Bleeding Duodenal Ulcer Research Articles

S4030 Duodenal Ulcer and Gastrointestinal Bleeding as a Late Adverse Event of Over-The-Scope Clip (OTSC) Placement

S4030 Duodenal Ulcer and Gastrointestinal Bleeding as a Late Adverse Event of Over-The-Scope Clip (OTSC) Placement

Utility of a self-assembling peptide in the management of refractory hemorrhagic duodenal ulcers.

Utility of a self-assembling peptide in the management of refractory hemorrhagic duodenal ulcers.

Transcatheter embolization for duodenal ulcer bleeding originating from cystic artery erosion

BackgroundUlcer erosion into the cystic artery is a rare cause of bleeding in duodenal ulcers, with only a limited number of cases described in the literature. Historically, treatment has predominantly involved surgical intervention. We present three cases of duodenal ulcer bleeding due to cystic artery erosion, which were successfully managed with cystic artery embolization.Case presentationThis case series includes three male patients with duodenal ulcer bleeding, aged 90, 81, and 82 years, respectively, and no prior history of biliary system disorders. The ulcer locations were identified as two in the post-bulbar region and one in the anterior bulb. After the failure of medical and endoscopic treatment, transcatheter arterial embolization was adopted. Initial angiography did not reveal any contrast medium extravasation. Empirical embolization of the gastroduodenal artery using gelatin sponge particles and coils failed to achieve hemostasis. Super-selective cystic artery angiography confirmed the source of bleeding as the cystic artery. One patient was embolized with gelatin sponge particles and coils, while the other two patients were embolized with N-butyl-cyanoacrylate. All patients achieved successful hemostasis without gallbladder infraction.ConclusionsCystic artery embolization proved to be a minimally invasive technique for achieving hemostasis in these cases, indicating that it may be a safe and effective alternative to surgery for this uncommon cause of upper gastrointestinal bleeding. Validation through further studies is warranted.

THE EFFECTIVENESS OF EMPIRIC TRANSARTERIAL GLUE EMBOLIZATION (TAGE) OF GASTRODUODENAL ARTERY (GDA) FOR BLEEDING DUODENAL ULCER - A RETROSPECTIVE STUDY

ABSTRACT: Purpose To conduct a clinical audit on clinical outcome of empiric transarterial glue embolization (TAGE) of gastroduodenal artery (GDA) for bleeding duodenal ulcers to evaluate treatment efficacy. Materials and Methods All patients treated for bleeding duodenal ulcers between June 2019 and June 2023, in a single tertiary center (Penang General Hospital) were identified based on intervention radiological reports. Patients with bleeding duodenal ulcers underwent empiric transarterial glue embolization (TAGE) of gastroduodenal artery (GDA) following endoscopic hemostasis were included. Information was extracted from patients' medical records, endoscopic and radiological reports. Data was computed and analyzed using Statistical Package for Social Sciences (SPSS). Results During the study period, a total of 26 patients were planned for empiric transarterial glue embolisation (TAGE) of gastroduodenal artery (GDA) for bleeding duodenal ulcer. The median age was 68 with 68% male (n=18) and 32% female (n=8). A total of 25 patients with duodenal ulcers of Forrest 1a (n=5), 1b (n=12), 2a (n=4), 2b (n=3) and 2c (n=1) who successfully underwent prophylactic TAGE of GDA were included in this study. It has a high technical success rate of 96.2% (n=25) with only one case of failure in cannulation due to tortuous arterial anatomy. Clinical success rate amongst the 25 patients who successfully underwent empiric TAGE of GDA was 84% (n=21) with only four patients developed rebleeding and required repeated endoscopic clipping. One of the four patients succumbed secondary to refractory bleeding. Conclusion Empiric transarterial glue embolisation (TAGE) of gastroduodenal artery (GDA) can be a useful adjunct treatment option in high risk bleeding duodenal ulcer with high technical and clinical success.

A novel strategy of combining abdominal surgery and endoscopy for the quick hemostasis of acute duodenal ulcer bleeding: a case report.

Uncontrolled ulcer bleeding of duodenal ulcer (DU) after endoscopic therapy often needs surgery. At present, cutting the bottom of the ulcer with ligation and performing its excision-lesion are the common ways to achieve immediate efficacy in stopping bleeding. For the problem of its great trauma, we seek an easy and useful technical method to reach the same therapeutic effect to stop acute bleeding. We determined the distribution of the lesion and its innervated blood vessels under the guidance of the endoscopy and then performed suture and hemostasis on the external surface of the stomach and duodenum. An immediate efficacy in stopping bleeding was shown and the hemoglobin (Hb) level returned to normal after operation with no recurrence of bleeding. We created a successful and novel strategy for laparotomy-endoscopic assisted suture for DU emergency hemostasis without duodenectomy.

THE FEATURES OF ENDOVASCULAR SURGERY FOR DUODENAL ULCER BLEEDING

Aim of the research was to study improvement of the results of surgical treatment of duodenal ulcer bleeding based on the use of endovascular embolization. Gastrointestinal bleeding is a relatively common condition with a wide range of underlying causes. In most cases, this acute bleeding is effectively managed by conservative, medical or endoscopic procedures. However, the proportion of endoscopically unrecognized or controlled non-variceal gastrointestinal bleeding still requires alternative, sometimes surgical, treatment. The current S2k guideline Gastrointestinal Bleeding gives importance to interventional radiology in considering its minimally invasive endovascular interdisciplinary therapy options, guideline-oriented endovascular treatment of Gastrointestinal bleeding by embolization and implantation of covered stents is a treatment approach with good technical and clinical success rates and low complication rates. Gastrointestinal bleedings (GIBs) are pathological conditions associated with significant morbidity and mortality. Embolization without angiographic evidence of contrast media extravasation is proposed as an effective procedure in patients with clinical and/or laboratory signs of bleeding. The purpose of this systematic review is to define common clinical practice and clinical and technical outcomes of blind and preventive embolization for upper and lower gastrointestinal bleeding. Knowledge of vascular anatomy is essential to achieve adequate hemostasis. Endovascular embolization dramatically reduces the mortality rate in high-risk patients who require open surgery after failed endoscopy, further studies are needed to fully address these objectives.

Causes of upper gastrointestinal bleeding in patients admitted to Erbil hospitals

Background and objectives: This study aimed to Find the causes of upper gastrointestinal bleeding in Erbil hospitals and to study these causes for the purpose of reducing their mortality. Methods: One hundred cases of upper gastrointestinal bleeding have been collected. All the cases have been admitted to Erbil hospitals from March 2019 to March 2021. Demographic data, blood investigation, ultrasound, and endoscopy with rapid urease test for Helicobacter pylori infection have been done for all patients to find the cause of upper gastrointestinal bleeding. Data analysis has been done by using a statistical package for Social Sciences -22. Results: A total number of fifty seven males and fourty three females, with upper gastrointestinal bleeding were included, eighty of them had positive rapid urease test by endoscopy, seventy five patients had duodenal ulcer, six cases had gastroesophageal varices, tumors found in five patients after histopathological investigation of the endoscopic biopsies, gastric erosions found in twelve patients. Ninty five of patients had first time bleeding, low hemoglobin found in fifty nine patients, that thiry of them presented in shock state, from these patients twenty two cases received more than five units of blood. Conclusion: Upper gastrointestinal bleeding mainly has been the cause duodenal ulcer bleeding which itself has been caused by infection with Helicobacter pylori. Secondly, drugs, which had been used, have been regarded as the main causes of bleeding.

SAT323 Management Of Severe Cushing’s Syndrome Due To Cortisol Secreting Adrenal Tumor In A Critically Ill Patient

Abstract Disclosure: H. Obeid: None. E.D. Buras: None. T. Else: None. Introduction: Severe Cushing’s syndrome is associated with multiple life threatening complications. Clinical Case: A 69 year-old man with Cushing’s syndrome was admitted to the hospital with septic shock due to bacteremia with necrotic left lower extremity infection. He required above knee amputation. His hospital course was complicated with invasive pulmonary Aspergillosis and ventilator associated pneumonia. He developed acute kidney injury that required dialysis, altered mental status, deep venous thrombosis bilateral pulmonary embolisms, bleeding duodenal ulcer and retroperitoneal hematoma. Prior to admission: Random cortisol was 31.7 mcg/dL (Normal: 4.8-19.5 mcg/dL), AM Cortisol following 1 mg oral dexamethasone was 47 mcg/dL (Normal: <1.8 mcg/dL), DHEA-s was 210 mcg/dL (normal: 33.6-249 mcg/dL) and 24 hour urine free cortisol was 622 mcg/day (Normal: <60 mcg/day). ACTH was undetectable. An FDG-PET scan showed a 6.5 centimeters hypermetabolic left adrenal mass with internal coarse calcifications but no evidence of metastasis. Etomidate drip, Metyrapone and Osilodrostat were tried to lower excess cortisol production. During admission while on Osilodrostat: Cortisol level: 20 mcg/dL (normal: 8-19 mcg/dL). Deoxycorticosterone: 53 ng/dL (Normal: 2-19 ng/dL). 11-Desoxycortisol: 580 ng/dL (Normal: 12-158 ng/dL). 17-alpha-hydroxyprogesterone: 45 ng/dL (Normal: 27-199 ng/dL). Surgery was considered, but adrenalectomy was deemed high risk and not pursued. Therefore, the patient underwent computed tomography (CT) cryoablation of the left adrenal gland. Labs following cryoablation: Cortisol: 7.7 mcg/dL. Deoxycorticosterone: 10 ng/dL. 11-Desoxycortisol: 34 ng/dL. 17-alpha-hydroxyprogesterone: 25 ng/dL. The procedure was complicated by T11/T12 intercostal artery injury leading to hemothorax. He was continued on physiologic doses of hydrocortisone. On follow up 4 weeks following discharge, he had complete resolution of hypercortisolism symptoms. A repeat whole body PET scan showed persistent FDG-avid neoplasm in left adrenal area, as well as metastasis in the liver and the duodenum. Conclusion: It is critical to control hypercortisolism in patients with Cushing’s syndrome. Several medications can be used. Surgical adrenalectomy remains the gold standard for treatment. CT-guided cryoablation of the adrenal tumor is a reasonable alternative when patient is not a surgical candidate. However, it is not a completely benign procedure as it can be associated with complications. Our treatment approach improved short term outcome for our patient, but did not provide long term benefit since he developed metastasis. Presentation: Saturday, June 17, 2023

FRI683 Every Dose Counts: Response To Half The Recommended Dose Of Romosozumab

Abstract Disclosure: B.P. Ramchandani: None. F.S. Mirza: None. Introduction: Romosozumab (RSB) is a monoclonal antibody that inhibits sclerostin, increases bone formation and decreases bone resorption. It was approved by FDA in 2019 at a dose of 210 mg monthly for 1 year, followed by an anti-resorptive medication. We present a case of a 76 y.o. female with severe osteoporosis and history of intolerance to multiple medications, who was given half the monthly recommended dose of Romo due to extreme concern about side effects. We hereby report the response of her bone density to the treatment. Case Description: A 76-year-old female with history of primary biliary cirrhosis, Sjogren’s syndrome, hemorrhagic duodenal ulcer, s/p subtotal gastrectomy in 1962 presented for evaluation of severe osteoporosis. Fracture history was significant for T11 compression fracture in 2020 requiring kyphoplasty, and a T10 inferior endplate compression fracture requiring vertebroplasty in 2022. Osteoporosis was first diagnosed in 2005. She was intolerant of teriparatide in 2005 (stopped after six months due to nausea, hypercalcemia, cramps, pain in extremities and fatigue). Zoledronic acid (ZA) was administered in 2006 and 2008. Baseline urine telopeptide cross-links (NTx) was low at 18 which decreased to 10 while on ZA and further infusions were held. She declined denosumab and teriparatide was tried again in 2013 that she did not tolerate. She received ZA again in 2016. BMD did not improve on ZA and she declined further infusions. She was physically active and walked daily and was taking calcium citrate, vitamin D and ursodiol during this time. On examination, she was frail and elderly, with BMI of 16.6 mg/kg2. She had mild kyphoscoliosis of the spine with no spinal or paraspinal tenderness. Remainder of the exam was unremarkable. Laboratory evaluation showed normal serum calcium (9.5 mg/dl), albumin (4.1g/dl), Vit D 25-OH (36 mg/ml), bone specific alkaline phosphatase of 22.7 U/L and urine NTx of 23 nm BCE/mm creatinine. Bone density (BMD) in January 2022 showed lumbar spine (LS) BMD of 0.613 g/cm2 (T-score −4.7) and a total hip BMD of 0.575 g/cm2 (T-score −3.4). She was reluctant to consider any medications due to concern about side effects, but finally agreed to a trial of RSB at half the recommended dose at 105 mg monthly for 12 months. DXA scan a year later showed 17% increase in LS BMD (0.715 g/cm2, T-score -3.9), with stable total hip BMD. She has been transitioned to denosumab, which she was now agreeable to take. Discussion: Our patient showed significant improvement in BMD with half the recommended dose of RSB, comparable to the increase in LS BMD reported in phase 3 trials. She was petite and her weight-based dose was just short of 3 mg/kg body weight. Phase 1 and 2 studies had tried weight based and smaller doses of Romo and showed improvement in BMD. This case highlights the need for additional studies with weight-based dosing of RSB, which may reduce the cost of treatment. Presentation: Friday, June 16, 2023

S4262 Plasmablastic Lymphoma: A Rare and Aggressive Variant of Large Cell Lymphoma Presenting as Duodenal Ulcer Bleed

S4262 Plasmablastic Lymphoma: A Rare and Aggressive Variant of Large Cell Lymphoma Presenting as Duodenal Ulcer Bleed

Bleeding due to successive duodenal and rectal ulcers in an 81-year-old patient with severe COVID-19: a case report

BackgroundIn the early stages of the coronavirus disease 2019 (COVID-19) outbreak, the most widely recognised symptoms of the disease were fever, cough, shortness of breath, myalgia, and fatigue. However, in addition to these symptoms, COVID-19 can cause systemic symptoms outside the lungs. Older patients with severe COVID-19 often require admission to the intensive care unit (ICU). Acute rectal ulcer bleeding, characterised by painless, profuse haematochezia, caused by solitary or multiple rectal ulcers, is one of the main causes of severe haematochezia in patients with COVID-19 in the ICU. However, recurrent duodenal ulcer bleeding followed by rectal ulcer bleeding has not previously been reported in older patients during ICU treatment for severe COVID-19.Cases presentationHerein, we report the case of an 81-year-old woman admitted to the emergency department due to severe COVID-19 and transferred to the ICU 2 days later for treatment. During treatment in the ICU, the patient developed recurrent duodenal ulcer bleeding and underwent endoscopic electrocoagulation haemostasis and gastroduodenal artery embolisation. However, the night after the final haemostatic operation, due to rectal ulcer bleeding, the patient discharged bloody stools intermittently, which was effectively controlled using endoscopic electrocoagulation, topical medication, blood transfusion, and haemostatic drugs.ConclusionsTo the best of our knowledge, this is the first report of duodenal ulcer bleeding followed by rectal ulcer bleeding in an older patient with severe COVID-19 infection. This report creates awareness for clinicians about the multiple and complex gastrointestinal symptoms that may occur during COVID-19 treatment.

A Comparison between Traumatic and Atraumatic Over-The-Scope-Clips in patients with Duodenal Ulcer Bleeding: a Retrospective Analysis with Propensity-Score-based Matching.

The over-the-scope-clip (OTSC) substantially improved the endoscopic armamentarium for the treatment of severe gastrointestinal bleeding and can potentially overcome limitations of standard clips. Recent data indicated a superiority of OTSC in hemostasis as first and second line therapy. However, the impact of the OTSC design (traumatic (-t) or atraumatic (-a) type) in particular in duodenal ulcer bleeding has not been analyzed so far. Retrospective analysis of a prospective collected database from 2009 until 2020 of six German endoscopic centers. All patients who underwent emergency endoscopy and were treated by an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by Fisher's exact test, chi-square- or Mann-Whitney U-test as appropriate. A propensity-score based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall-Score and treatment regimen had similar distributions in the two groups. However, OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a: 90.9%, OTSC-t: 87.9%, p=0.82) or 72h-mortality (OTSC-a: 4.5%, OTSC-t: 6.0%, p>0.99) were not significantly different but the OTSC-t group revealed a clearly higher rate of rebleeding (34.9% vs. 7.6%, p<0.001) and necessity of red blood cell transfusions (5.1±3.4 vs. 2.5±2.4 concentrates, p<0.001). OTSC-a should be the preferred option for duodenal ulcer bleeding if the endoscopist aims for an over-the-scope-clip.

P189 WHEN A PACEMAKER CAN BE HARMFUL IN A PATIENT WITH COMPLETE AV BLOCK

Abstract The occurrence of complete AV block in patients with aortic valve stenosis is a frequent event and the implantation of a dual–chamber pacemaker is the therapy of choice for these cases. We present the case of an 84–year–old hypertensive diabetic patient hospitalized with heart failure during a severe anemia caused by bleeding duodenal ulcer (Hb &amp;lt; 7g/dl). The patient was treated with blood transfusions, proton pump inhibitors, and endoscopic ulcer treatment with clinical stabilization. However, he presented a third–degree AV block, with a narrow QRS escape rhythm of about 45 bpm. The echocardiogram showed a calcified aortic valve with severe stenosis (transvalvular flow 4m/s, valvular area 0.9 cm2) ( fig1–2), with moderate mitral regurgitation and preserved systolic function (EF 60%). He was therefore subjected to a dual–chamber pacemaker implant. In the hours following the procedure, with heart rate increased to 90 bpm and correct AV synchronism, the patient presented an episode of acute pulmonary edema, treated with diuretics, oxygen and nitrogliceryn. with initial clinical improvement but subsequent new instabilization. The echocardiogram showed worsening of systolic function with septal dyssynergia secondary to electrostimulation and a severe mitral regurgitation (fig 3). The clinical status definitively stabilized only after changing the pacemaker programming to VVI 40 bpm (sentinel mode). The patient repeatedly refused the indications for aortic valve replacement surgery, and was therefore discharged with medical supportive care, third–degree AV block at electrocardiogram and a dual–chamber pacemaker programmed in sentinel VVI to obtain a minimal ventricular pacing. After 24–month follow–up, the patient remains in good clinical conditions, he was never hospitalized again, the third–degree AV block persists with PM stimulation percentages of 5%. This clinical case shows how electrostimulation and increased heart rate, in the presence of aortic outflow obstruction and significant mitral valve disease, can cause very insidious acute left ventricular systolic dysfunction, while restoring correct AV synchrony.

Pulsation of visible vessel or adherent clot in duodenal ulcer may indicate pseudoaneurysm: Case series.

Owing to the anatomical characteristics of the duodenum, gastroduodenal artery (GDA) pseudoaneurysms can be caused by duodenal ulcers, which may rupture and lead to massive or repeated bleeding. Pseudoaneurysms are usually diagnosed using enhanced computerized tomography or angiography, whereas endoscopic signs have rarely been reported. Three patients aged 18 to 83 years with bleeding duodenal ulcers and GDA pseudoaneurysms were treated. All patients had symptoms of gastrointestinal bleeding, and endoscopy revealed duodenal ulcers with visible vessels or adherent clot pulsations. Angiography confirmed the presence of a GDA pseudoaneurysm, which had an adjacent relationship with the duodenum. The GDA pseudoaneurysm was embolized in each patient. Through transcatheter arterial embolization, endoscopic treatment, and traditional treatment, hematemesis or melena was gradually stopped and all patients were discharged. The pulsation of visible vessels or adherent clots observed during endoscopy in patients with duodenal ulcer may indicate the formation of a gastroduodenal artery pseudoaneurysm. Therefore, we suggest that such patients receive enhanced computerized tomography or angiography to assess whether they need timely endovascular intervention treatment to avoid bleeding caused by a pseudoaneurysm.

EUS-directed transgastric endoscopy for upper gastrointestinal bleeding.

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips Figure 3. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient’s anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2,3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.Figure 1: EUS gastro-gastric fistulaFigure 2: LAMS ballon dilatationFigure 3: Conventional endoscopic treatmentDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Hemorrhagic duodenal ulcer as a rare complication prior to antiplatelet therapy for Kawasaki disease.

Hemorrhagic duodenal ulcer as a rare complication prior to antiplatelet therapy for Kawasaki disease.

Fibre-optic, electronic pH test device compared with current NHS guidance to confirm nasogastric tube placement

The clinical objectives of this prospective, random, convenience series were:1. Compare a novel fibre-optic pH test device (NGPOD) to gastric aspirate and pH testing for nasogastric tube (NGT) confirmation.2. Determine...

Frequency of Bleeding Duodenal Ulcer in Patients Presenting with Upper Gastrointestinal Bleeding

Acute upper gastrointestinal bleeding is a well-known complication of peptic ulcers and erosions. The prevalence of Upper Gastrointestinal bleeding ranges from 48-160 patients per 100,000 people, with consistent reports of higher incidence among elderly and men. Objective: To determine the incidence of duodenal ulcer bleeding in patients admitted to the tertiary care hospital with bleeding from the upper gastrointestinal tract. Methods: The study included 270 patients, 20 to 70 years of age, of both sexes with upper gastrointestinal bleeding within 24 hours of symptom onset. A detailed interview and complete physical examination were performed. Endoscopic examination protocols were followed and accomplished within 48-hrs of the start of symptoms as bleeding. All of the above information, including age, sex and duodenal ulcer, was documented in a formerly designed proforma. The data were analyzed and entered in SPSS 22.0. Results: The mean age and SD were 54.5 + 10.54. 110 (40.74%) patients were 20-45 years old and 160 (59.25%) subjects were 46-70 years old. 190 (70.37%) patients were male and 80 (29.62%) females. While in this study duodenal ulcer was seen in 64 (23.70%) patients, 206 (76.29%) patients did not have duodenal ulcer. Conclusions: Upper Gastrointestinal bleeding is secondary to duodenal ulcers due to an increase in early readmissions over time, as observed in this local population, resulting in a higher incidence of duodenal ulcers in our local population.

LBODP069 Parathyroid Crisis And Recalcitrant Hypercalcemia From Double Parathyroid Adenomas

Abstract Parathyroid crisis is a rare and life-threatening manifestation of hyperparathyroidism. Patients present with severe hypercalcemia and associated symptoms of bone disease, nephrolithiasis, abdominal pain, and fatigue. Multi-organ dysfunction in the form of encephalopathy, cardiac dysrhythmias, and renal failure is often present. There have also been reports of bleeding duodenal ulcers secondary to marked elevated parathyroid hormone. The most common etiology is a single parathyroid adenoma (85%) followed by hyperplasia (10%), double adenomas (4%), and carcinoma (1%). Parathyroid crisis requires immediate medical management of hypercalcemia and in recalcitrant cases, urgent parathyroidectomy. A 67-year-old female presented to the hospital with weakness and intermittent hematochezia. She was found to have acute renal failure, new onset anemia, and profound hypercalcemia of 17.1 mg/dl. On exam, she was slow to respond and exhibited diffuse muscle weakness. EKG showed sinus tachycardia, a right bundle branch block, and normal QTc. She received aggressive intravenous fluids and calcitonin. Bisphosphonate was not given due to renal failure. Due to refractory hypercalcemia, she was initiated on cinacalcet. She ultimately required hemodialysis due to failure of medical therapy. Further work-up showed a PTH of 2627 pg/ml. Vitamin D levels, TSH, and serum and urine protein electrophoresis were unremarkable. Renal ultrasound did not show nephrolithiasis. Given hematochezia and anemia in the setting of parathyroid crisis, endoscopy was done and was unrevealing of ulcers. A parathyroid ultrasound and nuclear medicine CT scan showed bilateral parathyroid adenomas. She underwent left superior and right inferior parathyroidectomy with biopsies revealing hypercellular parathyroid tissue with no features of malignancy. Following surgery, calcium levels gradually normalized. However, she remained dialysis dependent. This case exhibits a rare presentation of parathyroid crisis from double adenomas, requiring urgent double parathyroidectomy due to refractory hypercalcemia. This patient had an astoundingly elevated PTH level of 2627 pg/dl, one of the highest values documented in literature, which may attribute to the recalcitrant nature of hypercalcemia. Prompt diagnosis and treatment of parathyroid crisis is critical in preventing life-threatening complications. Presentation: No date and time listed

PMON40 A Rare Etiology of Chronic Diarrhea: Zollinger-Ellison Syndrome

Abstract Introduction Zollinger-Ellison Syndrome (ZES) is a rare etiology of chronic diarrhea caused by a gastrin-secreting neuroendocrine tumor. Early suspicion can prevent multiple readmissions for recurrent diarrhea thus improving clinical outcomes through prompt diagnosis and treatment, as the following case highlights. Case presentation A 74-year-old African-American female with hypertension and chronic atrial fibrillation presented to the ED complaining of watery, non-bloody diarrhea for the past 3 weeks. She reports her symptoms worsened after completing a course of amoxicillin for pharyngitis one week prior. On further questioning, she reported intermittent diarrhea for over 20 years lasting approximately two days per episode. She denied recent travel, sick contacts, pet reptiles, and recent ingestion of undercooked meat. On arrival, she was afebrile and hemodynamically stable. She was admitted for an acute kidney injury with an elevated creatinine of 3.23 mg/dL (N: 0.6-1.1 mg/dL) due to dehydration. Her renal function improved with fluids, but she developed bloody diarrhea for which gastroenterology was consulted. Stool studies were negative for Shiga-toxin, C. difficile, lactoferrin, and parasites. Computed Tomography of the abdomen showed enteritis with fluid noted throughout the colon consistent with colitis. Unprepped colonoscopy revealed blood throughout the length of the colon, suggestive of an upper gastrointestinal bleed. Esophagogastroduodenoscopy (EGD) revealed multiple bleeding duodenal ulcers controlled with hemostasis. Her symptoms improved and she was discharged home on oral pantoprazole, and told to follow up outpatient. Two weeks later, she denied any new episodes of diarrhea, and a random serum gastrin level was elevated at 413 pg/mL (N: &amp;lt;180 pg/mL). Repeat gastrin level off pantoprazole for 7 days was also elevated at 678 pg/mL, and a serum Chromogranin A level was elevated at 629 pg/mL (N: &amp;lt;390 pg/mL). Repeat EGD found her Gastric pH to be 1 with multiple non-bleeding duodenal ulcers. Somatostatin receptor scintigraphy revealed a high intensity signal consistent with a duodenal gastrinoma causing ZES. She elected for surgical resection, and was discharged home on high dose pantoprazole. Three months later, she stated that her diarrhea had completely resolved. Conclusion This case confirms ZES as a rare cause of chronic diarrhea in the setting of multiple duodenal ulcers refractory to proton pump inhibitors. Diagnosis can be made with a fasting serum gastrin level &amp;gt;1000 pg/mL or &amp;gt;400 pg/mL with a gastric pH &amp;lt;1. A Secretin Stimulation Testing can also be used. Treatment starts with high dose proton pump inhibitors, octreotide for hormonal regulation, and surgical resection if necessary. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.