Intermittent Hematemesis Research Articles

Esophagogastric Reconstruction in Cobra-Head Shape with Toupet-Like Partial Anti-Reflux Technique for Resection of Proximal Gastric Tumors. Experience with Three Cases from a Non-Asian Population

Background: Proximal gastrectomy is a rarely performed procedure but a feasible option in benign tumors and malignant neoplasms in the proximal third of the stomach since novel options of reconstructions are available nowadays with fewer long-term sequels. Methods: Report of three cases of proximal gastric gastrointestinal stromal tumors (GIST), with a description of its presentation, histological characteristics, and follow-up after being treated with proximal gastrectomy with cobra head reconstruction. Results: Case 1: A 62-year-old woman with epigastric pain of four months with endoscopic evidence of a cardia GIST. The surgery was performed without complications. The histopathological report confirmed a fusiform GIST of 3.2 × 3 × 2.5 cm, stage IA. No adjuvant treatment was considered. An esophagogram showed no evidence of reflux and no stenosis, and no disease recurrence after 40-months follow-up. Case 2: A 66-year-old woman with dyspepsia and a palpable tumor in the epigastrium. The surgery was performed without complications. The pathology report confirmed a proximal gastric GIST of 13 × 8 × 7 cm, staged II. She received adjuvant treatment with imatinib for 36 months without recurrence and no reflux or stenosis. Case 3: A 55-year-old woman with intermittent hematemesis and right subscapular pain. The surgery was performed without complications. The histopathological report concluded that a GIST tumor of the cardia, 1.4 × 1.2 cm, staged IA. She was left in observation. At a 6-month follow-up, she does not report dysphagia, reflux, or stenosis, and no locoregional recurrence. Conclusions: Open and laparoscopic proximal gastrectomy is a safe therapeutic option for GIST. Furthermore, the reconstruction of the esophagus-gastro anastomosis in the cobra head after proximal gastrectomy is feasible and secure in our population, with good functional results in a short follow-up.

Culprit or Innocent Bystander? A Case of Hematemesis.

An 11-year-old previously healthy female presented with 1 year history of generalized abdominal pain, early satiety and intermittent hematemesis without history of melena. She underwent esophagogastroduodenoscopy (EGD) as a part of her workup. EGD was notable for diffuse gastric erythema and retained food in stomach despite being nil per os for solid food for 14 hours (Fig. 1). Histopathologic examination showed chronic gastritis in the gastric body and focal organisms identified morphologically as Sarcina ventriculi (Fig. 2).FIGURE 1.: Gastric mucosal erythema and retained food in stomach.FIGURE 2.: Photomicrograph showing S. ventriculi organisms in the stomach mucosa with characteristic morphology: Aggregates of basophilic stained, cuboid organisms in tetrad packet arrangement with flattening of the cell walls in areas of contact with adjacent cells. Hematoxylin and eosin stain, original magnification ×40.S. ventriculi is a Gram-positive anaerobic coccus with a birefringent cellulose coating, averaging from 1.8 to 3 μm in size, that is found in water and soil and thrives in low pH environment. In the stomach, it appears as clusters of tetrads. Its metabolism is strictly carbohydrate dependent. It is unclear if S ventriculi has a pathogenic role, but it has been associated with gastroparesis, gastric ulcers, mucosal inflammation (1), emphysematous gastritis (2), gastric perforation (3), and esophagitis (4). Local accumulation of acetaldehyde and ethanol from carbohydrate fermentation by S. ventriculi may cause gastric mucosal injury. The most common endoscopic feature (5), which was found in this patient, is the presence of food retention due to delayed gastric emptying, often accompanied by an inflamed gastric mucosa. There are neither consensus on which patients need treatment nor guidelines regarding antibiotic selection or duration of treatment. In this case, the child received empiric treatment with metronidazole and amoxicillin/clavulanic acid for 1 week along with a proton-pump inhibitor for 2 weeks, with resolution of hematemesis and improvement of her abdominal pain. ACKNOWLEDGMENTS Informed consent was provided by patient’s parents for this report to be published

Abernethy malformation

A 59-years-old woman presented to the emergency department with sudden onset of intermittent hematemesis and melena. The patient had a history of stage IV cervical cancer, sigmoid colostomy (because of rectovaginal fistula). A complete blood count showed normocytic anemia (79 g/l) and other laboratory evaluation showed the elevation of ammonia (38 µmol/l). The total bilirubin, transaminase and creatinine level were normal. Upper endoscopy revealed hemorrhage of esophageal varices that was stopped by local treatment with the combinations of spraying hemostatic and sclerotherapy (Figure 1). The CT-scan revealed no cirrhosis and liver lesion but did 10 show the absence of the portal vein with a complete extrahepatic shunt of the portal blood, considered Abernethy Malformation Ib (Figure 2,3), determined to be the possible reason of esophageal varices and megalosplenia. The old patient suffered from first-onset gastrointestinal bleeding and was diagnosed the only curative treatment is liver transplantation. This patient was stopped bleeding and transferred to cancer center for tumor therapy.

Isolated Congenital Bronchoesophageal Fistula in a Pediatric Patient: Case Report

Abstract Introduction/Objective Congenital bronchoesophageal fistula (BEF) results from an undue passageway caudal to the foregut lung anlage. BEF may be associated with esophageal atresia and commonly involves the right lung. Herein we present a pediatric case of isolated congenital BEF masqueraded by severe dyspeptic symptoms. Methods A five-year-old child with a longstanding history of gastroesophageal reflux was hospitalized because of acute onset sharp lower chest/epigastric abdominal pain associated with emesis. Imaging disclosed a left lung abscess and empyema that responded to intravenous antibiotics, chest tPA instillation and drainage. After resolution of her empyema, she experienced severe dysphagia, chocking sensation, vomiting, and intermittent hematemesis. Esophogram disclosed a fistulous tract to the left lower chest cavity. Esophagoscopy revealed severe esophagitis and a stricture just proximal to a 0.6 to 0.8 cm ostium of a fistulous tract at 26 cm from the incisors, 2 cm above the gastroesophageal junction. Results A 103 g, 12 x 7.5 x 5.0 cm thoracoscopic left lower lobectomy showed a focally ulcerated fistulous tract that entered a 1.9 cm in diameter cyst that connected to a basilar-medial segmental bronchus. The passage was lined by stratified squamous epithelium, continuous with columnar ciliated epithelium, and was surrounded by intense chronic inflammation. The fistulous lumen contained partially degraded vegetable matter. Diagnosing BEF can be clinically challenging. Symptoms are often intermittent, alternating between digestive and pulmonary in nature. Often, cough, gastroesophageal reflux, pneumonia, and bronchopulmonary suppuration can lead to medical management that is only masking, not definitively treating the underlying pathology. While tracheoesophageal fistulas are relatively common in presentation, and usually diagnosed in the newborn period, BEFs are rare and with varied clinical expression, which may explain delayed diagnosis. Conclusion BEF is a rare anomaly that may manifest ambiguous symptoms, thus delaying the diagnosis and options for earlier, less invasive curative interventions.

S3413 Cholangioscopy Through the PTC Route: Suddenly I See

INTRODUCTION: Black esophagus is a rare endoscopic finding caused by acute esophageal necrosis (AEN). Studies suggest the incidence of AEN is less than 1%. We describe a case of a patient presenting with coffee ground emesis and black esophagus. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of HIV on HAART (CD4 count of 399 and undetectable VL), alcohol abuse, ESRD, DMII and HTN presented to the ED for intermittent hematemesis. The patient described several episodes of coffee ground emesis associated with worsening abdominal distention, pain and diarrhea. Two days prior, he was discharged from another hospital after being treated for the same condition, however EGD was not performed. His surgical history was significant for G-tube placement, one year prior. He was afebrile and hemodynamically stable. His abdomen was soft, distended, non-tender with normal BS. His rectal exam revealed melena. Initial labs were significant for a leukocytosis of 15.4 K/uL, Hg of 8.2 (MCV 83), Platelets 373, INR 1.3 and lactate of 1.8. CT demonstrated distal esophageal wall thickening, suggestive of esophagitis. EGD confirmed esophagitis with eschar (LA Grade D) at the mid and distal esophagus (45 cm from the incisors.) There was no extension of the lesion beyond the GE junction. No blood, clots or old heme was seen in the stomach. However, multiple non-bleeding clean base ulcers (Forrest Class III) were visualized in the duodenum. The patient's hematemesis was caused by acute esophageal necrosis. The patient was treated with fluid resuscitation and intravenous proton pump inhibitors. The patient declined further workup. He was discharged to a skilled nursing facility with plan for repeat upper endoscopy in 4-6 weeks. He declined repeat endoscopy. DISCUSSION: The pathogenesis of AEN is not fully understood however poor vascular perfusion may be a contributor. AEN manifests in the distal portion of the esophagus and frequently coexists with duodenal pathologies. Treatment begins with nil-per-os (NPO) restriction, intravenous proton pump inhibitors, fluid resuscitation and treatment of underlying medical comorbidities. Follow-up upper endoscopy is recommended in 4–6 weeks. Although uncommon, clinicians should consider AEN when evaluating patients with an upper GI bleed, as early recognition and prompt treatment may improve outcomes. Further studies are needed on treatment outcomes and survival when multiple comorbidities coexist.

1925 GIST Kidding: Primary Gastric Synovial Sarcoma Presenting as Hematemesis

INTRODUCTION: Synovial sarcoma (SS) is an uncommon subtype of mesenchymal derived solid tumors that is characterized by its unique histologic pattern. It is most often found in the extremities and rarely, the digestive tract, which can lead to gastrointestinal bleeding. Gastric tumors of mesenchymal origin often have overlapping radiographic and endoscopic appearances, which presents a significant challenge in diagnosis. We report one of only 3 confirmed cases of primary gastric synovial sarcoma of the lesser curvature in a patient who presented with hematemesis. CASE DESCRIPTION/METHODS: A 26-year-old male presented with a two-week history of worsening abdominal pain and intermittent hematemesis. He denied any history of hematochezia, melena, early satiety, weight loss, recent NSAID use or alcohol ingestion. Exam was notable for epigastric tenderness without rebound or guarding. Labs revealed microcytic anemia and thrombocytopenia without transaminitis or elevated lipase. Abdominal CT showed an 8 cm mass along the posterior gastric body with suspicion for intratumoral hemorrhage, highly suggestive of a gastrointestinal stromal tumor (GIST) [Figure 1]. EGD revealed a large, ulcerated, non-bleeding, non-circumferential, submucosal mass on the lesser curvature of the stomach, also concerning for a GIST [Figure 2]. Endoscopic ultrasound showed neither hepatic invasion nor lymphadenopathy. Partial gastrectomy pathology supported the endoscopic biopsy results, which showed high grade, monophasic, atypical spindle cells with t(X;18)(SYT-SSX) chromosomal translocation by fluorescence in situ hybridization (FISH). Immunohistochemistry (IHC) was strongly positive for TLE1 staining, but negative for C-KIT and DOG-1, to which GISTs are immunoreactive, confirming a diagnosis of primary gastric synovial sarcoma [Figure 3]. He tolerated 6 cycles of sarcoma-directed chemotherapy without evidence of progressive disease. DISCUSSION: Intramural gastric spindle cell malignancies are difficult to distinguish from one another, and require different disease-tailored therapies. Though GISTs account for 90% of these tumors, other rare pathologies exist. These include synovial sarcomas, which are characterized by a variable degree of epithelial differentiation associated with a disease-specific gene translocation. In patients with hematemesis found to have endoscopic and radiographic findings suspicious for GIST, ICH and FISH analyses are crucial to differentiate between mesenchymal malignancies to guide effective therapy.

Gastrointestinal Tract Bleeding Secondary to Blind Pouch Syndrome

A 60-year-man was admitted to our hospital with the complaints of intermittent hematemesis for 6 months. The patients underwent side-to-side enter anastomosis because of intestinal tuberculosis 30 years prior. Except for the iron deficiency anemia and decreases of the hemoglobin values down to 78g/L, all the other laboratory values were within the normal range. Further investigation of the anemia included repeated colonoscopies and gastroscopies which didn’t disclose a possible source of bleeding. Abdominal CT scan demonstrated multiple oval stones within regional blind end of small intestine and retained fluid was also noted in the sacculation (Figure 1-3). Operation revealed an inflamed, edematous, mesenteric sacculation in the blind end of intestinal afferent limb, which was located approximately 90cm from the ileocecal valve. The involved segmental resection was completed with end-to-end stapled anastomosis. Surgery confirmed to be blind pouch syndrome and cut surface of the resected specimen showed mucosal ulcer and multiple stones in the lumen (Figure 4). The patient recovered well without any complications on the follow-up of one year.

On Razorʼs Edge: (S)Hell of a Mussell Impaction With Upper Gastrointestinal Bleeding

Esophageal seafood shell impactions have been reported to cause erosions, tears, perforations and fistulae due to sharp broken edges. Severe upper gastrointestinal hemorrhage as an initial presentation can very rarely occur due to tears and lacerations by razor sharp edges, particularly if lodged for prolonged period due to esophageal peristalsis. They require early recognition and removal, which may be very difficult. We report a rare case of such a challenging broken mussel shell impaction with delayed presentation causing severe pain and hemorrhage and discuss the methodology employed for successful retrieval and management of such difficult shell ingestions.Figure: Impacted broken (umbo/dorsal) edge in crico-pharynx.Figure: Retrieved mussel shell with broken sharp (umbo/dorsal) edge and intact ventral beveled egde.Figure: Lacerations in the upper esophagus with bleeding.A 79 year old woman presented to ED with neck pain and spitting up blood after consumption of Italian seafood pasta 2 hours post consumption. She signed out against medical advice after initial ED presentation as she felt better and again presented to the ED 8 hours later with immense throat and neck pain and intermittent hematemesis. An urgent endoscopy revealed an impacted broken mussel shell in the upper esophagus with the broken beak/umbo/dorsal margin in the oropharyngeal sphincter (Image 1). This was grabbed with an alligator forceps and broken edge was snugged with the tip of scope to avoid lacerations and pushed down into the stomach. The shell was released in the fundus and subsequently grabbed with a Roth net. The broken sharp umbo/dorsal edge was snugged with the scope tip with ventrally beveled margins facing away to avoid trauma/laceration during withdrawal. The mesh of the net afforded some level of protection as well. Additionally, plenty of lubricant was applied on the scope externally and the scope was inserted all the way further down to pylorus to enable sufficient lubrication of esophagus prior to withdrawal of the Roth net with the broken shell. The shell was successfully withdrawn. Esophageal reintubation revealed lacerations akin to Mallory-Weiss tear in the upper esophagus (Image 3). This is a unique case presenting with hematemesis after consumption of Italian seafood pasta. Sea shell impaction should be suspected in such cases and our technique of grabbing the broken sharp (dorsal/umbo) edge and moving it down to stomach and providing enough esophageal lubrication and withdrawing in a Roth net, with the beveled ventral shell edge (Image 2) facing away from the scope, ensured a safe procedural outcome.

Esophageal submucosal tumor-a red flag in patients receiving thoracic aortic aneurysmal stent-graft.

A 75-year-old man presented to our hospital with symptoms of fever, abdominal pain, intermittent hematemesis and melena for 2 days. The patient underwent stent-graft placement for a thoracic aortic aneurysm (TAA) 6 months prior to this presentation. Seven days ago, he suffered from dyspepsia; an upper gastrointestinal (UGI) endoscopy indicated a submucosal tumor (Fig. 1A, arrow) in the middle portion of the esophagus. Endoscopic biopsy was then conducted, which disclosed inflammatory cells. Upon hospitalization, laboratory data indicated marked anemia with a hemoglobin of 6 g/dL. Chest radiography revealed a widening of the mediastinum and a TAA stent-graft (Fig. 1B, arrow) in place without unusual mediastinal air. Emergent UGI endoscopy was performed due to intermittent hematemesis and anemia. It demonstrated an ulcerative hole located in the middle portion of the esophagus (Fig. 1C, arrow indicates the ulcerative hole). Due to fever of an unknown focus, contrast-enhanced computed tomography (CT) of chest was done in order to rule out any occult infectious process associated with the stent-graft, showing a gas-forming peri-stent-graft abscess formation with posterior mediastinal extension (Fig. 1D, pre-contrast CT; Fig. 1E early-phase CT; Fig. 1F, reconstructed image; Fig. 1E to F, white star indicates the abscess and white arrow indicates the nasogastric tube). The radiographic and endoscopic findings were consistent with an aortoesophageal fistula formation (AEF). The patient was put on broad-spectrum antibiotics, but succumbed to sepsis before emergent operation. Fig. 1 Aortoesophageal fistula is a rare complication after thoracic endovascular aortic repair. The rate of incidence is around 1.9%.1) AEF formation after thoracic endovascular aortic repair is probably associated with the erosion of the esophageal wall by an infected stent-graft, pressure necrosis caused by the direct compression of a self-expanding stent-graft, or a compromised blood supply of the esophageal wall.1),2) Presentations of AEF include new-onset fever, chest pain or symptoms of UGI bleeding, such as hematemesis or melena.3) Contrast-enhanced CT is a useful imaging modality if AEF is suspected clinically. When a new heterogeneous mass with some air bubbles inside is found on the CT, subsequent UGI endoscopy can be performed to confirm the diagnosis. Endoscopic findings vary from submucosal tumor, ulceration, small defect of esophagus or direct visualization of a stent-graft. The mortality rate of AEF is extremely high if treated conservatively.3) Surgical intervention is challenging and important for the management of this devastating complication.

Adult female with hematemesis—Dieulafoy lesion

A 40-year-old healthy woman presented to the emergency department with a complaint of intermittent hematemesis, despite the absence of usual factors associated with upper gastrointestinal bleeding (ie, nonsteroidal anti-inflammatory drugs, alcoholism, etc). The patient was diagnosed with a Dieulafoy lesion. This is an uncommon finding, which clinicians must be familiar with and maintain in the differential diagnosis because the consequences of this disease process are grave. It is vital to properly diagnose this condition and be familiar with the treatment.

Herald Bleeding: A Diagnosis of Aorto-Duodenal Fistula Treated with Graft Within a Graft Repair

Purpose: Introduction: An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Secondary aortoenteric fistula is an uncommon but very important complication of abdominal aortic reconstruction. Herald bleeding sometimes precedes a catastrophic bleed. We report a case with this rare complication with typical herald bleeding treated with endovascular graft repair. Case report: An 80-year-old Caucasian male with a history of abdominal aortic aneurysm repair 18 years ago with a tube graft, presented with back pain, and vomiting “bloody slime.” He was on aspirin, but denied taking non-steroidal anti-inflammatory drugs or blood thinners. On examination, he was afebrile, his heart rate was 108/min and blood pressure was 101/53 mm Hg. His hemoglobin was 6.4 g/dL. He received packed red cells transfusion. An endoscopy was performed which revealed a large adherent clot in the third portion of the duodenum. This was not removed as there was a concern for aorto-enteric fistula. A review of previous CT scan revealed a closely adherent tube graft to the duodenum. Patient was deemed to be a poor surgical candidate and an endovascular graft repair was performed using a stent graft with CO2 angiography. A repeat upper endoscopy after removal of the adherent clot showed the previous aortic graft eroding through the duodenal wall, but there was no active bleeding. Patient had no further episodes of bleeding and was discharged with a close follow up. Discussion: Aorto-duodenal fistulas (ADF) after endovascular abdominal aneurysm repair are rare. Secondary ADF is an uncommon (0.3-2%) and life-threatening, long-term complication of aortic reconstructive surgery. The classic presentation of an aortoduodenal fistula is that of a “herald bleed” (brief, with spontaneous resolution), followed anywhere from hours to weeks later by a massive upper gastrointestinal bleed. Untreated cases have a mortality rate of up to 100%. In our patient, intermittent hematemesis was a warning symptom. Though laparotomy with repair is the treatment of choice, our patient was treated with graft within a graft repair in view of the comorbidities. In summary we report a rare case of aorto-duodenal fistula treated with endovascular graft repair.Figure: Visible aortic graft in the duodenum.

An exceptional postoperative gastric tube bleeding after esophageal resection for cancer

A case of gastric tube bleeding after an Ivor-Lewis esophagectomy with gastroesophageal anastomosis is reported. During the early postoperative course, the patient had a gastric tube stasis that improved progressively. The subsequent onset of a serious and intermittent hematemesis, which was endoscopically deemed to be the result of a hemorrhagic gastritis, required multiple blood transfusions. The evolution to a severe hemodynamic instability obliged us to reoperate on the patient. During surgery, a band-related obstruction of the first jejunal loop with local signs of vascular hypertension was noted. As soon as the obstruction was solved, the gastric bleeding stopped. The authors discuss the clinical aspects and physiopathology of the gastric tube bleeding and, in particular, they evaluate the influence of the intestinal obstruction with vascular involvement on the development of this exceptional and severe complication.

Detection of an aortoenteric fistula in a patient with intermittent bleeding

A 57-year-old male with an aortobifemoral bypass graft presented to a gastroenterology clinic with a 3-month history of intermittent hematemesis, melena and fever. The patient had received antibiotic therapy 2 months before for the same symptoms; however, following brief regression ( approximately 3 weeks) the symptoms had returned. Physical examination; analysis of full blood count; measurement of erythrocyte sedimentation rate, C-reactive protein levels, liver enzymes, electrolytes, renal function, serum cholesterol and serum triglyceride; HIV serology; blood, sputum, urine and stool culture analysis; performance of esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography and multidetector CT scanning. Aortoenteric fistula with an inflammatory mass surrounding the aortobifemoral bypass graft. Laparotomy with removal of the aortobifemoral bypass graft, performance of an extra-anatomic right axillofemoral bypass graft and an extra-anatomic right-left femorofemoral bypass graft.

PRIMARY AORTODUODENAL FISTULA AFTER RADIOTHERAPY-REPORT OF A CASE-

Aortoduodenal fistula is a rare and life-threatening cause of gastrointestinal hemorrhage. The patient was a 44-year-old woman who repeated intermittent hematemesis and melena after hysterectomy, para-aortic lymph node dissection, and subsequent radiotherapy. Angiography revealed no bleeding point. Upper gastrointestinal endoscopy showed an ulcer at the third portion of the duodenum. Emergency laparotomy revealed an aortoduodenal fistula which was inferred to be caused by radiotherapy because no recurrence of malignancy was detected. After the fistula was closed, the patient repeated hematemesis and anal bleeding. She died of acute hemorrhagic shock, in spite of three operations including axillo-femoral bypass. We propose that radiation might have played a role in the pathogenesis of the aortoduodenal fistula in our case. The new case of primary aortoduodenal fistula following radiotherapy is added to four cases previously reported in the literature. Six cases in which the lesion of the duodenum could be demonstrated by endoscopy, have been reported in Japan. Aortoduodenal fistula should be considered as a probable diagnosis in patients presenting massive gastrointestinal hemorrhage after radiotherapy. Rapid surgical treatments are needed, and operative procedures to be considered include resection of the aorta with aortic stump closure and axillo-femoral bypass.

More Cases of Multiple Phlebectasia

ABSTRACT To the Editor:— The paper by I. Rappaport and M. A. Shiffman, Multiple Phlebectasia Involving Jejunum, Oral Cavity, and Scrotum (JAMA185:437 [Aug 10] 1963) described a group of lesions not previously noted to be associated. The occasional instance of bleeding from jejunal phlebectasia makes recognition of the concomitant mucocutaneous vascular malformations extremely important. Since that paper was published, three new cases of multiple phlebectasia have been noted at the Veterans Administration Hospital, Long Beach, Calif. The intestinal lesions were restricted to the jejunum in two cases, and an additional lesion was noted in the proximal ileum in another. Two patients had no history of peptic ulcer or upper gastrointestinal bleeding. The third patient had a diagnosis of peptic ulcer for nine years associated with intermittent hematemesis and melena. The ages ranged from 62 to 76.A total of six cases of multiple phlebectasia have now been noted. Careful