Duodenal Erosions Research Articles

Intelligent tongue diagnosis model for gastrointestinal diseases based on tongue images

BackgroundCurrently, the diagnosis of gastrointestinal diseases relies heavily on electronic endoscopy, which is not suitable for all individuals and insufficient for dynamic patient monitoring. Therefore, there is an urgent need for a convenient and noninvasive examination method to enhance the diagnosis and monitoring of gastrointestinal diseases. MethodsSince the tongue is a significant reflection of the digestive system and closely associated with gastrointestinal diseases, our study aims to develop a diagnostic framework based on tongue features. We have collected a dataset of 2,167 tongue coating images from 949 consecutive patients, including 905 images from healthy individuals and 1,262 images from patients with various gastrointestinal conditions. Notably, each patient sample may represent distinct gastrointestinal diseases. This study introduces a novel approach to information fusion detection, integrating hand-crafted and auto-encoded features, alongside disease detection employing Squeeze and Excitation (SE) and Slot attention mechanisms. These two branches respectively analyze image feature and spatial position information when utilizing tongue images for diagnosing gastrointestinal diseases. The amalgamation of predictions from both aspects yields the final detection outcome. ResultsFor both healthy and diseased cohorts, the optimal classification metrics were achieved: AUC = 0.886, ACC = 0.849, and TPR = 0.965, indicating satisfactory performance. Notably, our framework demonstrated promising results in detecting five common gastrointestinal diseases: Helicobacter pylori infection, bile reflux, reflux esophagitis, gastric erosion, and duodenal erosion. Ablation experiments underscored the efficacy of mixed features in multi-color space, showcasing an increase in AUC and ACC by 13.48 % and 12.05 % respectively. Furthermore, the attention mechanism, by focusing on the middle region of tongue images, contributed to a 6.12 % increase in AUC and a 6.35 % increase in ACC. ConclusionsIn this study, we successfully develop and validate a diagnosis framework for gastrointestinal diseases based on tongue image features. By utilizing tongue images, we achieve intelligent diagnosis of gastrointestinal diseases, establishing tongue diagnosis as a convenient, cost-effective, and noninvasive method for diagnosing and screening gastrointestinal diseases.

Perioperative and Mid-Term Outcomes of Bovine Xenografts in Infected Aortic/Iliac Surgery

Abstract Background Various methods of open-surgical treatment of infected aortic and iliac pathologies are available. The use of surgeon-made bovine pericardium grafts in infected aortic/iliac context has been associated with a low re-infection rate as well as high feasibility. Prefabricated (factory pre-sewn) bovine pericardium prostheses have been available for a few years. Studies reporting clinical results are rare. Aims Present the perioperative and mid-term outcomes of a bifurcated and straight bovine pericardium prostheses (BioModiVasc®) in infected aortic and iliac pathologies. Methods Retrospective database analysis of all vascular surgery operations between 2021 and 2023 at our centre. Results 28 BioModiVasc® grafts were implanted in 27 patients due to INAA (40,7%), VGEI (51,9%), trauma (3,7%) or Leriche-Syndrome (3,7%). Patients were predominantly male (85,2%) and often presented arterial hypertension (88,9%). Significant risk factors were infection in a remote site (29,6%), emergency/urgent operations in the past 12 months (22,2%) and previous vascular procedures (44,4%). Elevated CRP (88,9%) and soreness at site (81,5%) were the most common findings at presentation. CT-scan showed infection-typical findings in 96,3%. Pathogen was isolated in 77,8% of the cases. Median operation time was 300 minutes. 88,9% of the operations were emergency/urgent ones. 96,3% of the reconstructions were orthotopic, access was mostly transperitoneal (59,3%). Median hospital/ICU days were 19 and 2 respectively. Infection a/o operation-associated 30-day mortality was 11,1%. 3-deaths occurred at follow-up (median 12 months), non-infection a/o operation related. 1 patient required a re-do due to a duodenal erosion caused by the prosthetic anastomosis. Conclusion Open surgical treatment of aortic/iliac septic pathologies with the BioModiVasc® prosthesis yields good results, which are similar to the reported results of the use of surgeon-made bovine pericardial reconstructions.

Bowel Cleansing Preparations Are Associated with Gastroduodenal Lesions

Background: During esophagogastroduodenoscopy performed with colonoscopy, gastric and duodenal erythema, erosions, and ulcerations are often observed. This investigation was designed to review the prevalence of gastroduodenal lesions in patients who have undergone wireless capsule endoscopy using standard bowel cleansing preparations, but no endoscopy or sedation. Methods: A retrospective analysis was conducted on patients referred for capsule endoscopy. Records and capsule reports were reviewed for the patient demographics, preparation prescribed, procedural indications, and gastroduodenal findings. The preparations studied included polyethylene glycol lavage (PEG), PEG plus bisacodyl (PEG + bis), bisacodyl (bis), oral sulfate solution (OSS), and no prep. Results: Among the 1236 records, 498 (40.3%) were men and 738 (59.7%) were women. The mean age was 56 years +/− 18 years SD. The percentage of patients with lesions after any bowel preparation was 52.7% for gastric lesions and 23.6% for duodenal lesions. The percentage of patients with gastroduodenal lesions was 58.3% with prep, compared to 38.2% without prep. These findings were statistically significant, with an RR of 1.53 [1.19–1.94] (p-value = 0.00004). This difference was more pronounced in the OSS group RR of 1.65 [1.29–2.1] and bisacodyl group RR of 1.64 [1.25–2.15] compared to the PEG group RR of 0.95 [0.7–1.3]. Conclusions: This study showed that patients undergoing wireless capsule endoscopy who received bowel preparations had a significant increase in gastric and duodenal lesions. Of the preparations studied, OSS was associated with a greater number of gastroduodenal lesions, while PEG was the least associated with lesions, with an occurrence similar to the non-prep group. The clinical significance of these lesions remains undetermined. Endoscopists should be aware that preparations are associated with gastroduodenal lesions to avoid the misinterpretation and misdiagnosis of these lesions.

Deceiving duodenal erosion: fishbone lies beneath.

Incidental identification of foreign body (FB) during daily screening endoscopy is not rare. The patients may have unspecific symptoms and do not report a history of FB ingestion at presentation. Although these FBs mostly pass through the gastrointestinal tract uneventfully, a certain proportion could be impacted and cause complications. Lack of a definite history of FB ingestion could make diagnosis difficult and delay treatment when FB presents with deceiving endoscopic appearances. We report a duodenal FB mimicking erosion found in screening upper endoscopy.

Effects of 14-days bismuth- and tetracycline-containing quadruple therapy with concomitant regimen for the first line Helicobacterpylori eradication.

Helicobacter pylori (H. pylori) has infected about 50% of the world's population and it is the main cause for peptic ulcer, gastric adenocarcinoma and even a major cause for gastric MALT lymphoma. This study was performed in Mazandaran, Sari, situated in North of Iran. Three-hundred and twenty-eight adult patients with endoscopically approved gastric or duodenal ulcers or erosions and H. pylori infection were randomly divided into 2 groups to receive either 14 days PABT (Pantoprazole 40 mg, Amoxicillin 1 g, Bismuth 425 mg (all twice daily) and Tetracycline 500 mg four times a day) and PACM (Pantoprazole 40 mg, Amoxicillin 1g, Clarithromycin 500 mg, and Metronidazole 500 mg, all twice daily). To evaluate H. pylori eradication, fecal H. pylori antigen test was performed 8 weeks after treatment. The eradication rates were 94.51% in the PABT and 91.46% in PACM group based on the intention to treat analysis. Moreover, the eradication rates were 95.58% and 92.72% according to per-protocol analysis, respectively. Also, both groups had very low rates of severe side effects. Regarding the ideal eradication rates achieved by both treatment groups and the low rates of severe side effects, both treatment protocols can be prescribed for H. pylori eradication in North of Iran.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

The frequency of ulcerative-erosive defects and ulcerative bleeding of the gastroduodenal zone in patients with coronavirus infection COVID-19

Aim : to determine the frequency of erosive and ulcerative defects and ulcerative bleeding of the gastroduodenal zone in patients with COVID-19 infection. Materials and methods . Fibroesophagogastroduodenoscopy was performed in patients in the hospital for the COVID-19 infection treatment when they had heartburn, dyspepsia, or signs of gastrointestinal bleeding among patients. In total, endoscopy was performed in 387 patients (116 men and 271 women, mean age 65.4 years). Erosive esophagitis was assessed according to the Los Angeles classification (1994), candidiasis esophagitis according to the Kodsi classification (1976), esophageal varices according to K. J. Paquet (1983), classification of ulcerative bleeding according to J. A. Forrest (1974). Results . Erosions in the esophagus was found in 25.3% of the examined patients, gastric and duodenal erosions—in 44.4% of persons, gastric and duodenal ulcers — in 10.1% of patients. Gastroduodenal bleeding was determined in 5.7% of the examined patients and was associated with ulcerative defects in 81.8% of cases. Male gender was a strong risk factor for erosions, ulcers, and bleeding from the upper gastrointestinal tract. Conclusion . In patients with COVID-19, complications from the gastrointestinal tract, manifested by ulcerative defects and bleeding from the gastroduodenal zone, are a significant problem. It seems rational to propose to treat patients with COVID-19 infection receiving massive anti-inflammatory, anthrombocytic, anticoagulant therapy in the same way as is customary in the management of cardiological and rheumatological patients for the prevention of NSAID-gastropathy.

S3482 Small Bowel Enteropathy Induced by Immune Checkpoint Inhibitors: A Case Series

Introduction: While there is a growing understanding of the identification and management of colonic complications of immune checkpoint inhibitors (ICI), less is known about proximal intestinal complications. In this case series, we present 3 patients who developed small bowel enteropathies (SBE) after initiation of ICI. Case Description/Methods: Case 1: A 68-year-old female with stage IV non-small cell lung adenocarcinoma on pembrolizumab developed diarrhea with 7 watery bowel movements daily. EGD was normal and colonoscopy showed minimal sigmoid erythema endoscopically with histologic duodenitis and colitis. Despite treatment with vedolizumab, she remained steroid-dependent. Repeat EGD and sigmoidoscopy showed variable villous abnormality in the duodenum with associated epithelial lymphocytosis, focal active duodenitis, and resolution of colitis. Serologic evaluation revealed hypogammagobulinemia. Nine months after last dose of pembrolizumab, and ultimately therapy with intravenous immunoglobulin therapy and open-capsule budesonide, her symptoms resolved. Case 2: A 42-year-old male with metastatic melanoma treated with ipilimumab and nivolumab developed grade 2 diarrhea with steatorrhea, nausea, vomiting, and unintentional weight loss. EGD was endoscopically normal with biopsies showing active duodenitis with normal colonoscopy. He was initially treated with steroids, but due to persistent symptoms transitioned to infliximab. After receiving 3 doses of infliximab, he had complete resolution of symptoms. Case 3: A 59-year-old female with celiac disease (CD) and metastatic melanoma was started on nivolumab. She developed abdominal pain, early satiety, softer stools, and unintentional weight loss. EGD revealed non-bleeding duodenal erosions and duodenal mucosal changes consistent with celiac disease. Biopsies showed subtotal villous atrophy with increased intraepithelial lymphocytes. CD typing did not suggest refractory sprue. Her presentation was suggestive of a nivolumab-induced exacerbation of CD. After a year of intermittent steroid therapy and adherence to a gluten-free diet, symptoms resolved. Repeat EGD with biopsies showed normal villi and reduced intraepithelial lymphocytes. Discussion: In this case series, we present three patients who developed SBE, highlighting the challenge of its diagnosis and management. SBE should be suspected in individuals with altered stools and no evidence of classic colitis.

First case report of gastric outlet obstruction due to aortofemoral bypass Dacron graft erosion of the duodenum treated with neo aortoiliac system procedure.

IntroductionGastric outlet obstruction is an uncommon complication of surgical treatment of aortoiliac occlusive disease with aortofemoral bypass. The most frequent presenting feature of duodenal erosion due to aortic synthetic graft is upper gastrointestinal bleeding, which can range from a minor “herald” bleed to exsanguinating hemorrhage.Case presentationA 64-year-old male patient with an aortofemoral Dacron bypass due to aortoiliac occlusive disease TASC II D with a chronic graft infection required emergency resection of the right limb of the Dacron graft two years ago. The patient developed abdominal pain, postprandial vomiting and progressive weight loss with an upper gastrointestinal endoscopy that showed Dacron graft material eroding into the fourth portion of the duodenum generating a gastric outlet obstruction without aortoenteric fistula and ulceration in the duodenal mucosa.Clinical discussionThe treatment goals of aortoenteric fistula are to control hemorrhage, treat infection, maintain adequate distal perfusion, graft explantation and aortic reconstructions like in this case. Traditional treatment of aortoenteric fistula is graft excision and establishing an anatomic autologous or an extra-anatomic synthetic bypass. Neo aortoiliac system procedure has shown to be the most effective and safest emerging technique today.ConclusionAortoenteric fistula is a life-threatening condition associated with high morbidity and mortality and it can also pose a diagnostic dilemma. There are many presentations of aortoenteric fistula including gastric outlet obstruction syndrome. The neo aortoiliac system procedure is the ideal curative surgical approach in stable patients.

MOST COLON CLEANSING PREPARATIONS ARE ASSOCIATED WITH GASTRODUODENAL LESIONS

Cesar Moreno: NO financial relationship with a commercial interest | Anas Khouri: NO financial relationship with a commercial interest | Jack DiPalma: YES financial relationship with a commercial interest;Braintree Labs:Other Activities Not in List During EGD performed at the time of colonoscopy, gastric and duodenal erythema, erosions and ulcerations have been observed, attributed to the colon cleansing preparation.

Exploring the potential of Cinnamomum zeylanicum oil against drug resistant Helicobacter pylori-producing cytotoxic genes.

Thirty-one of sixty dyspeptic patients tested positive for Helicobacter pylori colonization in this study, as determined by histopathology and 16S rRNA. The cytotoxin-associated gene A (cagA) and vacuolating cytotoxin A (vacA) genes were found in 67.7 and 93.5% of H. pylori patients, respectively. The cagA gene was found to be associated with 100% of patients with duodenal erosion and ulceration identified via endoscopy examination. In addition, 86.7% of patients with cancerous and precancerous lesions, glandular atrophy, and intestinal metaplasia identified via histopathology examination. The vacA s1m1 mutation was associated with more severe forms of gastric erosion and ulceration, as well as the presence of precancerous and cancerous lesions. Eighteen (64.3%) of the twenty-eight isolates were classified as multi-drug resistant (MDR) or pan-drug resistant (PDR) H. pylori. Due to a resurgence of interest in alternative therapies derived from plants as a result of H. pylori resistance to the majority of commonly used antibiotics, the inhibitory activity of five essential oils extracted from some commonly used medicinal plants was evaluated in vitro against drug-resistant H. pylori clinical isolates. Cinnamomum zeylanicum essential oil demonstrated the highest anti-H. pylori activity when compared to the other essential oils tested. Cinnamaldehyde was the most abundant compound in C. zeylanicum (65.91%). The toxicological evaluation established the safety of C. zeylanicum oil for human use. As a result, C. zeylanicum essential oil may represent a novel antibacterial agent capable of combating drug-resistant H. pylori carrying cytotoxin genes.

Endoscopic Evaluation of Dyspeptic Patient in Tertiary Care Hospital

Objectives: To observe the organic change occurs in dyspeptic patient by upper gastrointestinal endoscopy. Methods: The present prospective, observational, cross-sectional study was conducted at Medicine and Gastroenterology department of Sir Salimullah Medical College & Mitford Hospital, over a period of 6 month from 2019 to 2020.The study population was 200with aged18 years and above, irrespective of sex and who were suffering from dyspeptic symptoms for at least 6 months duration. Data regarding the demographic profile of study population nand endoscopic findings were processed and analyzed using software SPSS (Statistical Package for social science) version 26. Results: It was observed that most of the dyspeptic patients 71%were showing normal endoscopic findings and 29% have abnormal endoscopy findingwhere majority of the patient were 51 – 70 years of age.Out of them 41% of male and 26% of female had organic changes. It was also found that 46% of the patients were smoker and among them 34(37%) had abnormal endoscopic finding where 24(22%) non-smokerpatient had abnormal finding, which were statistically significant (p,0.05) between two group. Among abnormal endoscopic finding, 11% gastric erosions, 08% gastric ulcer, 04% duodenal erosions, 03% duodenal ulcer, 02% reflux oesophagitis, and carcinoma stomach rare 01%. Conclusion: The study concludes that majority of patients with complaints of dyspepsia have no organic lesion and can be considered non ulcer dyspepsia. The common abnormal endoscopic findings included gastric erosion and gastric ulcers relating to dyspepsia. The study findings also suggest that smoking is a risk factor for developing organic changes in dyspeptic patients specially in middle age group. Bangladesh J Medicine July 2022; 33(1) : 3-7

Establishing the Gastroduodenal Maximum Tolerated Dose for Ablative 5-Fraction Stereotactic MR-guided Online Adaptive Radiation Therapy (SMART) in a Novel Swine Model

Daily variations in abdominal anatomy introduce significant uncertainty in estimating the maximum tolerated dose (MTD). We investigated the gastroduodenal toxicity using stereotactic MR-guided online adaptive radiotherapy (SMART) to precisely control the dose to a novel swine model that closely matches human physiology and can be maintained at 80 kg. We hypothesized for a cumulative SMART course of 50 Gy in 5 fractions to the pancreas, the duodenum MTD is significantly > 37 Gy to 0.5 cc (D0.5cc).A total of 18 WMSTM were included at 3 duodenal dose levels: 37 Gy (n = 12), 43.5 Gy (n = 3), and 50 Gy (n = 3) in 5 fractions. We defined MTD as: > 10% (≥2 of 12) WMSTM present with dose limiting toxicity (DLT). A DLT was defined as ≥ Grade 3 non-hematologic toxicity due to RT per NCI CTCAE v4.0. All WMSTM underwent SMART on a clinical MR-guided radiotherapy (MRgRT) LINAC, under ventilation at breath hold (BH). Plans were IMRT and prescribed 50 Gy/5 fractions to pancreatic head, while maintaining uniform dose level (37, 43.5, 50 Gy) to duodenal circumference at 3 cm inferior to pylorus sphincter, typical uniform irradiated range 3-9 cc based on duodenal diameter. Circumference approach was used to eliminate underestimation of cumulative D0.5cc. Duodenal hotspot was 1.03% of the dose level (37, 43.5, 50 Gy) to 2 cc, 1.05% to 0.1 cc. Gated BH delivery was performed with sagittal plane tracking of the duodenum at 4 frames per second. Toxicity monitoring occurred for 30 days post-RT. Fecal occult blood test (FOBT) was done during RT and toxicity monitoring. Endoscopy occurred 14 days post-RT. Gross pathology was obtained at time of necropsy, 30 days post-RT.For the 37 Gy level, 1 of 12 WMSTM presented with DLT-pinpoint ulcer with surface damage on gross pathology (30 days post-RT). No DLT for 2 of 3 WMSTM at the 43.5 Gy level. One WMSTM at the 43.5 Gy level perforated on endoscopy, potentially due duodenal wall degradation and unknown RT-induced DLT on gross exam of emergency necropsy. Endoscopy was eliminated for the 50 Gy level. DLT was found for 2 of 3 WMSTM at the 50 Gy level upon gross pathology at necropsy, with each subject having 2-3 visible ulcerations at level of RT. One WMSTM at the 50 Gy level had duodenal pre-ulcer erosion at necropsy. All three WMSTM at 50 Gy level had visibly damaged papilla at necropsy. Another WMSTM at the 50 Gy level had common bile duct blockage, gall bladder obstruction, and jaundice at necropsy. FOBT were negative for all 18 WMSTM at 14 days post-RT.A duodenum D0.5cc of 37 Gy in 5 fractions was found to be safe in a swine model for a 50 Gy SMART course to the pancreas, showing the duodenal MTD is > 37 Gy - an increase from the RTOG 1112 limit (i.e., 30 Gy). Our results translate to a recommended MTD in human subjects and can potentially allow for greater tumor dose escalation and survival outcomes in future pancreatic patients. We are currently pursuing an expansion cohort to evaluate the MTD at 43.5 Gy.

S610 Endoscopy Findings in Patients With COVID-19: A Community-Based Single Center, Retrospective Study,

Introduction: Gastrointestinal (GI) manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) COVID-19 infections have been an area of active interest since early in the pandemic. GI symptoms including diarrhea, anorexia, and nausea have been commonly reported. A few studies have described “COVID-19 related inflammatory lesions” in the GI tract but there is very limited information on acute and chronic endoscopic findings in COVID-19 patients. Methods: Endoscopy reports performed at Advocate Lutheran General Hospital in patients infected with COVID-19 were reviewed between March 2020 to February 2021. Endoscopic findings of patients were compared between those who had a GI procedure within 14 days of their first positive PCR test for COVID-19 (Group 1) versus those who had a procedure greater than 14 days after their first positive PCR test for COVID-19 (Group 2). Between group differences regarding endoscopic findings and timing of procedure were compared using the chi square test. Results: There were 4714 encounters of COVID-19 at our facility and 45 patients had an esophagogastroduodenoscopy (EGD), colonoscopy, or both during their hospitalization. A total of 53 procedures were performed: 35 (69%) were EGDs and 16 (31%) were colonoscopies. Of the 35 EGDs, 15 (43%) were categorized to Group 1 and 20 (57%) to Group 2. 6 of 16 colonoscopies (37.5%) were categorized to Group 1 and 10 (62.5%) to Group 2. In group 1, 2 (13%) had normal EGDs and 2 (33%) had normal colonoscopies. In group 2, 6 (30%) had normal EGDs and 5 (50%) normal colonoscopies were found. Endoscopic findings involved non-specific inflammation in the stomach (characterized by erythema and erosions), (7 (47%) in group 1; 8 (40%) in group 2) and duodenum (2 (13%) in group 1; 1 (5%) in group 2). A small number of cases of esophagitis (2 (13%) in group 1; 4 (20%) in group 2) and recto-sigmoid ulcerations (1 (17%) in group 1; 1 (10%) in group 2) were described. Other endoscopic findings are as listed in Table 1. There were no statistical differences in the findings between Group 1 and Group 2 (p= 0.30). Furthermore, histological findings did not reveal specific infection related pathology. Conclusion: In a group of 45 patients infected with COVID-19, there was no endoscopic evidence of specific acute or chronic infection-related pathology. These findings do not support the concept of COVID-19 related GI mucosal disease.Table 1.: List of various pathological findings noted in both groups. Divided by anatomical locationFigure 1.: Endoscopic findings of patients with COVID-19. A. Minimal inflammation characterized by erythema seen in the gastric antrum. B. Localized minimal inflammation characterized by erythema seen in the gastric body. C. Duodenal erosions seen in the duodenal bulb. D. Ulceration and mucosal edema seen in the rectum

ENDOSCOPIC PROFILE OF UPPER GASTROINTESTINAL BLEEDING IN A TERTIARY CARE CENTRE.

Background:Astudy describing the endoscopic prole of upper gastrointestinal bleeding in a tertiary care centre. Aim:The aim was to study endoscopic prole in patients presenting with upper GI bleeding. Introduction: Upper gastrointestinal bleeding is a common medical emergency associated with signicant morbidity and mortality. The presentation of bleeding depends on the amount and location of bleed. The primary diagnostic test for evaluation of upper gastrointestinal bleeding is endoscopy. The aim was to study endoscopic prole in patients presenting with upper GI bleeding. Methods: This is a cross sectional study data conducted in Department of Gastroenterology DDHD Anna nagar Chennai from January 2019 to January 2020 . In this patients presenting with manifestations of upper gastrointestinal bleed were included and were subjected to upper GI endoscopy. Results: Atotal of 160 patients presenting with hematemesis and melena were studied. 124(77.5%) were males and 36(22.5%) were females. The mean age was 47.15 ± 17.12 . The most common ndings on endoscopy of upper gastrointestinal bleeding was portal hypertension related (esophageal and gastric varices, portal hypertensive gastropathy ) seen in 40% of patients, gastric erosions in 17.5% patients, peptic ulcer disease was seen in 13.75%, Esophagitis in 6.25% cases, Mallory-Weiss tear was seen in 6.25% patients, gastric malignancy in 5% patients, post EVL ulcers in 3.75% patients, Normal study in 3.75%, Duodenal erosions in 2.5% patients, Vascular ectasia of stomach in 1.25%. Conclusion: The present study reported portal hypertension as the most common cause of upper gastrointestinal bleeding, while most common endoscopic lesions reported were esophageal varices, followed by gastric erosions and peptic ulcer.

Paradigm shift in Etiology of Upper Gastrointestinal Bleed in Emergency Department

Background and Aims: Acute upper gastrointestinal (UGI) bleed is an emergency requiring immediate intervention. Recent data have shown peptic ulcer disease (PUD) to be commonest cause of UGI bleed. We aimed to evaluate all patients of UGI bleed reporting in emergency department. Methods: A cross-sectional, observational study from a tertiary care centre and evaluated all patients with UGI bleed presenting to outpatient and emergency department between December 2017 and December 2018 conducted. Results: 356 patients with UGI bleed were undertaken for diagnostic and therapeutic endoscopy. Variceal bleed was present in 231 (65%) [cirrhosis 217(61%) vs non-cirrhotic 14 (4%)], non-variceal 93 (26%) [cirrhosis 22(6%) vs non-cirrhotic 71(20%)] and no cause determined in 32 (9%). Among cirrhotic patients, alcoholic liver disease (n=172) was most common followed by cryptogenic (n=32), HCV (n=22) and HBV (n=7) and AIH (n=6) related cirrhosis. Among variceal non-cirrhotic causes, non-cirrhotic portal hypertension was present in 14 patients. In non-cirrhotic non-variceal group, causes of UGI bleed included esophagitis (n=26), erosive gastritis (n=9) and Mallory Weiss Tear (n=7) followed by PUD (n=23), carcinoma stomach (n=3), carcinoma esophagus (n=2) and duodenal polyp (n=1). Non-variceal cirrhotic patients had portal hypertensive gastropathy (n=8), PUD (n=5), duodenal erosions (n=1), esophagitis (n=7), antral varix (n=1). Interestingly, even in non-variceal group, alcohol was the underlying cause of UGI bleed in majority of patients with esophagitis and erosive gastritis. Conclusion: Alcohol was the commonest cause of UGI bleed in majority of cases with or without chronic liver disease followed by PUD in small number in emergency department.

Comparison of endoscopic and pathological findings of the upper gastrointestinal tract in transplant candidate patients undergoing hemodialysis or peritoneal dialysis treatment: a review of literature

BackgroundDyspepsia is a common disorder in kidney transplant recipients, and the risk of post-transplant complications is increased in candidates with upper gastrointestinal disease. We evaluated gastrointestinal lesions of kidney transplant candidates on dialysis.MethodsIn this study, endoscopic and pathological findings in hemodialysis (HD) and peritoneal dialysis (PD) patients with gastrointestinal symptoms on the waiting list were compared.ResultsThe most common non-ulcerous lesions in the endoscopic examination were gastritis (62.3%), erosive gastritis (38.7%), duodenal erosion or duodenitis (18.9%) and esophagitis (13.2%). The ulcerous lesion was present in only 3 patients. Gastroesophageal reflux disease, ulcerated lesion and non-ulcerated lesion rates were similar in both dialysis groups. Histopathological examination revealed Helicobacter pylori (HP) positivity in 28.3% of patients. HP positivity rate was significantly higher in PD patients than in HD patients (38.7% vs. 13.6%, p = 0.046). Chronic gastritis (75.5%) was the most common pathological finding. HP positivity rate was 37.5% in patients with chronic gastritis, but HP was negative in patients without chronic gastritis. In multivariate analysis, male gender, urea and albumin levels were associated with the presence of pathological chronic gastritis. The presence of gastritis, total cholesterol and ferritin levels were found significant for HP positivity. A total cholesterol > 243 mg/dL was significantly related to an increased risk of the presence of HP positivity.ConclusionsGastrointestinal lesions and HP infection are common in dialysis patients. Dialysis modality may affect the frequency of some lesions. It may be useful to have an endoscopic examination before entering the transplant waiting list for all candidates.

S2125 Gastroduodenal Artery Pseudoaneurysm Presenting With Bleeding Pancreatic Necrosis, Duodenal Erosion, and Melena: A Unique Case

INTRODUCTION: Melenic stools are typically indicative of gastrointestinal bleeding that may originate anywhere from the nares to cecum. Most common etiologies include gastritis, peptic ulcer disease, angioectasias, gastro-esophageal varices or malignant lesions. Here, we describe a rare case of melena caused by gastroduodenal artery (GDA) pseudoaneurysm with bleeding pancreatic necrosis and duodenal erosion. CASE DESCRIPTION/METHODS: A 58-year-old female with a history of class III obesity, chronic obstructive pulmonary disease, and recurrent pancreatitis presented with melenic stools, abdominal pain, and fatigue. Initial labs were significant for a hemoglobin of 6.0 g/dL. Computed Tomography (CT) of abdomen showed diffuse pancreatic necrosis with gas throughout the pancreas, which had progressed from imaging one month prior. Upper endoscopy was significant for erythematous duodenopathy but did not reveal any clear source of bleeding. Colonoscopy showed dark stool mixed with blood and hematin. In view of ongoing bleeding and transfusion requirements, push enteroscopy was performed showing a large blood clot and necrotic material in the duodenal bulb and second portion of the duodenum. Findings were concerning for erosion of pancreatic necrosis through the wall of the duodenum and erosion through a blood vessel resulting in active bleeding. Interventional radiology (IR) was consulted, and angiography demonstrated a GDA pseudoaneurysm which was successfully coil embolized. After the embolization, she was managed non-operatively due to her substantial co-morbid conditions. In total, she required 14 units of packed red blood cells during the hospitalization. Her bleeding resolved and she was discharged on high dose of oral proton pump inhibitors. DISCUSSION: Representing only 1.5% of visceral arterial aneurysms, GDA pseudoaneurysms very seldomly occur as a result of acute pancreatitis with necrosis. A history of recurrent pancreatitis is frequently noted. Pseudoaneurysm formation occurs due to pancreatic enzyme release and subsequent chronic inflammation, resulting in breakdown of the arterial wall and blood collection enclosed by adjacent fibrous tissue. Our case demonstrates an even rarer occurrence of erosion of the pancreatic necrosis through the wall of the duodenum, with active bleeding from the GDA pseudoaneurysm manifesting as severe gastrointestinal bleeding. Timely recognition is vital, as 40% of ruptured GDA pseudoaneurysms result in death. Management is completed through IR embolization or surgery.

S3085 Incidence of Peptic Ulcer Disease in Patients Undergoing ERCP for Pancreato-Biliary Disorders: A Retrospective Study at a Tertiary Care Medical Center

INTRODUCTION: Peptic ulcer disease and biliary disease typically have overlapping symptoms of abdominal pain and frequently require endoscopic evaluation for diagnosis and management. Alteration in the normal biliary physiology due to obstruction effects bicarbonate and biliary secretion which are protective to the duodenal mucosa from the gastric acid secretion. We hypothesize that biliary stasis effects the normal biliary and bicarbonate secretion leading to prolonged exposure of duodenal mucosa to gastric acid resulting in duodenitis and ulcers. Our study aims to investigate any correlation between incidence of duodenitis and PUD in patients with biliary or pancreatic disease undergoing ERCP. METHODS: A retrospective chart review of patients who underwent ERCP between January to June, 2019 at our institute were included. Patients were grouped into six categories these included: (1) choledocholithiasis; (2) chronic pancreatitis; (3) pancreatic cancer; (4) bile leak; (5) cholangiocarcinoma (CCA); and (6) abnormal imaging. Extracted data included several lab values (e.g., AST, ALT) and PUD. Use of non-steroidal and corticosteroids were taken into account in the final data analysis. ANOVA with Bonferonni-corrected post hoc analyses were utilized for continuous measures, and Chi-square were utilized for categorical measures. All analyses were conducted in SPSS (v. 25). RESULTS: Out of the total 77 patients, 41 (53.2%) patients had evidence of duodenitis and 39 (50.6%) patients had evidence of PUD. Female patients accounted for the majority of the sample (62.3%; P = 0.030), though 70% of pancreatic cancer patients were male. For clinical measures, significant differences were found for PUD (X2 = 12.143, P = 0.033), with the greatest percentage for chronic pancreatitis (60%) and CCA (75%) and for duodenitis (X2 = 20.645, P = 0.001), with the greatest percentage for choledocholithiasis (63.4%), Pancreatic cancer (60%). (Figure 1,2). CONCLUSION: Our study represents the first comprehensive research demonstrating increased incidence of duodenitis and PUD in patients undergoing ERCP for Pancreatico - Biliary disorders. Potential limitation includes small sample size, use of side viewing duodenoscope, and lack of Helicobacter pylori testing. This study emphasizes the importance of a more careful mucosal examination during ERCP to diagnose duodenitis and duodenal erosions as these patients may benefit from proton pump inhibitors. Future prospective studies are required to further validate the results of our study.Figure 1.: Incidence of duodenal ulcers in patients with pancreato-biliary disorders.Figure 2.: Incidence of duodenal erosion in patients with pancreato-biliary disorders.

Evolution of spontaneous dissecting mycotic Superior Mesenteric aneurysm in a 12-year-old child: A case report

Visceral artery aneurysms are uncommon especially in children. One of the main complications before surgery is rupture. This 12-year-old child presented with a large, fast growing, mycotic superior mesenteric aneurysm that had all the favourable conditions for rupture. There was spontaneous dissection of the weakened media with partial erosion of the aneurysm into the wall of the third part of the duodenum. However, this aneurysm formed a thrombus that gradually occluded the lumen. This led to formation of collateral vessels for the continued vascular supply of the midgut. The uniqueness of this case report has been highlighted from several points (the rarity of the condition in children, the favorability of the conditions to rupture, the gradual but complete luminal occlusion with the eventual formation of collaterals to supply the midgut, and the spontaneous medial dissection with partial duodenal wall erosion without causing rupture). Although there is no standard surgical approach, early elective surgery is recommended. Nonoperative approach is an option that should aim at reducing the risk for rupture. Control of blood pressure is key. This child underwent surgery. Under total vascular exclusion, the aneurysm was opened. After total luminal occlusion and collateral blood supply to midgut was noted, infected thrombus was evacuated and the aneurysm walls debrided.