Mallory-Weiss Research Articles

Endoscopic Findings in Patients With Upper Gastrointestinal Bleeding in Ogun State, Nigeria.

IntroductionAlthough the global incidence of upper gastrointestinal bleeding (UGIB) appears to have reduced substantially in the past few decades, acute UGIB still carries significant morbidity and mortality worldwide. There are currently no published data on UGIB in Ogun State, Nigeria. This study examined the endoscopic findings in patients with UGIB in Ogun State. MethodologyThe study was a retrospective cross-sectional survey of patients with UGIB who had upper gastrointestinal endoscopy at three endoscopy centers in Ogun State, Southwest Nigeria, from January 2015 to December 2021. Patients’ data, which included age, gender, and endoscopic findings, were extracted from the endoscopy registers into a spreadsheet and analyzed statistically. Summary statistics included means ± standard deviation for continuous variables and frequencies and percentages for categorical variables. Categorical variables were compared for differences by chi-square test or Fisher’s exact test as appropriate. The statistical significance cutoff was p-value <0.05.ResultsA total of 171 had endoscopy for UGIB during the period under review but 168 had complete data. Out of the 168, 113 (67.3%) were males, giving a male-to-female ratio of 2:1. The mean age of the patients was 52.4 ± 18.1 years, with an age range of 7-85 years. The modal age group was ≥60 years (75; 39.9%). The most common endoscopic finding was peptic ulcer disease (77; 45.8%), followed by esophagogastric varices (27; 16.1%), erosive mucosal disease (25; 14.9 %), portal hypertensive gastropathy (15; 8.9%), suspected malignancies (11; 6.6%), hemorrhagic gastritis (7; 4.2%), gastric antral vascular ectasia (2; 1.2%), and Mallory-Weiss tear (1; 0.6%), respectively. Forty-four patients (26.2%) had no lesion that could explain UGIB. ConclusionPeptic ulcer disease was the most common cause of UGIB among our patient population, and the elderly male patients were the most affected.

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation: A case report

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation: A case report

Efficacy and Safety of Pancreatic Juice Cytology with Synthetic Secretin in Diagnosing Malignant Intraductal Papillary Mucinous Neoplasms of the Pancreas.

The risk of malignant transformation of intraductal papillary mucinous neoplasm (IPMN) is presently assessed using imaging, which remains unsatisfactory. Given the high viscosity of pancreatic juice, pancreatic juice cytology (PJC) is considered an investigational procedure. We previously demonstrated that the diagnostic performance of PJC was improved via synthetic secretin loading in pancreatic ductal carcinoma. This study aimed to evaluate the efficacy of synthetic secretin-loaded PJC (S-PJC) for IPMN. The usefulness and safety of S-PJC were prospectively evaluated in 133 patients with IPMN. Overall, 92, 12, and 26 patients had branch duct, main duct, and mixed-type lesions, respectively. The risk classifications based on the 2017 international consensus guidelines were high-risk stigmata, worrisome features, and no risk in 29, 59, and 45 patients, respectively. Synthetic secretin loading improved the sensitivity of PJC from 50.0% to 70.8%. Complications included 13 (9.8%) cases of mild pancreatitis, 1 (0.8%) case of acute cholangitis, and 1 (0.8%) case of Mallory–Weiss syndrome, all of which resolved with conservative treatment. In conclusion, synthetic secretin-loaded PJC improved the diagnostic performance of cytology for malignant IPMN. We recommend using synthetic secretin-loaded PJC for the preoperative pathological diagnosis of malignant IPMN in clinical settings.

Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review.

BACKGROUNDAcute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.AIMTo evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.METHODSEmploying PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding. RESULTSOverall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.CONCLUSIONEndotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

Boerhavve syndrome in pregnancy

Objectives: To present a rare but life threatening complication of Hyperemesis gravidarum and review the related literature aiming to bring Boerhaave Syndrome, its presentation, diagnosis, and management to our attention. Methods Used: Detailed presentation of the case treated in our hospital followed by a review of the literature about similar cases of Boerhaave Syndrome in pregnancy with analysis of best options of diagnostic and therapeutic approaches. Results: Our case had a mild degree of oesophageal tear in the first trimester presented with chest pain and an episode of ground coffee coloured vomit.

Improved anastomotic technique for esophagojejunal anastomosis using circular stapler.

In total gastrectomy, Roux-en-Y reconstruction with esophagojejunal anastomosis has been widely used in gastrointestinal reconstruction. In the case of anastomotic leakage of RY reconstruction, esophagojejunal anastomosis should be paid attention, and esophageal fragility is considered the reason for the leakage. Here, we introduce an atraumatic and innovative technique for esophagojejunostomy. We prospectively performed routine novel esophagojejunal anastomosis using circular stapler device and reviewed the records of 14 consecutive patients with gastric cancer who underwent open total gastrectomy at Kitasato University Hospital from April 2019 to March 2020. By placing about 10 stay sutures around the entire esophageal stump, the esophageal stump can be opened to the maximum diameter. The forceps grasping the tissue was not necessary for these procedures, consequently preventing either tears the esophageal stump tissue or narrowing the esophageal lumen. These 14 cases were far advanced cases of gastric cancer, 6 cases of splenectomy and 3 cases of distal pancreatectomy. No technical problems such as esophageal tear were observed in all cases. Postoperative complications were observed in 6 patients (42.9%), and their contents varied. However, they all improved conservatively. Regarding anastomotic complications, anastomotic leakage of Clavien-Dindo-II was observed in one case, but it improved conservatively. Our new atraumatic anastomosis technique could abolish problems such as tear of esophagus wall due to introduce a larger-sized anvil, trauma of esophageal wall by grasping with forceps such as Alice or Babcock. Consequently, the atraumatic and innovative technique might make the esophagojejunostomy safe. This method might prevent anastomotic leakage and other complications effectively.

Causes and Management of Esophageal Hematoma: A Review

Intramural hematoma of the esophagus (IHE) or dissecting intramural hematoma is a relatively unusual complication of acute mucosal and submucosal lesions that results in a blood accumulation between the layers of the esophagus. Esophageal hematoma is a rare condition that can develop spontaneously or as a result of trauma, poisoning, or medical intervention. Mallory-Weiss syndrome, Boerhaave syndrome, and IHE are all forms of acute mucosal damage of the esophagus, with IHE being the rarest of the three. In general, esophageal traumatic damage, including traumatic penetration and perforation, is uncommon, making IHE incidence and prevalence difficult to measure. Although most esophageal hematomas are asymptomatic, they can cause significant chest discomfort, dysphagia, and hematemesis. Esophageal hematomas should be distinguished from Mallory-Weiss tear and Boorhaave's syndrome, which they may closely resemble in such cases. Moreover, cardiovascular and respiratory diseases should be ruled out, therefore further tests such as an electrocardiogram, chest X-ray, and laboratory testing can be useful. The majority of cases resolve with conservative treatments, with symptoms disappearing in 1-2 weeks. NPO, IV fluids, acid suppression, and treatment of coagulopathy are all conservative procedures. This review aims to summarize current evidence on etiology, epidemiology, diagnosis and management of esophageal hematoma.

Evaluation and Management of Mallory – Weiss Syndrome: A Review

Upper gastrointestinal bleeding is a symptom of Mallory-Weiss syndrome, which is caused by longitudinal mucosal lacerations (known as Mallory-Weiss tears) near the gastroesophageal junction or gastric cardia. Mallory-Weiss syndrome is rather prevalent, accounting for 3 to 10% of all upper gastrointestinal bleeding episodes. In mild circumstances, the disease may be asymptomatic. Hematemesis is the presenting symptom in 85 percent of patients. Blood is present in varying amounts, ranging from blood-streaked mucous to huge bright red haemorrhage. Other symptoms such as melena, dizziness, or syncope might occur as a result of heavy bleeding. The majority of the time, the bleeding is little and ends on its own. Endoscopy is frequently used to confirm the diagnosis of MWS. Although most patients may be treated with monitoring or conservative medicinal treatment, certain cases require endoscopic or surgical treatment. Despite the fact that MWS is a common cause of nonvariceal upper gastrointestinal bleeding (NVUGIB), little research has been done on it. This article discusses MWS Etiology, epidemiology, evaluation and management.

P-EGS25 Boerhaave’s Syndrome Secondary to Symptomatic COVID-19 Infection

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention.MethodsA 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. ResultsThe management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted.ConclusionsCOVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.

Diagnostic challenge and surgical management of Boerhaave\u2019s syndrome: a case series\xa0

BackgroundBoerhaave’s syndrome is the spontaneous rupture of the esophagus, which requires early diagnosis and treatment. Symptoms may vary, and diagnosis can be challenging.Case presentationCase 1: A 54-year-old Chinese man presented to us with sudden-onset epigastric pain radiating to the back following hematemesis. Upper gastrointestinal endoscopy revealed a full-thickness rupture of the esophageal wall. Subsequent computed tomography showed frank pneumomediastinum and heterogeneous pleural effusion. Immediately, esophageal perforation repair operation and jejunostomy were performed. The postoperative period was uneventful, and he was discharged.Case 2: A 62-year-old Chinese man was admitted to the emergency department with thoracic dull pain and chest distress. Chest computed tomography scan showed pneumomediastinum and large left-sided pleural effusion. Esophagus fistula was confirmed by contrast esophagography. Then, we performed thoracotomy to repair the esophageal tear as well as to debride and irrigate the left pleural space. His postoperative period was uneventful, with no leakage or stricture.Case 3: The patient was a 69-year-old Chinese male presenting with severe retrosternal and upper abdominal pain following an episode of forceful vomiting. Thoracic computed tomography scan revealed a rupture in the left distal part of the esophagus, a pneumomediastinum, and left-sided pleural effusions. Conservative treatment failed to improve disease conditions. Open thoracic surgery was performed with debridement and drainage of the mediastinum and the pleural cavity, after which he made a slow but full recovery.ConclusionsWe highlight that early diagnosis and appropriate surgical treatment are essential for optimum outcome in patients with esophageal rupture. We emphasize the importance of critical care support, particularly in the early stages of management.

Resection of esophageal duplication cyst in a 6-month child: a surgical challenge by video-assisted thoracoscopic surgery VATS

Introduction and importance: Esophageal duplication cysts (EDCs) are rare congenital entities, with an incidence of 1:100,00. The majority of patients are asymptomatic and lesions are usually found incidentally on imaging. However, these cysts were removed via open surgery. Nowadays, video-assisted thoracoscopy surgery (VATS) is an alternative safe method to remove ECDs. Case presentation: Here we present a 6-month-child male complaining of shortness of breath, stridor associated with cough, repeated vomiting, and fever. Furthermore, laboratory test results are within normal limits. Chest x-ray showed well-defined soft tissue density on the right upper and middle lobe with normal lung field, and computed tomography scan revealed that cystic lesion measuring 7×3 cm extended from the thyroid cartilage downward to the posterior mediastinum and toward the right side of the chest causing compression of the trachea, esophagus, and right mainstem bronchus. Finally, the patient was diagnosed with an EDC by histopathologic examination. The patient underwent surgery under general anesthesia by uni-portal VATS through the right fourth intercostal space was performed. The cyst was resected, and an esophageal tear occurred because of the wall of the esophagus as part of the cyst. The patient was discharged on day 11 postoperative. Conclusion: EDC is an exceedingly rare entity. VATS is a less invasive procedure, effective, safe, and has a good clinical outcome compared with open surgical resection. We conclude that EDC should be maintained in the differential diagnosis of unexplained stridor, wheeze, and recurrent chest infection in children.

EP.WE.1015Management of Boerhaave Syndrome

Abstract Aim Boerhaave’s Syndrome is a rare and fatal condition, characterised by a distal oesophageal tear induced by an abrupt rise in intra-luminal pressure. Treatment remains controversial; we present a recent case and review relevant literature. Methods A retrospective analysis of case-notes was performed, and a literature review undertaken on PubMed. Results A 58-year-old male presented as an emergency with severe chest pain, having choked and vomited following the ingestion of steak. Computed tomograpy scan of the thorax demonstrated a large pneumomediastinum associated with an oesophageal perforation on the anterior wall and bilateral pleural effusions. A primary laparoscopic repair was performed with jejunostomy placement for feeding. The post-operative period was complicated by a prolonged stay on intensive care with sepsis secondary to mediastinitis. A contrast swallow performed eleven days post-surgery confirmed no persistent leak and the patient was discharged five days later. Boerhaave’s syndrome accounts for 10% of oesophageal perforations and is typically associated with a history of overindulgence and vomiting. Stable patients with a contained disruption and minimal contamination, can be managed conservatively. Endoscopic therapies include clipping small perforations, self-expanding stents for larger defects, and endoluminal vacuum therapy. Operative interventions comprise primary repair, debridement and drainage of thoracic cavity, diversion operations and single stage resection with or without primary reconstruction. Conclusion Boerhaave’s Syndrome is associated with significant morbidity and mortality, but with early recognition and prompt intervention, patients can be successfully managed. Options include conservative, endoscopic and surgical, depending upon the site and size of the perforation.

S683 Trend Analysis of Upper Gastrointestinal Bleeding in the Last 15 Years: A Population-Based Study

Introduction: Upper Gastrointestinal Bleeding (UGIB) is defined as the bleeding originating from the gastrointestinal tract above the ligament of Treitz. UGIB is commonly caused by peptic ulcer disease (PUD), Mallory-Weiss tears, esophageal varices, and esophagitis. Although the diagnosis and management of UGIB have largely evolved with recent advancements, the incidence and trends of UGIB are unclear. Therefore, we sought to look at the incidence and trends of UGIB 2006-2020 using a population-level database. Methods: Retrospective analysis of individuals ≥ 18 years who were hospitalized with UGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of UGIB were identified. The trend in the rates of hospitalization and annual percentage change (APC) due to various etiologies of UGIB were analyzed between 2006-2020 using Excel, 2016. Results: Among a cohort of 63,000,000 unique patients, 7.63% of hospitalizations in 2020 were due to UGIB. The most common diagnosis associated with UGIB was gastritis (70.92%), followed by esophagitis (38.20%), PUD (24.67%), esophageal/gastric varices (7.73%), angiodysplasia/dieulafoy lesions (6.26%), Mallory-Weiss tears (4.18%), and esophageal and gastric tumors (2.63%). The hospitalization rates due to UGIB increased from 4.90% in 2006 to 7.63% in 2020 (Table 1). The trend in the rates of hospitalizations due to UGIB and the APC of UGIB based on etiology is depicted in Figure 1. Conclusion: The rates of upper gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last two decades. Among UGIB hospitalizations, the proportion of PUD and Mallory-Weiss tears have decreased while that of gastritis/duodenitis and esophageal/gastric varices have increased over 5-year intervals (Table 1). Patient awareness, improved diagnostic techniques, an increase in the use of anticoagulants and non-steroidal anti-inflammatory agents, and an aging population probably contribute to the rise in the rates of UGIB.Table 1.: Mortality in post-bariatric surgery patients that had UGIB (OR).Figure 1.: A. Demographics and mean ago of the study population. B. Group comparisons using a post hoc test.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

PERIPROCEDURAL HEMOTHORAX AFTER WATCHMAN LEFT ATRIAL APPENDAGE CLOSURE IMPLANTATION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Left atrial appendage occlusion with the WATCHMAN device has had decreasing periprocedural complications since its approval by the Food and Drug Administration [1]. Hemothorax is a rare complication after WATCHMAN device deployment. Here a case is presented of a left sided hemothorax occurring within 24 hours of device deployment. CASE PRESENTATION: A 77-year-old male with a history of persistent atrial fibrillation on warfarin developed an abdominal hematoma when his INR was supratherapeutic, so he was evaluated for WATCHMAN (Boston Scientific Corporation, Marlborough, MA) left atrial appendage occlusion. Transesophageal echocardiography (TEE) showed an adequately sized left atrial appendage so a 27mm WATCHMAN device was deployed. Angiogram showed the device in good position and TEE showed no peri-device leak or pericardial effusion. He was placed on a continuous heparin infusion which was maintained in the therapeutic range based on anti-Xa assay. The following morning, he was confused, clammy, and short of breath. Shortly thereafter the patient went into cardiac arrest. During arrest it was noted that the patient had a 4g drop in hemoglobin and intra-arrest bedside ultrasound revealed a complex left pleural effusion, so he was transfused with protamine sulfate, vitamin K, fresh frozen plasma, packed red blood cells, and incompatible platelets. Return of spontaneous circulation was achieved after 16 minutes. Post-arrest a CT angiogram of the chest revealed a large left pleural effusion without evidence of perforation of any large arteries. Transthoracic echocardiogram showed no evidence of pericardial effusion. A left chest tube was placed with drainage of 2200 cc of frank blood in the first 12 hours. Endoscopy showed a superficial ulcer of the mid-esophagus but no evidence of esophageal perforation or tear. The patient was stabilized but ultimately had poor neurologic recovery due to anoxic brain injury and palliatively extubated and discharged home to family on comfort measures. DISCUSSION: Left atrial appendage closure with a WATCHMAN device has similar bleeding rates compared to warfarin alone, with a majority of major bleeding events occurring in the periprocedural period[2]. Although periprocedural bleeding after device implantation is not uncommon, hemothorax is a very rare complication occurring in only 0.1% of cases[1]. In this case rupture of the left atrial appendage or other perforation of cardiac structures was ruled out by the absence of a pericardial effusion, as well as bleeding from esophageal rupture after TEE. It is unclear whether dissections or perforations of smaller arterial or venous structures lead to the hemothorax or whether it was a spontaneous event related to heparin infusion. CONCLUSIONS: Hemothorax is a rare bleeding complication of WATCHMAN device implantation but needs to be considered as a potential major bleeding event after device deployment. REFERENCE #1: 1. Munir MB, Khan MZ, Darden D, Pasupula DK, Balla S, Han FT, Reeves R, Hsu JC. Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States. J Cardiovasc Electrophysiol. 2021 Jan;32(1):83-92. REFERENCE #2: 2. Price MJ, Reddy VY, Valderrábano M, Halperin JL, Gibson DN, Gordon N, Huber KC, Holmes DR. Bleeding outcomes after left atrial appendage closure compared with long-term warfarin: a pooled, patient-level analysis of the WATCHMAN randomized trial experience. JACC Cardiovasc Interv. 2015; 8:1925–1932. DISCLOSURES: no disclosure on file for Michael Caniglia; No relevant relationships by John Cox, source=Web Response No relevant relationships by Thomas Maloney, source=Web Response

S2058 Three Rare Cases of Neuroendocrine Carcinoma of the Esophagus in a Rural Community

Introduction: The frequency of cannabis use has increased in the USA in the last few years. The prevalence of cannabis induced hyperemesis has also increased during this time. We present a case of presumed esophageal perforation in a patient with cannabis hyperemesis syndrome. Case Description/Methods: A 26 year old female with daily inhaled cannabis use presents with nausea, vomiting and epigastric pain for 3 weeks. She denies chest pain or fever. She has been told in the past that she has Cannabis Hyperemesis Syndrome. Typically, her bouts last for one week and her symptoms improve with hot showers. On initial physical exam she was in moderate distress and tachycardic with tenderness over the epigastrium. Her WBC count was elevated at 18.53. She was also COVID-19 positive. CT of the abdomen performed in the ED noted free air surrounding the distal esophagus consistent with pneumomediastinum concerning for esophageal rupture. She was managed conservatively with close monitoring for a presumed esophageal perforation with spontaneous closure. She was made NPO and started on IV antibiotics. Over the next 48 hours, she developed crepitus in her neck and chest wall. Repeat imaging confirmed progression of pneumomediastinum. 48 hours later, she underwent a water-soluble esophagram negative for perforation and her diet was advanced. She was counseled on cannabis cessation and provided community resources for rehabilitation and discharged. Discussion: Cannabis Hyperemesis Syndrome is a functional disorder marked by episodes of nausea and vomiting provoked by cannabis use. It is considered to be a variant of cyclical vomiting syndrome. These episodes of retching and vomiting can lead to complications including Mallory-Weiss tears and in rare cases esophageal rupture. The treatment for cannabis hyperemesis syndrome includes volume resuscitation, anti-emetics and cannabis cessation. Esophageal perforations often present a diagnostic challenge due to the variability in presentation. This patient was fortunate to present early. She remained clinically stable without evidence of systemic inflammation or pleural or peritoneal collections and therefore was able to be managed conservatively. With increasing legalization and popularity of cannabis use, it is important to recognize the potentially devastating complications of chronic marijuana use resulting in cannabinoid hyperemesis syndrome. Although esophageal perforation is rare, it has the potential for great morbidity.

S2370 Full Thickness Esophageal Tear Due to Food Impaction in 87-Year-Old Male

S2370 Full Thickness Esophageal Tear Due to Food Impaction in 87-Year-Old Male

Vomito esplosivo con sangue

A case of Mallory-Weiss syndrome presenting after an episode of explosive vomiting is discussed.

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

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

Bleeding from the upper gastrointestinal tract in patients with acute coronary pathology receiving dual antiplatelet therapy

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): own funds Routine administration of dual antiplatelet therapy reduces the incidence of thrombotic complications and deaths in patients with acute coronary syndrome. However, the widespread use of antithrombotic therapy in these patients is associated with a significant risk of bleeding from the upper gastrointestinal tract. Their frequency in patients with AMI according to various data ranges from 1.1% to 2.3%. Purpose of the study. To determine the risk factors for upper gastrointestinal bleeding and its outcome in patients with acute coronary pathology receiving dual antiplatelet therapy. Methods. Analyzed 2632 patients with acute myocardial infarction and 2114 patients with unstable angina who were admitted for a 10-year period (2011-2020) and underwent emergency coronary angiography. The average age of patients is 57 ± 9 years, women – 1649 (35%), men – 3097 (65%). All patients received dual antiplatelet therapy (acetylsalicylic acid and P2Y12 inhibitor). Studies of the state of the gastric mucosa and duodenum were carried out by endoscopic method, which revealed 31 cases of bleeding. Various baseline characteristics and risk factors for upper gastrointestinal bleeding were evaluated. Results. The source of bleeding was: gastric ulcer - 8 cases (26%), duodenal ulcer - 6 (20%), simultaneously 2 or more ulcers - 4 (14%), multiple acute erosions - 8 (26%), single acute erosions of the antral part of the stomach - 2 (7%), Mallory-Weiss syndrome - 2 (7%) and bleeding from varicose veins of the esophagus - 1 (3%). Clinically, patients noted pronounced weakness, dizziness, coffee ground vomitus was observed in 8 (26%) patients, melena in 14 (45 %) patients. Bleeding from the upper gastrointestinal tract was detected in 20 patients with AMI (1% of all AMI) and is characterized by a high frequency of deaths (9; 45%). Fatal cases are mainly associated with the appearance of several ulcers of different localization (multiple acute erosions of the stomach and duodenum). In patients with unstable angina, the frequency of bleeding from the upper GIT is about 0.5%, while the duration of hospitalization is extended by an average of 8 days. Predictors of bleeding from the GIT in patients with acute coronary pathology include the presence of peptic ulcer disease in the anamnesis, elderly (senile) age, previous long-term use of antiplatelet agents (anticoagulants). Conclusion Bleedings from the upper GIT are a serious clinical problem in patients with acute coronary pathology. They are characterized by a long stay in the hospital and a high mortality rate.