Episodes Of Melena Research Articles

Castleman's disease, an unusual presentation

Presentation with intra-abdominal lymphadenopathy comes with a wide range of differentials, usually metastasis from regional organs, tuberculosis and lymphomas. But sometimes they surprise us with a histopathological diagnosis of Castleman's disease (CD). CD, also known as angiofollicular lymph node hyperplasia or giant lymph node hyperplasia is a distinct form of lymphoproliferative disorder of uncertain origin that typically affects mediastinal or axillary lymph nodes. The present report describes a 30-year-old serving male who presented with pain abdomen and on and off episodes ofmelena, found to have peripancreatic lymphadenopathy on CECT abdomen. Ultrasound guided FN AC was done in private hospital revealed reactive lymphadenopathy. Excision biopsy was done in our institute and a diagnosis of Castleman's disease was made.

Non Peptic Ulcer Upper Gastrointestinal Bleeding in Patients Treated with Non-Steroidal Anti-inflammatory Drugs for Musculo-articular Disorders

Introduction: Complications in the evolution of digestive tract benign pathology leads to symptoms: hemorrhagic, occlusive or perforative syndrome. Method: We present three cases of gastrointestinal (GI) hemorrhage with a different pathology and rarely seen in clinical practice in patients treated with non-steroidal anti-inflammatory drugs for muscular-articular pathology. Cases’ presentation: (1) A 47 years old man known with recurrent episodes of upper GI bleeding was admitted for a new massive hemorrhage; the emergency laparotomy revealed a splenic arteriovenous fistula penetrating the Wirsung duct. A splenopancreatectomy was performed with uneventful recovery. (2) A 57 years old woman with chronic anemia, nausea, weight loss and vomiting was admitted for intermittent recurrent episodes of melena. The exploratory laparotomy revealed several jejunal diverticulum with active bleeding; a segmental enterectomy was performed with uneventful recovery. (3) A 24 year old patient was admitted for massive inaugural melena. The upper GI tract endoscopy was negative; due to hemorrhagic shock an emergency exploratory laparotomy was performed and revealed a jejunal GIST. The resection was performed with uneventful recovery. The histo-pathologic exam confirmed a benign GIST. Conclusions: During Non-Steroidal Anti-inflammatory Drugs (NSAID) therapy anemia and upper GI bleeding are usually considered as common disorders related with peptic ulcer. However NSAID therapy can hide another more complex causes of bleeding. In majority of cases the bleeding is brutal and surgical approach remains the only alternative to perform the diagnosis and to cure the patient.

Romiplostim in Management of the Thrombocytopenic Surgical Patient

Background: The thrombopoietin (TPO) mimetics are FDA-approved for the treatment of chronic immune thrombocytopenia (ITP) and have the potential for use in several additional clinical settings. At our institution, the TPO-mimetic romiplostim has been used to boost platelet counts in the perioperative setting.Objective: Use of romiplostim for perioperative thrombocytopenia was examined with regards to patient characteristics, dosing and duration of use, success in achieving platelet counts high enough for surgery, and clinical outcomes.Methods: A retrospective review of patients with thrombocytopenia who received romiplostim prior to an operative intervention in 2010-2014 was performed. Inclusion criteria included age 18 or older, thrombocytopenia (baseline platelet count <150,000/uL), administration of at least one dose of romiplostim, and documentation of platelet counts before and after administration of romiplostim.Results: 18 patients undergoing 22 procedures were included. Median age at surgery was 61 years (range 47-74). Etiologies of baseline thrombocytopenia (some patients had more than one) included mild ITP (not on romiplostim at baseline) in 8 patients, liver disease in 12 patients (5 with hepatitis C, 2 with hepatitis B, 2 with alcoholic cirrhosis, 1 with fatty liver, and 2 with hepatocellular carcinoma), hematologic malignancy in 4 patients (2 with lymphoma, 1 with MDS, and 1 with myeloma) and drug-related thrombocytopenia in 3 patients (2 chemotherapy induced and 1 antibiotic-related). 3 patients were Jehovah’s witnesses. Median platelet count at time of romiplostim initiation was 46,500/uL (range, 11,000-120,000) and median starting dose of romiplostim was 2.5 mcg/kg (range 1-7.5). Patients remained on romiplostim for a median of 5 weeks prior to surgery (receiving doses on average once weekly) and while on therapy the dose of romiplostim was changed on average one time. Procedures performed included 5 orthopedic surgeries (3 total hip replacements, 1 total knee replacement, and 1 open reduction/internal fixation), 3 open cardiac surgeries, 2 cholecystectomies, 2 EGD/colonoscopies, 2 biopsies of masses, and 1 each of: angioplasty and stenting, dental extraction, eyelid resection, liver biopsy, lung resection, prostate surgery, spinal surgery, and a TACE procedure. Median platelet count at the time of surgery was 144,000/uL (range 28,000-370,000). All patients had a rise in platelet count between time of initiation of romiplostim and time of surgery (see Figure); median rise was 97,500/uL (range 17,000-252,000). There were no surgical delays or cancellations for thrombocytopenia. Four bleeding events occurred: one thigh hematoma (at a platelet count of 185,000/uL), one episode of hematemesis (at a platelet count of 98,000/uL), one episode of melena (at a platelet count of 88,000/uL), and one persistent oozing from a tooth extraction (platelets 82,000/uL). Four patients received perioperative platelet transfusions and 3 received perioperative red cell transfusions. One patient developed a Foley-catheter associated clot after prostate surgery. No other thromboembolic events were recorded during the time of romiplostim administration and for up to 30 days following the last dose.Conclusions: 18 patients with thrombocytopenia due to several conditions (primarily ITP and liver disease) received romiplostim prior to 22 surgical procedures. Romiplostim prompted a rise in platelet count in all patients, allowing all planned procedures to be performed without delays or cancellations for thrombocytopenia. Few patients received perioperative platelet transfusions. Four bleeding episodes occurred (none in the context of significant thrombocytopenia), and one patient developed a clot (likely procedure-related). Romiplostim may be of clinical utility in the preoperative management of thrombocytopenic patients, and further trials are indicated. [Display omitted] DisclosuresOff Label Use: Romiplostim (Nplate) used for periprocedural management of thrombocytopenia. Kuter:Amgen: Research Funding.

Hereditary Hemorrhagic Telangiectasia: A Rare Cause of Recurrent Upper GI Bleeding

Introduction: Hereditary hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu syndrome, is an uncommon autosomal dominant disease that usually presents as epistaxis. Recurrent upper GI bleeding is a rare presentation and the diagnosis of HHT can only be elucidated with a detailed history, thorough exam and high index of suspicion. Case Report: A 68-year-old female with history of multiple upper GI bleeds presented with 3 episodes of melena and associated nausea, increased GI motility, periumbilical pain and lightheadedness. She was admitted 8, 6 and 4 weeks prior with similar presentations. Previous EGD showed a healing ulcer in proximal stomach from prior AVM treatment and non-bleeding angioectasias in stomach and duodenum, treated with bipolar probe and clipping. Exam was significant for conjunctival pallor and telangiectasias on tongue, palate, fingertips and toes. Initial labs revealed Hgb of 8.8. Platelets, PT, and PTT were within normal limits. Patient was treated with IV fluids, PRBC and IV PPI drip. EGD showed distended veins in the esophagus and gastric fundus and 2 hemostatic clips in the fundus from a previous procedure. A single non-bleeding angiodysplastic lesion in the duodenum was treated with thermal therapy. After the procedure, the patient had no further episodes of bleeding throughout the hospitalization and was discharged home. Discussion: Vascular lesions are a common cause of GI bleeding and are more frequently identified due to widespread use of endoscopy, angiography and imaging. They may be singular or multiple, benign or malignant, isolated or due to a systemic disorder. HHT is an autosomal dominant disorder of abnormal blood vessel development. Incidence is anywhere from 1/5000-1/8000. Penetrance varies from irritating nosebleeds to life threatening manifestations of AVMs in the lung, GI tract, nose and brain. Pulmonary AVMs can result in right-to-left shunting, paradoxical emboli, and hemorrhage. While cerebral AV shunts are usually silent, they may cause seizures, ischemia or hemorrhage. GI involvement usually presents as iron deficiency anemia or recurrent GI bleeding. Diagnosis is based on Curacao Criteria: epistaxis, telangiectasia, visceral lesions and a first degree relative with HHT. Gastrointestinal AVMs can be treated endoscopically with yttrium aluminum garnet laser, electrosurgical and heat probe coagulation, clip application, local injection of ethanol or endoscopic resection; although they carry a high risk of repeat bleeding. Estrogens and aminocaproic acid are systemic therapies available to reduce telangiectasias, while bevacizumab and thalidomide are under investigation.

An unrecognized disease in routine clinical practice: the Heyde’s syndrome

Heyde’s syndrome (HS) is a triade constituted by aortic stenosis, gastrointestinal angiodysplasia and deficiency of high-molecular-weight von Willebrand factor multimers. Until now few cases of HS has been reported and we believe of interest to add a new patient having this disorder. We report a case of HS in an 86-year-old female patient admitted for the second episode of melena in the last 4 months. A colonoscopy revealed a bleeding due to angiodysplasia in the ascending colon and an endoscopic argon laser photocoagulation of the colonic angiodysplasia was successfully carried out. Physicians should be aware of the possibilities of acquired von Willebrand disease and gastrointestinal bleeding from angiodysplasia in patients with aortic valve stenosis because a right diagnosis affects the management of these patients, especially in emergency situations.

Colonic Dieulafoy's Lesion: A Rare Cause of Lower Gastrointestinal Hemorrhage and Review of Endoscopic Management.

Dieulafoy's lesions are a rare cause of gastrointestinal hemorrhage. Extragastric Dieulafoy's lesions are even more uncommon. We report the case of a 75-year-old woman who presented with gastrointestinal bleeding from a transverse colonic Dieulafoy's lesion. She presented with two episodes of melena followed by one episode of fresh blood per rectum. In addition, there was associated presyncope and anemia (hemoglobin 69 g/L) in the setting of supratherapeutic warfarin anticoagulation (INR 6.2) for nonvalvular atrial fibrillation. Esophagogastroduodenoscopy was negative for an upper GI source of bleeding but on colonoscopy an actively oozing Dieulafoy's lesion was identified in the transverse colon. Bipolar cautery and hemostatic endoclips were applied to achieve hemostasis. Clinicians should consider this rare entity as a potential cause of potentially life-threatening lower gastrointestinal bleeding and we review the endoscopic modalities effective for managing colonic Dieulafoy's lesions.

Hyperplastic Gastric Polyposis Complicated by a High-Grade Sarcomatoid Malignancy

1Departments of Medicine (Gastroenterology) and 2Pathology, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Hugh J Freeman, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, British Columbia V6T 1W5. Telephone 604-822-7216, e-mail hugfree@shaw.ca Received for publication January 24, 2014. Accepted February 7, 2014 CASE PRESENTATION A 70-year-old Asian-born woman experienced intermittent melena and iron-deficiency anemia that was treated with long-term omeprazole and iron supplements. Previous studies in other hospitals in 2009 and 2010 revealed multiple hyperplastic gastric polyps in the gastric antrum and body, but no dysplasia. There was no known family history of gastric neoplasia or previous Helicobacter pylori infection. In 2012, she experienced an additional episode of melena. Gastroscopic evaluation confirmed the presence of multiple small and large gastric polyps, typical of hyperplastic polyps (1) (Figures 1A and 1B), some with focal erosions but no dysplasia, along with a superimposed large ulcerating and polypoid lesion in the gastric body consistent with a high-grade malignancy (Figures 2A and 2B). Routine immunostaining of these biopsies to exclude stromal tumours as well as tumours of smooth muscle and neural origin with CD-117, actin and S-100 were negative. Subtotal gastrectomy showed an anaplastic spindle and epithelioid neoplasm consistent with an undifferentiated high-grade sarcomatoid malignancy (sarcoma versus sarcomatoid carcinoma), but not a gastrointestinal stromal tumour (GIST), localized to the stomach without nodal or distant metastases. Extensive immunohistochemical staining for epithelial, neuroendocrine, hematopoietic and melanocyte differentiation on the resected gastric malignancy were negative. The following stains were all negative: CD117 and DOG1 for GIST; smooth muscle actin, desmin, caldesmon for leiomyosarcoma; S100, Melan A, HMB45 for malignant peripheral nerve sheath tumour, melanoma and PECOMA; CD31 and CD34 for angiosarcoma; synaptophysin, chromogranin and TTF1 for neuroendocrine differentiation; cytokeratins 7, 19, 20, Cam 5.2 and CDX-2 for epithelial differentiation; and CD45, CD20, CD3 and ALK1 for lymphoreticular origin.

Sporadic Pediatric GIST With Novel Gene Mutation

Advanced understanding of pathogenesis and tumor metabolism has increased the number of recently diagnosed gastrointestinal stromal tumors. We present a case of a young girl who attended our hospital with an episode of melena. Endoscopy revealed an irregular gastric lump with overlying ulceration. Following further investigation and biopsy, a gastrointestinal stromal tumor of the stomach was diagnosed and subsequently resected. Histopathology showed mixed type of epithelioid and spindle cells with exon 11 KIT mutations. Early diagnosis, prompt management, and long-term follow-up are the key prognostic determinants. J Med Cases. 2013;4(11):722-725 doi: https://doi.org/10.4021/jmc1491w

Small Bowel Kaposiʼs Sarcoma: An Unusual Cause of GI Bleeding

Purpose: A 34-year-old previously healthy man presented with 1 week of melena and new right sided hemiplegia for 1 month. Initial hemoglobin was 6 g/dL from a baseline of 13.5 g/dL two years prior. Brain MRI showed two ring enhancing lesions in the left cortex and cerebellum suspicious for toxoplasmosis. An HIV antibody test was positive, with a CD4 count of 1. An upper endoscopy was performed and showed white adherent material in the esophagus (biopsy pathology positive for candidiasis), gastric erythema and normal duodenum without a bleeding source. Colonoscopy showed normal terminal ileal and colonic mucosa. A capsule endoscopy demonstrated a raised medium-sized submucosal erythematous mass in the mid-jejunum, suspicious for Kaposi's sarcoma (KS). A detailed skin exam yielded a violaceous plaque on the abdomen, with biopsy pathology diagnostic of KS. The patient was started on antiretroviral therapy (ART) and treatment for cerebral toxoplasmosis, with no further episodes of melena. KS is a vascular tumor that is associated with human herpesvirus 8 and is the most common tumor arising in HIV-infected persons. Its prevalence is increased with lower CD4 counts. KS was over 20,000 times more common in persons with AIDS than in the general population prior to the widespread use of highly active antiretroviral therapy (HAART), and the incidence has declined substantially since that time. Although KS can involve virtually any site in the body, cutaneous disease is most common and is the usual initial presentation for KS. The most frequent sites of noncutaneous disease are the oral cavity, gastrointestinal tract (most commonly the small intestine) and respiratory system. Prior to widespread ART, the gastrointestinal tract was involved in approximately 40% of patients with KS at initial diagnosis, and in up to 80% at autopsy. However, visceral involvement as the initial manifestation of KS in the HAART era is relatively uncommon. GI lesions may be asymptomatic or cause weight loss, abdominal pain, nausea and vomiting, upper or lower gastrointestinal bleeding, malabsorption, intestinal obstruction or diarrhea. On endoscopy, KS lesions are easily recognized as hemorrhagic nodules that can appear anywhere along the GI tract. In the HAART era the incidence of AIDS-related KS has dramatically decreased to less than 10% of the incidence reported in the pre-HAART era, but it is still recognized as a primary AIDS-defining illness that can lead to significant morbidity. Rarely, visceral KS can present as occult or gross GI bleeding. In persons with underlying AIDS presenting with anemia and/or GI bleeding, it is important for physicians to consider intestinal KS as a possible etiology.

Crystal Meth Gave Me Diarrhea! An Uncommon Cause of Diarrhea in a HIV Patient

Purpose: Diarrhea is one of the most common gastrointestinal complaints in a HIV patient and should not be taken lightly. Infectious etiologies should always be ruled out or treated for if the clinical scenario is appropriate. However, other less common causes of diarrhea should be considered in the differential diagnosis. We present a case of severe diarrhea in an HIV patient with recent ingestion of methamphetamine. A 31-year-old male with past medical history significant for HIV presented to the hospital with the complaint of diarrhea. The patient's most recent CD4 count was 350 and viral load was undetectable. He claimed to be compliant with his anti-retroviral therapy regimen that he had been taking for the last two years. Diarrhea was of sudden onset with duration of two days. Frequency of bowel movements was 12-15 times a day. Diarrhea was described to be watery. The patients denied rectal bleeding and episodes of melena. The patient denied recent fevers and chills. On examination, patient was found to be hypovolemic with positive orthostatics. Notable laboratory findings included hypokalemia and hypomagnesemia. The patient was started on aggressive intravenous hydration and electrolyte correction. Stool studies including bacterial culture, examination for ova and parasites, examination for ova and parasites was unremarkable. In addition, acid-fast smear was negative for Cryptosporidium, Isospora, and Cyclospora. The patient also underwent a flexible sigmoidoscopy with biopsy, which was also normal. After the extensive workup, alternative diagnoses were considered with a thorough social history. It was discovered that the patient has started taking methamphetamine prior to onset of diarrhea. Diarrhea had resolved at the third day of admission without any treatment except for supportive therapy. Since discharge, the patient has abstained from methamphetamine and has not experienced similar episodes of diarrhea. Diarrhea is a common complaint in HIV patients. The differential diagnosis is broad but it is prudent to search for underlying infectious etiologies for rapid initiation of antibiotic therapy. In this case, infectious workup was negative. Because there were no recent changes in medications, prescribed drugs was an unlikely cause of the acute diarrhea. The temporal relationship with methamphetamine ingestion and onset of diarrhea makes the illicit drug the most likely cause of diarrhea. The patient in our case underwent an extensive workup but with negative findings. Past case reports have illustrated an association between methamphetamine and ischemic colitis. In this case we propose that methamphetamine use can also lead to severe diarrhea.

Methylene blue dye injection for identification of occult gastrointestinal bleeding

The exact site of small bowel bleeding is difficult to detect intraoperatively. We present a simple method of on-table identification of the site of the bleed. A 55-year-old lady presented with recurrent episodes of melena and drop in hemoglobin. Digital subtraction angiography (DSA) revealed angiodysplasia of a vessel supplying the proximal jejunum. A microcatheter was placed at this site in the DSA suite, just prior to laparotomy. Two cubic centimeters of methylene blue dye was injected into the microcatheter on-table which demarcated the 6 in. of involved jejunum which was then resected. Patient is currently doing well over a 6-month follow up with no further episodes of melena. In conclusion, preoperative DSA and selective catheterization of the affected vessel allow for on-table localization of the exact site of bleed. This simple method avoids more invasive techniques of detection and enables limited segmental resection of the affected bowel.

Sporadic Pediatric GIST With Novel Gene Mutation

Advanced understanding of pathogenesis and tumor metabolism has increased the number of recently diagnosed gastrointestinal stromal tumors. We present a case of a young girl who attended our hospital with an episode of melena. Endoscopy revealed an irregular gastric lump with overlying ulceration. Following further investigation and biopsy, a gastrointestinal stromal tumor of the stomach was diagnosed and subsequently resected. Histopathology showed mixed type of epithelioid and spindle cells with exon 11 KIT mutations. Early diagnosis, prompt management, and long-term follow-up are the key prognostic determinants. J Med Cases. 2013;4(11):722-725 doi: https://doi.org/10.4021/jmc1491w

An Unusual Cause of Recurrent Massive Upper Gastrointestinal Bleeding

Question: A 50-year-old man presented with acute onset of massive hematemesis and a transient loss of consciousness. He denied acid reflux, or abdominal pain or distension. His past history revealed bleeding duodenal ulcer diagnosed by endoscopy 1 year ago. Although treated with esomeprazole continuously, he suffered from recurrent hematemesis 4 times during the last year. Physical examination showed unstable vital signs with hypotension (92/70 mmHg) and tachycardia (heart rate, 106 bpm). The patient was treated conservatively with fluid infusion and esomeprazole. After 2 episodes of melena, there were no signs of massive rebleeding. Gastroscopy was performed and blood-like fluid effusion in the duodenal bulb was detected (Figure A). After washing with normal saline, a deep ulcer-like lesion with a diameter about 0.2 cm was revealed on noninflamed duodenal mucosa (Figure B). Both cross-sectional (Figure C) and coronal (Figure D) imaging of contrast-enhanced computed tomography (CT) showed a large hematoma between the duodenal bulb and pancreas in the artery phase. What is the most likely cause of upper GI bleeding in this patient? Look on page 872 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT angiography revealed that splenic artery coursed a pseudoaneurysm (Figure E, F). The splenic artery pseudoaneurysm (SAPA) was further disclosed by volume rendering reformatted coronal (Figure G) and left oblique sagittal images (Figure H). The patient underwent splenectomy and gastrojejunal Roux-en-Y anastomosis. Surgical findings showed a SAPA–duodenal bulb fistula that was temporarily embolized by thrombus. Postoperatively, the patient recovered uneventfully and was discharged on day 18 after admission. Gastrointestinal bleeding from SAPA is unusual but potentially lethal.1Pasha S.F. Gloviczki P. Stanson A.W. et al.Splanchnic artery aneurysms.Mayo Clin Proc. 2007; 82: 472-479Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar To date, only about 160 cases of SAPA have been reported.2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar Causes of SAPA include pancreatitis (52%), trauma (29%), iatrogenic and postoperative causes (3%), and rarely peptic ulcer (gastric ulcer; 2%).2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar To the best of our knowledge, duodenal ulcer erosion of a SAPA has yet to be reported. SAPA rupture is life threatening. A common site of hemorrhage is the pancreatic duct, with some into peritoneal cavity, stomach, or even into colon.2Tessier D.J. Stone W.M. Fowl R.J. et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 3Sweetser S.R. Wong Kee Song L.M. An unusual cause of hematochezia.Gastroenterology. 2009; 137: 1895Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, SAPA fistulizing to duodenal bulb is extremely rare, which makes accurate diagnosis difficult. In the present case, the unusual patient history and endoscopic findings preclude pharmaceutical and endoscopic approach for diagnosis and hemostasis. In this situation, imaging techniques, especially CT angiography and 3-dimensional rendering, are beneficial for survey of the bleeding vessels. Surgical intervention or endovascular therapy is recommended to repair the bleeding pseudoaneurysm. Jun Wang and Bin Wang contributed equally to this work.

The primitive squamous cell carcinoma of the third duodenum

The duodenum is an exceptional location of the primary squamous cell carcinoma. Few cases have been reported in the literature. We report here the second case of this tumor in this exceptional location (transverse duodenum) in a sixty years-old women without medical history, who consulted for epigastric pain since 3 months, associated with an episode of melena and weight loss of 5 kg. The assessement and pathological study of endoscopic specimen confirms the squamous cell nature of the tumor. The treatment consisted of palliative chemotherapy with analgesic treatment.

Isolated Jejunal Varices: A Cause of Occult Gastrointestinal Hemorrhage in a Cirrhotic Patient With Mild Portal Hypertension

A woman with hepatitis C cirrhosis and a history of lymphoma was admitted to our medical center because f recurrent melena. Although hemodynamically stable, she equired frequent blood transfusions. Upper and lower endosopies failed to reveal the source of hemorrhage. Capsule enoscopy showed an isolated bleeding jejunal varix (Figure A). bdominal/pelvic computed tomography venography showed a luster of isolated jejunal varices (Figure B, arrowhead) draining ia a patent umbilical vein (Figure B, arrow) and right inferior epigastric vein to the external iliac vein. Superselective venography of the mesenteric varix was performed (Figure C) during a transjugular intrahepatic portosystemic shunt procedure, confirming the computed tomography venography findings. The transjugular intrahepatic portosystemic shunt reduced the portosystemic pressure gradient from 13 to 2 mm Hg, and within 48 hours the bleeding stopped. Postprocedure encephalopathy was managed medically, and there were no further episodes of melena at the 3-month follow-up evaluation.

Meckel’s diverticulum causing severe hemorrhage

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.

Clinical, Radiologic and Pathologic Characteristics of the Carney Triad: A Case Report and Literature Review

This report describes a patient with a gastrointestinal stromal tumor (GIST) and upper gastrointestinal hemorrhage as initial presentations of the Carney triad, a synchronous or metachronous condition involving gastric leiomyosarcoma, extra-adrenal paraganglioma and pulmonary chondroma. A 26-year-old woman presented with dizziness and several episodes of melena over 3 days. Physical examination revealed pale conjunctiva but normal hemodynamic status. Gastroendoscopy showed one antral submucosal tumor with evidence of an associated bleeder (the bleeder over the mucosal surface of the gastric tumor). An abdominal computed tomography scan showed an antral submucosal tumor, two secondary lesions over segment II/V of the liver and a retroperitoneal tumor. Surgical removal of the tumor and subsequent recovery were uneventful. The gastric GIST with liver metastasis and retroperitoneal paraganglioma were confirmed by pathologic study. The patient was treated with imatinib mesylate for the GIST with liver metastasis, and continued follow-up treatment at our hospital. An abdominal computed tomography scan at 32 months after surgery showed no change in the liver metastatic lesions and no evidence of local recurrence. Another follow-up visit at 33 months after surgery confirmed the stable condition. Of nearly 100 cases reported in the literature, this case is the first to be reported in Taiwan. This case highlights the possibility of this rare syndrome occurring in young female patients with one of the three components of the triad and the need for further diagnostic studies for early identification of tumors when curative surgery is still possible.

CHRONIC DIARRHEA IN AN ELDERLY MAN

CHRONIC DIARRHEA IN AN ELDERLY MAN

High Rectal Injury During Trans-1 Axial Lumbar Interbody Fusion L5–S1 Fixation

A case report. To report a case of high rectal injury during trans-1 axial Lumbar Interbody Fusion (axiaLIF) L5-S1 fixation. Trans-1 axiaLIF procedure is gaining in popularity for L5-S1 fusion due to the ease of access to the sacrum through the presacral space. Normally, the midline of the sacrum at S1-S2 is relatively free from neurovascular and intra-abdominal structures, making this level a safe entry point for the axiaLIF procedure. We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 procedure due to altered intra-abdominal anatomy as a result of multifactorial adhesions formation. A 44-year-old female patient with a history of previous anterior and posterior spinal surgeries, pelvic inflammatory disease, and non-disclosed previous diverticulitis, developed a high rectal injury during Trans-1 axiaLIF L5-S1 fixation. After Trans-1 axiaLIF L5-S1, the patient presented with an episode of melena and hypogastric pain with nausea and vomiting. A computed tomography (CT) scan of the abdomen with intravenous and oral contrast showed presacral soft tissue fluid density with fat stranding and extraluminal rectal contrast and gas with some areas of soft tissue enhancement compatible with probable high rectal perforation. Patient's symptoms gradually subsided during a period of 6 months with aid from a temporary diverting ileostomy and a course of i.v. antibiotics. No spine implants were removed. We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 fixation and strongly advice that patients who are candidates for this surgery and have any risk factors for intra-abdominal adhesion formation, undergo a pelvic CT with rectal contrast before the surgery to evaluate for any signs of altered rectal-sacral anatomy.

Ulcerative Jejunoileitis Diagnosed by Capsule Endoscopy as an Obscure Source of GI Bleeding in Refractory Celiac Disease

Purpose: A 58 year old woman with a history of refractory celiac disease was admitted with coffee-ground emesis and melena. She had recently begun taking daily aspirin. Her medications were also notable for iron supplements and omeprazole. Upon admission, her hemoglobin was 6.6 gm and BP was 94/53. Her exam was notable for pallor, cachexia, and diffuse abdominal tenderness with high-pitched bowel sounds. After resuscitation with blood products, an EGD was performed. This found only LA grade A esophagitis without evidence of active bleeding. In the subsequent days, the patient continued to have episodes of melena with worsening of her anemia. As such, she underwent a colonoscopy which showed only small non-bleeding internal hemorrhoids. Having failed to find a source of bleeding, a capsule endoscopy was performed which revealed two chronic ulcers in the distal small bowel with scalloping and nodularity noted throughout the mucosa. A push enteroscopy confirmed the mucosal abnormalities and found multiple areas of luminal narrowing with proximal dilation. Unfortunately, the ulcers were not visualized by the enteroscope as it was unable to extend past the mid-jejunum. Random biopsies of the duodenum and jejunum showed atrophic villi and were negative for lymphoma. A double-balloon enteroscopy was then recommended to the patient however she declined as her symptoms had resolved. Ulcerative jejunoileitis (UJI) is a rare complication of celiac sprue and an obscure cause of GI bleeding in such patients. When suspected, capsule endoscopy and double-balloon enteroscopy are important tools to confirm the diagnosis and identify complications. In particular, biopsies of ulcerative sites during double balloon enteroscopy should be obtained to rule out enteropathy-associated T cell lymphoma (EATL), a rare but serious complication that may decrease the 2-year survival rate in celiac patients to as low as 15%. As such, it is imperative that patients with celiac disease who present with obscure GI bleeding undergo appropriate testing to evaluate for UJI and its associated complications.Figure