Ulcer Base Research Articles

3128 A Rare Case of a Gastroduodenal Ulcer Arising From Checkpoint Inhibitors

INTRODUCTION: Ipilimumab and Nivolimuab are in a class of immune checkpoint inhibitors that are widely used in the treatment of advanced malignancies. 1 Immunotherapy with monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen 4 (CTLA4) and the programmed death-1 receptor (PD-1) and its ligand PD-L1 has become the standard of care for cancer treatment today. 1 Gastrointestinal (GI) toxicity from cancer immunotherapy is well described for anti-CTLA4 Abs, but less well studied in combination of anti-CTLA4 and anti-PD-1Abs. GI effects of these immunotherapies range from enterocolitis, pancreatitis, diarrhea, and ulcerations involving the sigmoid colon and rectum. 1 CASE DESCRIPTION/METHODS: Here, we present the case of an 80 year old male with past medical history of renal cell cancer (RCC) that was diagnosed 3 months prior to admission, who presented with melenic stool for one day. The patient had been initiated on a chemotherapy regimen of Ipilimumab and Nivolimuab of which he received three rounds, the last dose one week prior to hospitalization. He had not been on any anticoagulation nor had he endorsed NSAID use. Patient's hemoglobin was closely trended. One day into admission, patient had a large melenic bowel movement with Hb change from 9.0 to 8.7 mg/dL with significant hypotension and tachycardia. Patient was emergently intubated for airway protection for an EGD. EGD revealed a large 4-5 cm ulcer in the second portion of the duodenum and found to have a large artery protruding from the ulcer base, likely the gastroduodenal artery. Endoscopic intervention was performed by placing 5 clips at the ulcer base in an effort to further prevent bleeding. Hemoglobin was trended closely following the procedure, however post-EGD bleeding continued and patient became acutely hypotensive, requiring vasopressor support. As further EGD intervention was considered to be high risk, Interventional Radiology was consulted for embolization with empiric embolization of gastroduodenal artery using a microcoil, which was successful. Hemoglobin continued to trend downwards despite control of bleeding and vasopressor support increased at which point patient was transitioned to comfort measures. DISCUSSION: This case outlines a rare case of immune checkpoint inhibitors as a cause of a gastroduodenal ulcer and the adverse outcomes with checkpoint inhibitors as treatment for malignancies.

182 A Comparison of the Mucosal Defects and Healing by Hot Snare Polypectomy (HSP) vs. Cold Snare Polypectomy (CSP) for Endoscopic Removal of Colorectal Polyps

INTRODUCTION: Screening colonoscopy with polypectomy of small polyp substantially reduces colorectal cancer incidence and mortality. CSP and HSP are two major methods for polypectomy. The basic difference of CSP and HSP is the use of a high frequency generator of HSP. HSP may damage deeper vessels with increased risk of delayed healing, thereby post-polypectomy bleeding and even perforation. For this reason, CSP is usually considered safer, in recent years, CSP has increasingly been used for the removal of colorectal polyps. On the other hand, CSP is concerned associate with a rate of incomplete resection. So far few studies have confirmed endoscopically the early condition after treatment. In this study, through a randomized controlled study, we evaluated to compare mucosal defects and healing one week after treatment, from polypectomy using CSP vs. HSP. METHODS: The 52 patients has tumor size under 10 mm were randomly divided into two groups using opaque envelopes: CP (n = 27) and HP (n = 25). We compared the mean tumor size, ulcer diameter one week after endoscopic treatment, exposed blood vessels, residual recurrence and contingencies for CSP and HSP. Pathological diagnosis of complete resection was defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps. RESULTS: The overall the mean tumor size did not differ between the two groups (CSP vs. HSP: 5.44 mm vs. 5.32 mm). Ulcer base diameter one week after treatment is CSP group had a smaller compared to the HSP group (2.7 mm vs. 4.84 mm; P < 0.001). And the CSP group had a lower exposed blood vessels compared to the HSP group (7.4% vs. 36.0%; P < 0.05). Delayed perforation or bleeding was not recognized in any patient during the one weeks after treatment. One case of residual recurrence was admitted to CSP group. CONCLUSION: Our study findings show that although there is no difference tumor diameter between the two techniques, the size of ulcer diameter one weeks after treatment, resection time and the rate of post-polypectomy bleeding is lower with CSP. However remnant recurrence was observed only in CSP. In clinically, CSP can be safely used as one of the effectively techniques for the resection colorectal polyps, but It is important to make an accurate endoscopic diagnosis and exclude cancer before treatment.

3231 Gastric Outlet Obstruction in a Patient After Hip Surgery

INTRODUCTION: Until the 1970s, peptic ulcer disease was the most prevalent cause for gastric outlet obstructions (GOO) and accounted for 90 percent of all cases. However, with the introduction of proton pump inhibitors (PPI) and the treatment of H. pylori infections, the etiology of GOO changed rapidly. Today, only around two percent of all peptic ulcers lead to GOO. Here we report the case of a woman with nausea, abdominal pain and coffee ground emesis, found to have a GOO, whose symptoms completely subsided under PPI treatment of a 12 mm large peptic ulcer (Forrest III) in the duodenal bulb. CASE DESCRIPTION/METHODS: A 62-year-old female patient with a history of hypothyroidism, recent left hip fracture repair and subsequent pulmonary embolism, presented with nausea, hematemesis, melena, epigastric pain, decreased appetite and weight loss. She was treated with daily aspirin 325 mg and apixaban, and denied any drug abuse. PPI prophylaxis was not administered. Her physical examination was unremarkable. Initial blood tests included blood count, electrolytes and coagulation monitoring, and were unremarkable except for mild anemia (hemoglobin 9.9 g/dL). Contrast CTs of the abdomen and pelvis with PO/IV contrast showed marked gastric distension with luminal narrowing at the level of the duodenal bulb. Small and large bowel appeared normal in caliber and neither obstructions nor wall thickenings could be found. Accordingly, an esophagogastroduodenoscopy was performed showing a non-bleeding, cratered ulcer with a clean ulcer base (Forrest III) in the duodenal bulb. The lesion was 12 mm in largest dimension and surrounded by edema and erythema, resulting in a complete luminal obstruction. Upon gastric decompression with a nasogastric tube and PPI treatment, the patient recovered quickly and was discharged after four days. DISCUSSION: Due to an increase in PPI administration and H. pylori eradication in the last decades, peptic ulcers are nowadays treated early on, and gastric outlet obstruction has become a rare complication of peptic ulcer disease. In this case, we report on a 62-year-old patient who developed an obstructive peptic ulcer following extensive hip surgery and anticoagulation with aspirin and apixaban. We hereby want to highlight the importance of a timely PPI prophylaxis for peptic ulcer disease in severely ill patients with chronic NSAID intake. Conservative measures can moreover suffice to resolve the issue.

2718 Gastric Pneumatosis in the Setting of Underlying Gastric Ulcer: An Uncommon Case Report Presentation

INTRODUCTION: Gastric Pneumatosis (GP) is a rare entity that is usually caused by emesis with forceful retching and inoculation of intraluminal gas into the stomach wall. GP is divided into two subtypes: emphysematous gastritis (EG) and gastric emphysema (GE). EG is a result of both direct inoculation and hematogenous dissemination of gas forming bacteria in the setting of immunosuppression, alcoholism, diabetes mellitus, and NSAID use. The clinical outcome tends to be septic shock and death. GE is less fatal and is diagnosed radiographically as air within the stomach wall. Conservative management is the treatment of choice. GE is commonly associated with gastric outlet obstruction, pulmonary injury, and other traumatic events. CASE DESCRIPTION/METHODS: A 56-year-old male nursing home resident, with Wernicke’s encephalopathy was sent to the ED after multiple episodes of hematemesis. On presentation, vital signs of HR:116, RR: 26. Physical exam exhibited diffuse abdominal tenderness, distension, decreased bowel sounds with noted involuntary guarding, but no rebound or rigidity. Decline in mental status and respiratory failure, prompted intubation. Initial labs showed leukocytosis of 15.2, normal Hb of 16.2, and AKI with Creatinine: 2.93. CT scan revealed severely distended stomach with gastric pneumatosis; distended small bowel loops, with a decompressed distal ileum and no discrete transition zone. CT showed also showed a large stool burden in the colon (Figure 1). EGD was initially deferred given high risk of gastric perforation. The patient was treated with bowel rest, NG tube decompression, IV fluids, PPI drip, and empiric Ceftriaxone and Metronidazole. Consequently, CT scan with IV contrast repeated on day 4 showed resolution of GP with patent mesenteric vasculature (Figure 2). EGD done on same day with evidence of diffuse moderate inflammation characterized by congestion (edema) in the entire stomach, and one non-bleeding linear gastric ulcer in the upper body, with a clean ulcer base (Forrest Class III) (Figure 3). Biopsies showed signs of chronic inflammation and reactive changes, as well as focal intestinal metaplasia in stomach antrum. DISCUSSION: Self-resolution of gastric pneumatosis after medical management is consistent with the benign course of GE, with reported positive clinical outcomes and low risk of recurrence. In this case, the patient’s gastric ulcer and vomiting associated with constipation contributed to his gastric emphysema. Absence of hepatoportal venous gas was a good prognostic sign.

Refractory Duodenal Ulcer and Upper Gastrointestinal Bleeding Following Yttrium-90 Transarterial Radioembolization

Abstract Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma. Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.

An Ulcer Base Rhythmically Pulsating With Cardiac Contractions: A Manifestation of Gastrocardiac Fistula.

An Ulcer Base Rhythmically Pulsating With Cardiac Contractions: A Manifestation of Gastrocardiac Fistula.

25-Hydroxyvitamin D Deficiency: Impacting Deep-Wound Infection and Poor Healing Outcomes in Patients With Diabetes

The Kingdom of Bahrain has a high incidence of diabetes and associated foot complications. Simultaneously, low 25-hydroxyvitamin D (25[OH]D) levels are common in this population and may be associated with the traditional clothing used in desert climates. This investigation compared 25(OH)D levels and glycemic control with quantifiable wound healing parameters in a prospective, analytic, nonexperimental, cross-sectional pilot study. Consecutive consenting adult patients (N = 80) who presented to the regional wound care unit in January 2016 with either an existing or new wound were included. Collected data included three-dimensional wound photography, NERDS and STONEES criteria, and an X-ray with a positive probe-to-bone test. Blood values for 25(OH)D and hemoglobin A1c (HbA1c) were collected simultaneously. Diabetes mellitus (types 1 and 2) was present in 90% of the sample patients. No patient had sufficient 25(OH)D levels; 15% had insufficient levels (30-50 ng/mL), and deficiency (levels <#20 ng/mL) was found in 85% of the sample. Males were slightly less affected by 25(OH)D deficiency compared with females (82.4% vs 91.3%). Poor glycemic control (HbA1c levels >#6.8%) was found in 69.4% (n = 50) of the persons with diabetes included in the sample. Those with both diabetes mellitus and a 25(OH)D deficiency (76.3%; n = 61) were more likely to demonstrate healing difficulty (40.9%; n = 25) or present with a stalled or deteriorating wound (44.2%, n = 27). A 3° F or higher periwound surface temperature elevation over a mirror image site was present in 82.5% of all wounds. Exposed bone in the ulcer base was found in 50% of the cases. For persons with diabetes, general linear modeling statistical analysis (adjusted R value = 47.9%) linked poor wound healing with three studied variables: 25(OH)D deficiency, poor glycemic control, and an exposed bone in the wound bed. Vitamin D may be an overlooked factor in the pathophysiology of diabetic foot ulcer development and subsequent delay in wound healing outcomes. The authors recommend adding 25(OH)D deficiency to the list of multifactorial aggravating factors providers should consider correcting in this subgroup of patients.

Tu2015 ENDOSCOPIC CLOSURE UTILIZING ENDOLOOP AND ENDOCLIPS AFTER GASTRIC ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) FOR PATIENTS ON ANTITHROMBOTIC THERAPY

Antithrombotic therapy is a well-known independent risk factor for bleeding after gastric endoscopic submucosal dissection (ESD). A novel method of ulcer base closure using endoloop and endoclips to prevent post procedural bleeding has been reported. (Abe S, et al. Endoscopy 2015). The aims of this study was to evaluate the effectiveness of post-ESD endoloop-endoclip closure in bleeding prevention for patients on antithrombotic therapy.

Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management

Background and Aims: The management of post-endoscopic variceal ligation (EVL) bleeding ulcers (PEBUs) is currently based on local expertise and patients liver disease status. The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes.Methods: Patients underwent EVL (primary or secondary), from January 2015 to January 2018, in two tertiary care hospitals in India (ILBS New Delhi and Dharamshila Narayana New Delhi). Mortality rates were determined at post-EVL day five and week six. PEBUs were typified based on Jamwal & Sarin classification system as follows: A, ulcer with active spurting; B, ulcer with ooze; C, ulcer base with visible vessel or clot; and D, clean or pigmented base.Results: Of 3854 EVL procedures, 141 (3.6%) patients developed PEBU, and 46/141 (32.6%) suffered mortality. Among the former, the PEBU types A, B, C, and D accounted for 17.7, 26.2, 36.3, and 19.8%, respectively. Of those who died, 39.1, 30.4, 21.7, and 8.8% had PEBU types A, B, C, and D. Treatments included transjugular intrahepatic portosystemic shunts (TIPS), esophageal self-expandable metal stent (SEMS), glue and sclerosant injection, Sengstaken-Blakemore tube placement and liver transplant. On univariate analysis, no correlation with hepatic venous pressure gradient, TIPS placement, size of varices, or number of bands was found. The Model for End-Stage Liver Disease (MELD)-sodium score correlated positively with outcome. After adjusting for MELD-sodium score, mortality was best predicted by type-A ulcer (p = 0.024; OR 8.95, CI 1.34–59.72).Conclusions: PEBU occurred in 3.6% of a large EVL cohort. Stratifying patients based on PEBU type can help predict outcomes, independent of the MELD-sodium score. Classifying PEBUs by endoscopic morphology may inform treatment strategies, and warrants further validation.

Ulcerative Lupus Vulgaris Primarily Involving the Ear Lobule.

Sir, Lupus vulgaris (LV) is the most common clinical variant of cutaneous tuberculosis. It was first described by Erasmus Wilson in 1865.[1] Clinically, the early lesions of LV are characterized by soft reddish brown plaques with an ‘apple jelly nodule’ appearance on diascopy and in the later stages present with healing and scarring in one area and active disease in another.[2] The different forms of LV include plaque, ulcerative or mutilating, vegetating, tumor-like, and papular and nodular forms.[3] We report an unusual case of ulcerative type of LV of the ear lobe. A 24-year-old girl presented to our department with ulceration of the left earlobe for 6 months. It started as a papule which slowly increased in size and broke down to form an ulcer. She did not give any history of trauma or ear piercing prior to the onset of the lesion. There was also no history of tuberculosis in the past or a family history of the same. There was no history suggestive of immunosuppression. The cutaneous examination showed a well-defined ulcer of size 1 × 2 cm on the tip of the left earlobe [Figure 1]. The margins were undermined and the floor was covered with slough [Figure 2]. The surrounding skin was erythematous with mild scaling. The general and systemic examination was normal. A Mantoux test showed an induration of size 11 × 12 mm after 48 hours. Chest X ray was normal. PCR (Polymerase Chain Reaction) and BACTEC (Becton Dickinson Diagnostic Instrument Systems) tests were not done due to financial constraints.Figure 1: An ulcer over the left ear lobeFigure 2: The ulcer base shows slough with surrounding erythemaThe histopathological examination of the skin biopsy showed ulceration of the epidermis and confluent epithelioid granulomas in the mid and deep dermis. The epithelioid granulomas showed minimal central caseous necrosis and peripheral palisades of histiocytes and lymphocytes [Figures 3 and 4]. However, Ziehl–Neelsen stain was negative for acid-fast bacilli. The features were consistent with granulomatous skin lesion. Other routine blood investigations were unremarkable. A final diagnosis of ulcerative LV was made due to the presence of caseating granulomas on histopathology and positive Mantoux test. The patient was treated with Cat 1 anti-tubercular treatment (ATT) under the Revised National Tuberculosis Control Programme which resulted in complete healing of the ulcer [Figure 5].Figure 3: Epithelioid granuloma with minimal central caseous necrosis (H and E, 40×)Figure 4: Epidermis is focally ulcerated with dermis showing confluent epithelioid granulomas (H and E, 4×)Figure 5: The ulcer healed with scar formation after 6 months of anti-tubercular therapyThe ulcerative type of LV is uncommon and it is characterized by scarring and deformity. The mode of infection is thought to be endogenous or exogenous inoculation following minor trauma.[1] In India, the common sites of involvement are buttocks, thighs, and legs, whereas in the European population, the head and neck are most commonly involved.[4] In a study done in India, ulcerative type of LV was the least common (14.2%).[5] Case reports of LV affecting the face indicate that the cheeks and nose are the most frequently affected sites.[6] Although the pinna may be involved by contiguity from a cheek lesion, primary involvement of the ear lobe is extremely rare.[78910] The above case reported here is unusual because of the exclusive involvement of the ear lobe and the occurrence in an immunocompetent girl without any past or family history of tuberculosis. Long-standing ulcerative LV in addition to scarring and deformity can lead to squamous cell carcinoma. Clinical dermatologists need to be aware of the myriad clinical presentations of this condition and make a correct diagnosis, and promptly treat as it can be disfiguring and destructive. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Assessment of endoscopic Doppler to guide hemostasis in high risk peptic ulcer bleeding

Introduction: Rebleeding or emergency surgery in failed endoscopic therapy of peptic ulcer bleeding are associated with high rates of morbidity and mortality. The clinical benefit of an endoscopic Doppler (ED) examination prior to endoscopic injection therapy was evaluated in high risk ulcer patients for rebleeding episode. Standard injection therapy (non-Doppler (ND)) was compared with targeted injection therapy after examination of the supplying vessel in the ulcer base by the ED.Materials and methods: Sixty patients with peptic ulcer bleeding (Forrest Ia–IIa; Rockall score of 5 or higher) were included in the study. Patients were assigned to ED or ND group with conventional therapy by chance. In the ND group injection was directed by the visual aspect of the ulcer, whereas in ED therapy was directed by ED.Results: Thirty-five patients were allocated to the ED group, and 25 to the ND group, respectively. No significant differences in patient or ulcer characteristics were observed regarding ulcer size, localization, Forrest classification or endoscopic treatment. Recurrent bleeding was observed in 7/35 (20%) in the ED group and in 13/25 (52%) of patients in the ND group (p = .013). Fewer ED patients needed surgery for rebleeding (1/35 vs. 6/25; p = .017). Bleeding related, but not all-cause mortality was significantly lower in the ED group (1/35 vs. 6/25, p = .017).Discussion: In this comparative analysis, use of ED to guide hemostatic therapy was associated with a significant reduction in recurrence of bleeding, surgical intervention and bleeding associated mortality.

A Coil Calamity

Management of acute upper gastrointestinal bleeding (GIB) is standardized with initial approach focusing on resuscitation and endoscopic evaluation with therapeutic intent. In the event that a lesion is not amenable to endoscopic therapy, endovascular treatments have been successfully utilized, ranging from foam gel to selective vascular coil embolization. Endovascular therapy has been shown to be successful with several peri-procedural and long term adverse events. Here we describe a case of a 66-year-old female with past medical history of acute myeloid leukemia (AML) and recent allogenic stem cell transplant who presented with melena for one month and labs demonstrating profound anemia without evidence of hemorrhagic shock. She had a history of GIB previously treated with transcatheter arterial embolization (TAE) of the gastroduodenal artery (GDA) five years prior to this presentation. On current hospitalization, an EGD demonstrated several duodenal ulcers and three micro coils extruding from the base of the ulcer. No endoscopic interventions were attempted. Her melena persisted with ongoing anemia. An angiography failed to identify source of bleeding, but due to high surgical risk from comorbid conditions, a conservative approach was undertaken with acid suppression therapy and as needed blood transfusions. Her hemoglobin stabilized and the patient was successfully discharged. She has not experienced recurrence of bleeding at three months follow-up appointment. Coil migrations through the gastric and duodenal wall is a rare but possible complication of TAE that has previously been reported in the literature in up to 3% cases. More typical complications of TAE include occlusion of a nontarget vessel, vessel injury, local abscess, and allergic reaction to coils. Bleeding after coil migration may occur from weeks to several years after TAE as in our patient. Unlike the high risk stigmata of rebleeding that has been well described, the prognostic value of finding migrated coils on endoscopy has not been assessed in the literature for predicting likelihood of rebleeding. Due to the paucity of data, the approach to patient management should remain individualized, utilizing a multidisciplinary approach, including surgery, interventional radiology and gastroenterology.1951_A Figure 1. Duodenal Bulb/ sweep: Large ulcer1951_B Figure 2. Duodenal sweep: Coils protruding from ulcer base

Non-Malignant Gastric Outlet Obstruction: Therapy With Endoscopic Ultrasound Guided Gastrojejunonostomy

We describe here an 82 year-old male with past medical history of coronary artery disease, sick sinus syndrome s/p permanent pacemaker insertion who presents with a three day history of nausea and vomiting. A CT scan was obtained in the emergency department that showed a markedly distended abdomen. Although no discrete mass was seen, findings were concerning for a gastric outlet obstruction (GOO) (Figure 1). The patient was made NPO and a nasogastric tube was placed for decompression. Of note, the patient was hospitalized at an outside facility 1 month prior due to a severe gastro-intestinal hemorrhage. An endoscopy performed at that time revealed that a ulcerated mucosa encompassing two-thirds of the second portion of the duodenum.2130_A Figure 1 No Caption available.A repeat EGD was performed at our facility revealing a benign appearing high grade stricture in the duodenal bulb at the base of a healing ulcer. Stone-like accretions were found in the pylorus and duodenal bulb which were noted to intermittently occlude the stricture (Figure 2). Biopsies were taken which were negative for malignancy.2130_B Figure 2 No Caption available.The decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ). Sonographic examination of the stricture did not reveal an obvious mass. A stone-extraction balloon over a wire was advanced thorough the duodenal stricture into the jejunum. Sterile water was used to dilate the jejunal limb. The linear echoendoscope advanced to the stomach and the jejunal limb was identified. A 19G FNA needle was used to puncture into the jejunum and a second wire was advanced into this limb. Under endoscopic, fluoroscopic and sonographic guidance a 15mm lumen-apposing metal stent (LAMS) was successfully deployed, creating a gastrojejunostomy (Figure 3).2130_C Figure 3 No Caption available.Post-procedure day one patient tolerated a soft diet and was discharged after a 48 hour observation periord. At outpatient follow-up, six weeks after presentation, the patient has done well without significant complications. EUS-GJ are not common-place, however their utility in the treatment of malignant as well as benign gastric outlet obstruction has been demonstrated in international prospective trials. Here we demonstrate that EUS-GJ can be a reliable intervention in patients with GOO. In the future we hope for a comparison study between LAMS, enteral stents and surgical gastrojejunostomies.

NSAID Aids in Diagnosis of Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal (GI) tract and may present either asymptomatically or with nonspecific GI symptoms. The subepithelial nature of these tumors and wide range of localization within the GI tract make the diagnosis of GIST difficult. A 53-year-old gentleman, with a history of non-steroidal anti-inflammatory drugs (NSAID) use for chronic pain, presented with lightheadedness. A week prior, he underwent tooth extraction secondary to severe periodontal disease. Patient noted increased NSAID use since surgery. Further, he also reported melanotic stool. Labs showed hemoglobin of 5.8 G/DL. The esophagogastroduodenoscopy found a large 3 cm duodenal ulcer with visible vessel. Biopsies were taken at the ulcer edge and due to the friability of the tissue, bleeding ensued. The brisk bleeding lead to difficulty localizing the site of bleeding, thus a hemo-clip was deployed near the ulcer site as a fiduciary marker. Subsequently, interventional radiology performed celiac / gastric duodenal artery (GDA) and superior mesenteric artery arteriogram with successful GDA embolization and cessation of bleeding. Computerized tomography of the abdomen with contrast, revealed a 5.0 x 5.5 cm mass adjacent to the pancreatic head/peri-ampullary. A duodenal GIST was suspected from biopsies, and the patient subsequently underwent a pylorus-sparing Whipple procedure with biopsies confirming GIST. GISTs occur in 15 per 1 million people. GI bleeds are encountered due to tumor erosion into the mucosal surface of the GI tract. GISTs are localized to the stomach in about 60-70% of cases with localization to the duodenum in only about 3-5% of cases. Due to the subepithelial localization that is typical for these tumors and the nonspecific nature of symptoms, diagnosis can be difficult with metastatic disease encountered upon initial diagnosis in approximately 50% of cases. Surgical resection is the primary treatment of choice for localized GISTs. Our patient's NSAID use led to a GI bleed that unmasked a duodenal ulcer which, subsequently, aided in the diagnosis of a GIST early enough for curative resection.2990_A Figure 1. Endoscopic view of ulcer base within duodenum.2990_B Figure 2. Lateral View CT imaging showing duodenal gastrointestinal stromal tumor (black arrow) and hemoclip (white arrow).2990_C Figure 3. Coronal View CT imaging showing duodenal gastrointestinal stromal tumor (black arrow) and hemoclip (white arrow).

Role of gastroscopic biopsy of gastric ulcer margins and healed sites in the diagnosis of early gastric cancer: A clinical controlled study of 513 cases.

The present case study aimed to evaluate the effect of gastroscopic biopsy of gastric ulcer margins and healed sites in the diagnosis of early gastric cancer. A total of 513 patients who were diagnosed with gastric ulcers using gastroscopy between January 1999 and December 2013 were included in the present study and were divided into either the experimental or the control group. In the control group, samples were only taken from the ulcer margin, whereas in the experimental group samples were taken from the ulcer margin and from the ulcer base. In the experimental group, a routine biopsy of the ulcer margin was performed on first examination, and recheck by gastroscopy was performed from the second week. For ulcers that remained unhealed, a biopsy of the ulcer margin was subsequently conducted; however, for healed or almost healed ulcers, a biopsy of the ulcer base was conducted. The duration of follow-up by gastroscopy ranged between 1 week and 24 months. For the control group, a biopsy of the ulcer margin was conducted using the conventional method. The detection rate of the experimental group was 3.88% (9/232), with 4 cases of gastric cancer confirmed from examinations of the ulcer base. The detection rate of the control group was 1.07% (3/281), which was significantly decreased compared with that of the experimental group (P=0.0345). Overall, patients who underwent regular follow-up gastroscopy following treatment exhibited a markedly increased detection rate of early gastric cancer, suggesting that early cancer may occur in healed gastric ulcer sites.

High-Resolution Spectral Analysis Accurately Identifies the Bacterial Signature in Infected Chronic Foot Ulcers in People With Diabetes.

Diabetic foot infections are a major cause of hospitalization, and delayed treatment can lead to numerous complications. The aim of this research was to investigate high-resolution spectroscopy of the wound center and periwound area for real-time estimation of multispectral signature of bacteria at the base of diabetic foot ulcers. We investigated the spectrum of the reflected visual light from diabetic foot ulcers and developed a method that identifies the presence of bacteria in the wound infections. We undertook a prospective pilot study on 18 patients with type 1 and type 2 diabetes and chronic diabetic foot ulcers. The spectral coefficients were directly compared with the results from the wound swab. The results of the multispectral analysis demonstrated 100% sensitivity, with 100% negative predictive values of identifying the presence of the bacteria, which was the cause of the infection in the wound. The results of our study suggest that the changes in the multispectral properties of the wound can be used to identify the presence of bacteria in the infected area using a noninvasive device without any contact with the wound. This technique holds great promise for real-time objective evaluation of the wound infection status beyond the standard visual assessment of diabetic foot ulcers.

Single Center Experience of a New Endoscopic Clip in Managing Nonvariceal Upper Gastrointestinal Bleeding.

To assess the safety and efficacy of the Instinct clip in the acute endoscopic treatment of upper gastrointestinal bleeding (UGIB). This is the first large series reporting this clip in achieving hemostasis. A retrospective descriptive chart review was performed on patients presenting with recent overt GI bleeding treated with endoclip therapy at Mount Sinai Beth Israel Medical Center between May 2013 and January 2016. Results are expressed in absolute numbers, percentages, and trends. In total, 178 consecutive patients with UGIB were included. Source of bleeding was identified as duodenal ulcer (29.2%), gastric ulcer (22.5%), gastro-esophageal junction tear (8.4%), anastomosis (5.6%), erosive gastropathy (5.6%), Dieulafoy (5.1%), gastric polyp (4.5%), postendoscopic procedure (3.9%), angioectasia (3.4%), esophageal ulcer (2.8%), benign duodenal mass (2.8%), peg tube site (2.3%), gastric neoplasm (1.7%), esophagitis (1.1%), and small bowel ulcer (1.1%). Lesions demonstrated active bleeding in 47.5% (11.3% spurting and 36.2% oozing) and nonbleeding lesions in 52.5% (25.0% visible vessel, 11.9% hematin in ulcer base, 10.0% adherent clot, 5.6% flat spot). Initial hemostasis was achieved in 96.6%. Additional methods were used in 24.1% (argon plasma coagulation and epinephrine injection in 21.3%, surgery in 0.6%, and interventional radiology in 2.2%). There were no adverse events. In-hospital rebleeding was 7.3% and 3.9% presented with rebleeding within 30 days. Average procedure duration was 22.9 minutes and average length of hospital stay was 11.3 days. The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.

Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation.

Purpose:The aim of this study is to describe a modified surgical technique of continuous intraoperative optical coherence tomography (iOCT)-guided shield ulcer debridement with tuck-in multilayered Amniotic membrane transplantation (ML AMT) in vernal keratoconjunctivitis (VKC) with shield ulcer with plaque.Methods:Seven eyes of seven patients presenting with VKC with shield ulcer with plaque were enrolled in this prospective case series and planned for shield ulcer debridement with ML AMT. Debridement of the ulcer base with double-layered AMT was done under the continuous guidance of iOCT. The main outcome measure was the time for complete reepithelialization. Statistical analysis was performed using the Stata-14.0 program for Windows. Data were presented as mean ± standard deviation/median (minimum-maximum) and frequency percentage as applicable.Results:The surgery could be completed successfully in all cases and iOCT could provide real-time assessment of the depth of dissection during the entire procedure. The duration of complete healing and disintegration of amniotic membrane varied from 7 to 12 days. Recurrence was not seen in any case till 2 months follow-up.Conclusion:iOCT provides continuous monitoring of the depth of dissection and allows for a safe and complete debridement of the shield ulcer with plaque.

Essential oil of Cymbopogon citratus (lemongrass) and geraniol, but not citral, promote gastric healing activity in mice

Cymbopogon citratus, popularly known as lemongrass, is used for the treatment of gastric, nervous and hypertensive disorders, in addition to its use in the food and pharmaceutical industries. This study evaluated the gastroprotective and gastric healing effect of essential oil of C. citratus (EOCC), citral and geraniol at doses of 1–100 mg/kg (p.o) on acute ethanol-induced ulcer and chronic acetic acid-induced ulcer. Histological and histochemical evaluation was also performed, as well as the in vitro evaluation of the effects of these phytochemicals on H+/K+-ATPase activity. In the ethanol-induced gastric ulcer, the minimum effective oral dose of EOCC, citral and geraniol were 10, 100 and 3 mg/kg, reducing the ulcer area by 51.67%, 96.57% and 55.74%, respectively, compared to vehicle group (25.82 ± 3.59 mm2). Moreover, EOCC (10 mg/kg, p.o) and geraniol (3 mg/kg), but not citral (100 mg/kg), accelerated the gastric healing process by 34.52 and 80.57%, compared to acetic-acid ulcerated group treated with vehicle (36.04 ± 1.03 mm2). These healing effects were confirmed histologically by the contraction of the ulcer base and by the enhancement on mucin staining in slices of ulcer site from mice treated with EOCC or geraniol. Interestingly, EOCC and citral at 100 μg/ml inhibited the H+/ K+-ATPase activity by 28.26% and 44.36%, whereas geraniol did not change this parameter. Together, these findings confirm the gastroprotective and healing gastric ulcer effects of essential oil from aerial parts of C. citratus and added the information that geraniol, but not citral, promotes healing effects on installed ulcers.

Short-term efficacy of potassium-competitive acid blocker following gastric endoscopic submucosal dissection: a propensity score analysis

Background: Endoscopic submucosal dissection (ESD) is a promising method for the resection of superficial gastric neoplasms. Vonoprazan is a novel potassium-competitive acid blocker (P-CAB) that is currently considered as a potential alternative to proton pump inhibitors (PPIs) for the treatment of acid-related diseases. However, the utility of vonoprazan in ESD-related ulcers is unclear. Therefore, we compared the short-term efficacies of vonoprazan and the PPI lansoprazole in ESD-related ulcer healing during the first two weeks following intervention.Methods: This study included 115 superficial gastric neoplasms that were treated by ESD at Hiraka General Hospital between April 2015 and January 2017. Patients treated with P-CAB (20 mg vonoprazan, n = 62) or PPI (30 mg lansoprazole, n = 53) were compared using propensity-score matching analysis. Primary outcome was rate of ulcer reduction at two weeks after ESD. Secondary outcomes were coverage ratio of ulcer base by granulation tissue and incidence of postoperative bleeding.Results: The rate of ulcer reduction was significantly higher (median [range], 80.6% [67.6%–94.5%] vs. 62.7% [33.4%–85.2%]; p < .0001) and coverage ratio of the ulcer base by granulation tissue was significantly accelerated (median [range], 84.1% [67.7%–95.3%] vs. 61.9% [12.1%–90.1%]; P < 0.0001) in the P-CAB group compared with the PPI group. Postoperative bleeding was not observed in either group.Conclusions: P-CAB achieved rapid artificial ulcer healing with promotion of granulation tissue formation. However, conventional PPI with initial intravenous infusion might be sufficient for prevention of postoperative bleeding following gastric ESD.