Case Of Ulcer Research Articles

A Rare Case of Transesophageal Echocardiography Probe-Induced Tongue Ulcer

AbstractTransesophageal echocardiography (TEE) is a commonly used diagnostic and monitoring modality in anesthetic practice. It is used in neurosurgery for monitoring cardiac function and detecting venous air embolism. TEE is a semi-invasive procedure and is considered to be reasonably safe with a few complications. During neurosurgical cases, access to the head end is limited and TEE can cause injury due to prolonged contact. These injuries can be noticed only at the conclusion of the surgery. We report a rare case of tongue ulcer caused due to the use of TEE in a sitting neurosurgical procedure with a complete resolution.

Decreased xCT activity in patients associated with Helicobacter pylori infection.

Objective: In animals, Helicobacter pylori (Hp)-induced gastric injury is accompanied by a decrease in the activity of the cysteine/glutamate transporter (xCT), which regulates extracellular glutamate levels. However, the impact of xCT activity in patients with Hp infection remains unclear. This study aims to investigate variations of xCT activity in the gastric mucosa of patients with Hp infection and to provide a clinical basis for identifying targets related to Hp infection. Methods: Our study included a total of 67 patients with gastritis, which consisted of 44 Hp-negative and 23 Hp-positive peptic ulcer cases. The inclusion criteria used to select patients were as follows: gastric histology was determined with a gastroscope, antral biopsies were taken for urease tests, and pathology and culture were performed for analysis of Hp-colonization. The clinical characteristics of the patients were obtained, the expressions of microRNAs and xCT protein were detected using immune histochemical analysis, and the concentration of glutamate in their gastric secretion was determined. Results: The findings revealed that xCT expression was significantly lower in Hp-positive patients as compared to Hp-negative individuals, which was accompanied by a decrease in glutamate concentration in gastric juice. We also discovered a high expression of microRNAs that have been shown to negatively regulate xCT expression, in Hp-positive patients. Conclusion: Reduced xCT activity in patients may play an important role in gastric ulcers caused by Hp infection. Our findings suggest that the microRNA/xCT pathway could be a potential treatment target for Hp-infection-related ulcers.

A retrospective observational study of mycotic keratitis in Saveetha Hospitals, Chennai

Aim and objective: 1. To study the manifestations of fungal corneal ulcer in different age groups and sex 2. To study the distribution of fungal corneal ulcer in relation to occupation 3. To know the effect of Natamycin and Fluconazole as anti-fungal agents. Materials and methods: This is a retrospective analysis of microbiology records of patients presenting with suspected microbial keratitis seen between January 2021 and June 2021. Patients with positive fungal cultures were analyzed in detail for the type of fungus isolated. Results: 90 patients with suspected microbial keratitis were reviewed. A microbiological diagnosis of mycotic keratitis was established 9 (10%) patients over a period of 6 months, based on positive fungal cultures. Filamentous fungi were isolated more often than yeasts. Aspergillus species followed by Fusarium species were the commonest filamentous fungi isolated. Conclusion: Over a period of 6 months, the cumulative incidence of mycotic keratitis was 10%. The pathogenic organisms most frequently responsible for mycotic keratitis were Aspergillus species. When beginning an empirical therapy for mycotic keratitis, etiological factors were helpful. Eight of the 90 patients with corneal ulcers who were admitted to the patient department for treatment had positive fungal cultures in Sabouraud’s media. The age range of 50 to 60 years had a high prevalence of illness. There were 90 total cases of corneal ulcers. Out of those there were 8 (8.8%) incidences of fungal ulcers. More men than women were impacted. Workers in agriculture are more impacted than others. The main cause of a fungus-induced corneal ulcer was trauma. Natamycin was the better option for the treatment of fungal keratitis. Filamentous fungi (Aspergillus species, fusarium, and curvularia) responded effectively to Natamycin 5% eyedrop.

Physicochemical Quality and Health Risks Associated with Use of Water from Nyamwamba River, Kasese, Western Uganda

Aim: In Kasese district of Western Uganda, farmers cultivating near Nyamwamba River (NR) experience crop wilting whenever the river banks burst. Increased cases of cancer and ulcers in the district is anecdotally blamed on ingestion of contaminated water from water resources polluted by tailings from Kilembe copper mines. Sand miners attested that mining in NR caused body irritations and itching while drinking water from the same river results in abdominal complications in infants. The aim of this study was to assess the seasonal variations in the physicochemical parameters and heavy metals (HMs) content of water from NR, and the associated health risks.
 Place and Duration of Study: The experiments were done at the Department of Chemistry, Faculty of Science, Mbarara University of Science and Technology, Uganda from 2018 to 2019.
 Methodology: This study employed quantitative research design. Water was sampled from down, middle and upstream of NR and Mubuku River, Western Uganda during the dry and wet seasons. The samples were analyzed for physicochemical parameters (pH, conductivity, total dissolved solids, total suspended soils) and HMs: chromium (Cr), cadmium (Cd), zinc (Zn), iron (Fe), lead (Pb), arsenic (As) and copper (Cu) by atomic absorption spectrometry. The estimated daily intake (EDI), target harzard quotient (THQ) and cancer risks were calculated to explore if there are any carcinogenic and non-carcinogenic health risks that could arise from ingestion and dermal contact with water from NR.
 Results: Most physicochemical parameters of the water samples only met WHO guidelines for drinking water in the upstream. The mean concentration of Fe, Cu, Pb, Zn, Cr, Cd and As were 0.90-29.66 mg/L, 0.21-10.74 mg/L, 0.40-8.21 mg/L, 1.10-13.47 mg/L, 0.79-13.47 mg/L, 0.05-1.40 mg/L and 0.22-4.34 mg/L, respectively. Wet season recorded higher HMs concentrations when compared to the dry season, with all its samples exceeding the WHO guidelines for drinking water. There was an extremely high concentration of HMs in the upstream samples than expected. Health risk assessment indicated that the EDI through dermal contact ranged from 0.015 to 4.150 mg/kg/day while through ingestion of contaminated water, the values ranged from 0.008 × 10-6 to 38.266 × 10-6 mg/Lday. Some of the EDI doses were higher than corresponding reference doses for ingestion and contact with the HMs in water. THQ and total THQ exceeded 1 while cancer risk values were beyond the US EPA cancer risk borderline.
 Conclusion: This study revealed that there are serious non-carcinogenic and carcinogenic health risks that could arise from consumption and contact with water from NR. Future studies should examine the relationship between the occurrence of trace metals in food stuffs with cancer, ulcers and other associated diseases in the area.

Helicobacter Pylori Infection among Patients Attending the Gastroenterology Department in Tertiary Care Hospital, Kathmandu, Nepal.

Helicobacter pylori is one of the most pathogenic organisms that cause gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue (MALT) lymphoma in humans. The main aim of this study was to determine the H. pylori infection among patients undergoing upper GI endoscopy and to compare the efficacy of the diagnostic method of H. pylori infection including invasive tests (biopsy-based tests like the rapid urease test (RUT), direct smear, and culture) and the noninvasive test (HpSA). A total of 100 stool samples and 200 gastric biopsy specimens were collected (2 samples from each patient) from June to November 2019. Stool samples were processed for the detection of an H. pylori stool antigen (HpSA) by a kit method. One biopsy specimen was processed for the RUT, and another was transported to the laboratory in an Eppendorf tube containing normal saline for preparation of the smear and culture. Out of 100 participants, 26% were found to be H. pylori positive by the RUT, 11% by the direct smear, 6% by the culture, and 17% by the stool antigen test. The prevalence of H. pylori infection was found to be 14%, considering at least two of the three biopsy-based tests that gave positive results. H. pylori infection was found to be higher in the age group of 46-55 years. The overall prevalence of H. pylori infection was higher in gastric ulcer cases, followed by erosive pangastritis and gastroduodenitis. Tea drinking habits and the frequency of meal consumption more than twice a day were found to be significantly associated with H. pylori infection (P < 0.05). Hence, the RUT was found to be more efficient than the direct smear and the culture method for finding H. pylori in the biopsy sample. However, none of these methods can be considered to be the gold standard alone. Thus, the RUT combined with other tests is preferable for the detection of H. pylori.

Nonhealing exuberant red ulcers on the genitalia in an immunocompromised patient

We report a case of atypical exuberant ulcers on the genitals, groin and lower abdomen in an HIV-positive patient. Histopathology of the lesion revealed hyperkeratosis, acanthosis and intraepidermal bulla formation.

TUBERCULAR ULCER ORAL CAVITY MIMICKING MALIGNANCY-WONDER FACE BEHIND MASK.

Oral tuberculosis (TB), a chronic inammatory disease, can manifest as oral ulceration and mucosal erythema. This article presents a case of an oral ulcer on the right side's palatal area. Clinicians must be aware of TB while assessing a differential diagnosis for oral ulcers. A delayed diagnosis might have serious consequences for the patient.

Analysis of immunologic comorbidities in ulcerative colitis patients: a tool to prevent exacerbations in ulcerative colitis cases.

There have been previous studies, especially in Western countries and even in some areas in Asia, about extra-intestinal manifestations (EIMs) and its link with the outcome of inflammatory bowel disease (IBD), which includes Crohn's disease (CD), and ulcerative colitis (UC). This link is crucial when discussing a patient's prognosis and important when dealing with UC management. The aim of this study was to clarify the most common comorbidities associated with UC, emphasizing immunologic comorbidities in Japan. This study was a retrospective analysis performed at Nagoya University Hospital. The data collection started in March, 2019, and continued for two years. We retrieved the medical records of 105 patients with UC diagnosis, from which the data of 176 EIMs were extracted and analyzed. Results showed that EIMs with UC in the active phase accounted for 43.7% of total EIMs. Twenty-six patients with immune-mediated inflammatory disease frequently had an active phase (odds ratio [OR] 3.84, 99% CI, 1.44-10.27). Comorbidities showing an active manifestation of symptoms and UC in the active phase were significantly correlated in patients with immunological comorbidities, such as peripheral arthritis (r = 0.97, p < 0.01) and rheumatoid arthritis (RA) (r = 0.99, p < 0.01), as well as in patients with primary sclerosis cholangitis (PSC) (r = 0.98, p < 0.01). In conclusion, this analysis suggests the importance of having full comprehension of how immunological comorbidities affect the natural development of UC, which is of vital importance to prevent further UC complications and properly adjust the management of the disease.

Utilising community volunteers can increase the detection and referral of Buruli ulcer cases in endemic communities in Southeast, Nigeria

BackgroundBuruli ulcer (BU) is a debilitating neglected tropical disease which causes disability and mostly affects inhabitants in impoverished settings where access to medical care is challenging. This study aims to determine the effect of training community members as volunteers for or in the detection and referral of people who have Buruli ulcer to the hospital.MethodsThe following study is a before and after study in the BU-endemic Local Government Areas (LGA) of Ebonyi State. A cluster random sampling technique was used to select 90 volunteers from three LGAs (30 from each LGA). In each LGA, the volunteers underwent a one-day training and six months field work to identify all those who have any form of ulcer on any part of their bodies. A short questionnaire was used to capture socio-demographic characteristics of the patient, site of the ulcer, duration of the ulcer, initial appearance of the ulcer, referral to hospital, result of laboratory investigation, and treatment received. The data was analysed using the Statistical Package for Social Sciences (SPSS) for Microsoft Windows version 20 software. The Z test statistic was used to compare the number of referred BU patients before and after the intervention by LGA. The Chi square test was used to examine the association between the dependent and independent variables.ResultsThe mean age of volunteers was 39 ± 9.5 while mean age of the patients was 42.3 ± 17.1. Most of the ulcers were on the legs (79.4%) and lasted 1–5 years (65.6%). There was a significant increase in the proportion of BU suspects identified by the community volunteers in all 3 LGAs (Afikpo north (p = < 0.001), Abakaliki (p = 0.02), Ikwo (p = 0.001). The duration of the ulcer was associated with the detection and referral of the patients with higher levels of detection and referral among those whose ulcer had lasted 1–5 years in two of the LGAs (P < 0.001).ConclusionWe recommend that program managers and stakeholders integrate and scale up the services of trained community health volunteers for the rapid detection of Buruli ulcer cases in rural endemic communities. Awareness and sensitization campaigns on BU preventive measures should be intensified.

Ilizarov Bone Transfer for Treatment of Large Tibial Bone Defects: Clinical Results and Management of Complications

The purpose of this study is to present our clinical experience using the Ilizarov bone transfer technique and free-flap technique in the reconstruction of large tibial bone and soft tissue defects, including an evaluation of both the management of postoperative complications and long-term outcomes. From January 2010 to May 2020, 72 patients with tibia bone and soft tissue defects were retrospectively evaluated. Either an anterolateral thigh perforator flaps (ALTP) or latissimus dorsi musculocutaneous flaps (LD), solely or in combination, were used to cover soft tissue defects. Once the flap was stabilized, an Ilizarov external fixator was applied to the limb. Follow-up was postoperatively performed at 1, 3, 6, 9, and 12 months. Postoperatively, there were two cases of total and five of partial flap necrosis, and two cases of subcutaneous ulcers, which were caused by vascular crisis, infection, and hematoma, respectively. All the patients underwent Ilizarov external fixator surgery after flap recovery. A total of 16 complications occurred, including 3 cases of simple needle tract infection (antibiotic treatment) and 13 cases of complications requiring reoperation. A correlation factor analysis revealed that the main factors affecting the healing time were the defect length and operative complications. All patients with complications treated with the vascularized iliac flap eventually healed completely. The Ilizarov method used together with an ALTP, LD, or a combination thereof yields good clinical results for repairing large bone and soft tissue defects of the tibia, thus reducing the incidence of amputations. However, longer treatment times may be involved, and postoperative complications can occur. The vascularized iliac flap may be a suitable choice for the treatment of postoperative complications of this type of Ilizarov bone transport.

Case - Leuprolide acetate-induced necrotic skin ulceration.

Androgen deprivation therapy (ADT) has become a well-established modality in the management of locally advanced and metastatic prostate cancer.1 Leuprolide acetate, a synthetically derived gonadotropin-releasing hormone receptor (GnRHR) agonist, is commonly used for ADT in men.2 Despite proven effectiveness, the administration of GnRHR agonists is associated with common adverse reactions, such as impotence, hot flashes, and fatigue. Injection site reactions have also been documented, however, are infrequent, with the most common being localized pain.3,4 Here, we report a case of necrotic skin ulceration following multiple administrations of intramuscular leuprolide acetate.

Diabetic Foot Ulcer Complicated with Fracture and Osteomyelitis: X-ray Findings

Diabetic foot ulcer is one of the complications of patients who have diabetes mellitus which is not well controlled. It is resulted from poor glycemic control, underlying neuropathy, peripheral vascular disease, and poor foot care. It could lead to osteomyelitis of the foot and amputation of lower extremities. Detailed history taking should be done in order to get a holistic view of disease progression and risk factors. Clinical presentations such as the presence of callus, loss of hair, muscle atrophy, ulcer, paresthesia, hypo- or hyperesthesia, anhydrosis could be present. Ulcers are most common in the weight-bearing areas such as plantar metatarsal head, heel, tips of hammer toes, and other prominent areas. Radiological investigations including plain x-rays should be done in order to look for any underlying osteomyelitis, the presence of air in the subcutaneous tissue, any signs of underlying fractures, and presence of a foreign body. In this case study, we presented X-ray finding of a diabetic foot ulcer case that complicated with fracture and osteomyelitis.

Effectiveness of intrastromal voriconazole injection in the management of deep non healing fungal corneal ulcer

One of the most difficult conditions to cure is often corneal fungus infections. Due to low stromal penetration, current topical antifungal medications are not very successful in the treatment of fungal keratitis, which makes it challenging to treat cases of deep fungal corneal ulcers. To assess the efficiency of voriconazole intra stromal injection in the treatment of deep fungal corneal ulcers that donot heal. In this prospective interventional study of thirty patients, deep non-healing fungal corneal ulcers were successfully treated by combining intrastromal voriconazole with topical therapy. Voriconazole 50 gm/0.1 ml was injected intrastromally into the corneas of 30 patients with deep stromal non-healing fungal corneal ulcers who had not responded to topical antifungal medication. Patients were monitored for six to ten weeks following the operation. The size of the corneal infiltration was noted to decrease more quickly, and in the majority of cases, ulcers completely disappeared between 6 to 10 weeks. As an additional therapy, intrastromal voriconazole injection may be a safe and efficient strategy to treat cases of deeply seated fungal corneal ulcers that refuse to heal.

Skin wounds in a rural setting of Côte d'Ivoire: Population-based assessment of the burden and clinical epidemiology.

BackgroundData on the burden and clinical epidemiology of skin wounds in rural sub-Saharan Africa is scant. The scale of the problem including preventable progression to chronic wounds, disability and systemic complications is largely unaddressed.MethodsWe conducted a cross-sectional study combining active (household-based survey) and passive case finding (health services-based survey) to determine the burden and clinical epidemiology of wounds within the Taabo Health and Demographic Surveillance System (HDSS) in rural Côte d’Ivoire. Patients identified with wounds received free care and were invited to participate in the wound management study simultaneously carried out in the survey area. The data were analysed for wound prevalence, stratified by wound and patient characteristics.Results3842 HDSS-registered persons were surveyed. Overall wound prevalence derived from combined active and passive case finding was 13.0%. 74.1% (403/544) of patients were below the age of 15 years. Most frequent aetiologies were mechanical trauma (85.3%), furuncles (5.1%), burns (2.9%) and Buruli ulcer (2.2%). Most wounds were acute and smaller than 5 cm2 in size. 22.0% (176/799) of wounds showed evidence of secondary bacterial infection. 35.5% (22/62) of chronic wounds had persisted entirely neglected for years. Buruli ulcer prevalence was 2.3 per 1000 individuals and considerably higher than expected from an annual incidence of 0.01 per 1000 individuals as reported by WHO for Côte d’Ivoire at the time of the study.ConclusionsSkin wounds are highly prevalent in rural West Africa, where they represent a widely neglected problem. The HDSS-based survey with combined active and passive case finding adopted in this study provides a better estimate than school- and health institution-based surveys which underestimate the frequency of skin wounds and, particularly, of neglected tropical diseases of the skin, such as Buruli ulcer and yaws. A comparison with country-specific WHO data suggests underreporting of Buruli ulcer cases.Trial registrationRegistration at ClinicalTrials.gov NCT03957447.

S1584 Prevalence of Non-Helicobacter pyloriPeptic Ulcers in Patients With Chronic Pancreatitis: A Population-Based National Study

Introduction: Acute and chronic pancreatitis are recognized as a continuum of the same disease, with a significant overlap in clinical manifestations. The association between peptic ulcer disease (PUD) and acute pancreatitis (AP) has been described in the literature. However, there is no available data on the prevalence of PUD in patients with chronic pancreatitis (CP). Methods: The aim of this study was to investigate if CP is associated with increased overall risk of PUD, gastric ulcers, and duodenal ulcers. Data was collected from a commercial database (Explorys Inc, Cleveland, OH), an aggregate of EHR data from 27 integrated healthcare systems in the US between 12/2016-12/2021. We identified patients with CP based on Systemized Nomenclature of Medicine – Clinical Terms and excluded patients with Helicobacter pylori infection of the gastrointestinal tract. We compared the prevalence of peptic ulcer, gastric ulcer, and duodenal ulcer after at least 30 days following a diagnosis of CP to a cohort without CP. Results: Of the 33,660,510 patients in the database without H. pylori, we identified 66,550 cases of CP. We identified 2,480 cases of peptic ulcer, 2,680 cases of gastric ulcer and 1,420 cases of duodenal ulcer in patients with CP. In comparison, we identified 160,270 cases of peptic ulcer, 201,600 cases of gastric ulcer and 81,920 cases of duodenal ulcer in patients without CP. Overall prevalence for peptic ulcer, gastric ulcer, and duodenal ulcer in patients with CP was 3727/100000, 4027/100000 and 2134/100000 people, respectively. In comparison, overall prevalence for peptic ulcer, gastric ulcer, and duodenal ulcer in patients without CP was 477/100000, 600/100000 and 244/100000 people, respectively. The prevalence ratios (PR) for developing each diagnosis after at least 30 days of a CP diagnosis were 7.81 (95% CI 7.51-8.12, P< 0.001), 6.71 (95% CI 6.47-6.97, P< 0.001), and 8.75 (95% CI 8.31-9.22, P< 0.001), respectively. Table 1 describes the prevalence of PUD among various demographics. Conclusion: In this large population-based study, peptic ulcer, gastric ulcer, and duodenal ulcer were all significantly more prevalent among patients with a diagnosis of CP. Future investigation will be useful in understanding the pathophysiology of this association. Table 1. - Prevalence of peptic ulcer, gastric ulcer and duodenal ulcer in patients with and without chronic pancreatitis Chronic Pancreatitis (CP) No CP Prevalence in CP /100,000 Prevalence in No CP /100,000 Prevalence Ratio 95% CI P-value Peptic Ulcer 2480 160270 3726.52 477.08 7.81 7.51-8.12 < 0.001 Adults (18-65) 1640 74130 3964.23 374.11 10.60 10.1-11.1 < 0.001 65)"}" > Elderly ( >65) 840 85440 3362.69 1088.74 3.09 2.89-3.30 < 0.001 Caucasian 1700 119480 3739.55 657.53 5.69 5.43-5.96 < 0.001 African American 670 24730 5153.85 648.38 7.95 7.38-8.57 < 0.001 Asian 20 2860 2985.07 536.31 5.57 3.61-8.58 < 0.001 Male 1210 64750 3587.31 434.60 8.25 7.81-8.73 < 0.001 Female 1270 95450 3861.36 516.79 7.47 7.08-7.89 < 0.001 Gastric Ulcer 2680 201600 4027.05 600.11 6.71 6.47-6.97 < 0.001 Adults (18-65) 1730 88420 4181.77 446.23 9.37 8.95-9.82 < 0.001 65)"}" > Elderly ( >65) 940 112280 3763.01 1430.75 2.63 2.47-2.80 < 0.001 Caucasian 1830 149090 4025.52 820.48 4.91 4.69-5.13 < 0.001 African American 740 28950 5692.31 759.02 7.50 6.99-8.05 < 0.001 Asian 30 3690 4477.61 691.96 6.47 4.56-9.19 < 0.001 Male 1260 77990 3735.55 523.46 7.14 6.76-7.54 < 0.001 Female 1420 123300 4317.42 667.58 6.47 6.15-6.81 < 0.001 Duodenal Ulcer 1420 81920 2133.73 243.85 8.75 8.31-9.22 < 0.001 Adults (18-65) 860 31370 2078.80 158.31 13.10 12.3-14.0 < 0.001 65)"}" > Elderly ( >65) 560 49880 2241.79 635.61 3.53 3.25-3.83 < 0.001 Caucasian 960 60480 2111.75 332.84 6.35 5.96-6.76 < 0.001 African American 400 11250 3076.92 294.96 10.40 9.46-11.5 < 0.001 Asian 20 1720 2985.07 322.54 9.26 6.00-14.3 < 0.001 Male 850 45120 2520.01 302.84 8.32 7.78-8.90 < 0.001 Female 570 36660 1733.05 198.49 8.73 8.04-9.48 < 0.001

S3546 Transcatheter Arterial Radioembolization (TARE)-Induced Gastric Ulcer in an Excluded Stomach After Roux-en-Y Gastric Bypass

Introduction: Transcatheter arterial radioembolization (TARE) is a commonly utilized locoregional treatment for hepatocellular carcinoma (HCC) and confers lower risk of hepatic ischemia owing to the safety profile of Yttrium-90 glass microspheres used in TARE. However, peptic ulcer disease occurs in 1-5% of TARE treatments. Here we describe a unique case of a TARE-induced gastric ulcer in an excluded stomach after Roux-en-Y gastric bypass (RYGB). Case Description/Methods: 70-year-old male with RYGB in 2012 and hepatitis C/nonalcoholic steatohepatitis cirrhosis complicated by HCC treated with TARE and liver transplant six months earlier was evaluated for melena. Esophagogastroduodenoscopy, colonoscopy, and an antegrade double balloon-assisted enteroscopy (DBE) found no obvious source. The excluded stomach could not be reached during DBE. Due to continued melena and transfusion dependence, he underwent a laparoscopic assisted gastroduodenoscopy (GD) to evaluate the excluded stomach. This revealed a 3 cm gastric ulcer in the pre-pylorus with biopsies showing radiation induced ulcer without evidence of malignancy, viral infection, or helicobacter pylori (Figure 1a). Gastrostomy tube (G-tube) access was maintained in the excluded stomach to administer twice daily liquid proton pump inhibitor (PPI) via the G-tube. Repeat GD after eight weeks of treatment showed a well-healing gastric ulcer (Figure 1b). Patient’s hemoglobin also stabilized and had no further transfusion requirement. Discussion: Gastric ulcers in the excluded stomach after RYGB are rare, especially 10 years after surgery. To our knowledge, this is the first reported incident of radiation induced ulcer in an excluded stomach. For treatment, G-tube access was maintained to the excluded stomach for administration of liquid PPI with excellent ulcer healing and resolution of melena and anemia. This treatment approach was selected based on previous data demonstrating benefit of open capsule PPI to treat marginal ulcers following RYGB1. Open capsule PPI administration is thought to enhance healing in these cases as this bypasses the need for capsular breakdown in the stomach for absorption, but it is unclear if a similar mechanism is true for an excluded stomach and warrants further studies to better understand its pharmacokinetics. This case highlights a unique case of a TARE-induced gastric ulcer in the RYGB excluded stomach that was successfully treated with liquid PPI.Figure 1.: (a) High power view of the ulcer slough shows fibrosis with prominent atypical fibroblasts consistent with radiation enteritis (H&E, 400×) (b) Repeat gastroduodenoscopy showing healing ulcer.

S3582 Disguised as Post-Operative Ileus: A Case of a Giant Gastric Ulcer Causing Outlet Obstruction and Gastric Pneumatosis

Introduction: Giant gastric ulcers (GGU), defined as ulcers larger than 2-3cm, are relatively rare in the setting of widespread proton pump inhibitor (PPI) use. Though usually located in the lesser curvature, GGU may occur in any part of the stomach. Typical symptoms are similar to that of peptic ulcer disease (PUD), i.e. epigastric pain and gastrointestinal bleeding, however GGU are highly prone to perforation and are more likely to be malignant in the elderly. Overall, gastric outlet obstruction is the least common complication of PUD. Case Description/Methods: A 74-year-old obese male with history diabetes, sleep apnea, and prior laparoscopic gastric banding surgery was admitted for elective surgery for Charcot arthropathy. Post-operatively, he developed nausea, vomiting and abdominal bloating. Abdominal x-ray showed distention of the small bowel concerning for ileus. Exam showed a non-tender abdomen with distention and tympany on percussion. His emesis resolved with antiemetics, however distention persisted despite passing gas and stool. Three days after surgery, he developed acute anemia without overt bleeding requiring blood transfusions. Abdominal X-ray and CT was performed which showed marked gaseous distention of the stomach and gastric wall pneumatosis. Nasogastric tube was placed for decompression with subsequent resolution of his distention. Due to concern for gastric band erosion, Gastroenterology was consulted. Upper endoscopy was performed which revealed a 4cm clean-based ulcer with overlaying eschar along the greater curvature with surrounding erythema and edema. Biopsies of the ulcer border showed acute erosive gastropathy with focal clustering of eosinophils without evidence of dysplasia. He was started on PPI and sucralfate, and remained clinically stable without further gastrointestinal symptoms. (Figure) Discussion: Gastric pneumatosis due to gastric emphysema is caused by disruption of mucosa leading to air migrating into the gastric wall. Etiologies vary, including injury from instrumentation, severe vomiting, pulmonary pathology, penetrating gastric ulcers, or gastric outlet obstruction. Few cases reports have described gastric emphysema resulting from gastric band erosion, however there are no reports describing this occurring in the absence of full erosion. Overall, gastric emphysema is relatively rare, as is development of GGU. To our knowledge, this is the first reported case of unperforated giant gastric ulcer resulting in outlet obstruction with gastric pneumatosis.Figure 1.: CT abdomen showing marked gaseous distention of the stomach and gastric wall pneumatosis (Figure 1a). Upper endoscopy findings of a friable, erythematous giant ulcer with clean-base overlaying the greater curvature with significant surrounding erythema and edema in the fundus/cardia (Figure 1b and 1c), as well as multiple surrounding small ulcerations, some with clean-base and some with flat pigmented spots, throughout (not pictured). No evidence of active bleeding, visible vessel, or high-risk features for bleeding.

S2684 A Rare Case of Helicobacter pylori Gastric Ulcer Causing Left Gastric Artery Pseudoaneurysm and Upper GI Bleed: A Case Report and Scoping Review of Human Cases

Introduction: Pseudoaneurysm is an uncommon but lethal presentation of upper gastrointestinal hemorrhage, as a rupture is associated with a 40-80% mortality rate. Here, we report a rare case of left gastric artery pseudoaneurysm secondary to Helicobacter pylori (HP) infection-associated peptic ulcer disease presenting as upper gastrointestinal hemorrhage. Case Description/Methods: A 62-year-old male with a history of oral cancer status post resection in 2015, polysubstance use disorder (cocaine, heroin, and methamphetamine), hypertension, and gastroesophageal reflux disease presented to the hospital with chest and epigastric pain and melena. Admission laboratory findings were notable for acute kidney injury, leukocytosis, and normocytic anemia. Computed tomography angiography (CT-A) demonstrated a small pseudoaneurysm arising from the left gastric artery projecting into the stomach wall, heterogeneous material within the stomach, and a prominent left gastric artery. These findings were concerning for intraluminal hemorrhage (Figure). The patient underwent emergent embolization of the left gastric artery pseudoaneurysm, followed by esophagogastroduodenoscopy (EGD). This revealed a 2.5 cm ulceration over the lesser curvature of the stomach, and biopsies were positive for HP infection. A systematic review in PubMed and Embase for gastric artery pseudoaneurysm due to gastric ulcer only resulted in one other case report. Though also rare, splenic artery pseudoaneurysm due to gastric ulceration is more common, as our search yielded 5 case reports. Discussion: Acute upper gastrointestinal bleeds presenting to the emergency department are most commonly secondary to variceal hemorrhage or peptic ulcer disease. Peptic ulcer disease can result in gastric artery pseudoaneurysm, however as we only found only one other case report documenting this presentation, it appears to be extremely rare. Recognition of gastric pseudoaneurysm on the CT-A should prompt endoscopic exploration and biopsy with HP testing, with close follow-up for a test of cure.Figure 1.: Computed tomography angiography. (a) Sagittal plane, (b) Transverse plane.

Homoeopathic management of duodenal ulcer: A case report

Introduction: Duodenal Ulcer is one of the most common gastrointestinal disorders encountered in clinical practice. It causes various distressing symptoms like dyspepsia, nausea and vomiting, abdominal bloating and weight gain due to post prandial amelioration of symptoms. Commonest complications include upper gastrointestinal bleeding, increased Blood Urea Nitrogen (BUN) and varying degrees of anaemia with associated fatigue.Case report: We present a case of 56year old male complaining of burning pain in epigastrium with nausea, vomiting and dyspeptic troubles for 6months. The endoscopic report confirmed it to be a case of Duodenal Ulcer. After thorough clinical evaluation, the patient was treated with different potencies of Nux vomica and Sulphur at different point of time as suggested by patient’s symptom-complex. Marked improvement in symptomatology was noted with Individualised Homoeopathic treatment for 16 months. The outcome was also recorded with endoscopy report following the treatment. Conclusion: The case shows excellent response of a patient suffering from duodenal ulcer to Individualised Homoeopathic medication. However, a single case report may not draw any significant inference regarding efficacy of Homoeopathic treatment in duodenal ulcer. So large scale clinical trials are required to establish the effectiveness of Homoeopathic therapeutic tools.

S2138 TACE-Induced Ischemic Colitis

Introduction: Transarterial chemoembolization (TACE) is a locoregional treatment used in patients with hepatocellular carcinoma (HCC). This therapy entails injecting a chemotherapeutic agent into a branch of the hepatic artery supplying blood to the tumor while cutting off blood supply through particle embolization. This procedure may be utilized in a patient who is not a candidate for surgical resection or as a bridge to liver transplantation. Here we present a case of a ischemic colitis in the setting of a recent TACE. Case Description/Methods: A 65-year-old female with history of HCC underwent an outpatient TACE procedure for a 3.6 cm liver lesion. Soon after the procedure the patient complained of severe abdominal pain and was admitted. On day 2 of hospitalization, she developed significant bright red blood per rectum. Computed tomography (CT) demonstrated mild wall thickening and pericolonic fat stranding in the ascending colon concerning for acute colitis. Lactic acid was elevated at 5.8 mmol/L (normal < 2). Colonoscopy demonstrated multiple ulcers and erythema stretching from the cecum to descending colon suggestive of ischemic colitis. Biopsies demonstrated superficial mucosal erosion and necrosis, crypt atrophy, and lamina propria hemorrhage with hyalinization, consistent with acute ischemic colitis. CT angiography demonstrated a patent abdominal aorta and all major branches. The patient was treated conservatively without further episodes of hematochezia and was discharged home (Figure). Discussion: Postembolization syndrome is the most common adverse effect of TACE, which occurs in 60 to 80 percent of patients. This has been reported to be related to either tumor necrosis or due to ischemic damage to normal liver parenchyma. One case of gastrointestinal ulceration has been reported after TACE. To date, there has been no reported case of ischemic colitis after TACE. This presentation of ischemic colitis in our patient may be due to regurgitation of embolized particles into superior mesenteric arterial circulation leading to hypoperfusion of the colon, resulting in ischemic colitis. One should consider this presentation on the differential diagnosis in a patient with hematochezia after TACE.Figure 1.: Ascending and transverse colon demonstrating multiple ulcers and erythema suggestive of ischemic colitis on colonoscopy.