Cause Of GI Bleeding Research Articles

Rectal phlebectasia: a rare cause of GI bleeding

Rectal phlebectasia: a rare cause of GI bleeding

Aorto-Digestive Fistula: A Serious Cause of Gastointestinal Bleeding

Aortodigestive fistula is a rare and potentially serious cause of GI bleeding, with a very high mortality rate if not diagnosed and managed early. Upper gastrointestinal endoscopy, in addition to the CT scan, is a key examination in the diagnosis, provided that it is performed up to the third duodenum. An early and adapted surgical management remains the basis of the treatment of these fistulas, in addition to an anti-infectious treatment adapted to the identified germs, as well as all the pre- and postoperative resuscitation measures.

Unusual Case of Hematochezia Controlled by Endoscopic Intervention and Antibiotics

Background: Lower gastrointestinal bleeding can cause a life-threatening condition especially in the elderly with multiple comorbidities. Whilst some infectious colitis can cause bloody diarrhea, usually the blood loss is minimal and does not require an endoscopic intervention. Case Presentation: In this report, we present a case of a 64-year-old Lebanese female with multiple comorbidities including renal failure on hemodialysis, hypertension and multiple myeloma on chemotherapy who presented for an acute episode of lower GI bleeding as a result of an antibiotic associated colitis by clostridium difficile infection. Conclusion: Therefore, we should be vigilant about infectious colitis as a cause of GI bleeding in the immunosuppressed individuals and elderly with multiple comorbidities.

Frequency of Lower Gastro-Intestinal Bleeding

Background: Rectal bleeding is considered an important sign of colonic disease, particularly colorectal cancer. Rectal bleeding is considered to be an alarm feature in particular for colorectal cancer that, in tum, is the second- leading cause of cancer death globally. Colonoscopy has been reported recently as cost effective method of evaluating asymptomatic rectal bleeding 14, while rectal bleeding as a diagnostic indicator has been questioned in general practice. Objective: The objective of this study is to determine the frequency of common causes of bleeding per rectum among patients presenting to surgical OPD at tertiary care hospital. Materials and Methods: This descriptive cross sectional study was carried out at Department of General Surgery Hayatabad Medical Complex Peshawar from September 2021 to March 2022. Total of 164 patients with lower GI bleed were included in the study. All patients were enrolled in a consecutive manner and subjected to lower GI proctoscopy, other relevant investigations to detect the cause of GI bleed. Results: Total 164 patients were included. Age ranged between 15-60 years with a mean age of 37.5 years. There were 107(65.2%) male and 57(34.8%) female, with a male to female ratio of 1.9:1. Age distribution was analyzed as 63(38.4%) belongs to age group of 20-30 years, 30(18.3%) in 30-40 years, 26(15.9%) in 40-50 years and 45(27.4%) in age group 50-60 years respectively. On proctoscopy, hemorrhoids were found in 54(32.9%) patients, colitis in 15(9.1%), inflammatory bowel diseases (IBD) in 39(23.8%), ulcerative colitis in 29(17.7%), diverticular diseases in 10(6.1%) and abdominal TB in 17(10.4%). None of the patients had colorectal cancer. Conclusion: Hemorrhoids, inflammatory bowel diseases and ulcerative colitis were common causes of lower gastrointestinal bleed in our population and ulcerative colitis was significantly high in female patients.

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

Haemosuccus pancreatitis: A rare cause of GI bleed, diagnosis on CT Angiography – Case series & review of literature

Haemosuccus pancreatitis also known as Pseudohaemobilia or haemoductal pancreatitis, is defined as upper gastrointestinal hemorrhage originating from the pancreatic duct into the duodenum via the Ampulla of Vater, or major pancreatic papilla. A triad of epigastric pain, intermittent gastro intestinal bleeding and hyperamylasemia [1,2]. We present three cases of chronic pancreatitis presenting as upper GI bleed and with epigastric pain and sudden drop in Hematocrit. One had bleed from pseudo aneurysm arising from hepatic artery leaking into pseudo cyst, second had erosion of wall of splenic vein leaking into pancreatic duct through small pseudocyst and the third patient was post cystojejunostomy with who bled into cyst, probably from a vessel in wall of cyst, well demonstrated on venous phase of CT angiography and later responded to conservative management. Hemorrhage from the pancreatic duct, i.e. Haemosuccus Pancreaticus (HP), is a rare cause of gastrointestinal bleeding. Pancreatic Homosuccus is usually due to the rupture of an aneurysm of a visceral artery, most likely the splenic artery, in chronic pancreatitis. Other causes of HP are rare. Keywords: haemosuccus pancreaticus; pseudo aneurysm; pancreatitic pseudocyst; upper gastrointestinal bleeding; embolization.

Cryptogenic Multifocal Ulcerous Stenosing Enteritis

Crytpogenic multifocal ulcerous setnosing enteritis is an unusual cause of gastrointestinal bleed. The objective of this report is to highlight small bowel ulcerations as a cause of anemia and the role of wireless capsule endoscopy in the diagnosis of CMUSE. We present here two young women who had been evaluated for anemia with normal gastroscopy, colonoscopy and contrast CT's and requiring multiple blood transfusions over the years. Both patients had wireless capsule endoscopy which showed multiple ulcerations with stenosis in the small intestine, resulting in capsule retention in the small intestine which was retrieved. Both patients improved with steroids and azathioprine. To summarize CMUSE could be cause of obscure GI bleed, when CMUSE is a consideration as the cause of GI bleed wireless capsule endoscopy should be used in caution.

S1581 Hemobilia From an Unlikely Culprit: A Case of a Ruptured Pseudoaneurysm

Introduction: Hemobilia, or bleeding from the hepatobiliary tract, is a rare cause of GI bleeding and jaundice. Most cases of hemobilia are iatrogenic secondary to hepatobiliary interventions, however, trauma and malignancy also represent a major source. We present a case of hemobilia secondary to a hepatic artery pseudoaneurysm, in the setting of acute cholecystitis and metastatic liver disease. Case Description/Methods: A 67-year-old man presented with 3 days of RUQ abdominal pain radiating to the epigastrium. On arrival, he was tachycardic, afebrile, and normotensive. He had RUQ tenderness and icterus. Laboratory findings were significant for leukocytosis, anemia, transaminitis, elevated alkaline phosphatase, and hyperbilirubinemia. An ultrasound of the abdomen was suggestive of calculous cholecystitis and a dilated CBD of 0.8 cm. He underwent a EUS which revealed a dilated CBD with heterogeneous mater. An ERCP showed altered blood at the ampulla. A sphincterotomy was performed and a large blood clot was extracted from the CBD via balloon sweeps. Two plastic stents were then placed for drainage after which brisk arterial bleeding was noted. Urgent angiography revealed evidence of a ruptured pseudoaneurysm arising from the anterior division of the right hepatic artery near segment 8 of the liver. Successful coil embolization was performed. A CT scan of the abdomen revealed rectal thickening and hypoenhancing liver lesions suggestive of metastatic disease. On flexible sigmoidoscopy, a fungating, partially obstructing rectal mass was seen, biopsies of which were positive for invasive adenocarcinoma. Cholecystitis confirmed on HIDA scan was treated conservatively with antibiotics. He was subsequently discharged and started on chemotherapy as an outpatient. He is now planned for a repeat ERCP with stent exchange. Discussion: Hemobilia can masquerade as biliary stones on EUS. Management includes early diagnosis, identification of the source of bleeding, achieving hemostasis, and relieving the obstruction. Transcatheter arterial embolization is preferred if there are any signs of arterial extravasation. Biliary obstruction can be relieved with ERCP and stent placement. In the presence of underlying malignancy, infiltrative disease and its surrounding vascular friability are often implicated. However, a benign etiology should not be overlooked as illustrated in our case. Cholecystitis leading to severe inflammation of the gallbladder bed can cause adjacent arterial wall degeneration and pseudoaneurysm formation.Figure 1.: (A) Superselective catheterization of the right hepatic artery and angiography demonstrating evidence of 1.2 x 0.9 cm pseudoaneurysm/contained perforation, arising from a suspected proximal segment 8 arterial branch. (B) Endoscopic ultrasound demonstrating a dilated common bile duct up to 12 mm, filled with heterogeneous material. The gallbladder wall appears thickened. (C) CT abdomen with contrast showing multiple hypoenhancing liver lesions within the right and left lobes. Surgical coils within the right lobe of the liver consistent with a recent embolization procedure. Common bile duct stent in place, and small foci of pneumobilia. (D) ERCP images showing blood clots protruding from the ampulla. After balloon sweeps and sphincterotomy, two 10 Fr by 7 cm plastic stents were placed in the CBD.Table 1.: Laboratory Values from Admission and Discharge day.

Variceal Bleeding is Leading Cause of Upper GI Bleed: A Study from Northern Part of Pakistan

Background: Upper gastrointestinal bleeding (UGIB) is a leading cause of hospitalization in medical emergencies around the world, with a high death and morbidity rate. In all cases of upper gastrointestinal bleeding, endoscopy is the primary diagnostic tool. Key management of depends on diagnosing the exact cause of disease. Methodology: This descriptive study was carried out at Gastroenterology Department, PIMS, Islamabad from January 2019 to December 2019. All patients having history of upper gastrointestinal bleed were included in the study. Patients unfit for endoscopy i.e. with perforation, peritonitis, comatose needing intubation and those unwilling to undergo the procedure were excluded. Total 490 patients fulfilled the criterion. The cause of GI bleed was noted upon endoscopy. Data was noted on set performa and further statistical analysis was performed via SPSS v 26. Results: Among 490 patients, 298 (61%) were males while 192 (39%) were females. Most common age group presenting with upper GI bleed belongs to old age group i.e. had age above 60 years (n=235, 47.9%) followed by 40 to 59 years (n=174, 35.5%).Most common cause of upper GI bleed was found to be variceal bleed (n=292, 59.5%), followed by ulcer bleed (n=88, 18.0%) and stomach cancer (n=28, 6%). In 82 (17%) cases no reason for gastrointestinal bleed could be found out. Chi-square test showed Variceal bleed to be the most significant reason (χ2=65.2, P-Value<0.001) of Upper GI bleed. Conclusion: Variceal bleed is the most significant cause of upper GI bleed in our study population. This trend can be attributed to increased prevalence of hepatitis C in Pakistan. Special attention to the patient’s symptoms especially with history of HCV can help in early diagnosis and timely management. Keywords: Variceal Bleed, Upper GI Bleed, Endoscopy, Ulcer, Hepatitis C.

S2131 Massive Hematochezia From a Large Bleeding Duodenal Diverticulum

INTRODUCTION: Duodenal diverticula are a rare cause of GI bleeding despite being a common finding in the GI tract. We present a case of a patient who had massive hematochezia due to a complex duodenal diverticulum. CASE DESCRIPTION/METHODS: A 74 year old Hispanic female with past medical history of type 2 diabetes mellitus presented with weakness. She denied any aspirin or NSAID use. On admission, vital signs were normal and she had pale conjunctiva. Labs were significant for Hgb 6.7 g/dL and blood glucose of 494 mg/dL. She was admitted for transfusion and glucose management. After admission, she had an episode of large amount of red blood per rectum. She became hypotensive and Hgb dropped to 3.7 g/dL. She was intubated, transferred to the ICU and started on pantoprazole drip. Repeat Hgb was 10.5 g/dL after 4 units of packed RBC. EGD using a forward-viewing endoscope was done which showed a 30 mm diverticulum in the area of the major papilla with multiple smaller diverticula within the main diverticulum. There were several angiodysplasias within the diverticulum that were oozing blood (Figure 1). The lesions were injected with epinephrine and four hemostatic clips were placed (Figure 2). There was no further bleeding after intervention and Hgb remained stable. DISCUSSION: Duodenal diverticula are common findings in the GI tract and the vast majority are asymptomatic. The most common location is the descending part of the duodenum. Duodenal diverticula are a rare cause of GI bleeding. Diverticular bleeding can be due to an inflamed diverticulum, erosion into a major vessel, Dieulafoy lesion, aortoenteric fistula formation or angiodysplasia. EGD is a useful tool in diagnosing bleeding duodenal diverticula, but a side-viewing endoscope may be needed if no bleeding source is identified on forward-viewing endoscopes. Various endoscopic therapeutic strategies such as injection with epinephrine, bipolar coagulation, APC and hemostatic clips have been used for treatment of bleeding duodenal diverticula. In our case, successful hemostasis was achieved with epinephrine injection followed by placement of hemostatic clips. Duodenal diverticula should be included in the consideration of rare causes of hematochezia. Prompt diagnosis and treatment is necessary to avoid life-threatening complications.Figure 1.: Actively oozing angiodysplasias within the diverticulum.Figure 2.: Angiodysplasias after injection and hemostatic clip placement. No bleeding seen post intervention.

S2171 Renal Cell Carcinoma Metastatic to the Stomach: A Case Report

INTRODUCTION: Renal cell carcinoma (RCC) accounts for 3% of cancer cases. About 25% are metastatic at time of diagnosis, most commonly to the lungs, brain, and bone. Metastatic RCC to the stomach is rare and can have several presentations, including as a solitary polyp, multiple polyps, or as ulcers, and are usually found in the submucosal layer. We present a case of GI bleeding in a male with known RCC found to have new mets to the stomach. CASE DESCRIPTION/METHODS: A 73yo WM with PMH of stage IV RCC with known mets to lung, bone, and brain, currently on bevacizumab and denosumab, who presented after an episode of hematemesis and melena. The patient had fatigue but denied any abdominal pain. His physical exam was benign with no hemodynamic instability. Admission labs were notable for hgb 7.1, down from 10 a week prior, plt 115, INR 1.1, BUN 43, creatinine 1.0. An EGD showed a 2cm clean based ulcerated mass in the cardia of the stomach (Figure 1). There were also several <1 cm, benign appearing, polyps in the body and antrum (Figure 2). EUS was performed prior to potential polypectomy to assess layer of origin and depth of invasion. EUS showed an isoechoic round mass arising from the mucosa. There was invasion into the muscularis mucosa but not submucosa. The mass was resected with snare. The tissue was sent to pathology and was consistent with RCC. The patient was discharged with outpatient follow up with oncology to discuss possible adjustments to his immunotherapy regimen. DISCUSSION: RCC is a rare cause of GI bleeding. In a study of 2082 patients with RCC, only 5 patients were found to have mets to the stomach. In this study it was found that even with RCC, a patient is still two times as likely to develop gastric cancer as they are a metastasis from RCC. While it is rare to have RCC mets to the stomach, it can be a poor prognostic sign. Almost all patients with RCC mets to the stomach have mets in other organs. Due to this, the diagnosis of a RCC met in the stomach, should prompt quick reimaging, and the patient needs to discuss with their oncologist about potential treatment modifications due to this poor prognostic sign. In terms of endoscopic findings, RCC can present as a wide variety of lesions, including ulcers, >1 cm polypoidal masses, <1 cm polyps, solitary, or multiples. They can also be mucosal or submucosal lesions. Due to this, it is important for both endoscopists and pathologists to keep RCC in the differential with most gastric polyps/ulcers even when they appear benign.Figure 1.: Ulcerated mass in the cardia of the stomach.Figure 2.: Subcentimeter gastric polyps.

Microthrombosis associated with GI bleeding in COVID-19

A 35-year-old man with sickle-cell trait and diabetes who had undergone renal transplantation presented with weeks of episodic severe cramping, abdominal pain, diarrhea, maroon stool, and anorexia despite using empiric antibiotics for gastroenteritis. At presentation, his laboratory results noted a mild leukocytosis and a hemoglobin of 6.4 g/dL. Real-time polymerase chain reaction of a nasopharyngeal sample gave a positive result for SARS-CoV-2 despite the lack of respiratory symptoms or fever. A CT scan demonstrated diffusely thickening of the stomach and small-bowel walls (A). Upper endoscopy revealed normal gastric mucosa but edematous, friable duodenal mucosa with contact bleeding (B). Examination of biopsy specimens from the duodenal mucosa demonstrated hemorrhage in the lamina propria with fibrin microthrombi (C, H&E, orig. mag. ×40). A biopsy specimen from a small gastroesophageal junction polyp incidentally showed dysplasia with a focus of adenocarcinoma (D). Magnetic resonance angiography failed to show any explanatory large-vessel disease. The patient’s melena resolved 4 weeks after symptom onset and 3 blood transfusions. Repeated endoscopy at 5 weeks showed normal mucosa; the polyp was successfully removed en bloc by submucosal dissection. No other thromboses were noted during his course; d-dimer peaked at 1633 mg/mL. GI involvement of SARS-CoV-2 is common; typical symptoms include diarrhea and nausea, although bleeding has been rarely described. To our knowledge, this is the first endoscopic description of biopsy-confirmed COVID-19–associated microthrombosis, reinforcing the importance of endoscopy with adequate biopsy. All authors disclosed no financial relationships. Commentary As our knowledge about COVID-19 evolves, we are starting to view the illness as a thrombotic microvascular injury of systemic nature in which the lung, skin, kidney, GI tract, and other organs are affected. Microthrombosis in COVID-19 is a complement-mediated disorder. It is unclear whether COVID-19–related coagulopathy is a byproduct of severe inflammatory response or a virus-specific–mediated coagulopathy. As seen in this case, COVID-19–related microthrombotic disease of the small intestine presents endoscopically as edema, granularity, and patchy erythema, as seen in other ischemic disorders. Biopsy specimens showing hemorrhage in the lamina propria with fibrin microthrombi are diagnostic of the condition. With the current rise of COVID-19 cases in hospitals worldwide, endoscopists should be aware of COVID-19–related microthrombosis syndrome as a cause of GI bleeding in this subset of patients. How prevalent this condition is among our hospitalized patients with COVID-19 and whether other comorbid conditions pose a synergetic effect on developing microthromboses are questions that remain to be answered. Mohamed O. Othman, MD, Associate Editor for Focal Points

SAT-496 Acute GI Bleed Associated with Myxedemic Coma: Yes It Still Exists!

Introduction: Myxedemic coma is a life-threatening medical emergency. It needs to be treated emergently & carries very high mortality. It involves multi-organ failure at cellular level due to severe thyroid hormone deficiency. Most common clinical presentation involves CVS. With advancement in health care it is now uncommon to see myxedemic coma especially associated with GI Bleed. Here in we present an interesting case of GI bleed associated with myxedemic coma. Case: 84 years old male was discovered in home, minimally responsive. EMS intubated & brought him to ED with agonal respirations, hypotensive & unresponsive, He was admitted to ICU. Past medical history was significant for smoking & hypertension. Physical Exam was significant for dryness of skin, obtundation, hypothermia, tachypnea & BMI >30. Initial Labs revealed anemia with Hemoglobin of 5.1mg/dL, Hematocrit 17.5%, Hyponatremia-134meq/L, Hyperkalemia-K+ levels 5.3meq/L, BUN-84mg/dL & creatinine-4.1mg/dL, His serum TSH levels were 352 mIU/ml with low free T4 and T3 levels at 0.15ng/dl and 1.99pg/ml, respectively. Stool was positive with Blood. IV fluids were given.GI was consulted. He underwent emergent upper GI endoscopy, which found the Dieulafoy’s lesion at cardiac end of stomach & treated with a combination of epinephrine injection, argon laser, & 3 hemo-clips. He had 6 PRBCs transfused. He was started on IV Thyroxine, Liothyronine and Hydrocortisone. His mental status improved, & hemoglobin remained relatively stable. Later on, he decided to move to palliative care & was discharged to hospice. Discussion: Myxedemic coma is a term generally used to denote most severe decompensated hypothyroidism. The typical progression is lethargy evolving into a stupor & eventually into a coma with respiratory failure and hypothermia. It can lead to volume depletion, hyponatremia, & AKI, which can worsen to ATN if prolonged ischemia remains.GI bleed is a rare manifestation of myxedemic coma. Pathophysiology of GI bleed in these patients involves mucosal edema & mucopolysaccharide infiltration. Also, myxedemic coma is associated with neurological changes resulting in slow peristalsis & GI atony. This coupled with coagulopathy associated with decompensated hypothyroidism results in increased risk of bleeding. Dieulfoy’s lesion are rare cause of GI bleed. Stress & ischemic changes are one of the inciting factors for these lesions. These lesions are more common in elderly males & are associated with severe systemic illness similar to our patient. Treatment is usually supportive with goal of identifying the lesions, stopping the bleed & aggressively managing myxedemic coma. We present an interesting case of GI bleed associated with myxedemic coma now relatively uncommon with advancement in healthcare. It provides an excellent learning opportunity for clinicians to consider while managing these patients.

Impact of neoadjuvant radiation on postoperative outcomes of patients with pancreatic cancer undergoing pancreatoduodenectomy

Presenter: Samer AlMasri MD | University of Pittsburgh Medical Center Background: Neoadjuvant chemotherapy (NC) and chemoradiation (NCRT) are increasingly used to downstage pancreatic adenocarcinoma (PDA), particularly in head tumors requiring pancreatoduodenectomy (PD). While NCRT may increase margin negative rates and sterilize regional lymph nodes, its impact on postoperative morbidity remains poorly characterized. This study aimed to compare the impact of NCRT and NC on the postoperative morbidity of patients with PDA undergoing PD. Methods: A single-center, retrospective analysis of consecutive patients with PDA treated with NC or NCRT followed by PD between 2009 and 2019 was performed. All complications within the first post-operative year were recorded. Logistic regression analysis was performed to identify predictors of morbidity. Kaplan-Meier estimates and Cox proportional analysis were performed with overall survival (OS) and complication-free survival as the primary outcome. Results: Of 354 patients, 271 received NC and 83 received NCRT [60% received SBRT and 40% received other RT (EBRT/ IMRT/ 3D-conformal therapy)]. Mean age was 66.4 years and 50.6% were females. Patients who received NCRT were more likely to be females, had higher rates of locally advanced disease, arterial involvement and received higher number of NC cycles (all p<0.05). Compared to NC, patients who received NCRT had higher rates of open surgeries and vascular resections, longer operative times, higher operative blood loss and rates of ICU admissions, longer hospital stay, higher 90-day mortality, serious complications (Clavien grade >3), lower rates of receipt of adjuvant therapy, and higher rate of complications within 1 year (all p<0.05). <br>Patients who received NCRT had significantly higher rates of GI bleed (p=0.012) and portomesenteric vessel thrombosis (p=0.0001) (Table). The most common cause of GI bleed in patients who received NCRT was a pseudoaneurysm (66.67%). On multivariate analysis, NCRT remained associated with longer (>10 days) post-operative hospital stay (OR=2.38; p=0.008), higher rate of serious complications (OR=1.95; p=0.04) and less receipt of adjuvant therapy (OR=0.41; p=0.011). On subgroup analysis of various RT modalities, SBRT was not a significant predictor of serious complications (OR=1.23; p=0.65) on multivariate analysis.<br>Patients who received NCRT had significantly shorter complication free survival within the first post-operative year compared to those who received NC, on Kaplan-Meier (p=0.018) and Cox- regression analysis (HR=1.5; p=0.049). Median OS of patients who received NCRT was not significantly different from those who received NC (28.7 vs. 31.4 months; p=0.962). Conclusion: NCRT is associated with increased morbidity following PD, which may be explained by a higher proportion of locally advanced disease and vascular resections in this cohort. In this analysis, neoadjuvant SBRT was not associated with serious complications and may offer a safer alternative to NCRT, warranting its prospective analysis.

2033 Gastrointestinal Bleeding: A Rare Manifestation of Renal Cell Carcinoma

INTRODUCTION: We describe a rare cause of gastrointestinal bleeding in a patient with metastatic renal cell carcinoma (RCC) and discuss consideration and workup of this manifestation, as it is becoming more common given improved survival of this patient cohort. CASE DESCRIPTION/METHODS: A 65-year-old male with history of RCC treated with left nephrectomy complicated by local recurrence and pancreatic tail involvement, on nivolumab, presented with melena and dyspnea. Vitals were notable for orthostasis, melena on rectal exam, and labs revealed a Hgb of 5.6 gm/dL. After resuscitation, the patient underwent push enteroscopy and colonoscopy which did not reveal a source. The following day, the patient developed large volume hematochezia with lightheadedness, hypotension, and acute blood loss anemia requiring transfusion. Given his negative endoscopy and known metastatic RCC, CT angiogram was performed demonstrating an enhancing left upper quadrant soft tissue mass invading into the small bowel lumen. Interventional Radiology was consulted and recommended against embolization due to high risk of small bowel necrosis. Subsequently, Surgery was consulted and requested video capsule endoscopy, but the patient deteriorated requiring emergent surgery. An ileal mass, confirmed to be metastatic RCC, was resected. The patient had no further bleeding and was discharged home; he continues to follow closely with Oncology. DISCUSSION: Metastases to the small bowel are a rare cause of GI bleeding, but are often due to malignancies of the breast, cervix, lung, and melanoma. RCC metastatic to the small bowel has only been described in case reports thus far, but may become more common. Advances in targeted chemotherapeutics of the VEGF and mTOR pathways lead to improved survival and thus, more opportunities for metastases. Patients may present with intussusception, bowel obstruction, or GI bleeding alone, with bleeding favored by their vascular nature. Patients will undergo extensive upper and lower endoscopic evaluation without localizing the source, prompting cross-sectional imaging which is more sensitive for confirming the diagnosis. Surgery is often required, as tumors supplied by branches of the mesenteric arteries pose significant risk of small bowel infarction if embolized. In patients with known history of RCC who present with GI bleeding, small bowel metastases should be considered as an etiology if endocscopy is negative, and obtaining CT imaging urgently may lead to timely management of such lesions.

1947 Unintentional Bread Bag Clip Ingestion Leading to High Risk Duodenal Ulcer

INTRODUCTION: Ingestion of bread bag clips has been described as a surprisingly common cause of GI bleeding or bowel perforation. CASE DESCRIPTION/METHODS: A 21-year-old man with no previous medical history or known foreign body ingestion presented after several episodes of acute onset coffee-ground and bright red hematemesis and hematochezia. Vital signs were notable for hypotension (90/65 mmHg) and tachycardia (120 bpm). Hemoglobin decreased from 15.5 to 12.2 mg/dL over four hours, and he received two units of pRBCs without an appropriate response in his hemoglobin concentration. During his EGD, we identified a 14 mm cratered ulcer with a visible vessel and an adjacent foreign body in the duodenal sweep. The object was grasped by rat-tooth forceps, but each attempt to remove it was complicated by hypotension and tachycardia. He then underwent urgent duodenotomy, where a bread-bag clip was identified and removed. Post-operative recovery was uneventful. DISCUSSION: Ingestion of foreign bodies poses a significant risk of GI bleeding or perforation. Guidelines generally recommend timely endoscopic removal of disk batteries in the esophagus, sharp objects, objects &gt;6 cm in length, or in patients with severe esophageal obstructive symptoms. Various retrieval devices are available, and an overtube may be used to protect the esophagus. Surprisingly, there are already several described cases of bread bag clip ingestion that describe esophageal, small bowel, or large bowel bleeding or perforation. The unique shape of these clips leads to snaring of mucosal tissue which may ultimately lead to progressive ulceration. Interestingly, described cases of bread bag clip ingestion occur after unknown or accidental ingestion and occurs most commonly in cognitively impaired patients. Identification of these objects is difficult due to radiolucency, and often goes unnoticed until symptoms begin. Some are amenable to endoscopic removal, while others require surgical resection.

3132 Duodenal Spindle Cell Lipoma as a Rare Cause of Upper GI Bleeding

INTRODUCTION: Spindle cell lipomas are benign tumors commonly seen arising from subcutaneous tissue. Incidence of duodenal lipoma as a cause of GI bleed is very rare, however spindle cell variant of duodenal lipoma has never been reported per our review. To our knowledge this is the first case of duodenal spindle cell lipoma in an atypical location presenting as upper GI bleed. CASE DESCRIPTION/METHODS: A 68 year old lady with medical history significant for coronary artery disease with stents and GERD came in with complaints of shortness of breath. She also complained of melena and weight loss without any hematemesis or abdominal pain. Vitals were stable. Labs remarkable for Hb 9.9, iron panel suggestive of significant iron deficiency with serum iron of 16, ferritin 17. Endoscopy showed a 5 cm non bleeding submucosal lesion with ulceration which was concerning for GIST and a possible source of chronic bleeding. Mass was not biopsied, however patient later underwent duodenal bulb lesion resection with end to end gastroduodenostomy. Pathology of intestinal resection showed duodenal mucosa with an associated spindle cell lipoma. Immunohistochemical stain of duodenal lesion was positive for S100 and CD34, and immuno-negative for remaining stains (CD117, beta-catenin, and EMA), thus consistent with spindle cell lipoma. On follow up, Hb increased and pt reported clinical improvement. DISCUSSION: Primary GI lymphoma is common in stomach. Small intestine and colonic lymphoma account for 9% and 1% respectively. There have been multiple reports published citing association of lymphoma in IBD patients treated with immunomodulators. Our patient had two stomas (ileostomy and colostomy). Both peristomal biopsies were positive for B cell lymphoma. Peristomal lymphoma has been rarely reported. Parnesh et al. (Case 1) reported a similar case of stomal lymphoma in a patient with history of Ulcerative Colitis. Levecq et al. (Case 2) reported a stromal lymphoma in a patient with transfusion related AIDS who underwent total colectomy and ileostomy for indeterminate colitis. The lymphoma was diagnosed at 20 years (case 1) and 2 years (Case 2) post-stoma formation. Lymphoma should be in the differential of stoma being complicated by peristomal tissue proliferation, fistula and infection.

A unique case of ileal Dieulafoy's lesion diagnosed and treatedbycap-assisted water immersion colonoscopy.

Ileal Dieulafoy’s lesions are rare causes of GI bleeding and are identified primarily through capsule endoscopy, single-balloon enteroscopy, or double-balloon enteroscopy. We describe a unique case of ileal Dieulafoy’s lesion identified and treated through cap-assisted water-immersion colonoscopy (Video 1, available online at www.VideoGIE.org). An 83-year-old woman with a history of transient ischemic attack on an aspirin regimen presented with a 5-day history of melena and anemia. She had a history of GI bleeding 1 year previously from presumed peptic ulcer and right-sided colonic arteriovenous malformations. Repeated EGD showed retained clips on previous ulcer sites. Colonoscopy showed a 1-cm nonbleeding ascending arteriovenous malformation with more proximal intermittent extrusion of fresh blood from the ileocecal valve. Advancement of a pediatric colonoscope (Evis Exera III PCF-PH190L/l; Olympus Medical Systems, Tokyo, Japan) with distal attachment cap (Reveal; US Endoscopy, Mentor, Ohio, USA) into the ileum revealed a trail of small scattered clots. Further advancement of the colonoscope 30 cm into the ileum (measured by withdrawal from the lesion to the ileocecal valve) demonstrated a 4-mm nonadherent clot. Irrigation of the clot uncovered a 1-mm actively pulsating bleeding vessel. Hemostasis was achieved with 3 hemoclips, and a tattoo was placed (Fig. 1). After discharge, no recurrent bleeding was observed. We highlight the use of cap-assisted water-immersion colonoscopy as a means to advance the colonoscope deeper into the small bowel compared with traditional gas distention colonoscopy. The cap extends the length of the colonoscope 3 to 4 mm, which allows the proximal adjacent intestinal folds to be pushed down ahead of the scope. In some areas where inevitable looping results and advancing the scope even 1 cm is difficult, the cap may assist in pushing down the proximal adjacent fold to help anchor the colonoscope forward and beyond where an otherwise introduced loop has difficulty advancing. Therapeutically, the cap stabilizes lesions into the field of view, preventing inadvertent deflection of the tip. The water-immersion method minimizes excessive looping and lengthening of the colon. The shortened colon length potentially allows more proximal advancement of the colonoscope. Deeper intubation of the ileum allows lesions like this one to be reached without the need for capsule or balloon enteroscopy. Cap-assisted water-immersion colonoscopy may allow more efficient and cost-effective means of identifying and treating ileal lesions thought to be otherwise unreachable by gas distention colonoscopy. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0YmI5NTA1YmQ2ZDcxMzczNmFkNmJiNmU3ZTk5ZGNjZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzQ4OTgwfQ.kUT-cUQDKFui2G-CNZc1qE2Xnpx_8VggXnt8HInPZ1TvsHQOAxBgrnGlQOrXb21rfpZsaBelzmgtc9QugNCH8jIEl0bwzSpqBj-hOyGqwahx7zMmrxqBkbF_XWU0Y-I9h-iyt_OxK_0vxGuPhe7-r4geZhxa-MZR6JSvu4t63wYcweKtN5YC6RadudcV3pjhJjo6B8XLf_lvRkrLMikeprWX06TON7qKuIP7MIFc0oboQmEKmh7you_wYi4YhKJFkAokaXdGUCjWlgAMx_a5xaBb-smXynCQVKSFYbXdhTNq41T5wbpshJJi0VyosoYFQFJGBCqpOVVbzao3upp8eg Download .mp4 (219.31 MB) Help with .mp4 files Video 1. Ileal intubation and endoscopic therapy with cap-assisted water-immersion colonoscopy.

Prescribing Warfarin to a Patient with Oesophageal Varices—A Case Report and Review of the Literature

We describe the case of a 42-year old man who presented with melaena. He was found to have bleeding varices during endoscopic investigation. Subsequent investigation revealed the aetiology to be a portal vein thrombosis (PVT) due to an underlying pro-coagulable state (Factor V Leiden). He was managed with cautious anticoagulation but suffered a life-threatening upper gastrointestinal bleed that was not amenable to endoscopic treatment or transjugular intrahepatic portosystemic shunting (TIPS). As such, the only therapeutic option involved the pursuit of surgical shunt operations. We review the literature regarding this atypical cause of GI-bleeding and discuss medical and surgical considerations for the management of such patients.

Emergency management of upper gastrointestinal bleeding

Upper gastro intestinal bleeding is one of the most common reasons of emergency department visits, totaling up to 400,000 annual admissions in the United States. Peptic ulcer disease and variceal bleeding are two of the most common causes of GI bleeding. Several studies have been done, and major advancements were made in its management leading to significant drop in morbidity and mortality. Our aim is to study the common causes of upper gastrointestinal bleeding that come to the emergency department and understand the latest guidelines to manage them. We conducted this review using a comprehensive search of PubMed, MEDLINE, and EMBASE from March 1981, through November 2017. The following search terms were used: upper gastro intestinal bleeding, management of upper GI bleeding, variceal bleeding, peptic ulcer bleeding, hemorrhage in the emergency department. Acute upper gastrointestinal bleeding is one of the most common cases encountered in the emergency department and leading to significant morbidity and mortality. Clearing airway and breathing and stabilizing the vitals of the patient by achieving hemodynamic stability and bleeding control is the primary goal in the emergency department.