Coffee Ground Emesis Research Articles

BS SO18 - Small bowel intussusception after Roux-en-Y gastric bypass: A case report and review of literature

Abstract Background Small bowel obstruction after RYGB for obesity can occur due to various common causes like internal hernia and adhesions. One of the rare complications of RYGB is retrograde intussusception of jejunum at the common channel. Since it does not present with typical symptoms of small bowel obstruction, it is often challenging to consider it as differential diagnosis at initial presentation. Also, managing the intussusception at non bariatric centres could prove difficult due to location of it in the common channel, which will require understanding of orientation of alimentary and biliary limbs as well as reconstruction after resection of the intussusception. Method We collected the details of our patients admission episode from a different centre where she was admitted initially to understand the clinical behaviour of the condition. Also, we conducted a systematic search of literature databases like PubMed, Embase, CINAHL, ProQuest Dissertations & Theses using MeSH terms and keywords Intussusception, Retrograde intussusception, J-J intussusception, Intestinal Obstruction, Small bowel obstruction, Bowel obstruction, Obesity, Morbid obesity, Gastric Bypass, Roux-en-Y gastric bypass, Jejunojejunostomy, Jejuno-jejunostomy, Gastric by-pass, RYGB, Roux-en-Y. Data were extracted on to Excel sheet for analysis. Results The search yielded 41 case reports. Patients were operated in most instances except in seven cases where they had multiple episodes. The average age of presentation was 38 mostly in females and few instances being during pregnancy including our patient. Intussusception happened between 5 to 360 months after the initial operation with the average time after the operation being 66 months. Pain was the principal mode of presentation without classical symptoms of bowel obstruction. There were few instances of coffee ground vomiting. CT was the diagnostic modality in almost all cases. Recurrence was invariable when not managed with resection. Conclusion Small bowel intussusception after RYGB occurs retrogradely and does not present with classical symptoms and signs of small bowel obstruction. It can be reliably diagnosed with CT abdomen. Of note, medical management and no-resectional surgical management results in recurrence of this condition.

Atypical Gastric Glomus Tumor of Uncertain Malignant Potential in A 16-Year-Old Female; A Rare Entity with Unique Findings

Abstract Introduction/Objective Gastric glomus tumor (GGT) is a rare mesenchymal tumor that is challenging to diagnose, especially when the immunoprofile overlaps with other more common gastric mesenchymal tumors. The majority of GGT are benign, however, rarely it can be atypical or even malignant. Herein, we present a case of a young female with atypical gastric glomus tumor of uncertain malignant potential. Methods/Case Report A 16-year-old female presented to the emergency with abdominal pain, coffee ground emesis, and melena. Imaging showed a 3.2 cm well-defined gastric mass arising from the muscularis propria. Results (if a Case Study enter NA) The FNA biopsy revealed clusters of tumor cells with uniform characteristics, exhibiting distinct cell membranes and eosinophilic to clear cytoplasm, surrounding prominent vasculature. Immunohistochemical analysis showed that the tumor cells were positive for SMA, synaptophysin, vimentin, calponin, and caldesmon, with weak, patchy positivity for DOG1. CD34 highlighted the vessels separating the tumor cellular clusters into lobules. CD117 and Desmin were negative. The Ki67 proliferation index varied with hotspot foci 25-30%. Morphology and immunoprofile suggest glomus tumor, however, neuroendocrine tumor and epithelioid GIST needed to be excluded. Subsequent resection specimen showed that the tumor was located within the muscularis propria with extension into the serosal vessels, suggesting vascular invasion, along with foci of cellular spindling and nuclear irregularity are identified. No necrosis noted. Tumor cells were positive for cyclin D1 while negative for myogenin, chromogranin, and DOG1. Overall, findings were consistent with GGT of uncertain malignant potential. Conclusion Although GGT are rare, they should be considered in the differential diagnosis of gastric mesenchymal tumors. The presence of diffuse SMA staining can help distinguishing them from GIST. It is crucial to scrutinize for signs of cellular and nuclear atypia, particularly in deeply seated glomus tumors.

Metastatic Melanoma of Unknown Primary with Plasmacytoid Morphology Presenting as Acute Liver Failure

Abstract Introduction/Objective Viral hepatitis, drug toxicity, and autoimmune disorders are common etiologies of acute liver failure (ALF). Very rarely, a cause like metastatic melanoma may present as a primary driver of ALF. Malignant melanoma is histologically diverse and plasmacytoid melanoma is an unusual variant that may present as a solitary tumor or metastatic disease. Methods/Case Report A 48-year-old female presented with 2 weeks of right upper quadrant pain, nausea, coffee ground emesis and bleeding per rectum. She had no history of liver disease or alcohol use. On presentation, AST was 83 U/L, ALT was 29U/L, ALP was 159U/L and total bilirubin was 12.7g/dl. Viral hepatitis panel, HIV and chronic liver disease workup was negative. Esophagogastroduodenoscopy and colonoscopy showed no sources of bleeding. She was diagnosed with decompensated cirrhosis, ALF, and acute kidney injury from hepatorenal syndrome. Cirrhosis and multifocal indeterminate T1 hyper/T2 hypo intense lesions (dysplastic or regenerative nodules) were seen on MRI. Liver biopsy revealed metastatic melanoma. Almost entire liver parenchyma on biopsy was replaced by a population of neoplastic cells with plasmacytoid features. Immunostaining was positive for MART-1, HMB45 and SOX-10. Staining for Pan Cytokeratin and CK-7 highlighted the bile ducts and negative staining was seen for CK20, CD3, CD20, PAX-8, GATA-3, CDX-2 and P63. No primary lesion was found. It was deemed unlikely that she would benefit from therapy before complications occur. She passed away in 16 days. Results (if a Case Study enter NA) NA Conclusion In most cases of ALF associated with malignant melanoma, the liver may have a seemingly normal appearance on imaging studies due to the distinctive histology of leukemoid tumor infiltration within the liver sinusoids, resulting in sinusoidal obstruction and subsequent hepatocellular dysfunction. The rapidity of liver failure in these cases is related to the replacement of liver parenchyma by malignant cells. The plasmacytoid morphology is seen in a variety of malignancies and to avoid a potential misdiagnosis of an aggressive malignant melanoma, it is imperative to perform a thorough histopathological evaluation aided with immunohistochemistry. It is important to keep in mind that the potential involvement of malignant tumor cell infiltration may cause ALF and early histological assessment with a liver biopsy may be of paramount significance and may possibly change the course of the disease.

8179 Complicated Pancreatitis Unveiled: A Case Of Untreated Primary Hyperparathyroidism

Abstract Disclosure: A. Rehan: None. H. Al Jumaili: None. J. Lim: None. Introduction: Acute pancreatitis (AP) triggered by hypercalcemia stemming from primary hyperparathyroidism (PHPT) is an infrequent occurrence, with a prevalence of about 1.5-7%. The proposed mechanism involves deposition of calcium in the pancreatic ducts and activation of pancreatic enzymes. While a causal connection between AP and PHPT has been described, it remains controversial. Calcium levels are thought to play a major role in determining the severity of the pancreatitis. Additionally, it is thought that genetic mutations may contribute to the development of AP in PHPT. Here, we report a case of necrotizing pancreatitis in a patient with untreated PHPT. Clinical Case: Patient is a 59-year-old male with a medical history of hypertension, nephrolithiasis and PHPT secondary to parathyroid hyperplasia (scheduled for parathyroidectomy) who presented with abdominal pain, nausea, vomiting and was found to have AP. He reported no history of alcohol use, trauma or insect bites. His workup was unrevealing for cholecystitis, choledocholithiasis or hypertriglyceridemia. He represented with calcium level of 16 mg/dL (NR 8.7-10.1) due to PHPT. PHPT was deemed the likely cause of AP. Course was further complicated by necrotizing pancreatitis and pseudocyst. A few months later, patient started having coffee ground emesis, worsening epigastric pain and weight loss of 60 lbs due to poor oral intake. CT abdomen/pelvis showed walled off pancreatic necrosis with peripancreatic stranding and concern for gastric outlet obstruction. EGD with PEG-J placement was done with plans for future endoscopic drainage. Few weeks after, he had another bout of worsening abdominal pain. Labs at the time showed corrected calcium between 11-13 mg/dL, PTH 147 pg/ml (NR 5-44), phosphorus 1.6 mg/dL (NR 2.5-4.5), vitamin D 25 hydroxy 19.5 ng/ml (NR 22-110). His condition became more complex with a hemorrhagic walled off pancreatic necrosis and splenic artery pseudoaneurysm requiring ICU care. The repeated escalation of symptoms resulted in multiple delays for the scheduled parathyroidectomy. Patient was started on treatment with Cinacalcet and vitamin D while in the hospital. Due to constraints in resources, he was unable to continue Cinacalcet outpatient. He subsequently was able to undergo parathyroidectomy with pathology showing benign adenoma. Conclusion: Hypercalcemic hyperparathyroidism causing AP, although rare, is often severe and poses a greater risk of complications making it important to be aware of this association, especially when more common causes have been excluded. Imaging techniques like cervical ultrasound, CT, and scintigraphy using 99mTc-Sestambi should be utilized to confirm suspicion. Surgical resection is the mainstay treatment, and having a multidisciplinary team with gastroenterologists, endocrinologists, and surgeons helps improve outcomes. Presentation: 6/2/2024

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management.

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

Coffee ground emesis and early endoscopy: Is timing actually relevant?

ObjectiveCoffee ground vomiting is a classical symptom of upper gastrointestinal bleeding. However, the clinical usefulness is limited, due to the low positive predictive value. Our goal is to determine if whether an urgent endoscopy does modify our therapeutic management with a real impact on survival. Patients and methodsIt is a retrospective, observational and descriptive study. We selected all patients that underwent a gastroscopy in our center for coffee ground vomiting over the last 4 years (2017–2021). Two groups were established: urgent endoscopy (first 24 h) and scheduled (over 24 h). Then we studied differences between both groups regarding survival, ICU admission, hospitalization days and rebleeding. Results314 patients were identified, from which 276 were included, with 176 belonging to the urgency group and 109 to the scheduled group. There were no differences in the ICU admission, hospitalization days, survival or rebleeding after 30 days. There were no differences either in the number of potentially bleeding lesions nor the need of endoscopic therapeutic. ConclusionsCoffee ground vomiting, without any other data supporting upper gastrointestinal bleeding, does not represent a reliable indicator. Performing urgent endoscopy is not beneficial in terms of morbimortality. Therefore, a more conservative strategy would allow to differ endoscopy, decreasing risks and reducing costs, without affecting the prognosis.

Inflammatory Myofibroblastic Tumor of the Esophagus and Stomach Successfully Treated With ALK Inhibitor in a Pediatric Patient: A Case Report and Concise Review of Literature.

An inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal neoplasm of borderline malignant potential. Nearly half of all IMTs have rearrangement of anaplastic lymphoma kinase (ALK) locus on chromosome 2p23 which can be treated with targeted therapy. Herein, we describe an unusual presentation of IMT involving an anatomical region rarely implicated in this disease process. A 15-year-old male patient came to the ER with dysphagia and coffee ground emesis. On esophagogastroscopy, a nodular luminal obstructing 30 × 50 mm mass in the lower esophagus was found, which was continuous with a large, partially circumferential gastric mass extending from the mid-body to the proximal antrum. Biopsies from esophageal and gastric masses revealed submucosal lesions composed of cytologically bland spindle and epithelioid cells, intermingled with inflammatory infiltrate, for which several immunohistochemical (IHC) stains were performed. The molecular study demonstrated ATIC::ALK fusion. Based on morphological, IHC, and molecular study findings, the diagnosis of ALK-positive IMT was rendered. Because surgical excision was deemed infeasible, the patient was started on ALK-inhibiting therapy with crizotinib. The patient responded well with no evidence of residual or recurrent disease on follow-up imaging or surveillance esophagogastroduodenoscopy. Crizotinib was ultimately discontinued after 10 months of therapy, and the patient continues to undergo surveillance imaging for monitoring of disease burden.

De-implementation of Fecal Occult Blood Testing in the Emergency Department and Hospital Units: A Quality Improvement Project.

Fecal occult blood tests (FOBT) are inappropriately used in patients with melena, hematochezia, coffee ground emesis, iron deficiency anemia, and diarrhea. The use of FOBT for reasons other than screening for colorectal cancer is considered low-value and unnecessary. Quality Improvement Project that utilized education, Best Practice Advisory (BPA) and modification of order sets in the electronic health record (EHR). The interventions were done in a sequential order based on the Plan-Do-Study-Act (PDSA) method. An annotated run chart was used to analyze the collected data. Education and Best Practice Advisory within the EHR led to significant reduction in the use of FOBT in the ED. The interventions eventually led to a consensus and removal of FOBT from the order set of the EHR for patients in the ED and hospital units. The use of electronic BPA, education and modification of order sets in the EHR can be effective at de-implementing unnecessary tests and procedures like FOBT in the ED and hospital units.

EGS P31 Small bowel obstruction in an elderly female secondary to congenital Ladd’s band. A rare case presentation

Abstract Background Intestinal malrotation is a congenital anomaly which arises during embryonic development. This can be associated with peritoneal tissue known as Ladd’s bands which can cause predisposition to intestinal obstruction. The incidence of intestinal malrotation is reported to be approximately 0.2% in the adult population [G]. Cases of intestinal obstruction secondary to malrotation commonly present in the paediatric population, but rarely may only be detected at adulthood. We present an elderly women who presented with features suggestive small bowel obstruction. Methods We present a rare case of a 78 year old female presenting with a three day history of coffee-ground vomiting, abdominal pain and dizziness. The patient had a notable background of a hiatus hernia and atrial fibrillation for which she was being treated with edoxaban. An abdominal X-ray film showed faecal loading. CT imaging revealed a high-grade small-bowel obstruction with an acute transitional point at the terminal ileum secondary to congenital Ladd's band which was confirmed at laparotomy. Subsequently, a Ladd’s procedure was performed and the patient was discharged after making a good recovery. Results In this case report, we highlight the importance of considering congenital anomalies in patients presenting with symptoms of bowel obstruction. We discuss the importance of appropriate investigations as well as multidisciplinary care to help facilitate early diagnosis. Conclusions Congenital Ladd’s band is a rare cause of small bowel obstruction in an elderly population. Although the diagnosis of intestinal malrotation can be challenging in adulthood, congenital anomalies should be considered as a differential in patients presenting with symptomatic obstruction.

THU387 Euglycemic Diabetic Ketoacidosis And SGLT-2 Inhibitor Use

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. N. Terrigno: None. Background: Diabetic ketoacidosis (DKA) is a known adverse effect of SGLT-2 inhibitors. (1) Incidences of euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors are reported on less. Clinical Case: A 39-year-old male past medical history of uncontrolled, non-insulin dependent diabetes mellitus and pancreatitis who presented with abdominal pain, nausea and coffee ground emesis. On initial work up, basic metabolic panel showed blood glucose level of 175 mg/dL with an elevated anion gap of 22 mmol/L. Initial differentials included suspicion for euglycemic diabetic ketoacidosis or acute intraabdominal pathology. Venous blood gas showed metabolic acidosis, with a pH of 7.21 and bicarbonate of 9.7 mmol/L, beta hydroxybutyrate was elevated at 7.83 mmol/L. CT abdomen pelvis found a small hiatal hernia, gastric wall thickening, likely gastritis, and was negative for other intraabdominal pathology. Home medications of the patient included dapagliflozin, semaglutide, metformin, gabapentin, and pantoprazole. Patient was admitted with the diagnosis of suspected euglycemic diabetic ketoacidosis and was started on an insulin drip along with D5 0.45 normal saline. Patient’s anion gap was monitored with basic metabolic panel orders every two hours. The insulin drip was discontinued once the patient had two consecutive normal anion gaps and the patient was subsequently started on a subcutaneous insulin regimen. Conclusion: SGLT-2 inhibitors may cause euglycemic diabetic ketoacidosis based on the physiology of the SGLT-2 transporter and the pharmacology of the SGLT-2 inhibitors. (2) Clinical importance of this case report is to consider euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors presenting with nausea, vomiting with normal blood glucose to not delay in the diagnosis and treatment of this life-threatening condition.

SAT110 Euglycemic Diabetes Ketoacidosis Associated With Sodium-glucose Cotransporter Inhibitors: A Case Series To Raise Awareness

Abstract Disclosure: D. Katwal: None. Y. Pokharel: None. M. Ghawji: None. Z. Liu: None. H.O. Steinberg: None. S. Dagogo-Jack: Consulting Fee; Self; AstraZeneca, Boehringer Ingelheim, Janssen Research & Development Company, Medtronic Diabetes, Merck & Co., Sanofi, Bayer, Inc. Research Investigator; Self; AstraZeneca, Novo Nordisk, Boehringer Ingelheim. Other; Self; Janacare. Introduction: Sodium-Glucose Cotransporter Inhibitors (SGLT2i) treatment is increasing partly due to its cardiovascular and renal benefits, enlarging the population at-risk for euglycemic diabetic ketoacidosis (euDKA), a potentially life-threatening adverse event associated with SGLT2i use. Unfortunately, even among healthcare providers, awareness of euDKA appears to be low, resulting in delayed treatment and increased morbidity/mortality; We describe three cases of euDKA to illustrate. Case 1: A 25-year-old morbidly obese male with recent onset of T2DM presented with nausea and vomiting for two days. A few days before his presentation, he was started on dapagliflozin 5 mg daily and metformin 500 mg BID. Symptoms began within 24 hours of starting his medications. Laboratory results were consistent with euDKA: blood glucose (BG) of 144 mg/dl (70-110 mg/dl), pH 7.05 (7.35-7.45), bicarbonate 6 mmol/L (21-31mmol/L), and anion gap (AG) 20 mmol/L (2-15mmol/L). The euDKA resolved after 48 hours on standard treatment. Case 2: A 54-year-old male with T2DM on empagliflozin 10 mg daily presented with progressive dyspnea and altered mental status for two days. He was tachypneic, tachycardic, and hypotensive. Laboratory results were consistent with euDKA with a BG of 121 mg/dl, bicarb 4 mmol/L(21-31mmol/L), pH of 6.82, and AG 30 mmol/L. In addition to standard treatment, he required pressor and antibiotics; euDKA resolved after 65 hours. Case 3: A 68-year-old male with T2DM and other comorbidities presented with nausea, coffee-ground emesis, and abdominal pain for three days. He had recently started empagliflozin 25 mg daily. He had tachycardia and a diffusely tender abdomen. Laboratory results revealed BG of 101 mg/dl, bicarb 19 mmol/L (22-32 mmol/L), and AG of 16 (5-20) progressing to a bicarb 12 mmol/L, BG of 133 mg/dl, AG>20, pH of 7.23, and beta-hydroxybutyrate 9.7 mmol (0.00-0.29 mmol). The patient was managed with standard therapy and euDKA resolved after 75 hours. Discussion: euDKA is a rare but potentially life-threatening emergency primarily seen in T1DM and rarely in T2DM. The lack of profound hyperglycemia contributes to the delay in diagnosis and treatment. Poor oral intake, pancreatitis, alcohol use, infection, and dehydration have been associated with euDKA in patients treated with SGLT2i. Increased glucagon-to-insulin ratio and excess counter-regulatory hormones have been postulated to cause euDKA. In agreement with the literature, our patients experienced euDKA between 2-360 days of initiating SGLT2i. While our patients responded to standard treatment, the duration of insulin infusion may have been longer than plain DKA. Given the increased morbidity and mortality of euDKA, it is reasonable to consider holding SGLT2i during acute illness and preemptively before elective surgery. Providing sick-day rules to patients treated with SGLT2i should also decrease the risk of euDKA. Presentation: Saturday, June 17, 2023

472 Right-sided diaphragmatic hernia causing gastric outlet obstruction 1 month after trauma

Abstract Diaphragmatic hernias arising from trauma are rare, and scarcely present in a delayed manner. This case report highlights a case of delayed presentation of a right-sided post-traumatic hernia in a 73-year-old woman following a fall. This report sheds light on the diagnostic peculiarities and management. The woman presented with a 3-day history of abdominal pain and coffee-ground vomiting. This followed a fall a month ago. Computed Tomography confirmed the diagnosis of a gastric outlet obstruction secondary to a right-sided diaphragmatic rupture. At surgery, the herniated abdominal contents were reduced, and the diaphragmatic defect fixed. The postoperative recovery was unremarkable and the patient discharged on day 4. This case highlights that diaphragmatic hernias should be considered as differential diagnoses following recent trauma.

Black Esophagus and Recurrence of Duodenal Ulcers: Two Signs of the Same Pathogenic Pathway? A Case Report

Black esophagus or acute esophageal necrosis is characterized by circumferential black discoloration of the distal esophageal mucosa. It is a rare condition with a multifactorial pathogenesis, and its most common clinical presentation is acute upper gastrointestinal bleeding. It usually affects elderly patients with multiple comorbidities and is associated with a high mortality rate. This is a case report of a 90-year-old man with multiple comorbidities, including diabetes mellitus, atrial fibrillation with complete atrioventricular block, and a history of ischemic stroke, who presented to the emergency department for a syncopal episode followed by coffee ground emesis. Thoraco-abdominal computer tomography showed thickening of the distal esophagus and ruled out major complications such as perforation. The following esophagogastroduodenoscopy showed black circumferential necrosis of the mid and distal esophagus. Multiple irregular ulcers with black necrotic areas were also present in the bulb and second duodenal portion. During the hospitalization, the patient was treated with PPI, NPO nutrition, and broad-spectrum antibiotics with benefits. Two months later, the patient returned to the emergency department due to a new episode of hematemesis with endoscopic evidence of esophageal stricture without necrosis and recurrence of duodenal ulcers. After a few days, the patient died due to worsening of the underlying comorbidities. A black esophagus is associated with duodenal ulcers, which may recur and are possibly due to a common ischemic origin. In this case report, we explore the potential link between black esophagus and duodenal ulcers, discussing the underlying mechanisms and relevant literature supporting this association.

Unusual Duodenal Ulcer: Metastatic Urothelial Carcinoma of the Renal Pelvis.

Metastatic urothelial carcinoma of the renal pelvis (MUCP), a type of metastatic upper tract urothelial carcinoma (MUTUC), is a rare malignancy, and some patients with MUCP present with distant metastasis at the time of diagnosis. MUCP in the gastrointestinal tract is even rarer. Herein, we report a 78-year-old man with MUCP that presented as a duodenal ulcer. He complained of anorexia, dizziness, and melena for one month. Endoscopic examination at a local clinic revealed a duodenal hemorrhagic and ulcerative lesion, and the patient was referred. He noted dark-colored stools with increasing frequency, but he denied hematochezia, coffee ground emesis, weight changes, or abdominal pain. Gastroduodenoscopic examination at our hospital demonstrated an ulcerofungating lesion of the second portion of the duodenum. Colonoscopic findings showed no abnormality. Computed tomography showed a 6.7 cm sized mass abutting the inferior vena cava, second portion of the duodenum, lower pole of the right kidney, and right iliopsoas. The mass showed heterogeneous enhancement and internal hemorrhagic necrosis and infiltrated the perinephric soft tissues, the second portion of the duodenum, the right psoas muscle, the right renal vein, and the right adrenal gland. Duodenal biopsy showed moderately differentiated squamous cell carcinoma. Immunohistochemistry (IHC) showed diffuse and strong positivity for CK5/6. Tissue from the liver biopsy showed similar histopathologic features and showed GATA3 positivity on IHC. The imprint cytology smears of the liver tissue showed "cercariform" cell features. We confirmed the diagnosis as MUCP. This case illustrated a rare cause of a secondary duodenal tumor, MUCP.

Blood and bile: A gastroduodenal artery pseudoaneurysm associated with endoscopic retrograde cholangiopancreatography stent migration

A man in his mid-forties presented with a two-day history of sudden onset right upper quadrant pain and coffee-ground vomiting. Eight months previously, he underwent successful endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting for cholangitis and severe gallstone pancreatitis. This was followed by a COVID-delayed uncomplicated laparoscopic cholecystectomy.

A144 BLACK ESOPHAGUS: A PEDIATRIC PRESENTATION OF ACUTE ESOPHAGEAL NECROSIS AND MANAGEMENT OF ITS COMPLICATIONS

Abstract Background Acute esophageal necrosis (AEN), or "Black Esophagus", is a rare diagnosis in children with adult literature citing high mortality. We present a pediatric case of this unusual condition. Purpose To report the rare presentation of AEN in a child and the response to intensive endoscopic management. Method Chart and literature review of AEN presentation and management. Result(s) A 13-year-old male who presented with a one-day history of severe chest pain, worsened with swallowing, followed by coffee ground emesis. No caustic ingestion. A nasogastric (NG) tube was placed and 2L of coffee-ground aspirate drained. The patient was an ex-preterm infant (25 weeks) who presented at age 2 years with an antral ulcer that developed into an antral stricture. This resolved with successive endoscopic dilatation with no recurrence after 5 years, off acid suppression. Physical exam showed BMI 99th %ile and palpated epigastric tenderness. CT-angiogram showed diffuse circumferential thickening of the esophagus and impressive gastric dilatation. A contrast study showed stasis of contrast in the esophageal lumen. Upper endoscopy revealed a thick, white membrane followed by circumferential black mucosa in the mid to distal esophagus. Previous antral stricture was noted with easy scope passage. Biopsies were negative for fungus, bacteria, HSV, CMV and parvovirus. Inflammatory infiltrate (mainly neutrophils and scattered histocytes with occasional lymphocytes) was noted in the esophagus. Necrotic tissue was identified and a diagnosis of AEN was made. The patient remained NPO, on TPN, and morphine was used for pain control. He responded well to this, along with high dose PPI. He tolerated clear fluids and oral sucralfate. Repeat scope one week later showed resolved necrosis with remaining oedematous white plaques and an unchanged antral stricture. 10 days later he developed severe dysphagia and a 15.5 cm long 6 mm diameter distal esophageal stricture was identified. This was managed by serial balloon dilatations. Due to frequent need for dilatations, endoscopic triamcinolone injections were used in several procedures as an adjunct therapy. A total of 80 mg of triamcinolone per session was injected along the length of the stricture in 4 aliquots in five out of nine endoscopic dilations in the last seven months. The most recent procedure successfully dilated the esophagus to 18mm. Currently, the patient is now tolerating a soft oral diet and remains on PPI therapy. Image Conclusion(s) AEN is very rare in children with no literature describing the endoscopic management of AEN related stenotic complications. We report the case of this unique presentation in a teenager, resulting in severe, long-segment esophageal stenosis. Intensive endoscopic therapeutic management has resulted in a positive clinical outcome allowing oral nutrition without any stenting or surgical interventions. Early recognition and active endoscopic management likely contributed to the positive outcome. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

An interval of clinically silent gastrointestinal bleed in dysautonomic spinal cord injury: a case report

BackgroundGastrointestinal bleed (GIB) has high incidence in traumatic spinal cord injured (tSCI) patients and can frequently be life-threatening, especially early post-injury. Several risk factors often compound bleeding risk, some are unique to this patient population. Normally, clinical suspicion for GIB arises from symptoms like coffee-ground emesis, hematemesis, melena or even hematochezia. A hemoglobin drop may be a late sign. Due to tSCI, however, patients often experience neurogenic bowels and dysautonomia, which may delay symptom presentation and complicate timely diagnosis of GIB. We report a case of an almost clinically silent GI bleed in the context of acute cervical tSCI.Case presentationA 21-year-old female presented with cervical cord transection at C-7 in the setting of motor vehicle rollover, for which surgical decompression was performed. During the acute injury phase, she also received a 10-day course of dexamethasone for symptomatic COVID-19 pneumonia. Two weeks after injury, she underwent percutaneous endoscopic gastrostomy (PEG) placement which demonstrated normal gastric and duodenal anatomy. One week later, a large spike (10x) in blood urea nitrogen: creatinine (BUN: Cr) ratio raised concern for GIB, but hemoglobin remained stable, and stool color remained unchanged. The following day, a gastroenterology consult was requested under increased suspicion of GIB from a sudden 3.5 g/dL hemoglobin drop. The patient received blood transfusion and pantoprazole. An upper endoscopy was performed, revealing three small duodenal ulcers. Melanotic stool ensued afterwards.ConclusionsDue to dysautonomia, clinical presentation of GIB can be significantly delayed in the tSCI patient population, leaving them vulnerable to succumb to illness. This case illustrates the possibility of an interval in which the patient was bleeding, with the sole indicator being an elevated BUN. Our case calls for closer monitoring of and vigilance for tSCI patients, and possibly employment of different strategies to reduce the incidence and enhance early detection of GIB in tSCI patients to subsequently decrease the morbidity and mortality associated with it.

Medical Management of Emphysematous Gastritis

A 95-year-old man presented to the hospital with altered mental status, sepsis, and coffee-ground emesis. His chest radiograph showed gas along the lesser curvature of the stomach, prompting abdominal computed tomography, which demonstrated intramural gastric air. This patient's clinical presentation and computed tomography findings were suggestive of emphysematous gastritis (EG). He was successfully managed with an intravenous proton-pump inhibitor and broad-spectrum antibiotics. Details of the case are presented to encourage the early diagnosis of EG, which may make conservative management more successful.

Acute Esophageal Necrosis Secondary to Cyanotic Spells Associated with Unrepaired Tetralogy of Fallot.

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease. Cyanotic spells occur more frequently after infancy in unrepaired cases. Acute esophageal necrosis (AEN) is a rare disease that causes circumferential mucosal necrosis in the distal esophagus. We report the case of a 26-year-old man who was admitted due to coffee-ground emesis, black stools, and decreased oxygen saturations. The patient had an unrepaired ToF and a congenital portosystemic venous shunt. An upper gastrointestinal endoscopy revealed AEN, which could be due to unstable hemodynamics of cyanotic spells. This is the first adult case presenting these 2 conditions occurring simultaneously.

Abstract 15313: Hypoglycemia: The Forgotten "H&T" in Cardiac Arrest

Introduction: Hypoglycemia is known to cause cardiac arrhythmias and even sudden cardiac death by inducing oxidative stress, QT prolongation, and myocardial injury. Chromosomal deletion of 1p36 is associated with learning difficulty, progressive renal disease, and cardiomyopathy. To our knowledge, this is the first case of a patient with 1p36 deletion syndrome and end-stage renal disease (ESRD) who developed cardiac arrest due to hypoglycemia. Case Presentation: A 26-year-old female presented to the emergency department with generalized itching, weakness, and progressive dyspnea after missing multiple hemodialysis (HD) sessions. She was admitted for HD and her stay was complicated by an episode of coffee-ground emesis and she was nil per oral (NPO) for an endoscopy. That night, the patient became bradycardic and had a cardiac arrest with pulseless electrical activity (PEA). Fingerstick blood glucose was undetectable during resuscitation and ROSC was achieved instantaneously after dextrose administration. The patient had no history of diabetes and was refusing glucose checks while NPO. She had a remarkable neurological recovery post-cardiac arrest. However, her glucose levels remained persistently low despite maximally tolerated feeds. An extensive workup for persistent hypoglycemia including peptide C levels, hba1c, and insulin level were within normal limits. Her cortisol level was appropriately raised. CT scan of the head performed was normal. Cardiac catheterization revealed no coronary artery disease. Discussions: Hypoglycemia was removed from the Advanced Cardiovascular Life Support (ACLS) algorithm as a reversible cause of cardiac arrest in 2010. Our case is a reminder of a life-threatening yet quickly reversible cause of cardiac arrest. Conclusions: ESRD increases the risk of hypoglycemia due to decreased insulin clearance and must be carefully monitored while NPO. Physicians have to be aware that routine dextrose administration during cardiac resuscitation does not improve survival and neurological outcomes.