Cause Of Upper Gastrointestinal Bleeding Research Articles

Interventional treatment of a huge hepatic artery aneurysm as an unusual cause of upper gastrointestinal bleeding

Interventional treatment of a huge hepatic artery aneurysm as an unusual cause of upper gastrointestinal bleeding

Demographic profile and endoscopic findings among patients with upper gastrointestinal bleeding in Ahmadu Bello University Teaching Hospital, Zaria, North-Western Nigeria.

Upper gastrointestinal bleeding (UGIB) is a common medical emergency that can result in significant morbidity and mortality. The aim of this study was to determine the demographic profile and etiology of UGIB in patients seen at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, North-Western Nigeria. This descriptive retrospective study was carried out at the Gastroenterology Unit of ABUTH Zaria. Data of patients referred for upper gastrointestinal endoscopy with UGIB from June 2017 to December 2019 were extracted from the endoscopy register and analyzed. One hundred and forty-four patients had upper gastrointestinal (UGI) endoscopy done for UGIB during the period under review. Of these, 105 (72.9%) were males while 39 (27.1%) were females with male-to-female ratio of 2.7:1. The mean age of the patients was 43.5 ± 17.3 and their age ranges from 11 to 89 years. The modal age group was 40-49 years. The most common cause of UGIB was esophageal varices (67 [46.5%]) followed by erosive mucosal diseases: gastritis/duodenitis 43 (29.9%), esophagitis 12 (8.3%). Less common causes were peptic ulcer disease (PUD) in five (3.5%) patients, gastric tumor in two (1.4%), hiatus hernia in one (0.7%), and portal hypertensive gastropathy in one (0.7%). Thirteen patients (9.0%) had normal findings. Esophageal varices are the most common cause of UGIB among our patients and middle-aged male patients were the most commonly affected group.

UPPER GASTROINTESTINAL ENDOSCOPY IN IDO-EKITI, NIGERIA: A FOUR-YEAR REVIEW

Background: Upper gastrointestinal complaints are common, and the underlying diseases varies widely. Upper gastrointestinal endoscopy is the gold standard investigation for upper gastrointestinal symptoms. It helps in the proper diagnosis and the appropriate management of the underlying lesions. Aim: To determine the characteristics of the patients undergoing upper gastrointestinal endoscopy in a rural community in south-western Nigeria. Methods: This was a retrospective cohort study of all patients who had upper gastrointestinal endoscopy between February 2016 and February 2020 (a period of 4 years). The Age, Gender, Indication and the Endoscopy findings were obtained from the Endoscopy Register. A total of 181 upper gastrointestinal endoscopies had been performed over the period. The data obtained was analyzed using the Statistical Package for the Social Sciences (SPSS) version 21.0. Descriptive statistics used included frequency tables, means and standard deviations. Results: A total number of 181 Oesophagogastroduodenoscopies (OGDs) were performed during the period under review, out of which 95 (52.5%) were males and 86 (47.5%) were females with a male to female ratio of 1.1 to 1. The age range of the patients was 9 to 89 years with a mean(±SD) of 52.4(±1.69) and median of 52.0 years. The highest number of OGDs were performed on individuals within the age bracket of 50-59 years whom were mostly females. Dyspepsia constituted the commonest indication for OGD (51.9%) followed by symptoms of upper gastrointestinal bleeding (haematemesis/melaena) 16.0%, unexplained persistent vomiting 6.6% and clinical suspicion of a gastric tumour 5.5%. The commonest endoscopic abnormality detected from this study was Gastritis 28.2% followed by Gastric erosions 12.2%, Duodenal ulcers 8.8%, Gastric tumours 8.3% and Oesophagitis 7.2%. Normal endoscopy findings were found in 24.9% of the patients. Gastritis was also the commonest endoscopic finding (constituting 40.4%) in patients who had OGD done on account of dyspepsia followed by Duodenal ulcers (8.5%) and Gastric erosions (6.4%). Gastric erosions constituted the commonest cause of upper gastrointestinal bleeding in this study (44.8%) followed by Duodenal ulcers (13.8%). Conclusion: The commonest indication for upper gastrointestinal endoscopy in this study was dyspepsia while the commonest endoscopic diagnosis was gastritis. Gastric erosion was most commonly seen in patients with upper gastrointestinal bleeding. From this study, Acid-Peptic disorders were the commonest underlying gastrointestinal pathologies of patients’ symptomatology necessitating endoscopic evaluation. The findings from this study conducted in a rural community in Nigeria were similar to those conducted in urban communities in the country. Therefore, a national guideline on the endoscopic evaluation of upper gastrointestinal disorders can be universally applied irrespective of the location of practice in Nigeria.

Proton Pump Inhibitors for Acute Upper Gastrointestinal Bleeding.

Upper gastrointestinal bleeding (UGIB) is common, with an annual incidence of approximately 67 to 150 per 100,000, with estimated mortality rates between 6% and 15%.1 Many patients require hospital admission and ultimately endoscopic evaluation for diagnosis and treatment of the hemorrhage. It is standard practice to start patients with undifferentiated UGIB on acid suppression therapy with an intravenous proton-pump inhibitor (PPI) in the emergency department prior to admission or endoscopy.2 This practice is based on data that the most common cause of UGIB is peptic ulcer disease. Intravenous PPI may create optimal conditions for clotting over arteries at ulcer bases, as neutralization of gastric acid leads to stabilization of blood clots.

Management of upper gastrointestinal bleeding

This paper will describe the common symptoms, signs and causes of upper gastrointestinal bleeding. We will then provide advice on the management of upper gastrointestinal bleeding at primary care level.

1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia. CASE DESCRIPTION/METHODS: A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery. DISCUSSION: Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.

2027 Upper GI Bleeding With Black Esophagus: Case Report of Acute Esophageal Necrosis

INTRODUCTION: Acute esophageal necrosis, a very rare cause of upper GI bleeding, is seen mainly in elderly men. We report a new case in an elderly woman. CASE DESCRIPTION/METHODS: A 90-year-old woman with a history of DM, HTN, and CHF presented with SOB and abdominal pain of 2-day duration. She didn’t vomit. Confusion, pallor, and large melanotic bowel movement were noted. Temperature was 36.1°C, BP 86/68 mmHg, HR 104 bpm, and RR 22 br/min. She had bilateral shallow coarse breath sounds and otherwise unremarkable abdominal and neurological exams. Urine ketones was negative, plasma glucose 98 mg/dL, WBC 40.8 K/mcL, hemoglobin 9.3 g/dL, platelet 437 K/mcL, GFR 18 mL/min/1.73 m2, lactate 15.5 mmol/L, and procalcitonin 1.49 ng/mL. Blood culture was negative. Chest CT showed small bilateral pleural effusions and ground glass opacities. Abdominal CT showed fecal impaction. Working diagnoses included septic/hypovolemic shock, pneumonia, encephalopathy, acute upper GI bleed, and acute hypoxic respiratory failure. Volume resuscitation, vasopressors (norepinephrine, phenylephrine, and vasopressin), mechanical ventilation, broad spectrum antibiotics (vancomycin, cefepime, and azithromycin), total parenteral nutrition, and proton pump inhibitor were started. EGD revealed friable, black, circumferential esophageal mucosal changes starting 25-30 cm from incisors and extending to GE junction without gastric outlet obstruction (Figure 1). Follow up EGD one week later showed slow healing with black and thin tissue, starting 4 cm proximal to GE junction without stricture (Figure 2). She continued to be encephalopathic, requiring mechanical ventilation and vasopressor support. She died upon intensive care withdrawal at family request. DISCUSSION: Our patient had endoscopic diagnosis of acute ischemic esophagitis, which was likely due to compromised esophageal perfusion secondary to septic/hypovolemic shock in the setting of chronic vascular compromise. Biopsy to differentiate ischemic esophageal necrosis from other etiologies, such as infection and malignancy, carries a high risk for perforation and was not performed. As seen in our patient, acute esophageal necrosis typically affects the relatively hypovascular distal esophagus down to GE junction and quickly resolves when blood flow is restored. Nevertheless, mortality remains high due to the underlying conditions. Unlike our case, acute esophageal necrosis affects mainly men, with a men/women ratio of 4/1.

2039 Invasive "Intracholecystic Papillary-Tubular Neoplasm" (ICPN) Presenting as Hemobilia in a Jehovah's Witness Patient

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal bleeding, which requires high index of suspicion for diagnosis. In various case series, hemobilia due to neoplastic disease of the hepatobiliary system ranges from 6% - 15%. ICPNs are rare neoplasms of the gallbladder that are usually detected incidentally. This is a case of a Jehovah’s Witness patient with severe symptomatic anemia secondary to hemobilia due to invasive ICPN. CASE DESCRIPTION/METHODS: 71-year-old Jehovah’s Witness patient with a 4 month history of anemia, suspected to be due to multiple small intestine angioectasias seen on prior enteroscopies, presented with a 3 day history of fatigue, dyspnea on exertion, and melena. Patient’s hemoglobin/hematocrit at presentation was 6.4/23.4. She underwent gastroduodenoscopy which showed blood in the second part of the duodenum which prompted a side viewing duodenoscopy examination which showed blood oozing from the ampulla (Figure 1). Abdominal MRI showed markedly distended gallbladder with polypoid appearing wall thickness and blood (Figure 2). Patient received iron infusions to improve hemoglobin and hematocrit. She then underwent open cholecystectomy, and intraoperatively the surgeons did not appreciate any mass lesion in the gallbladder. Surgical pathology found invasive mucinous adenocarcinoma (1.0 cm) arising from a large (14.5 cm) ICPN with high-grade dysplasia (Figures 3a,b). The tumor invaded the muscularis propria and had negative cystic duct margins for carcinoma or dysplasia. Two lymph nodes were positive for malignancy. It was staged as III-b and pT1b, pN1, pMx. After discussion in the tumor board, she was recommended to have surveillance imaging in 3 months because her comorbidities precluded chemotherapy. DISCUSSION: To the best of our knowledge this is the only reported case of ICPN presenting as hemobilia. Residual changes of ICPN are seen in only 6.4% of the patients with invasive GB carcinomas. The presence of angioectasias in the small intestine acted as a red herring in this patient. The fortuitous timing of endoscopy to visualize bleeding from the ampulla clinched the diagnosis of hemobilia. The presence of blood in the gallbladder made it difficult to identify the mass lesion which was eventually confirmed on surgical pathology. Hemobilia should always in the differential diagnosis for patients presenting with upper GI bleed and should be actively investigated when no obvious bleeding lesions are noted from the gastric or intestinal mucosa.

1937 A Deadly Diagnosis: Aortic Stent Causing Aorto-Esophageal Fistula

INTRODUCTION: An aorto-esophageal fistula (AEF) is a rare but life-threatening cause of upper gastrointestinal bleeding caused by an abnormal communication between the esophagus and aorta. Etiologies include foreign body ingestion, malignancy, post-operative trauma, and ruptured TAA. We present the fatal case of a patient with profound anemia who suffered catastrophic consequences secondary to graft-esophageal fistula. CASE DESCRIPTION/METHODS: A 66-year-old male with history of percutaneous thoracic endovascular aortic repair 3 months prior presented with complaints of 2 weeks of dizziness, nausea, and intermittent dark stools. EGD/colonoscopy 2 months ago were negative for acute GI bleed. Upon evaluation, the patient was mildly tachycardic with positive orthostatic vital signs and fever of 100.4 F. Rectal exam did not demonstrate gross blood. Labs were remarkable for Hgb 6.8 with repeat 5.9, WBC 14, and BUN 14. CTA chest was done to investigate tachycardia and identified an enlarging distal aortic endoleak with stable short segment dissection. Vascular surgery was consulted but felt the endoleak was chronic. CT A/P ruled out retroperitoneal hematoma and he was treated with transfusions and beta blocker therapy. Following recurrent melena, our EGD revealed two areas concerning for aortic stent erosion into the esophagus at 34 and 36 cm from incisors with trace oozing, locating the source of hemorrhage. Vascular surgery reevaluated the patient with plan for graft removal and reconstruction of thoracic and abdominal aorta. Unfortunately, before advancing to surgery he decompensated after large volume hematemesis. Vasopressors were initiated for hemorrhagic shock but life-sustaining measures were eventually discontinued to respect family wishes. The etiology of his acute symptomatic anemia and massive hemorrhage was suspected to be graft-esophageal fistula. DISCUSSION: AEF is an unusual post-operative complication of prosthetic aortic repair. Secondary AEF can develop after open or endovascular repair of the aorta, occurring in 1.9% of patients post-endovascular aortic repair. Pathophysiology remains unclear but it is thought to arise from erosion of graft material into esophagus, graft infection with abscess rupture, or anastomotic pseudoaneurysm. Our case emphasizes the importance of raising clinical suspicion not only for hematemesis but for new onset fever with elevated inflammatory markers in the appropriate clinical setting as well as the need for emergent surgical intervention to avoid fatal outcomes.

1917 Fatal Gastrointestinal Hemorrhage Secondary to Rare Aortoesophageal Fistula in a Patient With Esophageal Adenocarcinoma

INTRODUCTION: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding which is associated with extremely high mortality despite timely intervention. We present a fatal case of gastrointestinal hemorrhage from AEF in a patient with esophageal adenocarcinoma who had recently undergone esophageal stent placement and chemoradiation therapy. CASE DESCRIPTION/METHODS: A 77 year-old Caucasian man with a past medical history of cirrhosis and TNM stage IIIA hepatocellular carcinoma, status post Yttrium-90 radioembolization in April 2017, presented with progressive dysphagia in January 2018. Patient underwent esophagogastroduodenoscopy (EGD) revealing a partially obstructing, non-bleeding mass at the gastroesophageal (GE) junction (Figure 1) and placement of an esophageal stent. Dysphagia improved post stent placement. Biopsy was consistent with primary adenocarcinoma of the esophagus. He received concurrent chemoradiation therapy with paclitaxel and carboplatin. In April 2018, patient presented to the emergency department with presyncope, hematemesis and epigastric pain. He was hyptotensive with a blood pressure of 88/56 mm Hg and anemic with a hemoglobin of 7.6 g/dL. Repeat EGD was performed with unintentional migration of stent into stomach, revealing friable and ulcerated mucosa in the lower esophagus (Figure 2). Retrieval of the dislodged stent caused the ulcerated mucosa to bleed. Hemostatic clip could not adhere to inflamed mucosa and a stent was placed to minimize bleeding. Interventional radiology was consulted. Fluoroscopy revealed presence of a small aortoesophageal fistula at the site of active bleeding (Figure 3). Hemostasis was achieved with coil embolization. Unfortunately, a few hours later, patient had a recurrence of massive re-bleed and expired. DISCUSSION: Esophageal malignancy is one of the primary causes of AEF. Thoracic radiation as a standalone cause has also been documented in non-esophageal malignancies. Several reports also document that aortic grafts and esophageal stents increase the risk of AEF development in patients who undergo radiation. This case adds to the growing literature that presence of esophageal stent and subsequent radiation compounds risk of AEF development in patients with esophageal tumors. Further studies are warranted for risk stratification. Such patients presenting with hematemesis and syncope need immediate AEF evaluation and emergent intervention.

3139 Variceal Bleeding, Beyond the Liver Disease: Case Report

INTRODUCTION: Varices are dilated blood vessels in the esophagus or stomach caused by portal hypertension. They cause no symptoms unless they rupture and bleed, which can be life-threatening (1). We report unusual cause of variceal bleeding which is polycythemia rubra Vera causing splenic vein thrombosis. Splenic vein thrombosis (SVT) is known as one of the rare causes of upper gastrointestinal bleeding and is mostly seen in the fifth decade of life and male sex (2). CASE DESCRIPTION/METHODS: 39 years old Lady presented to the emergency room with history of hematemesis and melena for 2 days. She had chronic headache for that she is advised to take paracetamol but did not work, so she took ibuprofen. She had more epigastric pain for which she took continuous ibuprofen too. She never had symptoms of dizziness, black out/syncope or palpitations with/without standing. Although she had active hematemesis and melena but her hemoglobin never dropped below 10 g/dl. She had no history of any chronic illness or surgical intervention. She was not smoker and denied alcohol intake. Gastroscopy revealed: Esophagus: normal, no varices Stomach: full of blood and there is large clot in the fundus. Large fundal varices (tortuous and complex). Isolated gastric varices IGV1: 2 large FIII ulcer seen in the fundus with one visible blood vessel seen on one gastric fold just near to gastroesophageal junction (Dieulafoy's lesion) which is typical for location. One rubber band was applied on the visible vessel. 1 mg histoacryl was injected in varices and hemostasis is maintained. Duodenum: normal. DISCUSSION: isolated obstruction (mainly due to thrombosis) of the splenic vein usually results in left-sided portal hypertension and isolated fundal varices formation. This syndrome is a rare cause of gastrointestinal bleeding. Pancreatic diseases are among the most common etiologies of splenic vein obstruction. Renal disorders are rarely reported as a cause of splenic vein thrombosis 3. We screen for most thrombophilia causes (Table 1). So, we deal with patient with Non cirrhotic liver. Isolated splenic vein thrombosis. Massive splenomegaly Negative hemophilia screen. No evidence of pancreatitis or pancreatic mass on cross sectional imaging. When we review her lab we noted that she had persistently high WBC, platelet and Hematocrit despite GI bleeding, so we screened for myeloproliferative Disorders, and we found mutation for JAK 2 exon 12 is positive. And this patient met the WHO criteria for polycythemia Vera. thrombophilia screen negative.

2013 Thoracic Aortic Erosion Into the Esophagus With Aortoesophageal Fistula

INTRODUCTION: Aortoesophageal fistula is a rare but well described life-threatening cause of upper gastrointestinal bleeding. Primary aortoesophageal fistula is predominately caused by descending thoracic aortic aneurysms (52.4%), followed by foreign body ingestion and esophageal carcinoma.1–3 Secondary aortoesophageal fistula is an increasingly recognized complication of thoracic endovascular aortic repair (TEVAR), occurring in 1.7-1.9% of cases.4,5 CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of known 6cm thoracic aortic aneurysm was transferred to our facility for one day of hematemesis and hematochezia to undergo upper endoscopy. On arrival the patient had an emergent esophagogastroduodenoscopy which revealed a visible thoracic aorta through a large transmural defect adjacent to an aortoesophageal fistula in the middle esophagus (Figure 1). After the procedure, the patient underwent emergent CTA of the aorta, which revealed corresponding images to the endoscopic findings with an aortoesophageal fistula directly superior to an area of thoracic aorta protruding into the esophagus (Figure 2). The patient then had an emergent endovascular repair of the aortoesophageal fistula and thoracic aortic aneurysm with fluoroscopic images demonstrating successful graft deployment and fistula closure (Figure 3). DISCUSSION: Aortoesophageal fistula is a life-threatening condition that must be on a gastroenterologist’s differential for upper GI bleeding, in particular in patients with a known aortic aneurysm. Proper and rapid identification of the diagnosis is essential to allow for emergent vascular intervention and hemostatic control. Additionally, literature review highlights a paucity of evidence on the options for endoscopic intervention with esophageal stents. In this particular case, there was fortunately no active gastrointestinal bleeding at time of endoscopy and the patient had successful endovascular grafting; however, there are a number of case reports suggesting that esophageal stenting may be another therapeutic option if there is active esophageal hemorrhage, albeit more of a temporizing measure and one associated with a number of complications.3,6,7

2003 Extragastric Dieulafoy’s Lesion: A Rare and Often Missed Cause of Upper Gastrointestinal Bleeding

INTRODUCTION: Dieulafoy’s lesions (DL) are an important, potentially life threatening, cause of gastrointestinal (GI) bleeding. Dieulafoy’s lesions are dilated, aberrant, submucosal arteries that erode overlying GI mucosa in the absence of an underlying ulcer, aneurysm, or intrinsic mural abnormality. They account for approximately 1.5% of acute upper GI bleeding and 70% of these lesions are found within 6 cm of the gastroesophageal junction. Although uncommon, DL have been reported in the duodenum, distal stomach, and esophagus. We present a case describing the discovery and management of an extragastric DL within the duodenum. CASE DESCRIPTION/METHODS: An 83-year-old male with multiple comorbidities, on warfarin therapy, presented to the hospital by instruction of his primary care physician for evaluation of a low hemoglobin (Hgb). He has a history of chronic anemia with regularly monitored Hgb. The patient endorsed 4 days of painless, dark, loose stools. He reported a similar episode to this several years prior and underwent upper and lower endoscopy, which were unrevealing. Capsule endoscopy at that time did show a small bowel arteriovenous malformation, but otherwise unremarkable. On admission, the patient was hemodynamically stable with mild pallor noted on exam. Initial workup revealed Hgb of 6.8 g/dL and an INR of 3.1. Upper endoscopy was performed revealing a single spurting spot of active bleeding in the second part of the duodenum consistent with a DL. The area was successfully treated with epinephrine, coagulation, and hemostatic clips. He remained hospitalized for five days post-procedure for medical optimization. His Hgb remained stable and his warfarin was resumed. DISCUSSION: Dieulafoy’s lesions are a rare cause of upper GI bleeding that should always remain on the differential diagnosis. While gastric DL are well-known, there are few reports describing DL of the duodenum. The scarce nature of their occurrence make these lesions difficult to diagnose. Thorough endoscopic evaluation is usually the first diagnostic test performed for acute upper GI bleeding. Thus, this is the primary modality used for the diagnosis of DL. Initial EGD is diagnostic in only about 70% of cases due to relatively small lesion size, intermittently active bleeding, and lesion location. This case represents a patient with acute on chronic anemia that had previously undergone a thorough investigation with few answers. Serial Hgb monitoring and follow-up endoscopy led to the discovery and treatment of his duodenal DL.

3002 Several Endoscopies Later, Hemosuccus Pancreaticus Comes to Light

INTRODUCTION: Hemosuccus pancreaticus (HP) is an extremely rare cause of upper gastrointestinal bleeding occurring in an estimated one in 1,500 cases. HP is believed to occur through a vascular malformation within the splenic artery leading to intermittent bleeding within the pancreatic duct. The most common causes of HP are due to chronic inflammatory changes from pancreatitis, pseudocysts, or pancreatic malignancy. HP is a challenging diagnosis due to intermittent bleeding, difficulty in localizing anatomical structures, and vague clinical symptoms. Clinically, patients present with vague abdominal pain and intermittent gastrointestinal bleeding not often visualized on EGD, which make diagnosis extremely challenging. Upper GI bleeding can have different etiologies, including but not limited to, peptic ulcer disease, varices, Mallory-Weiss tears, and angioectasis. A rare form of upper GI bleeding can be caused by HP, which is described as bleeding from the pancreatic duct via the Ampulla of Vater. Here we present a case of Hemosuccus Pancreaticus after ruling out common causes. CASE DESCRIPTION/METHODS: 45-year-old male with medical history significant for chronic pancreatitis complicated by enlarging pancreatic cysts and alcoholic cirrhosis, who presented with melena, left upper quadrant pain, and significant acute blood loss anemia. Patient had several admissions to our facility and underwent several endoscopic procedures without an obvious etiology. During endoscopy on his most recent admission, blood was seen oozing from the ampulla concerning for HP. Patient then had diagnostic angiography by IR notable for distal aneurysm formation communicating with the distal pancreatic duct. Once patient had been discharged, patient had another episode of syncope and was transferred to another facility where he had ultrasound-guided right common femoral artery arteriogram with subsequent coiling of a large pseudoaneurysm arising from the inferior pancreatic artery. DISCUSSION: Hemosuccus Pancreaticus is a rare entity but can be seen in patients with chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. HP occurs when a direct communication is formed between the pancreatic duct and a vessel after a pancreatic cyst or malignancy erodes into an arterial pseudoaneurysm. Given the fact that this diagnosis is rare and can be potential life-threatening with the rupture of the pseudoaneurysm, it is imperative for physicians to be familiar with the pathology, presentation, and appropriate management of HP.

Gastrointestinal: A rare cause of upper gastrointestinal bleeding: Epiphrenic esophageal diverticula

An 87-year-old man presented to the Emergency Department after a syncopal event at home associated with a 3-day history of melena. This was on a background of ischemic heart disease with previous coronary artery bypass graft and recent transesophageal echocardiogram cardioversion for atrial fibrillation 10-days prior. He was commenced on apixaban during this admission and re-commenced on aspirin by his general practitioner on review post discharge. On assessment, he was hemodynamically stable, with melena noted on digital rectal examination. His laboratory results revealed a hemoglobin of 68-g/L, urea of 22.8-mmol/L, and INR of 1.7. He was commenced on intravenous pantoprazole (proton pump inhibitor), transfused with two units of packed red blood cells, and underwent a gastroduodenoscopy the following day. Upper endoscopy revealed a 2–2.5-cm diameter esophageal diverticulum (Fig.-1) just above the gastroesophageal junction (GOJ) in the right posterior-lateral wall. There was no active bleeding, but there was evidence of recent bleeding with altered blood and mild mucosal erythema in the surrounding tissue. The remainder of the endoscopy also identified two further diverticula: one in the gastric fundus within a large hiatus hernia with evidence of some altered blood and a 3rd diverticulum noted in the second portion of the duodenum with no evidence of a recent bleed. No endoscopic therapy was required at the time for hemostatic control due to the absence of active bleeding or visible high-risk stigmata. We proceeded with a computed tomography of the chest and upper abdomen (Fig.-2) as well as a barium swallow that confirmed numerous diverticula involving the GOJ (22-×-6-mm), stomach, and duodenum. Upon further history, the patient did describe having intermittent dysphagia over many years. The patient's melena resolved, and he was discharged home off aspirin with continuation of an oral proton pump inhibitor. Esophageal diverticula have a reported annual incidence of 1:500-000 per year and epiphrenic esophageal diverticula (EED) that occur within 10-cm proximal to the GOJ account for about 15% of these. EED is a very rare cause of upper gastrointestinal bleeding. As far as we are aware, there have been only a handful of these cases published to date. Although EED are largely noted incidentally, some common symptoms of presentation include dysphagia, vomiting, chest pain, and heartburn. Assessment may also involve barium swallow and computed tomography of the chest, especially for pre-operative evaluation. There are no clear guidelines or consensus as to the best course of treatment. Therapeutic interventions that have been described in previous case reports include administration of adrenaline, heater probe thermocoagulation, and hemostasis clips. If endoscopic intervention is not successful, surgical options may include diverticulectomy, myotomy, and fundoplication. Although rare, this case demonstrates that EED could potentially cause significant upper gastrointestinal bleeding and should be considered as a differential in clinical practice.

Comparison Between Argon Plasma Coagulation And Endoscopic Band Ligation InTreatment Of Gastric Antral Vascular Ectasia In Egyptian Cirrhotic Patients

Background and study aim: The Gastric antral vascular ectasia (GAVE) is one of the causes of upper gastrointestinal bleeding and accounts nearly four percent of all non-variceal upper gastrointestinal hemorrhage. Although Argon Plasma Coagulation is the standard treatment of GAVE, EBL may be used in the treatment of GAVE. This study was done to evaluate the therapeutic effect of APC in comparison to EBL for the treatment of bleeding GAVE in cirrhotic patients. Patients and Methods: Our study was conducted on 36 adult cirrhotic patients with bleeding from GAVE. Patients were divided into 2 groups: 18 patients in each group. Group I was subjected to APC and group II was subjected to EBL. All patients were followed endoscopically after the first endoscopic intervention for 6 months as well as their hemoglobin level had been evaluated monthly during that period. Results: There was a statistically non-significant difference between both treatment groups as regards cessation of bleeding, increase in hemoglobin levels, reduction of transfusion requirements, decreasing of hospital admissions or decreasing of endoscopic recurrence of GAVE during the follow-up period (6 months), but EBL group has a better result than APC group. The application of the EBL technique has significantly increased in the band related complications as hypertrophied polyps and post band ulcerations, which are decreased in the following sessions, in comparison to the APC technique, which had no complications-related. Conclusion: EBL and APC are effective methods in the treatment of bleeding GAVE in cirrhotic patients.

Mo1330 RENAL DYSFUNCTION IS AN INDEPENDENT RISK FACTOR FOR REBLEEDING AFTER ENDOSCOPIC HEMOSTASIS IN PATIENTS WITH PEPTIC ULCER BLEEDING

Acute upper gastrointestinal bleeding (UGIB) is the most common disease requiring hospitalization in patients with gastrointestinal disease. Peptic ulcer bleeding (PUB) is the most common cause of UGIB. Rebleeding after PUB is thought to be the risk factor for mortality, and the rate of rebleeding after endoscopic hemostasis for PUB ranges from 10% to 30%. This study aimed to evaluate the risk factors associated with rebleeding after endoscopic hemostasis in patients with PUB.

Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India.

Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality. Clinical and endoscopic findings were recorded in patients aged > 12years who presented within 72h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6weeks after discharge. A total of 305 patients were included in this study, mean age being 44 ± 17years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis. Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.

Clinical and Endoscopic Profile of Patients with Upper Gastro-Intestinal Bleeding (UGIB)

Background: Upper gastro-intestinal bleeding (UGIB) is a cause of significant morbidity and mortality. Prevalence as well as mortality is higher in elderly persons above sixty years because of increasing use of nonsteroidal anti-inflammatory drugs and associated comorbidity. Conventionally upper GI bleeding is divided as variceal and nonvariceal sources and the treatment protocol varies accordingly. There are limited data regarding UGIB in our country.
 Objective: This observational study was designed to delineate the clinical and endoscopic profile of patients with UGIB in our country.
 Materials and Methods: This prospective observational study was done in the Department of Gastroenterology in Enam Medical College & Hospital during the period of 2014–2017. Patients with UGIB were followed until discharge or death. Patients were subjected to upper GI endoscopy, preferably within the first 24 hours. Clinical and endoscopic data of 131 patients were compiled and analyzed in this study. The data were analysed using SPSS version 21.0.
 Results: Among the 131 final participants 101 were male and 30 were female. Mean age of the patients was 43.65 ± 18.63 years. Patients mostly presented with both haematemesis and melaena (66, 50.4% patients), 33.6% with haematemesis only, and 16% patients with melaena only. The most common endoscopic finding was duodenal and or gastric ulcer (57); next common lesions were gastric/duodenal erosions (23), oesophageal varices (13), oesophageal erosions/ulcers (10), corrosive burn (10) and carcinoma (7). Forty patients had history of NSAID intake and gastric/duodenal ulcer and/erosions were the most frequent lesions among them (27). One patient with oesophageal varices died due to rebleeding.
 Conclusion: In our study peptic ulcer-related bleeding is the most common cause of UGIB. A significant proportion of UGIB is due to corrosive burn (harpic) emphasizing the need for public awareness. Mortality was due to rebleeding.
 J Enam Med Col 2019; 9(2): 78-83

Endoscopic findings and outcomes of upper gastrointestinal bleeding patients in northern Iran population referred to the emergency department

Gastrointestinal bleeding is one of the reasons that patients referred to the emergency department. In the majority of these patients, the bleeding stops spontaneously but some of them are high risk patients who may experience complications and may need endoscopic and surgical treatment. Mismanagement of these cases leads to high mortality. Different studies evaluated the causes of Upper GI bleeding but there is not any information about the distribution of these reasons in north of Iran. Methods and material. This prospective study included patients with history of upper gastrointestinal bleeding between January 2017 and December 2018. A total of 224 patients underwent endoscopy for UGIB and the data were studied. Follow up was done for occurrence of re-bleeding or mortality. Results. Our study revealed that the most common cause of upper GI bleeding was duodenal ulcer and gastric ulcer. Antrum was the main anatomical site for gastric ulcer. After the 15 days follow up in 17 (6.8 %) patients mortality existed and rebleeding was found in 11 (4.4 %) patients and the need for surgery in 3 (1.2 %) patients. Conclusions. Like many parts of the world the most common source of upper gastrointestinal bleeding in our study was peptic ulcer diseases. Our study revealed that despite all diagnostic and treatment procedures still there is mortality (6.8 % mortality existed) due to GI bleeding.