Bleeding Gastric Ulcer Research Articles

A Case of Cardiopulmonary Arrest Due to a Hemorrhagic Gastric Ulcer That Could Be Saved by Transcatheter Arterial Embolization and Subsequent Multidisciplinary Treatment

A Case of Cardiopulmonary Arrest Due to a Hemorrhagic Gastric Ulcer That Could Be Saved by Transcatheter Arterial Embolization and Subsequent Multidisciplinary Treatment

Gastric Ulcer Bleeding associated with a Left Gastric Artery Pseudoaneurysm

A left gastric artery (LGA) pseudoaneurysm is known to occur as a complication of abdominal surgery, trauma, or pancreatitis. However, an LGA pseudoaneurysm presenting with gastrointestinal bleeding is rare. A 77-year-old man complained of dizziness and three episodes of melena in the last 24 hours. He did not have a history of surgery, trauma, or pancreatitis. He underwent primary coronary intervention for unstable angina and started dual antiplatelet therapy 1 month prior. Esophagogastroduodenoscopy (EGD) revealed a 3-cm ulcer in the lesser curvature of the gastric high body with a pulsating subepithelial tumor-like lesion in the ulcer. Hemostasis was achieved endoscopically. Three days after the endoscopic hemostasis, hematemesis and hypovolemic shock occurred. Emergent angiography of the superior mesenteric artery revealed an LGA pseudoaneurysm with extravasation. Coil embolization was successfully performed. Three days after the angiographic embolization, EGD revealed improvement of the gastric ulcer, which was covered with exudate, and disappearance of the subepithelial tumor-like lesion. At the 2-month follow-up, EGD showed that the ulcer was in the healing stage.

A case of Epstein Barr virus-associated primary squamous cell carcinoma of stomach

BackgroundPrimary squamous cell carcinoma (SCC) of stomach is extremely rare. The pathogenesis of SCC of stomach remains unclear. There is only one report that Epstein Barr virus (EBV) infection may be involved in the pathogenesis of SCC arising in the stomach ever before. Here, we report a case of Epstein Barr virus infection-associated primary SCC of stomach in a 70-year-old woman. She was presented to the referring hospital with hematemesis. Initial endoscopy revealed a bleeding gastric ulcer in the upper part of gastric corpus and the coagulation therapy was followed. After a 3-month follow-up, endoscopy revealed a submucosal tumor-like protrusion instead of an ulcer. Computed tomography revealed a mass in the upper part of stomach and swollen lymph nodes along with the lesser curvature and para-aortic lymph node. Biopsy could not confirm the definitive diagnosis. We performed total gastrectomy with para-aortic lymph node sampling. Histological analysis revealed squamous cell carcinoma with EBV infection with lymph node metastases. Tumor cells were positive for EBV-encoded small RNA (EBER) by in situ hybridization. The postoperative course was uneventful and the patient was discharged on day 11 after the operation. CapeOX was started as adjuvant chemotherapy, and the patient remains alive without recurrence 7 months after surgery.ConclusionThis is the first case report of EBV infection-associated primary SCC of the stomach diagnosed by in situ hybridization of EBER. EBV infection may be related to the pathogenesis of primary SCC. Further evidence and studies are required to establish optimal strategy for this rare disease.

DNA diagnostics for reliable and universal identification of Helicobacter pylori.

Reliable diagnostics are a major challenge for the detection and treatment of Helicobacter pylori (H. pylori) infection. Currently at the forefront are non-invasive urea breath test (UBT) and stool antigen test (SAT). Polymerase chain reaction (PCR) is not endorsed due to nonspecific primers and the threat of false-positives. The specificity of DNA amplification can be achieved by nested PCR (NPCR), which involves two rounds of PCR. If the primers are properly designed for the variable regions of the 16S rRNA gene, it is not difficult to develop an NPCR assay for the unambiguous identification of H. pylori. Elaborate NPCR for a 454 bp amplicon was validated on 81 clinical biopsy, stool, and saliva samples, each from the same individuals, and compared with available H. pylori assays, namely histology, rapid urease test, SAT, and 13C-UBT. The assay was much more sensitive than simple PCR, and it was equally sensitive in biopsy samples as the 13C-UBT test, which is considered the gold standard. In addition, it is sufficiently specific because sequencing of the PCR products exclusively confirmed the presence of H. pylori-specific DNA. However, due to the threshold and lower abundance, the sensitivity was much lower in amplifications from stool or saliva. Reliable detection in saliva also complicates the ability of H. pylori to survive in the oral cavity aside from and independent of the stomach. The reason for the lower sensitivity in stool is DNA degradation; therefore, a new NPCR assay was developed to obtain a shorter 148 bp 16S rRNA amplicon. The assay was validated on stool samples from 208 gastroenterological patients and compared to SAT results. Surprisingly, this NPCR revealed the presence of H. pylori in twice the number of samples as SAT, indicating that many patients are misdiagnosed, not treated by antibiotics, and their problems are interpreted as chronic. Thus, it is unclear how to properly diagnose H. pylori in practice. In the first approach, SAT or UBT is sufficient. If samples are negative, the 148 bp amplicon NPCR assay should be performed. If problems persist, patients should not be considered negative, but due to threshold H. pylori abundance, they should be periodically tested. The advantage of NPCR over UBT is that it can be used universally, including questionable samples taken from patients with achlorhydria, receiving proton pump inhibitors, antibiotics, bismuth compound, intestinal metaplasia, or gastric ulcer bleeding.

CD36 maintains the gastric mucosa and associates with gastric disease

The gastric epithelium is often exposed to injurious elements and failure of appropriate healing predisposes to ulcers, hemorrhage, and ultimately cancer. We examined the gastric function of CD36, a protein linked to disease and homeostasis. We used the tamoxifen model of gastric injury in mice null for Cd36 (Cd36−/−), with Cd36 deletion in parietal cells (PC-Cd36−/−) or in endothelial cells (EC-Cd36−/−). CD36 expresses on corpus ECs, on PC basolateral membranes, and in gastrin and ghrelin cells. Stomachs of Cd36−/− mice have altered gland organization and secretion, more fibronectin, and inflammation. Tissue respiration and mitochondrial efficiency are reduced. Phospholipids increased and triglycerides decreased. Mucosal repair after injury is impaired in Cd36−/− and EC-Cd36−/−, not in PC-Cd36−/− mice, and is due to defect of progenitor differentiation to PCs, not of progenitor proliferation or mature PC dysfunction. Relevance to humans is explored in the Vanderbilt BioVu using PrediXcan that links genetically-determined gene expression to clinical phenotypes, which associates low CD36 mRNA with gastritis, gastric ulcer, and gastro-intestinal hemorrhage. A CD36 variant predicted to disrupt an enhancer site associates (p < 10−17) to death from gastro-intestinal hemorrhage in the UK Biobank. The findings support role of CD36 in gastric tissue repair, and its deletion associated with chronic diseases that can predispose to malignancy.

Gastric acid-response chitosan/alginate/tilapia collagen peptide composite hydrogel: Protection effects on alcohol-induced gastric mucosal injury

Long-term excessive alcohol intake can easily lead to gastritis, gastric ulcer, and gastric bleeding. In this paper, the gastric acid-responsive hydrogel of CS-NAC/alginate/tilapia collagen peptide (CS-NAC/ALG/TCP) was developed. Its structure and properties were determined. The alcohol-induced gastric mucosal injury models in mice were established to evaluate the protective effects of CS-NAC/ALG/TCP. The results showed that CS-NAC/ALG/TCP was successfully fabricated, and it showed a sustained release of TCP, strong mucoadhesion, and excellent biodegradability in vitro. In the animal experiments, CS-NAC/ALG/TCP improved the oxidative stress status of the gastric mucosa by increasing the levels of SOD, GSH, and CAT in tissues. It also down-regulated the expression of MPO, TNF-α, IL-1β, and IL-6, and increased the production of gastric protective factors such as PGE2 and NO in mouse stomach, thereby reducing the alcohol-induced inflammation and protecting the gastric mucosal injury. Besides, CS-NAC/ALG/TCP can also increase the activities of alcohol metabolism enzymes to improve alcohol metabolism, thereby reducing alcoholic damage. In conclusion, CS-NAC/ALG/TCP is a promising candidate for the treatment of alcohol-induced gastric injury.

Diagnosis and Management of Benign Gastric and Duodenal Disease

The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy. This review contains 15 figures, 2 tables, and 43 references.

The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands

BackgroundSignificant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives.MethodsWe conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score.ResultsWe included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10).ConclusionHospitals were in general more likely to provide recommended care after first-time accreditation.

Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding

Objectives Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. Materials and methods Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. Results There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. Conclusions When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.

Comparison of Effectiveness of Minimum and Maximum Dose of Pantoprazole in the Treatment of Patients with Hemorrhagic Gastric Ulcer Referred to Ali-Ebn Abitaleb Hospital in Rafsanjan in 2016-2017: A Randomized Clinical Trial

Comparison of Effectiveness of Minimum and Maximum Dose of Pantoprazole in the Treatment of Patients with Hemorrhagic Gastric Ulcer Referred to Ali-Ebn Abitaleb Hospital in Rafsanjan in 2016-2017: A Randomized Clinical Trial

A case of diabetic ketoacidosis with hemorrhagic gastric ulcer.

This is a case of diabetic ketoacidosis with hemorrhagic gastric ulcer. Mortality rates increase when DKA is complicated with upper gastrointestinal bleeding, so it is important to consider this possibility.

Gastric ulcer bleeding in acquired hemophilia A patient and persistent inhibitor successfully treated with endoscopic methods of hemostasis

Gastric ulcer bleeding in an AHA patient with persistent inhibitor can be effectively stopped with endoscopic methods of hemostasis and appropriate dosing of rFVIIa. In the event of recurrent bleed-ing episodes the treatment should be repeated several times, in or-der to minimize indications to surgical treatment as far as possible. Surgery in AHA patients with persistent inhibitor must be avoid-ed due to the risk of uncontrolled fatal bleeding; it should only be undertaken in immediately life-threatening situations.&lt;/BR&gt; &lt;/BR&gt;

The American Society of Colon and Rectal Surgeons 2021 Annual Scientific Meeting Abstracts

Purpose/Background: Faecal immunochemical test (FIT) is widely adopted for the screening of colorectal cancer in the United Kingdom. At the start of the coronavirus pandemic we incorporated FIT testing into our department's urgent referral pathway for patients with suspected colorectal cancer. This aimed to triage those symptomatic patients who required urgent investigation and those who were unlikely to have significant colorectal pathology and therefore could have investigations delayed until it was safer and endoscopy services had recovered capacity. This study aimed to identify the diagnostic accuracy of FIT in this setting. Methods/Interventions: Patients referred to our institution under our urgent cancer referral pathway between 28th April and 19th June 2020 were identified from a prospectively kept database. FIT results were accessed from electronic laboratory records. Results were analysed using a threshold of 10ug/ml and the current screening threshold in England of 120ug/ml. Patient outcomes were determined by electronic patient records. Significant polyps included polyps greater than 10mm or meeting British Society of Gastroenterology high risk criteria. Results/Outcome(s): 373 patients were referred to the colorectal department during the study period. 24 referrals did not meet urgent referral criteria. 202 (54%) patients had FIT performed by their general practitioner and 47 (13%) patients had FIT undertaken in the colorectal clinic. In patients who had FIT, 97 (41%) patients had a FIT result less than 10ug/ml and 193 (81%) patients had FIT less than 120ug/ml. 25 (10%) patients were not investigated further based on FIT result and 16 (6%) patients declined further investigation. 13 (3%) patients in the cohort were subsequently investigated and diagnosed with a colorectal cancer (FIT range 24-8438ug/ml). One patient was diagnosed with a gastric cancer (FIT 259ug/ml) and two other patients had incidental findings of other nongastrointestinal cancers. 9 (4%) and 19 (8%) patients had significant colonic polyps and colitis respectively. Other diagnoses included bleeding gastric ulcer (2), angiodysplasia (1) and solitary rectal ulcer syndrome (1). In this symptomatic cohort, with a threshold of 10ug/ml the sensitivity of FIT was 100% and specificity of 36% for the diagnosis of colorectal cancer. At the 120ug/ml threshold the sensitivity was 77% and the specificity 81% for the diagnosis of colorectal cancer. Conclusions/Discussion: Incorporating FIT to triage symptomatic patients with symptoms suggestive of colorectal cancer is feasible with acceptable levels of diagnostic accuracy when utilizing a threshold of 10ug/ml. FIT testing will continue to be incorporated into our urgent cancer referral pathway, although general practitioners may still refer patients with a negative FIT but high clinical suspicion. Further work will continue to audit the use of FIT in this symptomatic setting.

The original scale prediction of recurrence risk of gastroduodenal ulcer bleeding

Research goal - to examine the effectiveness of active-individualized tactics in treatment of chronic gastric and duodenal ulcers. Material and methods. Analysis of treatment of 251 patients with chronic gastric and duodenal ulcer bleeding was conducted. Duodenal ulcer bleeding was present in 202 cases (80,5%), gastric ulcers were the reason of bleeding in 49 cases (19,5%). Treatment conducted according to principles of active-individualized tactics. Results. The provided characteristics and the acquired results were presented according to the fundamental components of active-individualized tactics in treatment of gastric and duodenal ulcers. Diagnostic and treatment abilities of endoscopy were determined, an unique scale of bleeding relapse risk was presented, the time limits and main indications for surgery were explained,, the role of bleeding relapse was emphasized as crucial in forming the main results of treatment of patients with bleeding gastric and duodenal ulcers. Conclusion. At present time, active-individualized tactics should be used for treatment of gastric and duodenal ulcer bleeding.

Innovative Endoscopic Technologies in the Complex Treatment of Patients with Unstable Stopped Gastroduodenal Bleeding

Background: The aim of our research was to improve the results of treatment of patients with unstable bleeding gastroduodenal ulcers (GDUs) through the use of innovative endoscopic technologies in the complex treatment of gastroduodenal bleeding (GDB). Methods and results: The study included 132 patients with unstable ulcerative GDB. Among all patients with GDB, there were 95(71.96%) men and 37(28.04%) women. The average age of patients was 56.1±18.45 years. Among the sources of gastroduodenal ulcer bleeding, duodenal ulcers complicated by bleeding predominated were observed in 77(58.3%) patients, bleeding gastric ulcers and ulcers of gastroenteroanastomosis areas in 49(37.7%) and 6(4.6%) patients, respectively. According to the endoscopic classification (J. Forrest, 1974), continued bleeding (Forrest Ia-Ib) was observed in 44(33.3%) patients, threat of rebleeding (Forrest IIa-IIb) in 88(66.7%) patients. All patients were divided, by random sampling, into two equivalent groups: the main group (MG, n=66) and the comparison group (CG, n=66). In the treatment of MG patients, an individual approach was applied that used the injection of ε-aminocaproic acid, argon-plasma coagulation, and the endoscopic pneumatic applications of hemostatic agents (Zhelplastan and the patient's platelet-rich auto-plasma) and granular sorbents (Aseptisorb-A, Aseptisorb-D). In CG, traditional methods of endoscopic hemostasis (injection method with ε-aminocaproic acid and vasoconstrictor drugs, argon plasma coagulation, etc.) were used without granular sorbents and innovative hemostatic agents. In patients with the Forrest Ia-Ib bleeding, primary EH was achieved in 95.2% of cases in the MG and in 91.3% of cases in the CG (P&gt;0.05). In patients with the Forrest IIa-IIb bleeding, effectiveness of endoscopic prevention of recurrent bleeding was achieved in 95.5% of cases in the MG and in 81.4% of cases in the CG (P=0.047). Mortality rate was 1.5% in the MG and 4.5% in the CG (P&gt;0.05). In the MG and CG, the overall frequency of recurrent bleeding from GDUs, the operational activity, and the length of hospital stay were 15.2% and 4.5% (P=0.041), 12.1% and 1.5% (P=0.033), and 11.1±0.6 days and 9.2±0.4 days (P&lt;0.01), respectively. Conclusion: The developed method for the complex treatment of patients with unstable GDB, based on the optimization of emergency and preventive endoscopic hemostasis, indicates that the use of therapeutic endoscopy to prevent bleeding recurrences with hemostatic agents and granular sorbents improves the reliability of endoscopic hemostasis, reduces the frequency of hemorrhage relapses and the number of emergency operations, as well as a length of hospital stay.

Pulse Pressure as a Predictor of Non-traumatic Hemorrhagic Shock in Cases with Acute Hemorrhagic Gastric Ulcers

Pulse Pressure as a Predictor of Non-traumatic Hemorrhagic Shock in Cases with Acute Hemorrhagic Gastric Ulcers

A case of hemorrhagic gastric ulcer treated by endoscopic hemostasis with IABO

A case of hemorrhagic gastric ulcer treated by endoscopic hemostasis with IABO

Diagnostic Value of Serum Gastrin and Epidermal Growth Factor to the Gastric Ulcer Complicated with Upper Gastrointestinal Hemorrhage.

To explore the predictive value of serum gastrin (GAS), epidermal growth factor (EGF) levels in gastric ulcer complicated with acute upper gastrointestinal bleeding. A descriptive study. Department of Emergency, Beijing Jiangong Hospital, China, from January 2019 to June 2020. One hundred and twenty-five patients with gastric ulcer and acute upper gastrointestinal bleeding were selected as Group A. One hundred and twenty-five patients with gastric ulcer and no upper gastrointestinal bleeding were selected as Group B. Logistic regression analysis was used to analyse the risk factors of gastric ulcer complicated with acute upper gastrointestinal bleeding. The value of serum GAS, EGF in early diagnosis of gastric ulcer with upper gastrointestinal bleeding was evaluated by receiver operating characteristic (ROC) curve. Univariate analysis showed statistically significant differences between Group A and Group B in taking non-steroidal anti-inflammatory drugs (NSAIDs), helicobacter pylori (Hp) infection, serum GAS and EGF (all p <0.001). Logistic regression analysis showed that raised serum GAS and serum EGF were independent risk factors for gastric ulcer and upper gastrointestinal bleeding (both p <0.001). The ROC area of serum EGF to predict gastric ulcer and acute upper gastrointestinal bleeding was 0.810 (95% CI: 0.753-0.867, p <0.001), greater than ROC area of serum GAS. At serum EGF of ≤109.95 pg/mL, had the 84.8%, sensitivity to predict gastric ulcer and acute upper gastrointestinal bleeding with specificity of 68.8%. The predictive value of serum GAS and EGF is high for gastric ulcer complicated with acute upper gastrointestinal bleeding; the predictive value of serum EGF is greater than that of serum GAS. Key Words: Gastric ulcer, Acute upper gastrointestinal bleeding, Serum, Gastrin (GAS), Epidermal growth factor (EGF), Logistic regression, Receiver operating characteristic (ROC) curve.

S2119 Upper Gastrointestinal Bleeding Caused by Iron Pill-Induced Gastric Ulcers

INTRODUCTION: The WHO reports that iron deficiency anemia (IDA) affects approximately 25% of the world's population. Iron supplementation via oral ferrous sulfate tablet is the most commonly prescribed treatment for IDA. It is known that high doses of oral iron can cause GI tract injury. However, it is not a common association at therapeutic doses of iron. CASE DESCRIPTION/METHODS: 75-year-old-male with PMH of afib on warfarin, CAD, CHF with preserved EF, aortic stenosis status post TAVR, and AV block status post pacemaker presented to ED with several days of epistaxis. Epistaxis ceased shortly after nasal packing. However, his hospital course was complicated by supratherapeutic INR and melena. Despite warfarin being held for a week, melena continued with down trending HgB, prompting EGD and colonoscopy. Initial endoscopy was unremarkable, and initial colonoscopy was poorly prepared revealing only copious blood and clots throughout. Even though bidirectional endoscopy was negative for active source, the patient continued to have dropping hemoglobin requiring 14 units of packed RBC. After 10 days the patient underwent repeat endoscopy, revealing multiple actively bleeding gastric fundus ulcers that were clipped. Fundic ulcers biopsies revealed features of iron pill-induced gastritis on iron staining. Patient's HbG stabilized status post EGD with clipping. DISCUSSION: Treatment for IDA is with oral iron supplements due to cost and efficacy. However, adverse outcomes, i.e. gastritis, can result due to iron oxidation. The level of gastritis seen here, is not seen at therapeutic dosages; making it easily missed in geriatric populations who have impaired gastric motility. Biopsy is the mainstay of diagnosis, and shows extracellular deposits of brown material. Liquid form of iron supplementation is much less toxic to the gastric mucosa and does not result in the injury to epithelium seen with iron tablets. This is thought to be because the liquid formulation cannot concentrate as easily into one site. Encouraging patients on iron pills to drink enough water with pill ingestion and avoid taking it at bedtime might reduce the risk of this problem. In conclusion, we recommend more studies in elderly populations with risk factors of impaired gastric motility for more conclusive results. In the meantime, it would be safer to prescribe these populations liquid iron supplementation.Figure 1.: Gastric mucosa biopsy with iron staining.

Natural history of upper and lower gastrointestinal bleeding in hemodialysis patients: A dual‐center long‐term cohort study

Knowledge on the risk of gastrointestinal (GI) bleeding in hemodialysis patients is limited. We evaluated the risk of GI bleeding in hemodialysis patients compared with non-hemodialysis patients. We performed a retrospective cohort study from 1996 to 2017 at the Graduate School of Medicine, University of Tokyo, and Horinouchi Hospital. We analyzed patients on hemodialysis for chronic renal failure and controls not on hemodialysis. The primary endpoint was GI bleeding. A survival analysis was performed to estimate the cumulative incidence and hazard ratio of GI bleeding. A total of 14451 patients were analyzed (417 hemodialysis and 14034 non-hemodialysis patients). In total, 524 GI bleeding events occurred. Upper and lower GI bleeding occurred in 432 and 92 patients in the hemodialysis and non-hemodialysis groups, respectively. The most frequent source of upper and lower GI bleeding was gastric ulcer and colonic diverticular bleeding, respectively. The cumulative incidence of GI bleeding was 4.44% at 1year, 7.15% at 3years, and 10.40% at 5years in hemodialysis patients; the respective rates were 2.35%, 2.98%, and 3.79% in non-hemodialysis patients during a mean follow-up period of 3.5years. Hemodialysis was significantly associated with an increased risk of GI bleeding after adjustment (hazard ratio 1.67, P=0.01, 95% confidence interval 1.13-2.50). Hemodialysis patients had a GI bleeding rate of 10% over 5years, and hemodialysis was a risk factor for GI bleeding.