Etiology Of Bleeding Research Articles

Incidence, Predictors, and Outcomes of Major Bleeding Among Patients Hospitalized With Acute Heart Failure

Acute heart failure (AHF) is a common etiology of hospitalization and is associated with morbidity, including bleeding.In this study, the authors sought to assess the incidence, types, and associates of major bleeding in patients hospitalized with AHF. The National Inpatient Sample from October 2015 to December 2018 was used to identify patients with AHF. The incidence of common bleeding etiologies, and patient demographics, co-morbidities, associated acute cardiac diagnoses, and invasive procedures, were identified. The multivariable logistic regression was used to identify predictors of bleeding and the association of bleeding episodes with inpatient mortality.During the study period, 1,106,634 patients were admitted with a primary diagnosis of AHF, of whom 58,955 (5.3%) had an episode of bleeding. Common bleeding sources were gastrointestinal (25.7%), hematuria (24%), respiratory (23.6%), and procedure-related bleeding (2.5%). Major bleeding was more common in patients with AHF with preserved ejection fraction (odds ratio 1.14, confidence interval 1.12 to 1.16, p <0.001) versus AHF with reduced ejection fraction and in men (odds ratio 1.3, confidence interval 1.29 to 1.31, p <0.001).Major bleeding was associated with higher mortality (7.0% vs 2.4%, p <0.001), longer length of stay (7 vs 4days, p <0.001), and higher inpatient costs ($49,658 vs $27,636, p <0.001). In conclusion, major bleeding occurs in 5.3% of patients hospitalized with AHF and is associated with higher inpatient mortality and costs and longer length of stay.

An Institutional Overview of Gastrointestinal Bleeding Among 563 Continuous-Flow Left Ventricular Assist Device Recipients

Background and AimsGastrointestinal bleeding (GIB) is a common morbidity among continuous-flow left ventricular assist device (CF-LVAD) recipients. The study objectives were to investigate the incidence, recurrence, risk factors, and medical and endoscopic management of GIB among CF-LVAD patients. MethodsThis is a single-center retrospective study analyzing 563 CF-LVAD recipients implanted at a large tertiary referral center from 2007 to 2018 with 619 bleeding events characterized. Patients with device exchanges or history of right ventricular assist devices were excluded. Chart review data pertaining to demographics, LVAD characteristics, endoscopic reports, and medications were collected. ResultsThe incidence of GIB was 44%, with a median time to first bleed of 133 days and a recurrence rate of 53%. Approximately 13% of patients had ≥5 GIB events. There is an association of reduced GIB among patients taking angiotensin-converting enzyme inhibitors (ACEis). There was no association with GIB and acid-reducing medications, antiplatelet medications, and history of GIB before device implantation. Arteriovenous malformations were the most common bleeding etiology. CF-LVAD patients that bled more frequently were older, had their CF-LVAD longer, and bled earlier after LVAD implantation. ConclusionThis is the largest comprehensive single-center GIB study among CF-LVAD recipients. The incidence and recurrence of GIB among CF-LVAD recipients is underreported. Push enteroscopy improves diagnostic yield for upper GIB. Special attention should be given to CF-LVAD patients that bleed within the first 18 days of implantation. There is an associative, dose-dependent benefit of ACEi medications among CF-LVAD recipients. Further studies on this effect are warranted.

An Unusual Etiology of Bleeding in an Inflammatory Bowel Disease Surveillance Colonoscopy

An Unusual Etiology of Bleeding in an Inflammatory Bowel Disease Surveillance Colonoscopy

A Study on Pregnancy Outcomes in Patients with First Trimester Vaginal Bleeding

Bleeding in first trimester of pregnancy poses a risk to embryo. It can be a natural symptom of implantation, sign of spontaneous abortion, or of pathologic condition like ectopic pregnancy/ gestational trophoblastic illness.4 Aim: To assess the etiology and outcome of first trimester bleeding. Objectives: (1) To study the etiology for first trimester bleeding. (2) To study the incidence of various etiological factors. Settings and design: This is the prospective observational study carried out in a tertiary health care centre over 2 years from October 2019 to october 2021. Materials and methods: This study was conducted on women with complaints of vaginal bleeding in first trimester of pregnancy. The methodology were explained to the women and valid informed written consent was recorded. The ethical clearance was obtained from ethical review committee of the tertiary care centre. After taking a detailed history and physical examination, the patient will undergo a urine pregnancy test, on confirmation she will be sent for a TVS scan depending upon the USG report further management and follow-up will be decided. Conclusion: Bleeding in first trimester doesn’t necessarily lead to miscarriage, but causes anxiety to the patient. Women and obstetricians should consider the outcome of continued pregnancies after the first trimester bleeding when planning antenatal care and clinical interventions. We need more researches on this to improve our better understanding and knowledge so that we can better plan the continued pregnancy as well as council the patient in better way.

How to manage lower gastrointestinal bleeding in 2022?

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.

S695 Factors Affecting Likelihood of Peptic Ulcer Disease as the Etiology of Suspected Upper Gastrointestinal Bleeding

Introduction: Patients presenting with suspected upper gastrointestinal bleeding (UGIB) have a broad differential diagnosis. Any process which affects mucosal integrity must be considered when developing a management plan. When treating UGIB a patient’s medical history may provide clues that prioritize consideration of certain diagnoses. This study aims to assess components of the medical history that affect the likelihood of finding a peptic ulcer during endoscopic evaluation. Methods: An IRB-approved retrospective study was performed to evaluate all adult patients who underwent endoscopy for suspected UGIB within five days of presentation, at two affiliated academic hospitals, between 2018 and 2022. Patients were excluded if they had prior endoscopy within 90 days of presentation. Demographic, procedural, and clinical data were obtained via electronic record. Descriptive statistics included t-tests and Chi-square tests. Multivariate analysis was conducted using logistic regression. (Table) Results: A total of 1392 charts were reviewed and 874 patients were included in the analysis. Average age was 64 years, and 525 (60%) were male. The most common symptoms were melena (68%), abdominal pain (32%) and hematemesis (28%). Peptic ulcer disease (PUD) was diagnosed in 397 patients (45%), with 97 patients (11%) classified as high-risk Forrest class 1a/1b/2a/2b lesions where endoscopic intervention is indicated. Another 300 patients (34%) had low risk PUD with Forrest class 2c/3 lesions, and 477 patients (55%) had no PUD. PPI-naïve patients were found to have PUD in 47% of endoscopies, compared to 36% in active PPI users. Multivariate analysis revealed PPI users were 37% less likely to have any ulcer (p< 0.0001). The risk of finding an ulcer increased by 2.0% for every year of age (p< 0.0001). High risk ulcers were more likely to be seen in males (OR 1.73, 95% CI 1.05-2.82), and a history of hepatic disease decreased the likelihood of finding these lesions (OR 0.56, 95% CI 0.37-0.85). Conclusion: Active outpatient PPI use leads to a significant decrease in the likelihood of finding PUD in patients with suspected UGIB. This result underscores the importance of considering other etiologies of bleeding in order to prevent a missed diagnosis and delay in care. The “protective” effect of hepatic disease likely stems from liver-related sources of UGIB present in this population. Even when PUD is suspected in these patients, the data suggest timely empiric treatment with antibiotics and vasoactive agents is warranted. Table 1. - Univariate & Multivariate Analysis of Factors Associated with Upper Gastrointestinal Bleed Presentations Any Ulcer High Risk Ulcer (Forrest 1a/1b/2a/2b) Low Risk Ulcer (Forrest 2c/3) No Ulcer Subjects (N=874) PPI Naïve (N=732) 346 (47%) 84 (11%) 262 (36%) 386 (53%) PPI Use (N=142) 51 (36%) 13 (9%) 38 (27%) 91 (64%) Active PPI Use OR 0.63 0.64 0.65 N/A (95% CI) (0.43-0.93) (0.33-1.23) (0.43-0.99) Age OR 1.02 1.04 1.01 N/A (95% CI) (1.01-1.03) (1.02-1.05) (1.01-1.02) Male Gender OR 1.29 1.73 1.21 N/A (95% CI) (0.97-1.72) (1.05-2.82) (0.88-1.64) Hepatic Disease History OR 0.56 0.86 0.46 N/A (95% CI) (0.37-0.85) (0.46-1.60) (0.28-0.73)

S2278 Black Esophagus: A Striking Etiology of Gastrointestinal Bleeding

Introduction: Black esophagus, or acute esophageal necrosis (AEN), is an uncommon etiology of upper gastrointestinal bleeding with incidence 0.01%-0.2% and poor prognosis. AEN is characterized by endoscopic findings of diffuse circumferential black discoloration of distal esophageal mucosa with sharp demarcation at the GEJ. The pathophysiology of AEN is unknown, however current hypotheses implicate ischemia, thromboembolic injury, critical illness, and corrosive injury. We describe a case of black esophagus in a patient with hemorrhagic shock. Case Description/Methods: An 83-year-old woman with hypertension presented to an outside hospital after a fall with lethargy, acute hypoxic respiratory failure, and shock. CT chest revealed right sided hemothorax. The patient was intubated, resuscitated with IV fluids and blood products, initiated on vasopressors, and a chest tube was placed prior to transfer to our institution. Repeat CT chest was concerning for the right thoracostomy tube traveling through the right middle lobe parenchyma and terminating within the mediastinum between the left atrium and the distal esophagus. The chest tube was removed and replaced in the operating room. Double contrast esophogram was without esophageal leak. The patient subsequently developed melena and worsening anemia. EGD demonstrated sharply demarcated circumferential black ulceration of the distal esophagus consistent with black esophagus without obvious signs of perforation. IV PPI and therapy aimed at reversing the underlying shock was pursued. Unfortunately, after a prolonged hospital course with worsening acute respiratory distress syndrome and inability to liberate from the ventilator, the patient’s family elected to pursue comfort measures and the patient expired (Figure). Discussion: In this case, AEN was most likely caused by ischemia secondary to hemorrhagic shock. Black esophagus carries a very poor prognosis, usually related to the underlying condition. Timely recognition of AEN and treatment aimed at reversing the underlying etiology can help prevent complications such as infection, esophageal stricture, and perforation. AEN is managed with aggressive IV PPI, NPO, and avoiding passage of nasogastric tubes due to risk of perforation. In rare instances, surgical intervention may be warranted. This case highlights the need to maintain a wide differential diagnosis for gastrointestinal bleeding and the importance of early recognition and treatment of this rare condition to prevent complications.Figure 1.: EGD indicating circumferential black ulceration of the distal esophagus with clear demarcation (arrow).

S2690 A Rare Cause of Gastrointestinal Bleeding

Introduction: Cryoablation is becoming a popular way to treat renal malignancy due to its low incidence of serious complications, low morbidity and mortality, lower cost, and ease of outpatient therapy. The technique uses cold temperatures to freeze, denature, and destroy cells in the tumor. This technique is usually reserved for nonsurgical candidates. It is rare to develop intestinal wall injury or fistula formation. Here we present a patient with an abnormal etiology for upper gastrointestinal bleeding (GIB). Case Description/Methods: An 87-year-old male presented to the hospital with lightheadedness and weakness. He had a past medical history significant for hypertension, gastric reflux disease, and renal cell carcinoma. He had recently been diagnosed with two solid right renal lesions measuring 4.7x4.3 cm and 1.6x1.9 cm. Due to his age, surgery was deferred and he underwent treatment with cryoablation the day before his presentation to the ER. He was noted after the procedure to have symptoms of lightheadedness, and was hypotensive. The decision was made to admit him for observation. He underwent an initial CT scan of his abdomen and pelvis, which showed an intratumoral hematoma without active bleed. He was started on IV fluids and antibiotics. Two days into his admission, he developed bouts of melena with a subsequent drop in his hemoglobin to less than 7 g/dL. He was started on proton pump inhibitor therapy, transfused packed red blood cells, and plans were made for upper endoscopy. However, prior to endoscopy, a repeat CT scan of his abdomen and pelvis was completed, which showed the development of a new fistula between his ablated renal lesion and his duodenum. He was continued on medical management with transfusion and antibiotic therapy. He however remained transfusion-dependent with ongoing melena. After further discussion with his multidisciplinary team and family, the patient elected to forgo any additional procedures or treatments, opting for home hospice care. (Figure) Discussion: This case illustrates an unusual and rare cause of upper GI bleed. Due to the low frequency of complications following cryoablation, there are limited cases on how to effectively manage these patients. Treatment options include medical management or surgical intervention. Typically, with medical management alone, over 50% of patients respond. However, this was not the case for our patient, and other potential therapy with intervention radiology and endoscopy should be considered for future management of these patients.Figure 1.: Sagittal view of the computed tomography scan showing the fistula connecting duodenum and kidney.

S2586 Don’t Get 2 Comfortable: A Rare Case of Meckel’s Diverticulum Causing Hemorrhagic Shock in an Adult

Introduction: Meckel’s diverticulum (MD) is a true diverticulum that results from incomplete obliteration from the vitelline duct during embryonic development. It is a one of the most common congenital disorders of the gastrointestinal (GI) tract. Often characterized using “The Rule of 2’s”: MD occurs in approximately 2% of the population, is 2 inches long, is within 2 feet from the ileocecal valve, is twice as common in males than females, can contain 2 types of tissue (gastric or pancreatic), 2% become symptomatic, and most present before the age of 2. The majority of symptomatic MD occur as painless hematochezia in children and therefore is often lower on the differential of an adult with a GI bleed. Even when MD is suspected as an etiology for GI bleeding in an adult, the evaluation can be challenging. Case Description/Methods: A 25-year-old male with no significant past medical history was admitted to the hospital for GI bleeding and then developed hemorrhagic shock requiring resuscitation with transfusion of large volumes of blood products. The etiology of his GI bleed remained elusive for several days despite evaluation with upper endoscopy, three colonoscopies, three CT angiograms of the abdomen and pelvis, and a video capsule endoscopy. Subsequently, he underwent two separate fluoroscopic angiograms with interventional radiology. While the first angiogram was unrevealing, the second angiogram demonstrated a tortuous ileal artery branch with active extravasation that was treated with embolization. Given IR findings, a Meckel’s scan was performed which was negative. A multi-disciplinary review of the case prompted further review of the patient’s abdominal CT angiogram and a potential finding of MD was seen at the distal ileum. Ultimately, the surgery team decided to take the patient to the operating room where they found and resected a segment of small bowel with tissue examination revealing the MD (Figure 1). Discussion: A Meckel’s scan is often considered the modality of choice for diagnosing MD in children, however, its diagnostic accuracy is considered to be much lower in adults. The typical approach to GI bleeding via upper endoscopy, colonoscopy, capsule endoscopy, CT and procedural angiography may be negative, as seen in our case. Balloon assisted enteroscopy, where available, may also be a potentially useful tool for diagnosing MD. This case highlights the importance of maintaining a broad differential diagnosis for GI bleeding and the challenges with current diagnostic modalities.Figure 1.: Meckel's diverticulum at the level of distal small bowel, approximately 60 cm from the ileocecal valve.

S2572 Bleeding Duodenal Varix Treated With Hemostatic Clips

Introduction: Duodenal varices are a rare etiology of upper gastrointestinal bleeding with a prevalence of 0.4% in patients with portal hypertension undergoing esophagogastroduodenoscopy (EGD). Ectopic varices account for 1–5% of variceal bleeding, of which 17–40% are estimated to occur within the duodenum. Definitive guidelines on the management of duodenal varices, which have an estimated mortality rate of 40%, have not been established. We report the use of hemostatic clips to achieve hemostasis in a case of a bleeding duodenal varix due to portal hypertension in an orthotopic liver transplant patient with a dysfunctional mesocaval shunt. Case Description/Methods: A 42-year-old female with advanced liver cirrhosis (MELD 17) secondary to alcohol use and primary biliary cholangitis status post orthotopic liver transplantation complicated by portal vein thrombosis and biliary stricture for which she underwent mesocaval shunting and biliary reconstruction with recurrent portal hypertension. She presented with one day of bright red blood per rectum. On admission, her vital signs were significant for hypotension (81/61 mmHg) and tachycardia (132 bpm). Her hemoglobin was 7.6 g/dL (baseline 12 g/dL). Computed tomography angiography was remarkable for prominent proximal duodenal mucosal varices, portosystemic shunting with prominent splenorenal and gastric/gastroesophageal varices, and portal vein thrombosis. EGD was significant for a large (>5 mm) actively bleeding varix in the second portion of the duodenum, for which two hemostatic clips were successfully placed with resolution of bleeding. The patient remained hemodynamically stable post-procedure and was transferred to her transplant center for further management with no further bleeding episodes. Discussion: Alcoholic-associated liver disease (ALD) is one of the most common causes of cirrhosis. As the incidence and prevalence of ALD continues to rise, it is important that management of duodenal variceal bleeding becomes more standardized. Only a few cases have reported the use of hemostatic clips in these patients. Treatment options include band ligation, coiling, cyanoacrylate injection, balloon-occluded retrograde transvenous obliteration, and transjugular intrahepatic portosystemic shunt. Standardized treatment modalities for duodenal variceal bleeds have not been well-established and further studies are required to investigate appropriate management strategies. Our case demonstrates that hemostatic clips can be effectively used to achieve hemostasis (Figure 1).Figure 1.: (A) Computed tomography angiography (CTA) revealing prominent proximal duodenal mucosal varices, likely from the superior mesenteric vein. (B) Esophagogastroduodenoscopy (EGD) demonstrating a large (>5 mm) actively bleeding varix in the second portion of the duodenum. (C) EGD demonstrating hemostatic clips placed on the duodenal varix with resolution of bleeding.

S2284 Black Esophagus as Cause of UGIB After a Complicated Urologic Procedure

Introduction: We report a case of upper endoscopy performed for a patient with coffee-ground emesis after a complicated urologic procedure. It showed diffuse black discoloration in mid-distal esophagus consistent with acute esophageal necrosis (AEN). Case Description/Methods: This is a 68-year-old male with diabetes mellitus (DM), chronic kidney disease, hypertension (HTN) and bladder cancer. He was admitted to intensive care after transurethral resection of bladder tumor (TURBT) was complicated by bladder perforation that required open laparotomy and bladder repair. Patient remained intubated for 48 hours. During the postoperative period, he developed ileus with nausea, vomiting and abdominal distention. He subsequently developed coffee-ground emesis and chest pain. He was not on acid suppressing medication. Upper endoscopy was performed to investigate etiology of upper gastrointestinal bleeding (UGIB), which showed diffuse areas of black discoloration in mid-distal esophagus suggestive for esophageal necrosis (Figure). Pathology showed tissue necrosis consistent with AEN. Patient was promptly treated with a proton-pump inhibitor and sucralfate. Symptoms rapidly improved without recurrence of bleeding or complication. Discussion: AEN, also known as “black esophagus” or necrotizing esophagitis, is a rare syndrome characterized by circumferential black mucosa at the distal esophagus and stops at the gastroesophageal junction. The prevalence is about 0.2% and 4 times more likely in men than women. Risk factors include DM, malignancy, HTN, alcohol abuse and coronary artery disease. The etiology is likely esophageal ischemia from a low-flow state followed by a backflow injury from chemical contents of gastric secretions. Majority of patients present with UGIB, followed by dysphagia and epigastric/chest pain. Symptoms can develop rapidly following an inciting event. With adequate resuscitation and medical therapy (proton pump inhibitors and sucralfate), patients can recover rapidly. Complications may include stricture, perforation, mediastinitis, and death. Prognosis is poor due to underlying critical illness, but mortality specific to AEN is much lower. Endoscopic appearance is suggestive, but biopsy is recommended to establish the diagnosis and exclude other diagnoses (e.g. melanoma and acanthosis nigricans). Repeat endoscopic evaluation is important to assess mucosal healing and determine duration of antacid therapy. Endoscopic balloon dilation may be necessary for stricture from AEN.Figure 1.: Diffuse circumferential black discoloration in lower esophagus.

S2646 Role of Point-of-Care Ultrasound in Diagnosis of Upper GI Bleed Secondary to Aorto-Esophageal Fistula

Introduction: Aorto-esophageal fistula (AEF) is a rare etiology of upper gastrointestinal bleed (UGIB) with a high mortality rate. In patients with vascular pathology or aortic aneurysms presenting with hematemesis and Chiari’s triad (midthoracic pain, sentinel arterial hemorrhage and exsanguination after symptom-free interval), there should be high suspicion for AEF as mortality is high even with timely diagnosis and surgical intervention. Diagnostic endoscopy, aortography, or thoracic computed tomography angiography (CTA) are current standards of care but may be unobtainable in emergent cases. Here, we report a case of UGIB in which bedside Point-of-Care Ultrasound (POCUS) facilitated prompt diagnosis of AEF. Case Description/Methods: A 75-year-old male with history of diabetes, uncontrolled hypertension and abdominal aortic aneurysm presented with large volume hematemesis resulting in two episodes of PEA arrests. ROSC was achieved with aggressive hemodynamic support. Gastroenterology was consulted, but the patient was deemed too unstable for endoscopy. Octreotide and pantoprazole drips were initiated. Placement of a Blakemore tube was attempted. POCUS demonstrated descending aortic intraluminal flap consistent with aortic dissection. After stabilization, CTA was pursued which showed descending thoracic aortic aneurysm with penetrating ulcer and active extravasation into the subcarinal mediastinum. Vascular surgery was urgently consulted but the patient became increasingly unstable and ultimately expired. Discussion: AEF is a rare cause of UGIB that should be suspected in patients with large volume hematemesis, chest pain, hemodynamic compromise. Index of suspicion should be high in patients with a history of aortic aneurysm, esophageal malignancy, ingestion of foreign body or recent esophageal surgery. Temporization, rapid diagnosis, and surgical intervention are critical, but guideline directed diagnostic modalities are limited in hemodynamically unstable patients. Here, POCUS allowed prompt diagnosis several hours before the patient was stable enough for CTA. This case demonstrates that POCUS has a diagnostic role in massive UGIB in patients with a high pretest probability of vascular pathology and may limit unnecessary invasive testing in select patients who are unlikely to benefit from endoscopy. Further research is needed to determine the diagnostic role of POCUS in UGIB, but it should be considered in patients with high suspicion for AEF (Figure).Figure 1.: (A) POCUS showing descending aortic intraluminal flap consistent with aortic dissection. (B) CTA showing descending aortic aneurysm with penetrating ulcer resulting in hematoma of the subcarinal mediastinum.

S2563 Upper GI Bleed Caused by Ampullary AVM

Introduction: GI bleed (GIB) is responsible for 1,000,000+ hospitalizations every year, and a mortality rate of 2-10%. Ampullary AVMs are an uncommon etiology of GIB and difficult from a diagnostic standpoint. We present a case of 77-year-old man presenting to emergency department (ED) with acute shortness of breath (SOB) and chest pain (CP), and dark stools for 4 days, found to have acute GIB caused by ampullary AVM. Case Description/Methods: 77-year-old white male presented to ED with acute SOB and CP. Past medical history included aortic regurgitation s/p valve replacement, atrial fibrillation s/p ablation and watchman, chronic anemia with baseline Hgb of 9, HTN, HFpEF, and ulcerative colitis s/p curative total proctocolectomy and ileostomy with modified Kock pouch procedure. Physical exam was unremarkable aside from dark-appearing ileal pouch output. He was not on anticoagulation and denied Pepto-Bismol use. Abnormal labs included Hgb/Hct of 5.1/16.4, BUN:Cr 37:1.93, and hemoccult positive stool from ileal pouch. Presenting symptoms of anemia (CP, SOB) were consistent with lab findings, concerning for GIB in setting of hemoccult positive stool. He received IV Protonix, Rocephin, and 1u pRBCs for acute blood loss anemia secondary to suspected GIB and was admitted to hospitalist. GI was consulted to do EGD, which showed active bleeding around major papilla, suggesting hemobilia. Subsequent CT A/P with contrast showed no clear etiology of bleed, so nuclear medicine bleeding scan was performed. The scan was unremarkable, and he continued to have melena, requiring 2u of pRBCs. Finally, ERCP was pursued to evaluate for potential biliary source. A normal bile duct (BD) was identified via cholangiogram, measuring 10mm without filling defect. Sphincterotomy was performed, followed by BD sweeping using a stone extraction balloon. No blood clots were noted, making hemobilia less likely. However, slow bleeding from inferior aspect of ampulla was visualized. The site was lavaged and appeared to be ampullary AVM (see Figure). Before ablation of AVM, a PD stent was placed to reduce likelihood of post-ERCP pancreatitis. Following procedure, his Hgb normalized, and he stopped having melenic stools. He continued PPI treatment outpatient and is doing well. Discussion: To our knowledge, no case of GIB caused by ampullary AVM is found in the literature. Thus, this case reports a rare finding of ampullary AVM and provides support for endoscopy as diagnostic approach in such patients.Figure 1.: Ampullary AVM.

Medical tactics for bleeding after oncological interventions on the pancreas

About 60% of malignant tumors of the hepatopancreatoduodenal region are represented by neoplasms of the pancreas, accounting for 10% of the total number of malignant tumors of the gastrointestinal tract. Simultaneously with the accumulation of experience, the improvement of the instruments used and the improvement of the supply of medical institutions, the number of cases of surgical treatment of pancreatic neoplasms is growing. The geography of these interventions is expanding. Accordingly, the issues of prevention and treatment of postoperative complications during these interventions, including such a dangerous complication as bleeding, are becoming increasingly important. Postoperative bleeding is diagnosed in 22% of operated patients with a given localization of a malignant neoplasm. The review analyzes modern views on the etiology, diagnosis and treatment of bleeding after resection interventions for pancreatic tumors.

Gastroinstestinal Bleeding in Pediatrics

Gastrointestinal bleeding (GI) may occurs in infants and children. Most etiologies of GI bleeding are mild and self-limited, but may advance into life-threatening condition if not treated properly. Upper GI bleeding and lower GI bleeding can be classified based on bleeding sites that is above or below Treitz ligament. Causes of GI bleeding in infants and children varies according to their age and bleeding sites. Some conditions may be misunderstood as GI bleed such as consumption of certain red coloured food. Diagnosis of gastrointestinal bleeding in children includes complete history taking, thorough physical examination, laboratory examination, radiological examination, and other supportive modality such as endoscopy. Early diagnosis and proper therapy can improve outcomes and prevent severe conditions.

Airway bleeding during extracorporeal membrane oxygenation treatment of covid-19 pneumonia: A case report

COVID-19 virus disseminates throughout the body but the host response to this infection is variable. Inflammation and coagulation are essential host defense mechanisms that protect from infection. When unregulated these processes can lead to profound end organ injury. Anticoagulation remains a standard for Extracorporeal Membrane Oxygenation (ECMO) support. However, bleeding complications are highly comorbid in ECMO patients. For ECMO-supported COVID-19 patients, invasive procedures like tracheostomy may also be required. Invasive procedures can compound ongoing bleeding complications during ECMO treatment like airway bleeding. Although the etiology of airway bleeding is broad, major life-threatening complications may go unrecognized.

Untreated bleeds in people with hemophilia A in a noninterventional study and intrapatient comparison after initiating emicizumab in HAVEN 1–3

BackgroundBleeding in people with hemophilia A can be life threatening, and intra‐articular bleeds can result in joint damage. Most clinical studies focus on treated bleeds, while bleeds not treated with coagulation factor(s) (untreated bleeds) are underreported. ObjectivesWe assessed the incidence of untreated bleeds during a noninterventional study (NIS) wherein people with hemophilia A, with or without factor VIII (FVIII) inhibitors, were managed according to standard practice. Patients/MethodsUsing the Bleed and Medication Questionnaire, we prospectively collected data from three cohorts: Cohort A, adults/adolescents (age ≥12 years) with FVIII inhibitors; Cohort B, children (aged <12 years) with FVIII inhibitors; Cohort C, adults/adolescents without FVIII inhibitors. Untreated bleeds were analyzed for site, frequency, and etiology of bleeding and compared with those during emicizumab prophylaxis in the same individuals after transferring to a Phase III HAVEN trial. ResultsIn the 221 participants enrolled in the NIS (Cohort A, n = 103; Cohort B, n = 24; Cohort C, n = 94), the incidence of untreated bleeds was approximately 40% of all bleeds in people with FVIII inhibitors and 26.2% in adolescents/adults without inhibitors. Approximately 70% of treated bleeds and approximately 54% of untreated bleeds in adults/adolescents were in joints. Untreated joint bleeds were less common (7.1%) in children. Overall, intra‐individual comparisons showed reduced treated/untreated bleeds following transition from standard to emicizumab prophylaxis. ConclusionA significant proportion of bleeding events are untreated in people with hemophilia A. There is a need to further understand why bleeds remain untreated and to capture such events in clinical studies.

Hemostatic powders for gastrointestinal bleeding: a review of old, new, and emerging agents in a rapidly advancing field.

Background and study aims Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000–2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents.

The Etiology and Outcome of Upper Gastrointestinal Bleeding in Patients Presenting to Tertiary Care Hospital, Karachi

Objective: The aim of this study was to determine the causative factors that lead to bleeding in upper gastrointestinal tract and assess the outcomes after endoscopy. Methods: this study was conducted at the Department of Gastroenterology &amp; Hepatology, JPMC, Karachi using a non-probability sampling technique and cross-sectional study design for the period of one year from October 2020 to September, 2021. Adult patients of age between 18 years to 60 years of both genders, presented either with upper GI bleeding were enrolled in this study. Baseline and clinical characteristics were collected in a structured questionnaire. After enrollment of patients, lower upper gastrointestinal and upper gastrointestinal endoscopy were performed to establish the diagnosis and source of bleeding and final analysis was performed using SPSS v. 23. Results: Five thirty-six patients with UGIB were recruited for final analysis and among them most common were males and accounted for 58.0% (n = 311) Large esophageal varices were was observed more prevalent cause of UGIB (57.4%, n = 308). Recurrent bleeding in 17 (5.6%) patients were observed under ≤50 years of age while 20 (8.6%) were of &gt;50 years of age with a significant association between them (p= 0.028). Moreover, 02 (0.7%) died within 30 days under ≤50 years of age while 36 (15.5%) deaths were seen for those who were &gt;50 years of age with a significant association (p&lt; 0.001). Conclusion: In our study, we have observed that irrespective of age groups and gender, UGIB was most commonly caused by esophageal varices. Males were comparatively more prevalent. Our study also proves that risk of re-bleeding occurs as the age increasing along with higher short-term mortality. Keywords: Esophageal varices, UGIB, peptic ulcer, re-bleeding, mortality rate

Superior mesenteric arteriovenous fistula embolization with a vascular plug for upper gastrointestinal hemorrhage: a case report

BackgroundSuperior mesenteric arteriovenous fistula is a rare vascular anomaly often presenting with sequelae of portal hypertension, heart failure, or mesenteric ischemia. This report describes a patient with a previously unidentified superior mesenteric arteriovenous fistula who presented with variceal bleeding, thought to be the leading cause of mortality associated with this condition. Although this patient was initially referred for a transjugular intrahepatic portosystemic shunt procedure, following a thorough review of her clinical history and imaging, she instead underwent embolization of the arteriovenous fistula likely responsible for her symptoms.Case PresentationA 75-year-old woman with a past surgical history of extensive small bowel resection presented with active variceal bleeding requiring transfusions. She was referred to vascular and interventional radiology for transjugular intrahepatic portosystemic shunt procedure; however, her clinical presentation was inconsistent with cirrhosis. This prompted a further review of her imaging, which identified a superior mesenteric arteriovenous fistula as the probable etiology of her varices. This fistula was subsequently embolized with a vascular plug and follow-up upper endoscopy at 1-month demonstrated complete resolution of her varices.ConclusionsThis report highlights a potential etiology of variceal bleeding in the acutely ill patient. Through a thorough consultation, the patient described here was able to avoid a procedure with the potential to cause catastrophic consequences, and instead receive the appropriate treatment for an uncommon condition.Level of EvidenceLevel 4, Case Report.