bluuebunny/crossref_metadata_2025_split huggingface dataset:
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