Black Tarry Stools Research Articles

Dieulafoy lesion in the jejunum: a rare cause of massive gastrointestinal bleeding

ABSTRACT Dieulafoy lesions are tortuous vascular malformations characterized by thick walled submucosal arteries/large caliber arterioles protruding through a small mucosal defect surrounded by normal mucosa. They can occur in the jejunum/ileum and can cause massive, life-threatening GI bleeding. We present an 80-year-old female with three weeks of black tarry stools, progressive dyspnea on exertion and generalized body weakness with no significant findings on Esophagogastroduodenoscopy (EGD). Push enteroscopy revealed a Dieulafoy lesion in the proximal jejunum and an overlying clot, with oozing of blood noted after clot removal. The lesion was treated with Argon plasma coagulation (APC) and a post-APC fleshy protuberance was clipped to secure hemostasis. It is therefore important to keep a high index of suspicion for jejunal/ileal Dieulafoy lesions in patients with massive GI bleeding of unclear etiology on EGD/colonoscopy.

2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome

INTRODUCTION: Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease. CASE DESCRIPTION/METHODS: 87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization. DISCUSSION: Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.

2716 A Rare Case of Gastric Glomus Tumor

INTRODUCTION: Glomus tumors are benign mesenchymal neoplasms found predominantly in the extremities. Involvement of the GI tract is rare (<2%). Stomach is the most common site in GI tract.(1) Clinical presentation is usually nonspecific and diagnosis is made based on pathological study after surgical resection. We describe the case of a 35 year old male presenting with upper GI bleeding found to have glomus tumor during endoscopy. CASE DESCRIPTION/METHODS: A 35 years old male with past medical history of musculoskeletal low back pain, who was on meloxicam for past several weeks presented to the hospital with complaints of black tarry stool and lightheadedness. This was associated with weight loss. On examination, he was hemodynamically stable, was found to have pallor, there was no icterus. He had mild epigastric tenderness. Esophagogastroduodenoscopy (EGD) was done that showed moderate inflammation with edema, erythema, friability and granularity around the gastric body and the gastric antrum. It revealed a large submucosal non-circumferential mass in the gastric body with no bleeding and no stigmata of recent bleeding (Figure 1). Contrast enhanced CT scan was obtained that revealed a 3 cm enhancing soft tissue mass. Endoscopic ultrasound (EUS) showed an intramural lesion in the body of stomach that appeared to originate from within the muscularis propria (layer 4) (Figure 2). Fine-needle aspiration (FNA) was performed that was positive for neoplastic cells. He underwent laparoscopic resection of gastric mass (3 cm × 3 cm). Biopsies showed a basaloid proliferation of cytologically bland cells growing in nodules with focal areas of fibrosis, some tumor cells showed cytoplasmic clearing. Tumor cells were positive for smooth muscle actin, calponin, h-caldesmon, synaptophysin, desmin. Final diagnosis of glomus tumor of the stomach was made. DISCUSSION: Diagnosis of glomus tumor should be considered in a patient with gastric submucosal mass. The diagnosis is usually by pathology and immunohistochemistry (2). Most of the tumors are benign in nature, malignant changes are rare. They need long term follow up to look for recurrence.

2747 A Rare Case of Esophageal Squamous Cell Carcinoma With Intramural Gastric Metastasis

INTRODUCTION: Esophageal cancer makes up about 1% of all cancers diagnosed in the United States . Gastric metastasis from esophageal cancer is relatively rare. Four different types of metastatic mechanisms were reported: 1) via peri-gastric lymph nodes; 2) gastric intramural metastasis; 3) direct invasion of the gastric wall, and 4) intra-epithelial spread to the gastric epithelium . Here we present a case with intramural gastric metastasis in a patient with esophageal squamous cell carcinoma. CASE DESCRIPTION/METHODS: A 76-year-old Indian male with past medical history significant for idiopathic pulmonary fibrosis and coronary artery disease, recently started on aspirin and clopidogrel, presented with new onset fatigue and five days of black tarry stools. Hemoglobin (Hgb) on admission was 7.1 g/dL. Despite transfusion of one unit of packed red blood cells, repeat Hgb dropped to 6.6 g/dL. Emergent upper endoscopy was performed for suspected active gastrointestinal bleeding in the setting of blood thinner use. Endoscopy showed a 3 cm, non-bleeding, fungating and ulcerated mass in the middle third of the esophagus, as well as a 4-5 cm fungating, infiltrative and ulcerated gastric mass in the cardia with stigmata of recent bleeding (adherent clot) (see Figure 1). Removal of the clot revealed underlying oozing from the ulcer bed which was treated successfully with dilute epinephrine injection followed by hemostatic clip placement. Forceps biopsies of both the esophageal and cardia masses were obtained. Histopathology of both lesions revealed keratinized squamous cell carcinoma. CT of the chest, abdomen and pelvis showed no evidence of other metastatic disease. Oncology consultation was scheduled to discuss potential chemotherapy, radiation, and endoscopic interventions. DISCUSSION: Esophageal cancer with intramural gastric metastasis is very rare compared to other mechanisms of tumor spread. The prognosis is very poor with the mean survival time reported to be 8.6 months . Conventional chemotherapy or radiotherapy after surgery were ineffective in improving prognosis in current report, suggesting other techniques could provide a benefit when used adjunctively or in combination with more traditional approaches.

1967 Unexplained Massive Recurrent Upper GI Bleeding: A Case of Missed Connection

INTRODUCTION: Erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures leads to formation of Aortoenteric fistula (AEF). It occurs after months to years after aortic surgery and may be related to graft infection and can result in torrential Gl bleeding. Here we present a case of recurrent GI bleeding, the cause of which initially remained obscure despite repeated endoscopies. CASE DESCRIPTION/METHODS: 61 y old male with PMH of peripheral vascular disease and femoropopliteal bypass on ASA and Eliquis presented with 3 days of passing black-tarry stools and dizziness. Initial hemoglobin was 7 gm/dL (normal baseline). Urgent EGD up to 2nd part of duodenum revealed clot in the stomach without any lesion or source of bleeding. EGD was repeated the next day due to ongoing melena, which again was nonrevealing. CTA also did not show any active bleeding. Eliquis was discontinued and the patient was discharged. 2 days later, he presented with ongoing melena and dizziness. EGD, however, this time revealed aortic graft eroding into 3rd part of the duodenal wall. He was transferred to a tertiary care center for repair of the fistula. DISCUSSION: AEF is an uncommon but life-threatening complication of aortic reconstructive surgery. Due to the anatomic proximity, most cases involve the duodenum, with the proximal suture line of an aortic prosthesis. It is imperative to inquire about the history of aortic reconstruction patients presenting with Upper GI bleeding, as these patients are considered to have an AEF until proven otherwise. In our case, the remote history of aortic reconstructive surgery was not put in the clinical perspective and aortic graft was overlooked on the CT scan. Both MRI and CT can fail to diagnose AEF and EGD has 50% sensitivity. Endoscopy should include the fourth portion of the duodenum. Prompt recognition and repair of fistula in highly critical for patient survival.

Bernard Soulier Syndrome: Presenting As High-grade Fever In A Young Male

Bernard-Soulier syndrome (BSS) is a rare inherited disorder of blood clotting (coagulation). They may be life-threatening and demand immediate attention. Congenital bleeding disorders especially pose a diagnostic challenge to the clinician because of their rarity and the need to be differentiated from the other common causes of bleeding in children. We present a case of young male presenting with generalized weakness, high grade fever with chills, dry cough and black tarry stools (2-3 stools/day). No response to steroids and further evaluation by platelet, ADP, collegen, epinephrine and defective response to ristocetin led to the correct diagnosis – Bernard soulier syndrome (BSS). However, it is imperative to have arrived at correct diagnosis in order to save unnecessary therapy and to take due precautions for prevention of bleeding

Giant Brunner’s Gland Adenoma Presenting as Upper Gastrointestinal Bleeding in 76 Years Old Male: A Case Report

Brunner's gland adenoma is a rare benign tumor of small bowel, often incidentally discovered during endoscopy or radiological imaging. Mostly they are asymptomatic or often present with nonspecific symptoms such as nausea, vomiting, gastrointestinal hemorrhage, iron deficiency anemia. We reported a 76 years old male case presented with chief complaints of vomiting and black tarry stool. General physical examination was normal except mild tenderness over epigastrium. Esophagogastroduodenoscopy revealed a pedunculated polypoid tubular structure with blind end distally of length approximately 10-12* 3.5*1.5 cm in the second section of the duodenum with multiple skipped ulcers on the exposed surface of it. Additionally, there were few erosions in the duodenum proximally and multiple superficial ulcerations in the antrum, associated with helicobacter pylori confirmed by rapid urease test kit. Surgical or endoscopic excision is the treatment of choice. We consider our case is the eldest case among Brunner's gland adenoma case in literature. Keywords: Brunner's gland adenoma; Brunner's gland hamartoma; Brunner's gland hyperplasia; case report.

Aortoenteric Fistula with Duodenal Graft Material Migration Resulting in Gastrointestinal Bleeding

Introduction: Aortoenteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal tract. AEF is a rare but life-threatening condition that requires emergent intervention. It usually results from a compression of an abdominal aortic aneurysm (AAA) or after an aortic surgery. Case summary: A 78-year-old male with a history of abdominal aortic dissection status post repair and mechanical aortic valve on chronic warfarin, presented to the emergency department (ED) with upper abdominal and lower back pain, black tarry stool and one episode of hematochezia. While in the ED, he had an episode of hematemesis and was noted to be hypotensive, so he was admitted to the intensive care unit. A Computed tomography (CT) scan of the abdomen and pelvis with contrast showed a calcified aortic plaque with surrounding soft tissue thickening and abutting of the second part of the duodenum, concerning of abdominal aortic dissection without contrast leak (Figure 1). Gastroenterology team performed an emergent Esophagogastroduodenoscopy (EGD), which showed blood in the fundus and an ulcer like lesion in the third portion of the duodenum with a graft material concerning for aorto-enteric fistula (Figure 2). Vascular surgery took the patient emergently to the operating room and performed an endovascular abdominal aortic aneurysm repair to control the acute bleeding. The plan was to do a definitive repair of the aorta and the aortoenteric fistula once he is more stable. Two days later the patient underwent removal of the aortic graft, duodenal diverticulectomy and duodenotomy repair, and replacement of abdominal aortic graft with HEMASHIELD?graft. The graft was found to be infected, so infectious disease team recommended discharging him home on intravenous IV antibiotics for 6 weeks. On follow up the patient was recovering well without any further GI bleeding. Discussion: Aortoenteric fistulae are uncommon but associated with high mortality. It should be considered in the differential diagnosis of upper gastrointestinal bleeding, especially in patients who have an aortic aneurysm or had a repair of an aortic disease.2996_A Figure 1. A: CT scan of the abdomen and pelvis showing calcified aortic plaques, B: CT scan of the abdomen and pelvis showing aotoenteric fistula.2996_B Figure 2. A: An EGD showing blood in the fundus, B: EGD showing an ulcer in the third part of the duodenum with graft material.

Hepatocelluar Carcinoma Invading the Gallbladder - A Rare Cause of Hemobilia

Bleeding from the hepatobiliary tract (hemobilia) is a rare cause of acute upper GI bleed. It should be considered in any patient with recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a rare case of hemobilia due to hepatocellular carcinoma (HCC) invading the gall bladder wall. A 52- year old female with Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical examination was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (Fig A). She was aggressively transfused multiple blood products, placed on a proton pump inhibitor and started on octreotide. An emergent EGD was performed which identified blood oozing from the ampulla of vater; consistent with a diagnosis of hemobilia (Fig B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gall bladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with unknown exact incidence. Traumatic etiology accounts for 40-80 percent of all cases. In patients with HCC, invasion into the blood vessels is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-biliary duct invasion. 21 percent developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with quinke's Triad: acute upper GI bleed (100 percent), biliary colic (70 percent) and jaundice (60 percent). Diagnosis is by visualizing blood from the Ampulla of vater via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95 percent). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25 percent.1950_A Figure 1. A 3.1 cm oval shaped arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity of the gall bladder.1950_B Figure 2. EGD oozing from the ampulla of vater (A) and showing blood oozing within the second part of the duodenum (B).

Alcoholic Liver Cirrhosis in Young Female: Diagnostic and Therapeutic Challenge

Alcoholic liver cirrhosis is a disease due to excessive alcohol consumption that manifest as fatty liver, alcoholic hepatitis, and chronic hepatitis with fibrosis or liver cirrhosis. Alcohol consumption as much as 60-80 g per day for 20 years or more in male, or 20 g/day (approximately 25 mL/day) in female significantly increases the risk of hepatitis and fibrosis as much as 7-47%. The aim of this case report was to explore the diagnostic and therapeutic challenge of alcoholic liver disease in young aged female. A female, 24 years old, came with complaints of bloody vomiting, blacktarry stool, abdominal distention and history of alcohol consumption (canned beer 5%, equal to 56-70 g/day) for 9 years. Physical examination revealed anaemic conjunctiva (Hb 2.9 g/dL), ascites, hepatosplenomegaly, and bilateral legs oedema. Laboratory examinations showed thrombocytopenia (125000/uL) and hypalbuminaemia (2.65 gr/dL). AST and ALP were increased with the value of 175 U/L and 456 U/L, respectively. Albumin-globulin ratio was 0.93 g/dL with serum ascites albumin-gradient was 2.20 g/dL (ascites fluid albumin level was 0.45 gr/dL and serum albumin level was 2.65 gr/dL). Abdominal USG revealed hepatomegaly with coarse heterogenic ecoparenchyma, portal vein dilatation, and splenomegaly. Diagnosis of alcoholic liver cirrhosis was made based on clinical, laboratory, and radiologic findings, while biopsy result did not confirm the pathology. Patients condition improved with education of stop alcohol consumption and was given supportive therapy.

Case 1: Hemoptysis, Hypoxia, and Anemia in a 10-year-old Girl

1. Tony Tarchichi, MD* 2. Kathryn Lupo, MD* 1. *Diagnostic Referral Group, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA A 10-year-old premenarchal girl with a history of chromosome 16 short arm duplication, seizures, and global developmental delay is transferred to us from another hospital for evaluation of new-onset severe anemia, hypoxia, and hemoptysis. At an outside hospital, her heart rate was 140 beats/min, blood pressure was 160/80 mm Hg, and oxygen saturation level was 88% on room air (100% on nonrebreather oxygen supplementation), and she was afebrile. There was no obvious bleeding source on examination. Laboratory evaluation revealed a hemoglobin level of 6.4 g/dL (64 g/L) compared with 13.2 g/dL (132 g/L) 3 years earlier. Chest radiography revealed bilateral diffuse infiltrates. She was transferred to our hospital. On admission to our hospital, the patient’s mother reports that the patient is acting more aggressive than usual and appears pale. Two weeks before admission she had a brief episode of mild upper respiratory tract symptoms without fever. The review of systems is otherwise negative, including no history of weight loss, hematochezia, black tarry stool, epistaxis, bruising/bleeding, scleral icterus, jaundice, or hematuria. Vital signs on hospital admission are as follows: temperature, 98.8°F (37.1°C); heart rate, 98 to 137 beats/min; respiratory rate, 22 to 36 breaths/min; and blood pressure, 96 to 120/47 to 89 mm Hg. Her oxygen saturation level is 80% on room air and increases to 100% on 100% nonrebreather mask. She is not …

Acute Upper Gastrointestinal Bleeding: Think Outside the Ampulla

Bleeding from the hepatobiliary tract (hemobilia), is a rare cause of an acute upper GI bleed. It should be considered in any patient with a recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a case of hemobilia due to hepatocellular carcinoma (HCC) invading the gallbladder wall.Figure. 3: 1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity to the gallbladder.Figure: EGD demonstrating blood oozing within the 2nd portion on the duodenum (A) and oozing from the Ampulla of Vater (B).A 52 year-old female with PMHx of Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical exam was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (fig. A). She was aggressively transfused multiple blood products and placed on a proton pump inhibitor and octreotide drip. An emergent EGD was performed which identified blood oozing from the Ampulla of Vader; consistent with a diagnosis of hemobilia (fig. B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gallbladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with an unknown exact incidence. Traumatic etiology accounts for 40 - 80 percent of all cases. In patients with HCC, invasion into the blood vessels (most commonly portal vein) is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-bile duct invasion. 21% developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with Quincke's triad: acute upper GI bleed (100%), biliary colic (70%) and jaundice (60%). Diagnosis is by visualizing blood from the Ampulla of Vader via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95%). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25%.

Primary Gastric Leiomyosarcoma: A Rare Entity

Introduction: In the post c-KIT era, true smooth muscle neoplasms of GI tract have received little attention and are an extremely rare tumor. Here we report a case of primary gastric leiomyosarcoma (LMS) in an adult presenting with anemia. Case Report: A 54-year-old Caucasian male with past medical history of interstitial lung disease presented to the hospital for evaluation of lighheadness and multiple episodes of black tarry stool. On examination, patient's stool was guaiac positive with positive orthostatic vital signs. Patient underwent EGD which revealed a 3 cm bull's eye lesion in mid-gastric body with central depression (Fig 1). Endoscopic ultrasound showed a16 mm hypoechoic lesion in mid-gastric body, appeared to be arising from muscularis propria without any lymphadenopathy. Pathologic examination classified the tumor as LMS grade 2 of 3 based on immunohistochemical staining (negative c-Kit and DOG-1, positive desmin and actin), confirmed by 2 pathologists at different institutions (Fig 2). Patient underwent computed tomography and PET scan, which was negative for any metastasis and showed only positive uptake in mid-gastric body. On repeat EGD, his lesion has grown in size to 3 cm and appeared to invade serosa. At that point, surgical resection was undertaken and patient underwent partial gastrectomy with frozen section showing clear margins. The patient had uneventful recovery.Figure: EGD showing Bull'e eye like lesion in mid-gastric body.Figure: Immunohistochemical staining showing positivity for Actin (A), Desmin (B) in sheets of spindle cell (C).Discussion: LMS of the gastrointestinal (GI) tract are rare entity in the post-GIST era since c-kit was described in 1998 representing only 1% of true smooth muscle neoplasm of the GI tract. There are approximately 100 reported cases of GI LMS, with small intestine being the commonest site and stomach being the least common site. There are only 10 reported cases of gastric leiomyosarcoma in post-GIST era. The median age of gastric LMS is 37 years with males (70%) more commonly affected than females (30%). The most common reported symptom was GI bleeding, followed by abdominal pain, weight loss, and gastroesophageal reflux. The mean tumor size is 6.45 cm +/- 3. GISTs are positive for CD-117 and CD-34, which are negative in LMS. Moreover, LMS are positive for vimentin, smooth muscle actin and desmin. There is no consensus on treatment of LMS as they are rarely encountered. Our patient's LMS grew from 16mm to 30 mm within a month, demonstrating the aggressiveness of the tumor. Complete surgical resection with negative margins remains the gold standard treatment.

Gastric Metastasis from Clear Cell Renal Cell Carcinoma Presenting with Gastrointestinal Bleeding: A Case Report

Introduction: Renal cell carcinoma (RCC) is the most common cancer originating from the kidney, it is responsible for 80 to 85 % of all primary renal neoplasms. The most common sites of metastasis include lungs, bones, liver, and brain. However, Gastric metastases from RCC are exceedingly. Hematogenous metastases to the stomach in general are rare with incidence in autopsy 0.2-9%. Breast cancer, malignant melanoma and lung cancer as the most common cancers metastasizing to the stomach. There are only few cases in literature of RCC gastric metastasis, most of them are of clear cell type. It can be diagnosed even many years after removal of the primary cancer which indicates slow growing potential. Case report: 67-year-old male patient with past medical history of polycystic kidney disease, live donor renal transplant in 2002, and metastatic left sided renal cell carcinoma treated with radical nephrectomy and resection of pulmonary metastasis in 2014. He presented with multiple episodes of black tarry stool for the last 2 days. He was on aspirin and ticagrelor. Initial laboratory workup showed Hemoglobin 8.8 g/dl; platelet count 344*1000/cmm; and INR 1.2. The patient was admitted for stabilization and further evaluation of gastrointestinal bleeding. The patient was started on pantoprazole infusion and ordered 2 units of PRBCs. His aspirin and ticagrelor were held. Esophagogastroduodenoscopy (EGD) showed a 2.5 to 3.0 cm polypoid mass in the gastric fundus. The polyp was 90% removed with a polypectomy snare and cautery. Bleeding occurred after the procedure and hemostasis was achieved by local epinephrine injection, and application two Cook hemostasis clips. Histologic examination demonstrates tumor composed of nests and fascicles of cells with abundant clear cytoplasm and moderately pleomorphic nuclei with prominent eosinophilic nucleoli. Immunohistochemical staining was most consistent with metastatic clear cell renal cell carcinoma, and it was comparable with right lung biopsy resected in 2014.Figure 1Conclusion: Gastric involvement in renal cell carcinoma is rare even-though it's reported. The possibility of gastrointestinal involvement should always be considered in any patient with history of cancer who presents with gastrointestinal symptoms. Immunohistochemistry is also very useful in the diagnostic workup and in many cases it is possible to make a diagnosis in the absence of access to the primary tumor.Figure 2

Iron deficiency anemia with mucocutaneous lesions

A 56-year-old man presented with fatigue and exertional dyspnea for 2 weeks, and few episodes of black tarry stools over the last 1 month. The patient endorsed recurrent episodes of epistaxis since his mid-20s and intermittent black tarry stools for several years. Family history was remarkable for similar problems in his father and brother. On physical examination, the patient had tachycardia, pallor, and mucosal and skin lesions shown in Fig. 1. Laboratory studies revealed a hemoglobin of 5.8 g/dL, mean corpuscular volume of 69 fL, and a serum iron profile consistent with iron deficiency. Platelet count and coagulation studies were normal.

Risk factors for deferral due to low hematocrit and iron depletion among prospective blood donors in a Brazilian center.

ObjectiveDeferral of blood donors due to low hematocrit and iron depletion is commonly reported in blood banks worldwide. This study evaluated the risk factors for low hematocrit and iron depletion among prospective blood donors in a large Brazilian blood center.MethodA case–control study of 400 deferred donors due to low hematocrit and 456 eligible whole blood donors was conducted between 2009 and 2011. Participants were interviewed about selected risk factors for anemia, and additional laboratory tests, including serum ferritin, were performed. Bivariate and multivariate analyses were performed to assess the association between predictors and deferral due to low hematocrit in the studied population and iron depletion in women.ResultsDonors taking aspirins or iron supplementation, those who reported stomachache, black tarry stools or hematochezia, and women having more than one menstrual period/month were more likely to be deferred. Risk factors for iron depletion were repeat donation and being deferred at the hematocrit screening. Smoking and lack of menstruation were protective against iron depletion.ConclusionThis study found some unusual risk factors related to gastrointestinal losses that were associated with deferral of donors due to low hematocrit. Knowledge of the risk factors can help blood banks design algorithms to improve donor notification and referral.

Prophylaxis and treatment of antibiotic-associated diarrhea: is there evidence for using probiotics?

A 66-year-old woman with a history of liver cirrhosis and alcohol abuse presented with hematemesis and black tarry stools secondary to a variceal bleed. The patient was started on ceftriaxone for prophylaxis of spontaneous bacterial peritonitis and subsequently developed Clostridium difficile negative antibioticassociated diarrhea (AAD). Are probiotics an appropriate adjunct to therapeutic regimens for AAD and could prophylactic use of probiotics have prevented this complication?

Empedobacter brevis Bacteremia in a Patient Infected with HIV: Case Report and Review of Literature.

Clinical disease caused by Empedobacter brevis (E. brevis) is very rare. We report the first case of E. brevis bacteremia in a patient with HIV and review the current literature. A 69-year-old man with human immunodeficiency virus (HIV) and CD4 count of 319 presented with chief complaints of black tarry stools, nausea and vomiting for 2 days. Physical exam was significant for abdominal pain on palpation with no rebound or guarding. His total leukocyte count was 32,000 cells/μL with 82% neutrophils and 9% bands. Emergent colonoscopy and endoscopic esophagogastroduodenoscopy showed esophageal candidiasis, a nonbleeding gastric ulcer, and diverticulosis. Blood cultures drawn on days 1, 2, and 3 of hospitalization grew E. brevis. Patient improved with intravenous antibiotics. This case is unusual, raising the possibility of gastrointestinal colonization as a source of the patient's bacteremia. In conclusion, E. brevis is an emerging pathogen that can cause serious health care associated infections.

Unusual Cause of Upper GI Bleed in a Patient With Lung Cancer

Question: A 60-year-old man presented with anemia and black tarry stools, off and on for the last 2 months. He had metastatic non–small-cell lung cancer with metastasis to the liver and spleen. He underwent a left upper lobectomy followed by recent chemotherapy. Physical examination revealed normal vital signs and splenomegaly. Laboratory results showed a drop in hemoglobin from 9.5 to 7.8 g/dL. Esophagogastroduodenoscopy (EGD) revealed a 1.5-cm ulcer in the fundus of the stomach (Figure A). There was no sign of recent bleeding at the ulcer site. Biopsy specimen was taken from the ulcer edges (Figure B). Based on the EGD and pathology, a computed tomography (CT) was performed (Figure C). Based on the image findings, what is your diagnosis and how would you manage the condition? Look on page 288 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. EGD showed a large ulcer in the fundus of the stomach with heaped edges and necrotic base suspicious of malignancy (Figure A). Biopsy from the ulcer (Figure B) showed metastatic squamous cells (arrows) invading into gastric mucosa consistent with metastatic lung cancer. Follow-up CT (Figure C) showed multifocal areas of air within the spleen (arrows) and oral contrast extravasating the stomach into spleen (arrow head) suggestive of a gastrosplenic fistula (GSF). GSF was first described in 1962 by De Scoville et al1De Scoville A. Bovy P. Demeester P. “Aerosplenomegalie” radiologique par lymphocarcome splenique necrosant a double fistulation dans le tube digestif.Acta Gastroenterol Belg. 1967; 30: 841-847Google Scholar as “aero-splenomegaly,” characterized by air in the splenic parenchyma in association with splenomegaly. GSF is an unusual complication of gastric or splenic neoplasms. Cases of GSF associated with splenic abscess,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar Crohn’s disease,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar and trauma3Nikolaidis N. Giouleme O. Gkisakis D. et al.Posttraumatic splenic abscess with gastrosplenic fistula.Gastrointest Endosc. 2005; 61: 771-772Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar have been described. Among the neoplasms, lymphomas are the commonest cause,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar either owing to spontaneous invasion or post chemotherapy regression. To our knowledge, we have described the first case of a GSF associated with lung cancer with metastasis to the spleen. The gastrosplenic ligament facilitates the communication of the 2 anatomically close organs. The fistula forms as a result of tumor growth and spread, tumor necrosis by chemotherapy as in our case, or infection. Bleeding can result from erosion of splenic artery. CT visualization of the fistulous tract or antegrade filling of the splenic cavity by orally administered contrast is diagnostic. Air in the spleen is indicative of GSF, but abscess should be ruled out.2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar Gastroscopy may visualize the fistula opening, and may help to establish the diagnosis by tissue sampling as in our case. Treatment of GSF depends on the etiology with surgery being the mainstay of treatment involving splenectomy, partial gastrectomy, and/or distal pancreatectomy.3Nikolaidis N. Giouleme O. Gkisakis D. et al.Posttraumatic splenic abscess with gastrosplenic fistula.Gastrointest Endosc. 2005; 61: 771-772Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Our patient underwent open splenectomy, partial gastrectomy and distal pancreatectomy. He did well postoperatively and his GI bleed resolved. He is being considered for further chemotherapy.

An Unusual Cause of Upper Gastrointestinal Bleeding

36-year-old man was admitted after a single Aepisode of hematemesis and 2-day history of black tarry stools, dizziness, and sweats. He was afebrile and denied abdominal pain. Laboratory results were significant only for mild anemia (hemoglobin, 12.3 gm/dL). Coagulation laboratory results were normal. The patient underwent esophagogastroduodenoscopy where a large, broad-based mass with mucosal ulceration was identified in the gastric body (Figure A, B). Subsequent endoscopic ultrasound confirmed a 5.5-cm hyperechoic, submucosal mass (Figure C, arrow). Endoscopic biopsies and ultrasound-guided fine-needle aspiration were inconclusive, consisting solely of bland spindle cells and ulcer bed. The patient opted for removal of the mass through laparoscopic partial gastrectomy. The surgical pathology diagnosis of the resection specimen was gastric calcifying fibrous tumor (Figure D, H&E). Immunohistochemical staining, specifically S-100, CD34, DOG-1, C-Kit, desmin, and ALK, were all negative. Calcifying fibrous tumor (CFT) is a rare, benign mesenchymal tumor. It was originally described by Rosenthal and Abdul-Karim in 1988 as childhood fibrous tumor with psammoma bodies because the tumor is composed of dense, eosinophilic, hyalinized fibrous tissue admixed with bland fibroblastic spindle cells, scattered psammomatous and/or dystrophic calcifications, and a variable mononuclear lymphocytic infiltrate. CFT was originally described in soft tissues of children and young adults but is now known to have a wide anatomic distribution. It is rare in the gastrointestinal tract, with only 13 gastric and 3 intestinal cases documented to date. Within the gastric cases including our own, there were 8 men and 6 women with a mean age of 52 years and mean tumor size of 2.1 cm. On ultrasound, the lesion tends to be isoechoic, with hyperechoic foci and acoustic shadowing corresponding to the calcifications. Although this is not entirely clear, CFTs are thought to be a reactive process caused by abnormal tissue repair. However, because local recurrences of CFT are documented, this lesion is best classified as a CFT rather than its former designation of a pseudotumor. Recurrence has not been documented in the largest gastric case series to date. CFT has morphologic overlap with other spindle cell tumors, namely gastrointestinal stromal tumor. Both can arise in the posterior stomach wall with varying involvement of the muscularis propria. However, their immunohistochemical profiles are distinctly different. CFT does not express C-Kit, DOG-1, or CD34. Desmoids, inflammatory myofibroblastic tumors, and gastric schwannomas are also diagnostic considerations, but again, immunohistochemistry can be used to exclude these diagnoses.