevertheless, mortality remains high due to the underlying conditions. Unlike our case, acute esophageal necrosis affects mainly men, with a men/women ratio of 4/1.
2034 Upper GI Bleed in a Young Male: A Rare Presentation of Eosinophilic Gastroenteritis
Authors: Priyadarshni Shivani , Surapaneni Balarama K. , Dave Kairavee , Patel Nehal , Yella Prashanth Reddy , Cantave Rulz T. , Kaplan Steven R.
Published: October 2019

INTRODUCTION:

Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease affecting multiple organs (stomach and small intestine) of the gastrointestinal tract (GIT). It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with GIT. Klein et al classified EGE into 3 subtypes predominant mucosal, muscular or subserosal. The prevalence has been found to be ranging from 8.4 to 28 per 100,000.

CASE DESCRIPTION/METHODS:

Our patient is 28-year-old male with PMHx EGE, duodenal ulcers and stricture who presented to hospital with chief complaint of 3 episodes of dizziness and melena for one day. Allergies included food allergies to peanuts. Home medications included prednisone, montelukast and pantoprazole. On admission he was found to be tachycardic (150). Initial labs showed a hemoglobin (hgb) of 9.3. His hospital course included 1 episode of large volume hematemesis >1.5L and brief loss of consciousness followed up by a rapid response. Between day 1 and 2, hgb dropped to 5.7; patient received blood transfusion and managed conservatively with continuous vital monitoring in ICU. Emergent endoscopy (EGD) revealed high grade duodenal stenosis, severe pyloric-duodenal deformity with duodenal ulcer with visible vessel and 2 clips were deployed blindly. Epinephrine could not be injected due to hard and fibrotic tissue around duodenal stenosis. IR was consulted; angiography revealed active bleeding from gastric artery. Cool in and with a subsequent embolization was done. He received 5 unit RBCs total and continued on pantoprazole. For his known duodenal stricture, surgery was consulted with recommendation of no acute surgical intervention in the hospital. On discharge he was sent home with PO PPI, prednisone 40 daily, liquid diet, hydration and close follow up with GI, Surgery and PCP as soon as possible.

DISCUSSION:

EGE is more common in pediatric population and affects adults between the 3rd and 5th decade of life with a female predominance in USA. The risk factors include: genetic factors observed in familial cases, higher socioeconomic status, Caucasian race and excess weight. EGE is seen in patients with various allergies, asthma and elevated serum IgE levels, suggesting an association with hypersensitivity involved in the pathophysiology of EGE. 3 clinical criteria used to diagnose EGE: Presence of gastrointestinal symptoms; Gastrointestinal eosinophilic infiltrates; Exclusion of causes of tissue eosinophilia such as drug reactions or parasitic infections.
2038 Jejunal Lymphangioma: A Rare Cause of Gastrointestinal Bleeding
Authors: Chaudhari Rahul B. , Shirodkar Manoj A. , Syed Rifat Mannan Abu Ala
Published: October 2019

INTRODUCTION:

Lymphangioma is a rare benign vascular tumor in adults. The etiology is not clear but is proposed to be from the anomalous development of the lymphatics or inflammation and obstruction of developed lymphatics (1). Although most cases are asymptomatic and thus detected incidentally, non-specific symptoms, including abdominal pain, nausea, vomiting and weight loss may be present (2). Here we present a case of such tumor presenting as obscure overt GI bleed.

CASE DESCRIPTION/METHODS:

A 76-year-old female with past medical history of DM, ESRD, CHF, AFib presented with SOB and hypotension. Three weeks prior, she had a cardiac arrest during dialysis and was found to be anemic on admission to outside hospital (Hb 5.9). She was diagnosed with PE and anticoagulation was started. This resulted in multiple episodes of melena. She was deemed clinically unstable for EGD/colonoscopy and was discharged (Hb 8.6). A week later, she was again found to be anemic (Hb 5.8) and continued to have multiple episodes of melena. Colonoscopy and EGD were unremarkable and she was eventually discharged again. Her symptoms recurred following discharge and she was hospitalized now with SOB and hypotension (Hb 6.4). She continued to have melena. Diagnostic tagged RBC scan showed possible focus of luminal hemorrhage in small bowel in left abdomen. A capsule endoscopy showed a jejunal mass with active bleeding. Subsequent single balloon enteroscopy revealed a 2.5 cm polypoid mass with active bleeding in the mid-jejunum. Biopsies were taken and hemostasis was achieved with argon plasma laser. Histology revealed this mass to be a lymphangioma. She was discharged with no further bleeding. At 2 months follow up, she still did not have any further bleeding. She elected not to pursue any further management.

DISCUSSION:

A lymphangioma is a rare benign tumor. For lymphangioma, intestinal tract involvement is very uncommon. GI bleeding, intestinal obstruction, intussusception and protein-losing enteropathy are very rare manifestations(5). Diagnostic tests include barium enema, CT scan and endoscopic evaluation (7-9). Surgical resection may be required to provide definitive diagnosis and treatment. The upper and lower GI endoscopies can sometimes miss the mass, as in our patient. In such cases, capsule endoscopy and push enteroscopy play an important role. In our case, conservative measure was chosen due to the surgical risks of the patient from multiple comorbidities.