Diagnosis Of Gastrointestinal Bleeding Research Articles

Gastrointestinal Bleeding as a Clinical Manifestation of Strongyloides stercoralis Hyperinfection in a Patient with HIV: A Case Report

AbstractStrongyloidiasis, caused by the nematode Strongyloides stercoralis, is an often neglected parasitic disease, with deeper prevalence in tropical and subtropical regions. This parasitic infection can range from asymptomatic to symptomatic, with nonspecific manifestations, including gastrointestinal symptoms. Herein, we reported the case of an human immunodeficiency virus (HIV)-positive patient, under effective antiretroviral treatment with a normal CD4 count, who was hospitalized due to gastrointestinal bleeding. The diagnosis of strongyloidiasis hyperinfection was confirmed following endoscopic biopsies of both the gastric and duodenal mucosa. Subsequently, a treatment regimen of ivermectin at a dosage of 200 mcg/kg/day for a duration of 14 days was initiated, leading to notable amelioration in the patient's clinical presentation. In considering the differential diagnosis of gastrointestinal bleeding, it is crucial to explore various possibilities, including peptic ulcers, portal hypertension, and cancer. Among immunocompromised individuals like those with HIV, chronic infection can compromise the Th2 immune response, which is pivotal in combating helminthic infections. This underscores the importance of remembering intestinal parasitosis, particularly strongyloidiasis, in such cases. Even in patients with preserved CD4 counts, careful evaluation for opportunistic infections in HIV-positive individuals is paramount. Early initiation of treatment is essential to mitigate the risk of serious complications.

Giant Lipoma of the Bauhin's Valve.

Lipomas are benign tumors that can affect the digestive tract, everywhere from the hypopharynx to the rectum. Lipomas affecting the large intestine are the second most common benign tumor, after colon adenoma. We present the case of a 46-year-old patient who was initially hospitalized in the Gastroenterology Clinic with a diagnosis of gastrointestinal bleeding. The colonoscopy raised the suspicion of a malignant tumor of the transverse colon, but the computed tomography scan showed the existence of a lipoma that measured 16/11/12 cm that occupied the ascending and transverse colon, though the CT examination could not determinate the origin of the lipoma. After restoring the hydro-electrolytic and fluid balance of the patient, surgery was performed and a huge lipoma of the ileocecal valve was discovered. Extended right hemicolectomy was performed, with good subsequent postoperative recovery of the patient, who was discharged on the fifth day after the surgery. The peculiarity of this case is the huge size of the benign tumor. Lipomas with digestive system localization, although rare, must be considered in patients arriving at the Emergency Department with digestive hemorrhages, intussusception and even intestinal obstruction.

Value of multidetector computed tomography angiography in severe non-variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit.

Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3h) or following (< 3h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. A total of 68 patients (38 men, median age 69years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.

Gastrointestinal sistem kanaması sebebiyle yatan hastalarda akılcı ilaç kullanımı ve geleneksel tamamlayıcı tıp kullanımının incelenmesi

AIM: The aim of this study was to determine the knowledge levels of rational drug use, the attitudes to traditional and complementary medicine, and the relationship between these in patients admitted to the Internal Medicine Clinic because of gastrointestinal system bleeding. &#x0D; METHOD: This descriptive, cross-sectional study was conducted with 124 patients hospitalised in the Internal Medicine Clinic of a training and research hospital with a diagnosis of gastrointestinal bleeding between 01.06.2022 and 01.10.2022.&#x0D; An Information Form including demographic and clinical characteristics, the Rational Drug Use Scale (RDUS), and the Complementary, Alternative, and Conventional Medicine Attitudes Scale (CACMAS) were applied to the patients. The data obtained were analyzed statistically using SPSS vn. 23.0 software. &#x0D; RESULTS: For the whole sample of patients hospitalised with a diagnosis of gastrointestinal system bleeding, the mean RDUS points were determined to be 19.8±4.17 and the mean total CACMAS points were 96.76±15. In the subscales of the CACMAS, the mean points were determined to be 28.15±9.42 for philosophical congruence with complementary medicine, 23.23±10.39 for dissatisfaction with conventional medicine, and 45.38±8.18 for holistic balance. &#x0D; The RDUS points were found to be significantly higher in females (20.33±4.37, p:0.04), patients with a good income status (22.17±4.02, p:0.03) and those who did not use painkillers (21.21±4.00, p:0.01) compared to other subgroups. The CACMAS subscale mean points for philosophical congruence with complementary medicine were determined to be significantly higher in males (29.77±9.52, p:0.03), patients who were single (36.33±9.06, p:0.002), and those who used anticoagulants (32.95±10.77, p: 0.04). The dissatisfaction with conventional medicine subscale points were determined to be significantly higher in females (26.04±9.74, p: 0,03), patients with a low income (30±15.17, p: 0.03) and those who used painkillers (26±10.67, p:0.01), and the holistic balance points were determined to be significantly higher in females (47.24±7.33, p: 0.02) and those who used medication regularly (46.49±8.34, p:0.02) compared to other sub-groups. A statistically significant negative correlation was found between rational drug use and dissatisfaction with conventional medicine (r=-0.381, p

Therapeutic Banding for Bleeding Duodenal Lymphangiectasias: A Novel Approach

ABSTRACT With endoscopic advancements, the number of detected intestinal lymphangiectasias has been on the rise. They are generally considered benign and incidental; occasionally, these lesions carry complications, and best management options need to be established. Bleeding intestinal lymphangiectasias should be considered a rare cause in the differential diagnosis for gastrointestinal bleeding. References in the literature primarily indicate surgical treatment in these situations. In this study, we report an uncommon case of a man with esophageal adenocarcinoma who developed acute gastrointestinal bleeding from duodenal lymphangiectasias that were successfully banded.

Dual-energy CT for gastrointestinal bleeding.

Dual-energy computed tomography (DECT) can be used for various types of analyses, including iodine quantification, and its usefulness in diagnosing gastrointestinal diseases has been reported. This pictorial review describes the use of DECT in the diagnosis of gastrointestinal bleeding. Virtual non-contrast computed tomography (CT) is available in DECT and can be used as a substitute for pre-contrast CT in the case of gastrointestinal haemorrhage. The omission of pre-contrast CT can reduce radiation exposure by approximately 30%. A low-keV virtual monochromatic X-ray image (VMI) can increase the contrast of iodine, and iodine maps can provide better visibility of extravasation. These analytical images can provide a diagnosis with a high degree of confidence. In addition, the low-keV VMI clearly illustrates the vascular structure, which may be useful for improving the visibility of vascular lesions and for confirming the arterial anatomy before embolisation. Considering that these analytical images are created on the basis of contrast-enhanced CT, the positional information of organs is entirely identical, thus allowing the comparison of images regardless of intestinal peristalsis or body motion. In conclusion, the analytical images of DECT can solve the problems of conventional protocols, and DECT is considered useful in the imaging diagnosis of gastrointestinal bleeding.

Cirrhotic patients on proton pump inhibitors are at a twofold risk of spontaneous bacterial peritonitis independently of gastrointestinal bleeding: a population-based retrospective study.

Recent findings suggest that cirrhotic patients on proton pump inhibitors (PPIs) are at a higher risk for developing spontaneous bacterial peritonitis (SBP) than non-PPI users. We aimed to identify whether PPI use is an independent risk factor for the development of SBP among cirrhotic patients in the United States (US). We enrolled a retrospective cohort using a validated multicenter database. Patients with a SNOMED-CT diagnosis of "cirrhosis" between 1999 and 2022 were identified. All patients below 18 years of age were excluded. We calculated the prevalence of individuals using PPIs in the total US population and in cirrhotic patients from 1999 to date, and the incidence of SBP in the past year. Finally, we constructed a multivariate regression model, controlling for multiple covariates. The final analysis included 377,420 patients. The 20-year-period prevalence of SBP in patients with cirrhosis was 3.54% and the prevalence of patients using PPIs in the US population was 12,000 per 100,000 people (12.00%). The 1-year incidence of SBP in cirrhotic patients using PPIs was 2500 per 100,000 people. After accounting for confounders, the risk of SBP was higher among males, patients with a diagnosis of gastrointestinal bleeding, and those using β-blockers and PPIs. To date, this is the largest cohort used to examine the prevalence of SBP among cirrhotic patients in the US. PPI use and hepatic encephalopathy offered the highest risk for the development of SBP, independently of gastrointestinal bleeding. Focusing on judicious PPI use should be encouraged among cirrhotic patients.

S2278 Black Esophagus: A Striking Etiology of Gastrointestinal Bleeding

Introduction: Black esophagus, or acute esophageal necrosis (AEN), is an uncommon etiology of upper gastrointestinal bleeding with incidence 0.01%-0.2% and poor prognosis. AEN is characterized by endoscopic findings of diffuse circumferential black discoloration of distal esophageal mucosa with sharp demarcation at the GEJ. The pathophysiology of AEN is unknown, however current hypotheses implicate ischemia, thromboembolic injury, critical illness, and corrosive injury. We describe a case of black esophagus in a patient with hemorrhagic shock. Case Description/Methods: An 83-year-old woman with hypertension presented to an outside hospital after a fall with lethargy, acute hypoxic respiratory failure, and shock. CT chest revealed right sided hemothorax. The patient was intubated, resuscitated with IV fluids and blood products, initiated on vasopressors, and a chest tube was placed prior to transfer to our institution. Repeat CT chest was concerning for the right thoracostomy tube traveling through the right middle lobe parenchyma and terminating within the mediastinum between the left atrium and the distal esophagus. The chest tube was removed and replaced in the operating room. Double contrast esophogram was without esophageal leak. The patient subsequently developed melena and worsening anemia. EGD demonstrated sharply demarcated circumferential black ulceration of the distal esophagus consistent with black esophagus without obvious signs of perforation. IV PPI and therapy aimed at reversing the underlying shock was pursued. Unfortunately, after a prolonged hospital course with worsening acute respiratory distress syndrome and inability to liberate from the ventilator, the patient’s family elected to pursue comfort measures and the patient expired (Figure). Discussion: In this case, AEN was most likely caused by ischemia secondary to hemorrhagic shock. Black esophagus carries a very poor prognosis, usually related to the underlying condition. Timely recognition of AEN and treatment aimed at reversing the underlying etiology can help prevent complications such as infection, esophageal stricture, and perforation. AEN is managed with aggressive IV PPI, NPO, and avoiding passage of nasogastric tubes due to risk of perforation. In rare instances, surgical intervention may be warranted. This case highlights the need to maintain a wide differential diagnosis for gastrointestinal bleeding and the importance of early recognition and treatment of this rare condition to prevent complications.Figure 1.: EGD indicating circumferential black ulceration of the distal esophagus with clear demarcation (arrow).

S2654 Severe Rectal Bleeding due to Foreign Body Ingestion

Introduction: Foreign body ingestion is often seen in children and the elderly. Food particles such as chicken or fish bones are the most often ingested foreign bodies; however, most patients do not recall ingestion. Clinically, most foreign bodies pass through the GI tract without issue, however, complications occur in roughly 1% of cases. Complications of foreign body ingestion include bleeding, bowel obstruction, and perforation. We present a case of a 95-year-old female presenting with bright red blood per rectum found to have foreign body impaction with ulceration in the rectosigmoid region. Case Description/Methods: A 95-year-old female with past medical history of diverticulosis and GERD presented with a complaint of rectal bleeding. She had experienced 7 episodes of voluminous bright red blood per rectum with diffuse crampy abdominal pain. She had no history of previous GI bleeds. Her most recent colonoscopy was 25 years prior with diverticulosis only. DRE was positive for bloody stool and her hemoglobin was 10g/dL with a baseline of approximately 13. CT scan showed rectosigmoid wall thickening consistent with inflammation, diverticula and a metallic-like object in the proximal sigmoid colon (Figurea). The patient was started on piperacillin-tazobactam and prepared for flexible sigmoidoscopy occurring next morning. Endoscopy revealed areas of multiple diverticula, surrounding ulceration and bleeding in the rectosigmoid colon (Figureb); cold biopsy was taken of the ulceration. A foreign body was found in the sigmoid colon (Figurec) and was successfully removed with a Roth Net. The foreign body appeared to be swallowed chicken bone. Biopsy showed cellular debris and colonic mucosa with acute and chronic inflammation. Pathology identified the object as a bone fragment. Discussion: The differential diagnosis of gastrointestinal bleeding is broad, but rarely is foreign body obstruction in the rectosigmoid region considered. The object must traverse 25 feet of small bowel prior to ulcerating the colon. The most common sites of complication occur at the ileocecal and rectosigmoid regions due to luminal narrowing and anatomic angulation. If complication occurs, 10-20% of foreign bodies can be removed endoscopically; 1% or less require surgical intervention. Intestinal strictures, cancer, diverticular disease, and hernias increase risk of complications after foreign body ingestion. Diverticulosis was the only identifiable risk factor in our patient case making it a unique clinical presentation.Figure 1.: Images from left to right (1a) foreign body as seen on admission CT (1b) sigmoid colon ulceration with diverticula seen proximal (1c) foreign body as seen on approach.

Gastroinstestinal Bleeding in Pediatrics

Gastrointestinal bleeding (GI) may occurs in infants and children. Most etiologies of GI bleeding are mild and self-limited, but may advance into life-threatening condition if not treated properly. Upper GI bleeding and lower GI bleeding can be classified based on bleeding sites that is above or below Treitz ligament. Causes of GI bleeding in infants and children varies according to their age and bleeding sites. Some conditions may be misunderstood as GI bleed such as consumption of certain red coloured food. Diagnosis of gastrointestinal bleeding in children includes complete history taking, thorough physical examination, laboratory examination, radiological examination, and other supportive modality such as endoscopy. Early diagnosis and proper therapy can improve outcomes and prevent severe conditions.

Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

BackgroundClinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding. MethodsPatients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment. ResultsA total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01). ConclusionIn the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.

CLINICAL CHARACTERISTICS AND CAUSES OF GASTROINTESTINAL BLEEDING IN&amp;NBSP;CHILDREN

Abstract: Background: Gastrointestinal bleeding (GI) is a complication of many diseases, caused by injury at the gastrointestinal tract or outside the gastrointestinal tract, causing bleeding from mild to severe severity, which can even cause shock and death. The causes of gastrointestinal bleeding vary by age. Objectives: To describe the clinical, subclinical and common causes of non-infectious gastrointestinal bleeding in children. Subjects and methods: Patients from 2 months to 15 years old admitted to Pediatrics Department I, Pediatric Center, Hue Central Hospital from February 2020 to February 2021 with a diagnosis of gastrointestinal bleeding. The study was carried out by cross-sectional descriptive research method. Results: The study included 116 patients, 7 children in the group of 2 months - &lt; 1 year old (6.0%), 36 children in the group 1 - &lt; 6 years old (31%), 36 children in the group 6 - &lt; 11 years old (31.1%) and 37 children in the group of 11-15 years old (31.9%). The mean age was 7.6 ± 4.6. Peptic ulcer disease is the most common cause of GI bleeding, accounting for 37%; 12.9% cases unknown cause. Most of the patients had mild and moderate GI bleeding, about 60.3% and 23.3%; severe bleeding 8.6% and very severe 7.8%. The most common cause of GI bleeding in the group of 2 months - &lt; 1 year old is Mallory-Weiss syndrome and milk protein allergy (22.2%), in the group of 1-5 years old is anal fissure (41.6%) and in children over 6 years old is peptic ulcer disease. Conclusion: The most common causes of gastrointestinal bleeding depend on the age and have different clinical features depending on the cause. Key words: gastrointestinal bleeding in children, melena, hematemesis, hematochezia.

Discussion Guide for the Kim Article.

Discussion Guide for the Kim Article.

Dictionary Learning-Based Ultrasound Image Combined with Gastroscope for Diagnosis of Helicobacter pylori-Caused Gastrointestinal Bleeding.

The study is aimed at evaluating the application value of ultrasound combined with gastroscopy in diagnosing gastrointestinal bleeding (GIB) caused by Helicobacter pylori (HP). An ultrasound combined with a gastroscopy diagnostic model based on improved K-means Singular Value Decomposition (N-KSVD) was proposed first. 86 patients with Peptic ulcer (PU) and GIB admitted to our Hospital were selected and defined as the test group, and 86 PU patients free of GIB during the same period were selected as the control group. The two groups were observed for clinical manifestations and HP detection results. The results showed that when the noise ρ was 10, 30, 50, and 70, the Peak Signal to Noise Ratio (PSNR) values of N-KSVD dictionary after denoising were 35.55, 30.47, 27.91, and 26.08, respectively, and the structure similarity index measure (SSIM) values were 0.91, 0.827, 0.763, and 0.709, respectively. Those were greater than those of DCT dictionary and Global dictionary and showed statistically significant differences versus the DCT dictionary (P < 0.05). In the test group, there were 60 HP-positives and 26 HP-negatives, and there was significant difference in the numbers of HP-positives and HP-negatives (P < 0.05), but no significant difference in gender and age (P > 0.05). Of the subjects with abdominal pain, HP-positives accounted for 59.02% and HP-negatives accounted for 37.67%, showing significant differences (P < 0.05). Finally, the size of the ulcer lesion in HP-positives and HP-negatives was compared. It was found that 71.57% of HP-positives had ulcers with a diameter of 0-1 cm, and 28.43% had ulcers with a diameter of ≥1 cm. Compared with HP-negatives, the difference was statistically significant (P < 0.05). In conclusion, N-KSVD-based ultrasound combined with gastroscopy demonstrated good denoising effects and was effective in the diagnosis of GIB caused by HP.

Laparoscopic treatment in gastrointestinal bleeding due to Dieulafoy's lesion.

Dieulafoy's lesion is a rare cause of gastrointestinal bleeding. Produced by the erosion of aberrant vessels in the submucosa, usually at the gastric level. The jejunal location is unusual. Its diagnosis is complicated by the intermittent characteristic of bleeding, initially recommending the endoscopic approach. It is an unusual entity that must be taken into account in the differential diagnosis of gastrointestinal bleeding. Massive bleeding can occur, compromising the life of the patient. Initial endoscopic/radiological management is recommended, reserving the surgical approach for refractory bleeding for less invasive treatments.

Abstract 12474: Acute Myocardial Infarction Following Hospitalizations for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

Introduction: Patients hospitalized with gastrointestinal bleeding (GIB) are at risk for acute myocardial infarction (AMI). Clinical characteristics of patients with AMI after a GIB are poorly characterized. We sought to evaluate the incidence, management and outcomes of AMI following hospitalization for GIB. Methods: Patients admitted with a diagnosis of GIB were identified in the 2014 United States Nationwide Readmission Database using ICD-9 diagnosis codes. Hospital readmissions for AMI within 90 days of GIB were identified. Patients with AMI after GIB were compared to those without a prior GIB to determine differences in management and in-hospital outcomes. Invasive management of AMI was defined as invasive angiography or coronary revascularization. Logistic regression models were used to estimate odds of invasive management and all-cause, in-hospital morality after adjustment for clinical covariates. Results: A total of 644,622 patients with GIB were identified, of which 7,523 (1.2%) were readmitted for AMI within 90 days. Older age, diabetes mellitus, chronic kidney disease, coronary and peripheral artery disease, unknown GIB source, and AMI during the index GIB hospitalization were associated with 90-day AMI readmission. Compared to AMI patients without a recent GIB, patients with AMI within 90 days after GIB were older (74.4 vs. 68.4 years, p&lt;0.01), more likely to be women (47% vs. 41.1%, p&lt;0.01), have kidney disease (43.2% vs. 22.4%, p&lt;0.01), present with non-ST segment elevation MI (82% vs. 73%, p&lt;0.01), and were less likely to undergo invasive management of AMI (28% vs 63%, P&lt;0.01; adjusted odds ratio [aOR] 0.40, 95% CI 0.37-0.44). Recent hospitalization for GIB within 90 days was associated with higher all-cause in-hospital AMI mortality (22% vs 9%, P&lt;0.01; aOR 1.86 [1.68-2.06]). Conclusion: In the first 3 months after hospitalization for GIB, 1 of every 83 patients was readmitted with AMI. Patients with AMI after GIB were less likely to undergo invasive management of AMI and had higher mortality than those without recent GIB. Strategies to reduce morbidity and mortality of GIB-associated thrombosis are needed.

S3303 Outcomes of Gastrointestinal Bleeding During the COVID-19 Pandemic

Introduction: The novel circumstances during the pandemic have led to many challenges for clinicians and patients, including cancellation of procedures, policy regulations and the reluctance of patients to seek medical attention, potentially leading to adverse outcomes. Patients with gastrointestinal bleeding (GIB) require early resuscitation and possible intervention. The aim of this study was to investigate differences in the outcomes of hospitalized patients who encountered GIB during the initial peak of Coronavirus 2019 (COVID-19) pandemic in March 2020, compared to the year prior. Methods: In this retrospective cohort study, patients with GIB who presented to our institution during the first two weeks of March 2019 and 2020 were identified using ICD-10 codes for GIB. The diagnosis of GIB was confirmed based on assessment of hemoglobin (Hb), diagnostic imaging, endoscopy or clinical evidence of gross hemorrhage. Analysis was conducted with the Welch T-test and Pearson's chi-square test utilizing R 4.1.0. Results: We identified 89 patients with GIB in 2019 and 76 in 2020. Of the 2020 cohort, 88.2% tested positive for COVID-19. Compared with 2019, patients in 2020 were significantly older (years) (62.1 vs 68.3, P < 0.01), required longer hospital length of stay (days) (11.3 vs 20.9, P < 0.01), had higher rate of mortality (12.5% vs 36%, P < 0.01), were less likely to have history of cirrhosis (25.8% vs 6.6%, P < 0.01), presented with a higher Hb (mL/dL) (9.9 vs 11.9, P < 0.001), were less likely to undergo EGD (58.4% vs 13.2%, P < 0.001), or colonoscopy (21.6% vs 4 %, P < 0.01). There was no significant difference between baseline Hb or nadir Hb, P >0.05. The most common primary causes of death in 2019 were decompensated liver failure (27.3%), followed by septic shock (18%) and cardiogenic shock (18%), compared to 2020 deaths, which were COVID-19 respiratory failure (67.9%), hemorrhagic shock (11.1%) and cardiogenic shock (7%). Conclusion: Despite presenting with higher Hb on admission, patients during the COVID-19 pandemic had a higher rate of mortality. The most common cause of death was respiratory failure secondary to COVID-19. Our results also suggested patients with GIB were less likely to undergo endoscopic evaluation during the pandemic. Given the limitations of our study, it’s difficult to say whether this was due to strict COVID-19 isolation precautions, cardiopulmonary instability making endoscopy high risk, or clinical assessment suggesting GIB was not the primary cause of patient decline.Table 1.: Primary causes of death in year 2019 and 2020.

S1221 Bundle Payments for Care Improvement in Patients With Gastrointestinal Hemorrhage: Reducing Costs and Readmission Rates at a Single Hospital Center

INTRODUCTION: As Medicare promotes value of care-based reimbursement through novel initiatives, bundle payments for care improvement (BPCI) are approaching the forefront. The primary drivers of increased costs in this system are readmissions and post discharge rehabilitation facilities. To date, standardization of care (SOC) in medicare patients enrolled in BPCI for gastrointestinal bleed (GIB) has not yet been reported. We implemented an evidence-based SOC aimed at reducing 90-day hospital readmission rates and healthcare costs for Medicare patients admitted for GIB. METHODS: Our institute implemented a multidisciplinary team to standardize care from initial hospitalization to post discharge follow up for Medicare patients being admitted with GIB. A daily email from the data-analytics team identifying these patients is distributed. A standardized protocol including GI evaluation within 24 hours, blood transfusion, pre/post endoscopy protocol, and medication reconciliation is initiated. Physical therapy evaluates the patient prior to discharge. Upon discharge, patients receive detailed instructions, medication counseling, and follow up with primary care physicians and gastroenterology. For patients discharged to home, care navigators conduct home visits. Data including patient demographics, endoscopy reports, discharge disposition, and changes to medication regimens were collected. We then assessed our interventions’ impact on readmission rates, disposition, and cost in this patient population. RESULTS: 100 patients with the diagnosis of GIB were reviewed prospectively from October 2018 through March 2019. 93% of patients had GI consultation of which 97.8% were seen within 24 hours. Of all endoscopies performed, 93% were done within 48 hours of admission. In aggregated Medicare data, 54 of these patients were enrolled into PCBI. The 90-day readmission rates fell from 41.3% to 27.8% with home discharge rates increasing from 84.4% to 85.2%. In addition, enrolling in this program reduced cost of care, generating a $99,000 gain. CONCLUSION: Two areas of opportunity for cost savings in bundled payments are post discharge disposition and readmission reduction. Involvement at a multidisciplinary level with focus on early identification, improving efficacy, and optimizing resource utilization were all important for achieving quality care and reduced expenditures. Further improvements can be made by investigating readmission patterns in patients with GIB to identify areas in need of intervention.Figure 1.: Chart depicting pathway of care in patients enrolled in the PBCI.

S3448 An Unusual Presentation of a Rare Pathology

INTRODUCTION: Although gastrointestinal stromal tumors (GISTs) are known to be the most common mesenchymal tumors of the GI tract, they account solely for approximately 1 percent of primary gastrointestinal cancers. GIST incidence is about 0.68 per 100,000 and they are found most commonly in middle aged and older patients. Most of these tumors are diagnosed incidentally via endoscopy, surgery, or imaging. This case report highlights an unusual presentation of an uncommon tumor. CASE DESCRIPTION/METHODS: A 66-year-old male patient with past medical history of hypertension, obesity, diabetes mellitus type II, and obesity hypoventilation syndrome presented to the emergency department due to a 1-week history of dark tarry stools. The patient reported about three episodes daily. Associated symptoms included palpitations and pressure-like, mid- sternal, intermittent chest pain without radiation. The patient denied use of aspirin, nonsteroidal anti-inflammatory drugs or anticoagulation. In 2015, he underwent an upper endoscopy due to melena and dyspepsia which showed evidence of non-erosive gastritis and duodenitis with a biopsy positive for H. pylori infection. Although he received treatment, there was no evidence of eradication. Two years later he had a colonoscopy without major findings. Initial labs upon arrival showed a Hgb of 7.6 g/dL (baseline value:15g/dL). BUN was not elevated and BUN/Cr was 15.3mg/dL. Rectal exam was negative for bleeding. He was started on a high dose proton pump inhibitor, placed NPO, and transfused two PRBCs. Initial upper endoscopy showed erosive gastropathy, duodenitis, and an inlet patch. The patient rebled 3 days after the procedure. A second look upper endoscopy showed evidence of blood beyond the second portion of the duodenum, reason for which the scope was changed to pediatric colonoscopy scope for further evaluation. A large subepithelial lesion was found at the third portion of the duodenum (Figure 1). The superior aspect of the lesion was ulcerated and oozing. Appearance was suggestive of a GIST. Pathology report confirmed the diagnosis of a gastrointestinal stromal tumor, spindle cell type C-KIT positive (Figure 2). DISCUSSION: This case is particularly relevant today as cases of GIST continue to increase given the availability of new diagnostic criteria. Although most GISTs are found incidentally, this uncommon entity should be included in the differential diagnosis of gastrointestinal bleeding when no other etiology is found.Figure 1Figure 2

Brunner’s gland cyst: rare differential diagnosis of dyspeptic symptoms

abstract A 60-year-old woman was under investigation of dyspeptic symptoms. The upper gastrointestinal endoscopy showed a cystic subepithelial lesion in the second portion of the duodenum, measuring 8 mm in its longest diameter. The biopsy showed dilated Brunner’s gland lobular ducts with scattered stromal elements, what characterized a Brunner’s gland cyst. Brunner’s gland cyst should be included in the differential diagnosis of gastrointestinal bleeding, dyspepsia, gastroesophageal reflux disease (GERD), malabsorption syndrome, anemia, among others. The correct nomenclature is important to facilitate research for articles specifically related to each duodenal cystic lesions and better understanding of these diseases, as some may have malignant potential.