Emergency Esophagogastroduodenoscopy Research Articles

Prediction of esophagogastroduodenoscopy therapeutic usefulness for in-ICU suspected upper gastrointestinal bleeding: the SUGIBI score study

BackgroundSuspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB.MethodsWe conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort.ResultsTwo hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91–99) for hemostatic endotherapy [AUC of 0.81; 0.75–0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66–0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92–97).ConclusionsOur study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD.

Management patterns of multiple magnet ingestion reported to New Jersey Poison Information and Education System.

Ingestion of multiple high-powered neodymium rare-earth magnets poses a significant risk for gastrointestinal (GI) injury such as bowel perforation or ischemia. Given the rising incidence of rare earth magnetic ingestions and the corresponding increase in serious injuries in children, published guidelines recommend urgent endoscopic removal of all magnets within endoscopic reach in cases involving ingestions of two or more magnets. Do management patterns for multiple magnet ingestion align with current practice guidelines, and does hospital length of stay (LOS) differ based on the initial emergency department (ED) approach? This is a retrospective chart review of consecutive patient encounters reported to the New Jersey Poison Information and Education System (NJPIES) between January 2021 and April 2022 involving multiple magnet ingestion. Potential cases were retrieved from the NJPIES TOXICALL® database, using substance codes relating to magnet or foreign body ingestion. Two-sample T tests were used to determine the statistical difference in the hospital LOS between the group of patients receiving early emergent esophagogastroduodenoscopy (EGD) versus those receiving expectant management on initial presentation. There was a difference in the average LOS of 2.7 days (p = 0.023)longer in the expectant management group with no medical complications in either group. Twenty-five percent or 2 out of 8 cases deviated from guidelines. The initial ED decision to pursue expectant management instead of attempting emergent EGD removal of magnets may result in prolonged hospitalization, increased risk for readmission, and delayed definitive removal of magnets due to nonprogression along the GI tract.

Association between time from esophageal food impaction to endoscopy and adverse events

Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events. In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events. Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders. Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding.

In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB). We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding. A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings(n=50,20%; n=29,11.7%; and n=28,11.3%, respectively). Of the participants,93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180). We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Decision-To-Scope Score: A novel tool with excellent accuracy in predicting foreign bodies in the esophagus.

Foreign body (FB) ingestion is a common indication for urgent esophagogastroduodenoscopy (EGD). Nevertheless, most pass spontaneously through the gastrointestinal (GI) tract. Differently from GI bleeding, there is no validated score aiming to identify "low-risk" patients in suspected FB ingestion. We aimed to create a score able to discriminate patients who are candidates to emergent EGD in this scenario. Retrospective study of consecutive patients admitted for suspected FB in the upper GI tract between 2016 and 2021. The evaluated outcome was endoscopic confirmation of FB in the esophagus. Variables significantly associated with the outcome on multivariate analysis were computed into a score predicting endoscopic confirmation. We included 228 patients. From these, 97 (42.5%) had a confirmed FB in EGD. Time since ingestion <6h (OR=4.0; P=0.042), absence of any meal after FB ingestion (OR=7.1; P=0.005), dysphagia (OR=11.8; P<0.001), odynophagia (OR=4.6; P=0.004), and drooling (OR=15.1; P<0.001) were independent predictors of confirmed FB. These variables were used to compute a FB predicting score-the Decision-To-Scope (DTS) Score: time since ingestion <6h (+1 point), absence of meals (+2 points), dysphagia (+3 points), odynophagia (+1 point), and drooling (+4 points). DTS-Score had excellent accuracy to predict the outcome (AUC=0.953; 95%CI=0.928-0.977; P<0.001). The optimal cutoff to identify low-risk patients was a score ≤5 (sensitivity 85.0% and specificity 94.7%). More than half of the suspected FB were not confirmed by EGD. The DTS-Score presented excellent accuracy at stratifying patients' risk and may contribute to the decision to perform emergent EGD in suspected FB ingestion.

Clinical outcomes of marginal ulcer bleeding compared with those of peptic ulcer bleeding.

Marginal ulcer bleeding (MUB) is a complication that can occur following several types of surgery. However, few studies exist on it. Therefore, this study aimed to compare the clinical outcomes of MUB with those of peptic ulcer bleeding (PUB). Between January 2013 and December 2017, 5,076 patients underwent emergent esophagogastroduodenoscopy for suspected upper gastrointestinal bleeding. We retrospectively reviewed and analyzed the medical records of MUB and PUB patients and developed a propensity score matching (PSM) method to adjust for between-group differences in baseline characteristics with 1:2 ratios. Sex, age, body mass index (BMI), underlying diseases, and drugs were included as matching factors. A total of 64 and 678 patients were diagnosed with MUB and PUB, respectively, on emergent esophagogastroduodenoscopy, and 62 and 124 patients with MUB and PUB, respectively, were selected after PSM. Rebleeding was significantly higher in patients with MUB than in those with PUB (57.8% vs 9.1%, p < 0.001). Mortality caused by bleeding was higher in patients with MUB than in those with PUB (4.7% vs. 0.4%, p < 0.001). Multivariate analysis revealed that proton pump inhibitor (PPI) administration (odds ratio [OR], 0.14; 95% confidence interval [CI], 0.03-0.56; p = 0.011) after first bleeding was inversely correlated with MUB rebleeding. Large ulcer size (> 1cm) (OR, 6.69; 95% CI, 1.95-27.94; p = 0.005) and surgery covering pancreas (OR, 3.97; 95% CI, 1.19-15.04) were independent risk factors for MUB rebleeding. MUB showed a severe clinical course than PUB. Therefore, MUB should be managed more cautiously, especially for large ulcers and pancreatic surgery. Prophylactic PPI administration may be helpful in reducing rebleeding in MUB.

Endoscopic variceal ligation and percutaneous transhepatic obliteration difficulty in esophageal variceal bleeding: a case report

A 48-year-old male patient with a history of alcoholic cirrhosis was admitted to our hospital due to hematemesis with a 7-day history of melena. Emergency esophagogastroduodenoscopy revealed esophageal variceal bleeding. We attempted hemostasis with endoscopic variceal ligation (EVL). The esophageal mucosa was not aspirated into the EVL device although the patient had no history of endoscopic injection sclerotherapy or EVL. Percutaneous transhepatic obliteration (PTO) was performed and esophageal variceal bleeding was successfully hemostasis. PTO is a viable option for refractory esophageal bleeding.

A Glasgow-Blatchford Bleeding Score of >2 Is a Poor Predictor of Endoscopic Intervention in Nonvariceal Upper GI Bleeding.

Recent data show that a Glasgow-Blatchford Bleeding Score (GBS) >2 does not identify patients with upper gastrointestinal (GI) bleeding who benefit from inpatient esophagogastroduodenoscopy (EGD). This study aimed to determine the rate of endoscopic hemostatic interventions (HI) in patients with nonvariceal acute GI bleeding (NVAUGIB) admitted with a GBS >2. Secondary aims included comparison of clinical outcomes in patients with and without HI and cost of nontherapeutic EGDs. We conducted a retrospective review of medical records of patients admitted to a referral hospital for NVAUGIB from January 2015 to December 2017. Mortality, blood transfusion rates, length of stay, length of intensive care unit stay, and cost of a nontherapeutic EGD were outcomes of interest. Patients 18 years of age and older of both sexes were included. The accuracy of the GBS >2 cutoff was determined using receiver operating characteristic curve analysis. A total of 357 patients were included and only 58 (16.2%) required HI. The area under the curve for GBS >2 as a predictor of HI was 0.57. The performance of HI did not influence mortality (P = 0.33), blood transfusion rates (P = 0.51), length of stay (P = 0.2), or length of intensive care unit stay (P = 0.36). The estimated cost of performing nontherapeutic EGD was approximately $855,000 for the 299 patients who did not need HI. A GBS cutoff of >2 is not an accurate criterion to triage patients with NVAUGIB for inpatient emergent EGD. More clinically meaningful and cost-effective methods to triage these patients are necessary.

Cerebral air embolism: A hidden cause of acute ischemic stroke

AbstractA 46‐year‐old man presented to the Emergency Department because of food bolus impaction after an emergent esophagogastroduodenoscopy (EGD). Three hours after the procedure, awakening from general anesthesia, he complained drowsiness and left‐sided weakness. Brain CT scan was unremarkable, while CT angiography performed later revealed signs of pneumomediastinum likely from an esophageal laceration. Thorough cardiological, hematological, and rheumatological investigations during hospital stay proved unremarkable. Cerebral air embolism (CAE) has been reported as a potential complication of endoscopic procedures, but the precise mechanism is still unknown.

S2374 Recurrent Strictures in a Patient With Missed Diagnosis of Eosinophilic Esophagitis

Introduction: EoE is an antigen-mediated inflammatory disorder of the esophagus that affects both children and adults. Diagnosis requires symptoms related to esophageal dysfunction and esophageal biopsy showing >15 eosinophils/hpf is confirmatory for diagnosis. Proton pump inhibitors (PPIs) are considered the first line agents for the treatment of EoE, together with elimination diet and topical corticosteroids. Nonadherence to therapy and undiagnosed disease can increase the risk of fibro-stricturing disease and food impactions. Practicing evidence-based guidelines in diagnosing and managing patients with EoE can allow standardization of care and prevent complications in patients with EoE. Case Description/Methods: A 34-year-old man presented with a longstanding history of intermittent dysphagia to solids. He had an emergent esophagogastroduodenoscopy (EGD) for food impaction about 3 years prior to presentation. No biopsies were obtained at that time, and he was prescribed a short course of PPI before discharge. On current presentation, the patient underwent an EGD which showed multiple untraversable strictures requiring dilation (Figure). Biopsy from multiple sites showed >200 eosinophils/hpf, consistent with a diagnosis of eosinophilic esophagitis (EoE). Thereafter, the patient was initiated on PPIs but had to undergo further dilations for recurrent strictures. Topical steroids were subsequently added to the therapy with satisfactory response. Discussion: Once considered rare, EoE is now a well-known entity, with an estimated prevalence of 51.6/100000 in the US. However, variability and deviations from standard therapy continues to persist among gastroenterologists. According to a national survey conducted in 2020 among 240 gastroenterologists, only 24 % were “very familiar” with the EoE guidelines and only 12 % followed EoE guidelines in their clinical practice. The current case underscores the need to standardize clinical practice related to the care of patients with EoE in order to provide quality and evidence-based care and improve overall outcomes.Figure 1.: EGD showed trachealization of the esophagus.

S2340 Massive Upper Gastrointestinal Hemorrhage Following Radiofrequency Ablation for Barrett’s Esophagus

Introduction: Radiofrequency ablation (RFA) is an established endoscopic technique for the management of Barrett’s esophagus (BE) with low grade dysplasia (LGD). Bleeding risk after RFA treatment has been reported to be around 1%. We present a case of massive upper GI bleeding following RFA treatment resulting in death as an adverse event. Case Description/Methods: A 79-year-old male with history of BE with LGD underwent esophagogastroduodenoscopy (EGD) with RFA treatment. The patient had a history of coronary artery disease for which he was taking aspirin and prasugrel. His prasugrel was held 7 days prior to the procedure. During the procedure, the esophagus was carefully examined using white light and narrow band imaging. No esophageal nodules were found; however, mucosal changes secondary to established short-segment Barrett's were seen. The Barrx 90 ultra RFA catheter was used to ablate the Barrett’s mucosa and the procedure was uneventful. Aspirin was resumed the following day, but prasugrel was held for 1 week post procedure. Ten days post procedure, the patient presented to an outside hospital with hematemesis and chest pain. An emergent EGD was performed that revealed massive bleeding in the esophagus with no obvious source. A mesenteric angiogram with embolization of left phrenic and gastric arteries was performed by interventional radiology. A subsequent EGD revealed multiple large, deep ulcerations in the distal esophagus. The patient stabilized and was downgraded from the ICU. However, 2 days later, the patient developed acute respiratory failure with multi-organ failure, thought to be due to aspiration. The patient was transitioned to comfort care and passed away. Discussion: RFA is considered a safe and effective technique for the treatment of patients with BE with either low- or high-grade dysplasia as it is associated with an increased risk of developing esophageal adenocarcinoma. The most frequent adverse events following RFA treatment are esophageal stricture (8-10%), chest pain, bleeding (1%) and perforation (0.6%). Current guidelines for patients on dual antiplatelet therapy for secondary prevention who are undergoing elective procedures suggest temporary interruption of the P2Y12 inhibitor while continuing aspirin. These guidelines were followed in our patient. However, no clear guidance for when to resume newer anticoagulants exists. After extensive literature review, we did not find any case reports of massive upper GI bleed resulting in death following RFA treatment.Figure 1.: A) Barret's esophagus under narrow band imaging B) RFA treatment.

S2560 A Rare Case of a Bleeding Duodenal Varix Causing Hemodynamic Instability

Introduction: Variceal bleeding is a life-threatening complication of portal hypertension (PH), affecting 25-35% of patients with cirrhosis. Duodenal varices are uncommon, accounting for 0.4% of variceal bleeds from PH, but are associated with poor outcomes. Presented is a rare case of a bleeding duodenal varix (DV) causing hemodynamic instability in a patient with cirrhosis. Case Description/Methods: A 42-year-old male with polysubstance abuse and alcoholic cirrhosis complicated by PH and esophageal varices (EV) presented via emergency medical services after being found down in the street. The patient was hypotensive, tachycardic to the 140s, and febrile to 40.4 degrees Celsius. Physical exam was remarkable for blood covering his lower extremities and a large blood clot in his rectum. Labs were significant for a hemoglobin of 6.7 g/dl, platelet count of 68 K/MM3, white blood count of 15.6, bilirubin of 4.4 mg/dL, ammonia of 76 umol/L, and lactic acid of 4.2. Triphasic computed tomography of the abdomen and pelvis with intravenous (IV) contrast showed cirrhotic liver morphology and thickening of the ascending colon. Two units of packed red blood cells, IV pantoprazole, and IV octreotide were given. An emergent esophagogastroduodenoscopy demonstrated PH gastropathy, non-bleeding EV, and a 5-millimeter bleeding DV (Figure a). To achieve temporary hemostasis, two clips were placed over the DV with plan for Interventional Radiology (IR) to definitively control bleeding with embolization (Figure b). Abdominal ultrasound with Doppler demonstrated a patent portal venous system. Venogram showed DV fed by inflow from the superior mesenteric venous circulation with outflow via an enlarged right gonadal vein. Retrograde coil embolization resulted in complete resolution of bleeding (Figure c). Discussion: Common sites of variceal bleeding include the esophagus and stomach. Though DVs are rare, it is essential to gain consensus on the optimal approach to treatment as the mortality rate is up to 40% due to origination of DVs in the deep serosal layer and high vascularity of the duodenum. In this case, clips were used to achieve hemostasis followed by embolization for definitive cessation of bleeding. Clips also served as a landmark for IR to target during the venogram and coil embolization. Clips on their own may not be sufficient to control duodenal bleeding as there is risk of inadequate occlusion of vessels or tissue perforation. This multimodal approach offers an effective path to managing bleeding DV.Figure 1.: (a) 5-millimeter bleeding duodenal varix, as indicated by arrow. (b) Duodenal varix after placement of hemostatic clips, as indicated by arrow. (c) Venogram with retrograde coil embolization of the duodenal varix.

Endoscopic treatment of a large gastric bezoar: A Case report

Bezoars are concretions of undigested or partially digested foreign material in the gastrointestinal tract. They occur in patients with altered gastrointestinal motility or anatomy (previous gastricsurgery, diabetes mellitus, neurological disorders). They are rare, with an estimated %0.3 on upper endoscopy. The most common symptoms include abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss. We present a patient who diagnosed with 8-9 cm phytobezoar, and treated by endoscopic method. An 87 years old woman presented to our emergency room with upper abdominal pain, nausea, and postprandial emesis for 3 days. Emergency esophagogastroduodenoscopy revealed prepyloric antrum, gastric phytobezoar (8-9 cm) and ulcers (10-12 mm). We used an endoscopic snare to cut the bezoar into several pieces. After endoscopy, all bezoars disappeared. There was no recurrence during 1-year follow-up. In conclusion, endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with gastric outlet obstruction. This is the rare case that such a large phytobezoar (8×9 cm) has been fragmented with an ordinary polypectomy snare.

Findings and outcomes of emergent endoscopies after cardiovascular surgery.

AimsStudies detailing endoscopic findings and hemostatic interventions for upper gastrointestinal bleeding after cardiovascular surgery are scarce. We conducted this study to determine the frequency and findings of emergent esophagogastroduodenoscopy (EGD) after cardiovascular surgery and the effect of bleeding requiring hemostatic intervention on clinical outcomes.Methods and ResultsWe retrospectively reviewed records of emergent EGD examinations conducted within 30 days after cardiovascular surgery at a tertiary referral center in Japan from April 2011 to March 2020. Of 1625 patients undergoing cardiovascular surgery, 47 underwent emergent EGD. Sources of bleeding were identified in 30 cases, including transesophageal echocardiogram (TEE)‐related injuries (8 patients), gastric ulcers (7 patients), and duodenal ulcers (7 patients). Patients who required endoscopic hemostatic intervention had more TEE‐related injuries (43% vs 3%, P = 0.005), gastric ulcers (35% vs 6%, P = 0.018), or ulcers in the first part of the duodenum (29% vs 0%, P = 0.006) than those who did not. Intraoperative TEE did not increase the need for endoscopic intervention (71% vs 64%, P = 0.435). Intraoperative TEE and the need for endoscopic intervention did not affect length of stay or all‐cause mortality. Only one death was associated with gastrointestinal bleeding.ConclusionDespite the potential severity of bleeding after cardiovascular surgery, most cases can be managed endoscopically with no increase in hospital stay or mortality.

S2555 Right Hepatic Artery Pseudoaneurysm: A Rare Complication of Biliary Stent Placement

Introduction: Formation of pseudoaneurysm is a rare but serious adverse event of biliary stenting. We present a case of a patient who presented with massive upper gastrointestinal bleeding two months after biliary stent insertion. Angiography revealed a right hepatic artery pseudoaneurysm which was successfully treated with transcatheter arterial embolization. Because bleeding may be fatal, timely diagnosis of the condition is important. Case Description/Methods: A 65-year-old-man with a past medical history of recurrent gallstone pancreatitis underwent Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with sphincterotomy and fully covered metal stent placement was admitted to our hospital for severe hematemesis. Labs revealed a drop in hemoglobin from 7.6 to 5.8. After endotracheal intubation, activation of the massive transfusion protocol (MTP) Minnesota tube placement, emergent esophagogastroduodenoscopy (EGD) was performed at the bedside, which showed a large amount of clotted blood but no active bleed. The next day, again he developed severe upper gastrointestinal bleeding leading to hypovolemic shock. MTP was activated again, and a Minnesota tube reinserted. After intensive resuscitation, a computed tomography angiography (CTA) was performed which showed a 6 cm large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery. Successful embolization of the common hepatic artery was performed without complications. No recurrent bleeding occurred over the following days. Discussion: This case demonstrates a rare complication of biliary stents which was successfully treated with transcatheter arterial embolization. It is important to consider that a pseudoaneurysm is a potential adverse event caused by a biliary stent because timely diagnosis and treatment are required to prevent fatal hemorrhage and death.Figure 1.: A. Large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery and abuts the distal gastric antrum/proximal duodenum. B. Injection from celiac artery demonstrating a bilobed pseudoaneurysm originating from the common hepatic artery/proximal right hepatic artery at the level of the intersection with the biliary stent. C. Post IR embolization CTA showing common hepatic artery without opacification and previously seen pseudoaneurysm.

S3690 Emergent Laparotomy to Remove Swallowed Denture That Failed Retrieval Under Endoscopy: A Case Report

Introduction: Foreign body ingestion is a common problem for gastroenterologists and general surgeons. Denture aspiration or ingestion is a less common type of ingested foreign body, but may cause hollow viscus necrosis, perforation, penetration to neighbor organs leading to fistula, bleeding, and obstruction. Here, we present a case of ingested metal denture that failed initial attempt to retrieve under esophagogastroduodenoscopy (EGD) and eventually removed by exploratory laparotomy and duodenotomy. Case Description/Methods: A 68-year-old male in Hefei, China presented with one-to-two days of epigastric discomfort. The patient denies any fever, nausea, vomiting, hematochezia, abdominal distention, or abdominal pain. Complete blood count (CBC) showed leukocytosis with a WBC of 15.21 x 109/L, and hemoglobin is within the normal range. Computed tomography (CT) scan showed the swallowed denture in the duodenum. EGD found a metal denture in the descending duodenum. One of the clasps of the denture appeared to penetrate the mucosa and the attempt to retrieve the denture under EGD failed. Therefore, emergent exploratory laparotomy plus duodenotomy to remove foreign body plus adhesiolysis was performed, and the denture was removed without complications. The patient was discharged on post-operation day 7 without complications. Discussion: Metal dentures can be accidentally swallowed and may cause gastrointestinal (GI) bleeding or perforation due to their material and structure such as the clasps. Therefore, consult for the gastroenterologist and possible emergent EGD should be considered early. However, when the denture clasps penetrate the mucosa of the GI organ with a relatively thin wall, such as the duodenum in our case, the attempt to retrieve under EGD should be performed cautiously due to the potential risk of tearing the mucosa leading to further damage. If the attempt under EGD is not successful or risky, consult for surgery should be considered. In this case, based on the request of the patient and his family, surgery was performed immediately without the further attempt of retrieval under EGD.In short, the ingested metal dentures may cause severe consequences such as GI bleeding and perforation, and thus patients with denture loosening visit the dentist as soon as possible. In addition, complications of endoscopic removal such as tears and perforations of the GI tract can not be ignored, therefore it must proceed with cautions and surgical intervention should be considered if needed.Figure 1.: A) The clasps of the swallowed denture penetrated the mucosa of the descending duodenum under esophagogastroduodenoscopy (EDG); B) Cross-section views of Computed tomography (CT) scan obtained from the First Affiliated Hospital of Anhui Medical University, Hefei, China showed the swallowed denture in the duodenum; C) Coronal plane of CT scan obtained from the First Affiliated Hospital of Anhui Medical University, Hefei, China showed the swallowed denture in the duodenum; D) The swallowed denture removed by surgical operation.

A rare case of penetration related to ischemic duodenitis after ventricular assist device implantation for dilated cardiomyopathy

A 66-year-old man with a history of diabetes and dilated cardiomyopathy underwent the implantation of a ventricular assist device (VAD) at the age of 62. He suffered from epigastralgia for a month and then visited our hospital with complaints of severe epigastralgia and hematemesis. A physical examination revealed abdominal distension without rigidity. Laboratory data showed severe systemic inflammation, multiple organ failure, and disseminated intravascular coagulation. Computed tomography showed multifocal thickness of the gastroduodenal wall with surrounding panniculitis, gas in a portal vein and a perigastric vein. Emergency esophago-gastro duodenoscopy (EGD) demonstrated a large erosion in the antrum of the stomach, and penetration surrounded by circumferentially ischemic mucosa in the second and third portions of the duodenum. Based on informed consent, conservative therapy was performed, and his condition improved enabling the start of oral intake on the 37th hospital day. However, 7days later, there was a relapse of epigastralgia after a meal. Gastrointestinal series and EGD revealed a 10-mm-long pinhole-like stricture at the site. After laparoscopic gastro-jejunal bypass surgery, he has remained in a good condition for 2years. We demonstrated a rare case of penetration due to severe ischemic duodenitis 4years after VAD implantation.

S1982 Life-Threatening Massive Upper Gastrointestinal (GI) Bleed and Airway Obstruction in a Patient With Megaesophagus From Longstanding Achalasia

INTRODUCTION: In 10% of patients, untreated or poorly managed Achalasia can cause progressive esophageal dilation and loss of functionality, forming a sigmoidolichomegaesopahagus, with less than 5% of cases requiring an esophagectomy. In extremely rare situations, this megaesopahagus can cause airway obstruction from the regurgitation of food and life-threatening esophageal bleeding from underlying pressure mucosal ulcers from the retained food debris. CASE DESCRIPTION/METHODS: A 65 year-old female with a past medical history of Achalasia, presented to the emergency department (ED) with complaints of worsening shortness of breath, chest pain, nausea, non-bilious hematemesis with regurgitated food and water since one day. These symptoms were accompanied by diaphoresis, fatigue and chronic intermittent dysphagia for both solid foods and liquids. In the ED, she experienced another massive episode of bright red hematemesis accompanied by severe dizziness with an acute drop in hemoglobin, resulting in a blood transfusion. Her chest x-ray showed a dilated megaesophagus occupying most of the right hemithorax and CTangiography displayed significant distention of the esophagus with intraluminal Solid material and fluid containing a small amount of gas as well partially obstructing the Right mainstem Bronchi (Image 1,2). Emergent Esophagogastroduodenoscopy was conducted, which revealed a large amount of food debris with areas of esophageal necrosis and dark red blood seen throughout, preventing visualization of the bleeding source (Image 3). The bleeding was likely from an ulcer caused by pressure necrosis from retained food. The patient was then transferred for an emergent esophagectomy to another Health care facility. DISCUSSION: Upper GI bleeding in Achalasia is usually associated with underlying mucosal ulcers caused by pill and infectious esophagitis, malignancies, excessive ingestion of tannins. Pressure ulcers from retained food debris is a rare but lethal etiology of Upper GI bleed in patient with Achalasia. The three factors that play an important role in the pathogenesis of this pressure ulcer formation in Achalasia are immobility from esophageal aperistalsis, non-uniform shearing forces induced from the regurgitation of food and the increased tendency of self-vomiting in these patients, and lastly, mucosal barrier disruption from gastric acid reflux and malnutrition. We hope to contribute to the current understanding of this topic and increase awareness among physicians about it by presenting this rare case.Figure 1.: Computed tomography Angiogram of Chest, Axial Scout (Left) with corresponding Coronal section (Right) showing dilated megaesophagus occupying most of the right hemithorax with intraluminal Solid and fluid material containing a small amount of gas partially obstructing the Right main Bronchi (Arrow).Figure 2.: Again Computed tomography Angiogram of Chest at lower level, Axial Scout (Left) with corresponding Coronal section (Right) showing severely dilated esophagus occupying most of the right hemithorax, with intraluminal Solid and fluid material containing a small amount of gas.Figure 3.: Esophagogastroduodenoscopy showing areas of esophageal necrosis and dark red blood seen throughout, preventing visualization of the exact bleeding source.

S2185 “Red Nipple Sign”: A Precursor to “White Nipple Sign”

INTRODUCTION: Cirrhosis affects approximately 3.6 out of every 1000 adults in North America and leads to about 32,000 deaths annually. Variceal hemorrhage occurs in 25–40% of patients with cirrhosis and is a major cause of cirrhosis related morbidity and mortality, associated with up to 20 percent mortality. Additionally, those patients who survive a variceal hemorrhage have a 70 percent chance of recurrent variceal hemorrhage within one year. CASE DESCRIPTION/METHODS: We present a case of a 70-year-old male with past medical history of alcoholic cirrhosis, hypertension and rheumatoid arthritis (taking nonsteroidal anti-inflammatory drugs [NSAIDs]) admitted with hematochezia and hematemesis. The patient was started on a proton pump inhibitor (PPI), octreotide and ceftriaxone, and underwent an emergent esophagogastroduodenoscopy (EGD). Two columns of large esophageal varices were identified extending from Z-line to mid-esophagus (Figure 1). One of the varices was noted to contain two adjacent red spots which appeared similar to stigmata labeled as “white nipple sign” but red in color (Figure 2). A decision was made to perform band ligation and one band was deployed to each variceal column base resulting in excellent decompressive effect. One additional band was then deployed over both “red spots,” which during suctioning into the bander cap began to actively spurt heme, however, bleeding resolved after band deployment. The sites of previous “red spots” were then noted to have classic “white nipple sign” appearance (Figure 3). The patient tolerated the procedure well, was monitored as inpatient and subsequently discharged home with follow-up in a hepatology clinic. DISCUSSION: Variceal hemorrhage is a gastrointestinal emergency with prognosis reliant on achieving hemostasis and preventing future hemorrhage. Therefore, it is extremely important to recognize endoscopic features of high-risk stigmata for future hemorrhage. The most commonly reported features are often described as “red signs,” and include red wales marks, cherry red spots and hematocystic spots. One stigma of recent hemorrhage is known as “white nipple sign,” which owes its appearance to the platelet-fibrin plug overlying a varix. On literature review, we found this to be the first case of showing endoscopic transition of a red spot (“red nipple sign”) into a “white nipple sign,” demonstrating likely pathogenesis from a finding significant for high risk of hemorrhage to the finding consistent with post hemorrhage state.Figure 1.: Two columns of large varices extending from z-line to mid-esophagus.Figure 2.: Close up endoscopic image of red spot overlying varix.Figure 3.: Site of previous red spot, subsequently noted to have "white nipple sign" after band ligation of varix.

Early endoscopic stent insertion for acute severe long-segment esophageal stricture

A 69-year-old man presented with dysphagia after drinking a little water. Two weeks earlier, he had visited the emergency department with a sore throat and shortness of breath after ingesting lye 2 hours prior. Emergency esophagogastroduodenoscopy and chest computed tomography revealed high-grade injury throughout most of the oropharynx (Fig. 1A and B) and esophagus (Fig. 1Cand D). He was hospitalized and managed conservatively and received broad-spectrum antibiotics intravenously. At his current presentation, esophagogastroduodenoscopy and esophagography revealed a severe mid-esophageal stricture (Fig. 2A and B).