Cause Of Upper Gastrointestinal Bleeding Research Articles

Acute Upper Gastrointestinal Bleeding in Hexagenerians or Older (≥60 Years) Versus Younger (

Background and aimsAcute upper gastrointestinal (UGI) bleeding is one of the serious and potentially life-threatening medical emergencies, causing significant mortality and morbidity. This study aimed to evaluate the clinico-endoscopic profile and outcome among patients aged <60 years who presented for UGI bleeding compared to those aged ≥60 years.MethodsThis prospective observational study was conducted among 194 patients who presented with symptoms or signs of UGI bleed. All patients were divided into two groups, group A (age <60 years), and group B (age ≥60 years). UGI endoscopy was performed using Olympus N19 Endoscope. Rockall scoring (RS) system and Glasgow Blatchford score (GBS) were used to predict the prognosis and re-bleeding.ResultsOf the total, group A included 150 (77.31%) patients and group B 44 (22.69%) patients. The most common presentation was hematemesis and melena in both groups, whilst isolated hematochezia was more common in group A (6.67%, vs. 2.27%, p>0.05). The main cause of bleeding was a variceal bleed in both groups, but it was significantly higher in group A patients (p<0.05). Elderly patients had a significantly higher number of peptic ulcer and malignancy-related bleed (p<0.05). Group A patients had a significantly higher proportion of patients with tachycardia (45.33%, vs. 27.27%, p<0.05), shock (43.33% vs. 13.63%, p<0.05), pallor (76.66% vs. 56.81%, p<0.05), and blood transfusion requirement (64% vs. 45.45%, p<0.05) as compared to group B. Thirty days re-bleeding and mortality rate were similar in both the groups. RS in both groups was 5.02±2.12 vs. 5.98±1.91, p>0.05. GBS was 11.65±4.61 vs. 10.68±4.65, p>0.05. Mortality was significantly higher in patients with RS ≥6 and GBS ≥10.ConclusionThis study concluded variceal bleeding as a predominant cause of UGI bleed in both age groups, and it was significantly higher in younger. Interestingly, younger patients were more hemodynamically unstable, probably due to the presence of more severe anemia, shock, and hematochezia. The presence of multiple co-morbidities in both the group kept the 30 days mortality and re-bleed rates similar.

Hemosuccus Pancreaticus: A systematic approach.

Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7±11.7years with 89.7% men. Median duration of bleeding before diagnosis was 10days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.

Helicobacter Pylori Infection is Associated with Portal ‎Hypertensive Gastropathy in Patients with Liver Cirrhosis ‎

Background and study aims‎: Portal hypertensive gastropathy (PHG) is a complication of portal hypertension in patients with liver cirrhosis, and it is considered one of the causes of upper gastrointestinal bleeding. Helicobacter pylori (H. Pylori) is one of the most common pathogenic organism worldwide because it infects 50% of the population all over the world. The role of H. Pylori infection in the development of PHG and its severity is controversial. The aim of this study is to determine the frequency of H. pylori infection in cirrhotic patients with PHG, and to find out the possible association of H.pylori infection with PHG severity. Method: This study was carried out on 90 patient with cirrhotic liver. Patients were divided into two groups according to the presence or absence of PHG diagnosed by upper endoscopy. Child's Pugh score, MELD, uMELD and detection of H.Pylori by histopathological examination were done for all patients. Results: The studied patients 47 were males and 43 were females their mean age was 51.96 ± 7.02 years (ranging between 38-66 years). H.Pylori infection was significantly more frequent in patients with PHG than patients without PHG (P= 0.001). H.Pylori infection was significantly more frequent in patients with severe PHG than those with mild PHG (P=0.012). By multi-variant analysis, splenomegaly, presence of esophageal varices, gastric varices and H. Pylori infection were independent predictors for PHG presence. Conclusion: H. Pylori infection could be an independent predictor for PHG development and ‎associated with its severity.

Outcomes of upper gastrointestinal bleeding are similar between direct oral anticoagulants and vitamin K antagonists.

The increased risk of upper gastrointestinal bleeding (UGIB) related to direct oral anticoagulants (DOACs) as compared to vitamin K antagonists (VKA) remains debated. To describe the epidemiology and outcomes of UGIB in patients treated with oral anticoagulants. A prospective, multicentre study in French general hospitals enrolled all consecutive patients with UGIB during one year. Patients treated with oral anticoagulants were retrieved from the cohort. Main outcomes were mortality and rebleeding during the first 6weeks and need for non-endoscopic treatment (surgery or interventional radiology). Among the 2498 patients included, 475 (19%) had an oral anticoagulant, mostly with VKA (267 patients [56.2%]). Baseline characteristics were similar between the groups except for renal failure and cirrhosis that were more prevalent in the VKA group. Gastroscopy was normal in 73 patients (15.3%); peptic lesions were the main cause of UGIB (n=233, 49%). Endoscopic treatment was performed in 128 patients (26.9%), leading to bleeding resolution in 74% (n=95). Mortality rate at 6weeks was 12.4% (59 patients), and was higher in the VKA group compared to DOACs (16.1% vs 7.8%, P<0.01). By multivariate analysis, only the Charlson index≥5 and UGIB occurrring in in-patients were independently associated with mortality. Rebleeding (56 patients [11.8%]) and need for non-endoscopic treatment (18 patients [3.8%]) were not associated with the type of anticoagulant. DOACs do not alter outcomes of UGIB as compared to VKA. Comorbidities and associated treatment are the most important factors worsening the prognosis of UGIB.

Dieulafoy lesions as cause of upper gastrointestinal bleeding in a patient with portal hypertension

ABSTRACT Dieulafoy’s lesion is an abnormally large and tortuous submucosal artery that protrudes through a small mucosal defect resulting in gastrointestinal bleeding. We present a case of a 53-year-old man with a history of HIV and alcohol abuse who presented to the emergency room with hematemesis and melena. Upper endoscopy revealed an actively bleeding dieulafoy lesion, but due to uncontrolled bleeding, embolization of the left artery was necessitated. The incidence of dieulafoy lesions is about 0.3% to 6.7% within the stomach. The etiology remains uncertain but has been linked to alcoholism and antiplatelet drugs. We are emphasizing the importance of considering uncommon causes of upper gastrointestinal bleeding in patients with portal hypertension.

Clinical and Endoscopic Profile of Upper Gastrointestinal Bleed: A Cross-sectional Study from a Tertiary Care Hospital in Southern India

Introduction: Acute Upper Gastrointestinal (UGI) bleed is a common potentially life threatening emergency. The aetiological profile of bleed and prognosis varies according to geographical region and availability of endoscopic facilities. Aim: To determine the clinical and endoscopic profile of UGI bleed, risk factors and prognosis in the patients. Materials and Methods: This was a cross-sectional study conducted over a period of 12 months at a tertiary care centre in Southern India. Patients admitted with history of hematemesis and melena, satisfying the inclusion criteria was taken consecutively. Clinical and endoscopic profile were noted and followed-up for six weeks. Statistical analysis was performed using chi-square test for qualitative variables and independent t-test for quantitative variables. Significance level was fixed as p-value of &lt;0.05. Results: A total of 138 patients were studied in this period. The male to female ratio in the study was 3.5:1. The mean age was 53.5±13.17 years. The most common clinical presentation was hematemesis in 57 patients (41.3%) followed by haematemesis and melena in 46 patients (33.3%). The most common cause on endoscopy was portal hypertension-related oesophageal and gastric varices (51.4%) followed by antral gastritis (15.2%). The cause of UGI bleeding could not be identified in 5.1% in which the endoscopy was normal. Haemogram, platelet count and serum albumin were significantly lower in variceal bleed group, compared to non-variceal group. Eleven patients succumbed to death secondary to UGI bleed. Conclusion: The most common causes of UGI bleed are portal hypertension related gastric and oesophageal varices. The in-hospital mortality in the study was 7.9%.

A prospective cohort study of patients presenting to the emergency department with upper gastrointestinal bleeding.

Background:Upper gastrointestinal (UGI) bleeding is a common presentation to the Emergency Department (ED), and is associated with re-bleeding and significant mortality. Although several studies have described etiology and outcome of UGI bleeding, few have been done in the EDs.Materials and Methods:This prospective observational cohort study included all patients presenting with hematemesis or melena, between June 2016 and January 2017 to the ED. Demographic data, risk factors, endoscopy findings and prognosticating scores were noted. Patients were followed up through telephonic communication after 3 months to assess re-bleeding rate and mortality.Results:The study cohort included 210 patients with a male predominance (76.2%). The mean (SD) age was 51 (16.8) years. They presented with either hematemesis (33.8%), melena (28.6%), or both (37.6%). One third (35.7%) had variceal bleed, 21% had peptic ulcer disease (PUD), and 43.3%bled due to other etiology. UGI scopy was performed in 85.2% of patients with banding (25.1%) and sclerotherapy (14%) being the most frequently performed procedures. Endoscopic intervention was not required in 58.6%of patients. Packed red cells were transfused in 46.7% patients. The 48-h re-bleed rate among variceal bleeders was 5.3% and 11.4% among peptic ulcer bleeders. The 3-month re-bleeding rate was 42.9% and the 3-month mortality rate was 17.5% among the variceal bleeders and the same was 5.6% and 2.8%, respectively, among the peptic ulcer bleeders. The overall mortality was 12.4%.Conclusions:Variceal bleeding and PUD were the predominant causes of UGI bleeding. Overall, a quarter of our patients had a re-bleed within 3 months, with majority being variceal bleeds.

"Hemosuccus pancreaticus:" an uncommon form of presentation of pancreatic intraductal papillary mucinous neoplasm.

"Hemosuccus pancreaticus" (HP), "wirsungorrhagia" or "pseudohemobilia" is a rare cause of upper gastrointestinal bleeding consisting of blood loss along the duct of Wirsung with exteriorization through the ampulla of Vater. Due to its rarity, the literature on HP is limited to retrospective studies, case reports, and case series.

Endoscopic treatment for gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40–100%; however, APC needs several treatment sessions, with a high recurrence rate of 10–78.9%. The endoscopic success rates of RFA and EBL are 90–100% and 77.8–100%, respectively; and their recurrence rates are 21.4–33.3% and 8.3–48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory–Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.

Risk Stratification in Acute Upper Gastrointestinal Bleeding Occurring in Hospitalized Patients: Comparison of Clinical Risk Scoring Systems and Clinically Significant Bleeding Criteria

Background: Upper gastrointestinal bleeding (UGIB) while being hospitalized is common, resulting in increased disability and mortality. Using the clinical risk scoring system to assess these patients is, therefore, important in assessing the necessity for endoscopic intervention, predicting rebleeding rate, and 30-day mortality rate. Objective: To assess the effectiveness of the clinical risk scoring system in terms of predicting the need of endoscopic intervention, rebleeding rate, and 30-day mortality in in-hospital UGIB patients. Materials and Methods: The patients with in-hospital UGIB who were admitted during August 2014 to August 2018 and underwent esophagogastroduodenoscopy within 72 hours after bleeding onset were included. The data were retrospectively collected. A comparison of the effectiveness of the clinically significant bleeding criteria, Glasgow-Blatchford score, and AIMS65 score was done. Results: One hundred and sixteen patients were included into the study. The main cause of UGIB was stress-related mucosal disease (SRMD) (88.8%). The effective system of predicting the necessity for endoscopic intervention was the clinically significant bleeding criteria (sensitivity 84%, specificity 74%). The effective scoring system for predicting rebleeding rate and 30-day mortality was the AIMS65 score (sensitivity 83%, specificity 59%). Conclusion: In-hospital UGIB is a common condition, mostly associated with SRMD. Patients with clinically significant bleeding would benefit from endoscopic intervention. Keywords: Upper gastrointestinal bleeding, In-hospital UGIB, Clinically significant bleeding, GBS, AIMS65

Reducing Rebleeding After Endoscopic Therapy of Dieulafoy Lesions

Although Dieulafoy lesions (DLs) are an unusual cause of upper gastrointestinal bleeding (UGIB), they are responsible for approximately 10% of severe

Findings of Esophagogastroduodenoscopy in Patients Suspected of Upper Gastrointestinal Bleeding Referred to the Main Endoscopy Unit at King Fahad Specialist Hospital.

IntroductionUpper gastrointestinal bleeding (UGIB) is defined as any blood loss originating from the esophagus, stomach or the proximal duodenum above the ligament of Treitz. Ethnic trends regarding the causes of UGIB have been reported. The aim of this study was to identify the most common causes of UGIB among patients residing in Tabuk city, Saudi Arabia.MethodsWe have conducted a retrospective descriptive cohort study at King Fahad Specialist Hospital (KFSH), Tabuk, Saudi Arabia. All adult patients above the age of 18 years who were suspected of UGIB and referred for esophagogastroduodenoscopy (EGD) were included. The collected data included age, sex, nationality, complaint, EGD, and histopathologic findings.ResultsBetween January 1, 2017 and December 31, 2019, 73 patients were included. 83.6% were Saudi, and 64.4% were males. Hematemesis was the main complaint (65.8%). Esophagogastroduodenoscopy was normal in 6.84% of cases; however, it showed UGIB due to esophageal and gastric varices (9.57%) as well as non-variceal causes (83.56%). The most frequent non-variceal findings which represent about two-thirds of the cases were duodenal ulcer (20.53%), antral gastropathy (13.68%), gastric ulcer (12.32%), antral gastritis (10.94%), and duodenal/gastric mass (9.57%), whereas much less frequent findings representing a total of 16.39% of cases included Cameron gastropathy, gastropathy/duodenopathy, esophagitis/gastritis, gastritis/duodenitis, gastroesophageal reflux disease (GERD), and Mallory-Weiss tear.ConclusionNon-variceal causes showed higher prevalence as causes of UGIB than variceal causes in the Tabuk area. Furthermore, chronic duodenal and gastric ulcers were the most common culprits of bleeding, whereas duodenitis, gastritis, esophagitis, and Mallory-Weiss syndrome were the least common non-variceal causes.

The Use of Thalidomide in Severe Refractory Anaemia Due to Gastric Antral Vascular Ectasia (GAVE) in Cirrhosis?

The chronic bleeding associated with gastric antral vascular ectasia (GAVE) presenting with cirrhosis is more severe than that associated with portal hypertensive gastropathy.Argon plasma coagulation remains the first-line treatment, but GAVE has a high recurrence rate.Thalidomide could be an effective and safe option for recurrent bleeding due to GAVE in patients with cirrhosis.

Time trends of causes of upper gastrointestinal bleeding and endoscopic findings.

Background:Upper gastrointestinal bleeding (UGIB) is a frequent cause for emergency endoscopy and, in a proportion, requires the application of endotherapy. We aim to evaluate the proportion of variceal and nonvariceal upper gastrointestinal bleeding (NVUGIB), the endoscopic findings that were detected, as well as the temporal trends of endoscopic findings over a period of 13 years.Methods:This is a retrospective study of patients who underwent an esophagogastroduodenoscopy with an indication of UGIB or presented with hematemesis, melena, or both, as well as those who had hematochezia, from January 2004 to December 2016 (13 years).Results:A total of 2075 patients were included with a mean age of 56.8 years (range 18–113) and males constituted 67.9%, while 65.9% had at least one comorbidity. Symptoms on presentation included hematemesis (52.5%), melena (31.2%), both hematemesis & melena (15.1%), and hematochezia (1.2%). The majority of UGIB were from a NVUGIB source (80.5%) and a variceal source was found in 13.1%, while no endoscopic findings were found in 6.4% of cases. The most common endoscopic diagnosis was gastroduodenal erosions (23.8%), duodenal ulcers (23.5%), reflux esophagitis (16.0%), esophageal varices (12.1%), and gastric ulcers (10.8%). There was no change in the endoscopic findings over the time period of the study. A third of duodenal ulcers (33.3%) as well as 21.9% of gastric ulcers were actively bleeding at the time of endoscopy, while 3.3% of duodenal ulcers had an adherent clot.Conclusions:NVUGIB composed the majority of cases presenting with UGIB and variceal bleeding was lower than that described in prior studies, but there were no clear trends in the proportion of causes of UGIB during the study duration.

Causes of Upper Gastrointestinal Bleeding Among Pilgrims During the Hajj Period in the Islamic Years 1437-1439 (2016-2018).

BackgroundApproximately 3.5 million pilgrims perform Hajj every year. Planning for their healthcare requires knowledge of the pattern of diseases and risk factors of pilgrims who require hospitalization during the Hajj period. The aim of the current study was to evaluate common causes and risk factors of upper gastrointestinal bleeding (UGIB) among pilgrims during the Hajj season.MethodWe conducted a retrospective cross-sectional study using a data collection checklist to collect data from medical records. We included all patients who had UGIB and attended the endoscopy department of the King Abdulaziz Hospital, Mecca, in the AL-Hajj season of the Islamic years 1437-1439 (2016-2018).ResultsA total of 93 patients were included in the current study; of those, 65.59% were males. The mean age of the patients was 63.37 ± 12.83 years, and about one-third (29.03%) of them were Indonesian. Overall, melena with or without anemia was the most common presentation (44.09%), followed by hematemesis (34.78%), melena with hematemesis (15.05%), hematemesis with ascites (9.68%), and abdominal/epigastric pain (3.23%). The most common cause of UGIB was the presence of gastric origin (erosive gastritis/gastric ulcer/gastric tumor) with 22.58% of the patients presenting with the same. The most common factors were medications, especially non-steroidal anti-inflammatory drugs (NSAIDs) (37.63%) and blood thinners (22.58%). Hypertension (31.18%), diabetes mellitus (DM) (29.03%), and chronic liver disease/failure (27.96%) were the most common chronic conditions in the studied population.ConclusionMedical orientation towards high-risk pilgrims prone to developing UGIB who intend to travel may help reduce the risk of developing the condition, by taking proper measurements of those groups by the medical teams, especially in those with preventable factors.

AORTO-GASTRIC FISTULA: A CATASTROPHIC CONNECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aorto-gastric/esophageal fistula is an abnormal communication between the gastrointestinal tract and the aorta. A high level of suspicion is required to diagnose it, as routine tests to diagnose upper gastrointestinal bleeding (UGIB) only detect one-third of the cases. We present a fatal case of aorto-gastric fistula. CASE PRESENTATION: A 60-year-old male presented to the hospital with multiple episodes of hematemesis with epigastric pain lasting for a day. He has a past medical history of esophageal adenocarcinoma treated with esophagectomy and adjuvant radiation twenty years back. The patient reported that since the last four weeks, he started taking an escalating dose of ibuprofen for new-onset lower back pain. On presentation, he was hemodynamically stable with a blood pressure of 120/70 mm Hg and a heart rate of 80 beats/minute. Physical examination was notable for epigastric tenderness. Labs revealed hemoglobin of 13gm/dl, normal electrolytes, liver, and renal function tests. He was started on intravenous fluids and intravenous pantoprazole. While we were planning for an upper endoscopy, he had an episode of large volume hematemesis leading to profound hypotension. He underwent an urgent computerized tomography scan of the chest that revealed an aorto-gastric fistula to the descending thoracic aorta. He was emergently taken to the operating room for an endovascular repair with successful repair of the fistula; however, the patient suffered a massive ischemic stroke post-procedure. Upon discussion with his family, his goals of care were transitioned to comfort. DISCUSSION: Aorto-gastric/esophageal fistula is a rare but catastrophic cause of UGIB. It can be secondary to foreign body ingestion, descending thoracic aneurysm, or malignancy. It is also seen as an early complication of esophagectomy and often presents 2-3 weeks after esophagectomy (1). The exact incidence is unknown, as a vast majority of people die before a definitive diagnosis is made. The patients present with the usual triad of symptoms called the Chiari’s triad that is characterized by midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval. Initial bleeding causes a drop in blood pressure that leads to a temporary cessation of bleeding due to clot formation (2). However, once the fluid resuscitation begins, there is clot dislodgment and rebleeding. CT arteriogram can show active extravasation from the aorta. Once the fistula is diagnosed, it should be treated emergently with aortic stenting and repair to control the bleeding. CONCLUSIONS: Gastrointestinal bleeding due to aorto-gastric fistula is a devastating and life-threatening complication of esophagectomy. It should be kept in mind that this often presents as a herald bleed, and causes massive bleeding after a symptom-free interval. Hence, timely intervention is essential. Reference #1: Molina-Navarro C, Hosking SW, Hayward SJ, Flowerdew AD. Gastroaortic fistula as an early complication of esophagectomy. Ann Thorac Surg. 2001;72(5):1783-8. Reference #2: Kokatnur L, Rudrappa M. Primary aorto-esophageal fistula: Great masquerader of esophageal variceal bleeding. Indian J Crit Care Med. 2015;19(2):119-21. DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Dimitrios Drekolias, source=Web Response No relevant relationships by Raymond Foley, source=Web Response No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Anantha Sriharsha Madgula, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response

S2193 Splenic Artery Collaterals Masquerading as Gastric Varices: An Uncommon Cause of Massive Upper GI Bleed

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is most commonly due to peptic ulcer disease (PUD). However in patients with splenic artery thrombosis, collateral arterial vessels can develop. If these abnormal vessels erode into the stomach mucosa, massive UGIB can occur. Here we present a case of UGIB from submucosal splenic collateral arteries. CASE DESCRIPTION/METHODS: A 56 year old male with history of Factor 5 Leiden and antiphospholipid antibody syndrome (APLS) presented with melena and hematemesis. Esophagogastroduodenoscopy (EGD) showed possible gastric varices in the fundus with an area of ulceration (Figure 1). The patient’s prior history of heavy alcohol use and the presence of a nodular liver on CT scan suggested underlying cirrhosis and portal hypertension as the etiology for the gastric varices. However the patient was found to have a low hepatic venous pressure gradient (2 mmHg) and a subsequent liver biopsy did not reveal cirrhosis. The splenic vein was also noted to be patent on CT scan. Several days after admission, the patient experienced another episode of hematemesis with associated hypotension and tachycardia. CT angiogram at the time did not reveal any active bleeding, but did show a splenic artery thrombosis with several collateral vessels. Subsequent angiogram demonstrated large arterial collaterals in the gastric fundus with outflow to the spleen, bypassing the occluded splenic artery (Figure 2). These collateral vessels were embolized successfully and he had no further bleeding. DISCUSSION: This case highlights the importance of multidisciplinary patient care and careful assessment of a patient’s medical history and anatomy to accurately diagnose and treat underlying pathology. While our patient was thought to have varices on EGD, he did not have cirrhosis, splenic vein thrombosis or portal hypertension which made the diagnosis of gastric varices unlikely. However, he did have a splenic artery thrombosis due to underlying APLS which led to the formation of submucosal gastric arterial collateral vessels and UGIB. Submucosal arterial collateral vessels are a rare cause of UGIB and there are only a few cases described in the literature. They can form as a result of splenic artery thrombosis due to underlying coagulopathy, pancreatitis, abdominal trauma or congenital absence of the splenic artery. If these abnormal collateral vessels erode through the stomach mucosa, they can lead to UGIB. Treatment involves surgery (partial gastrectomy and splenectomy) or embolization.Figure 1.: Possible gastric varix in the stomach fundus with an area of ulceration seen on EGD.Figure 2.: Angiogram demonstrating large arterial collaterals in the gastric fundus with outflow to the spleen, bypassing an occluded splenic artery.

S2986 Ischemic Gastropathy in a Patient With Severe Atherosclerotic Disease Treated With Mesenteric Revascularization

INTRODUCTION: Gastric ischemia is rare due to the rich vascular supply to the stomach. This arterial supply is achieved through five major direct sources, which include the right and left gastric, the right and left gastroepiploic, and the short gastric arteries. Upper GI bleeding caused by Ischemic gastropathy from mesenteric ischemia is rare, however isolated gastric ischemia resulting in bleeding is even less common with only few cases reported in literature. We report a case of a 71-year-old man with history of peripheral vascular disease who presented to the hospital with upper GI bleed. CASE DESCRIPTION/METHODS: A 71-year-old man with history of severe peripheral vascular disease, hypertension and hyperlipidemia presents to the hospital with complaints of abdominal pain worsened by food ingestion and melena. On presentation Hb was 7.4 mg/dL, which dropped to 6.0 mg/dl. CT scan of the abdomen showed diffuse atherosclerosis of the celiac, superior mesenteric (SMA) and inferior mesenteric arteries. Patient underwent upper endoscopy which showed multiple ulcers through the body of the stomach as well as areas of pale gastric mucosa raising suspicion for ischemic gastropathy. Patient underwent aortogram which showed celiac artery occlusion and severe stenosis of the SMA. Subsequent stenting of the SMA resulted in the resolution of patient’s symptoms. Repeat EGD performed 8 weeks later showed healing of the ulcers. DISCUSSION: Ischemic gastropathy is a rare cause of upper GI bleeding due to the rich blood supply of the stomach. The definitive treatment is revascularization. It should be suspected in patients with risk factors that presents with upper GI bleeding and endoscopic findings of multiple ulcers and pale gastric mucosa. Few cases showed clinical improvement with revascularization of the superior mesenteric artery. Our patient is a rare case of isolated ischemic gastropathy with complete occlusion of the celiac artery who responded to SMA revascularization.Figure 1.: Endoscopy showing multiple ulcers.Figure 2.: Patchy areas of pale mucosa observed during first EGD.Figure 3.: Last endoscopy showing appropriate ulcer healing.

S3445 Dieulafoy’s Cecal Lesion: A Rare Cause of Lower GI Bleeding

INTRODUCTION: Dieulafoy’s lesion is a rare cause of upper GI bleeding and even a much rarer cause of cecal bleeding. It is most commonly located in the lesser curvature or proximal body of the stomach but rare occurrences in extra gastric sites have been reported. They often elude diagnosis due to their small size, normal surrounding mucosa and intermittent nature of bleeding episodes. CASE DESCRIPTION/METHODS: A 79 year old male with past medical history of CAD, Paroxysmal atrial fibrillation on long term anticoagulation with xarelto presented to the ED with complaints of dark tarry stools for 4 days. Hemoglobin level was noted to be 13.2g/dl two days prior to admission and on day of admission was noted to be 10.9gdl. Further work up revealed positive occult blood, TIBC level of 464, ferritin level of 57 and a transferrin saturation of 15. Xarelto was held and patient underwent upper and lower endoscopic assessment. Colonoscopic assessment revealed an active bleeding cecal dieulafoy’s lesion that was successfully clipped with three hemostatic clips and epinephrine infiltration to the surrounding area. Hemostasis was achieved, patient’s hemoglobin remained stable post procedure and he was subsequently discharged home after 48 hours. DISCUSSION: Dieulafoy’s lesion (DL) also known as caliber persistent artery accounts for about 1- 2 % of GI bleeding. It is a dilated aberrant submucosal artery that impinges and erodes through the muscularis mucosae. The overlying mucosa shows erosion and the surrounding mucosa appears normal. Almost two thirds of the lesions are located in the stomach along the lesser curvature. The remaining one third of lesions are extra gastric mostly involving the duodenum followed by the colon. Endoscopy is the gold standard of diagnosis but is only successful in detecting 49-70% of the lesions mostly because of the small nature of the lesions, normal surrounding mucosa and intermittent nature of hemorrhage. Repeat endoscopy is usually effective in diagnosis especially if repeated on a different occasion. Angiography is useful in diagnosis when endoscopic evaluation is unsuccessful in localizing the lesion. Treatment of DL involves a combination of epinephrine injection followed by bipolar probe coagulation, thermal coagulation or hemoclip placement. Conclusion: Dieulafoy’s lesion of the cecum, though rare, can be a cause of life-threatening lower GI bleeding and can easily be diagnosed and treated during endoscopic assessment.Figure 1.: An actively bleeding dieulafoy cecal lesion.Figure 2Figure 3.: Hemostasis achieved with three hemostatic clips.

S2121 Overt Small Bowel Bleeding From a Jejunal GIST

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare causes of gastrointestinal malignancies. Herein we describe a cause of upper GI bleeding from a jejunal GIST. CASE DESCRIPTION/METHODS: A 58-year-old male with history of chronic hepatitis B, hypertension and hyperlipidemia presented to the hospital with melena and lightheadedness. The patient was hemodynamically stable with an elevated BUN/creatinine ratio and initial hemoglobin of 11.5 g/dL. His repeat CBC twelve hours later revealed down trend of hemoglobin to 8.5 g/dL. Review of the patient’s past admission and outpatient history revealed the patient was admitted two years prior for GI bleed requiring multiple blood transfusions. At that time, upper endoscopy, colonoscopy and CT scan of the abdomen/pelvis were unrevealing as was a 99 Technetium bleeding scan. He was discharged and scheduled for outpatient small bowel video capsule but was lost to follow up. He returned to the clinic one year later and repeat upper endoscopy and colonoscopy were performed. Upper endoscopy revealed mild gastritis and colonoscopy revealed medium sized hemorrhoids but he had a poor colon bowel prep. Small bowel video capsule endoscopy revealed AVM's in the proximal small bowel but the study was also poor due to bile obscuring most of the small bowel mucosa. Due to concern for possible small bowel AVM bleed, we opted to perform upper endoscopy with push enteroscopy. A large ulcerated friable nodular mass with stigamata of recent bleeding was identified in the proximal jejunum. Bite on bite biopsies were obtained to evaluate the mass and a tattoo was placed for identification purposes. Despite the deep biopsies, pathology later returned as normal small bowel mucosa. A CT enterography was obtained revealing a 3.5 × 3.6 × 3.5 cm hyperenhancing mass arising from the proximal jejunum with adjacent wall thickening. Surgical consultation was obtained and the patient underwent laparoscopic resection of the mass. Pathology demonstrated low grade spindle-cell type gastrointestinal stromal tumor. DISCUSSION: Although an uncommon cause for GI bleeding overall, GISTs are a common cause of small bowel bleeding. Obtaining a thorough history and evaluation of the patient’s prior outpatient records proved useful in identifying the cause of bleeding in this case even though it was different from what was suspected.Figure 1Figure 2