Linear Ulcers Research Articles

Discrimination of pediatric cryptogenic multifocal ulcerous stenosing enteritis from small bowel Crohn's disease and gastrointestinal tuberculosis: A retrospective study (with videos).

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare entity that mimics various inflammatory strictures of the small intestine. Pediatric literature is scarce. We analyzed the clinical, radiological, endoscopic and histopathological features of children with CMUSE that differentiate it from small bowel Crohn's disease (SBCD) and gastrointestinal tuberculosis (GITB). CMUSE was diagnosed by the following criteria: (1) unexplained small bowel strictures with superficial ulcers, (2) chronic/relapsing ulcers of small bowel after resection, (3) no signs of systemic inflammation, (4) absence of other known etiologies of small bowel ulcers. SBCD and GITB were diagnosed based on standard criteria. The clinical features, laboratory parameters, radioimaging, endoscopy (including video capsule endoscopy [VCE], intra-operative endoscopy), histopathological features and treatment outcome were noted. Out of 48,CMUSE was diagnosed in 13 (27%) isolated small bowel and ileocecal strictures, while GITB and SBCD accounted for 41% and 21% cases, respectively. Common presentations were sub-acute obstruction (46%), obscure gastrointestinal bleeding (38%) and protein-losing enteropathy (38%). CMUSE patients had significantly longer disease duration compared to SBCD and GITB (p < 0.001). SBCD (90.0%) and GITB (85%) cases had elevated C-reactive protein (CRP), none with CMUSE had elevated CRP (p < 0.001). The disease was localized in jejunum (100%) and proximal ileum (56%) in CMUSE, ileocecal region (85%) in GITB, but evenly distributed in small intestine in SBCD. Endoscopy showed evenly placed, superficial, circumferential ulcers with strictures in CMUSE, deep linear ulcers in SBCD and circumferential ulcers in GITB. Upfront immunosuppression was given in four; three (75%) of them relapsed. Only surgery was done in three with one (25%) having relapse. Upfront surgery followed by immunosuppression was used in six, but all relapsed and two required repeat surgery. CMUSE is important but underdiagnosed in children. Lack of constitutional symptoms, normal inflammatory parameters and characteristic ulcers with strictures helped in differentiating CMUSE from GITB and SBCD.

Ulcerative stomatitis associated with yellow bristle grass in New Zealand dairy cows

ABSTRACT Case history A line of 25 cull cows were all found to have ulcerative lesions of the tongue at post-mortem inspection in a New Zealand slaughter plant. A further 9 of 10 cows inspected at the farm of origin had similar oral lesions. There were no other clinical signs or indicators of ill-health observed at ante-mortem inspection in the abattoir or on the farm. The cows had been fed baleage for 3 weeks prior to slaughter, made from pasture in paddocks heavily contaminated with yellow bristle grass (Setaria pumila). Clinical findings There was extensive and deep transverse linear ulceration in the lingual fossa immediately rostral to the torus linguae. At histological examination, full-thickness ulceration of the stratified squamous epithelium was observed with a bed of disorganised collagenous tissue and extensive mixed inflammatory infiltrate extending into the sub-epithelial connective tissue and skeletal muscle. Barbed plant fragments were embedded in both the superficial and deeper areas of inflammation. Detailed examination of the baleage also found that yellow bristle grass seedheads were present. Diagnosis Based on the presence of barbed plant material in the tongue and yellow bristle grass seeds in the baleage, a diagnosis of ulcerative stomatitis associated with yellow bristle grass was made. Clinical relevance Clinicians should be aware of the potential for hay or baleage contaminated with yellow bristle grass to cause oral lesions in cattle.

Oral manifestations in Crohn's disease - Two patient cases from the clinic

Crohn’s disease (CD) is an inflammatory disease of the gastrointestinal system. It is suspected to be caused by a combination of genetic and environmental factors and changes in the patient’s intestinal microbiome. As opposed to colitis ulcerosa, which usually only affects the large intestine, CD may affect various parts of the gastrointestinal tract. Many patients show oral lesions related to CD, which sometimes can precede the first gastrointestinal symptoms. Specific oral lesions include granulomatous cheilitis, cobblestone-like mucosal tags and linear ulcerations. Non-specific lesions occur in the form of angular cheilitis and opportunistic candidiasis, aphthous ulcerations, reduced salivation, dental caries and many more. We present two cases of patients suffering from Crohn’s disease with different oral manifestations and discuss the dentist’s role in early detection of specific oral lesions and the importance of the follow-up care of affected patients.

Comparative study of laser versus open lateral internal sphincterotomy in the treatment of anal fissure

Background: Anal fissure is a common proctological problem that causes anal pain during and after defecation. An anal fissure is a linear ulcer that presents at the anal verge. It is more common in females than males and can be seen either in the anterior or posterior midline, just distal to the dentate line. Aims and Objectives: Comparison of Laser versus Open lateral internal sphincterotomy (LIS) in the treatment of anal fissures. Materials and Methods: The study was conducted in 50 cases of Open LIS compared with 50 cases of laser LIS (LLIS) in patients admitted to the Department of Surgery, M.L.B. Medical College, Jhansi (UP), India, between January 2021 and June 2022. Results: Out of 50 cases of open LIS, 10 patients presented with bleeding, 10 patients presented with hematoma/perianal swelling and 5 patients presented with pain as compared to 50 cases of LLIS, hematoma/perianal swelling (1 patient) and pain (2 patients) were found as an early post-operative complication. Mean hospital stay was 2.84±1.128 days in Open LIS as compared to 1.02±0.141 days in LLIS. The pain was presented in 1 patient as the only late post-operative complication in LLIS as compared to pain (25 patients), bleeding (10 patients), infection (2 patients), and flatus incontinence (1 patient) in Open LIS, at 2 weeks follow-up and recurrence in 1 patient in laser and in 3 patients in open LIS at 6 weeks follow up. Conclusion: LLIS significantly reduces early postoperative complications such as postoperative pain, bleeding, and hematoma as compared to open LIS. The duration of hospital stay was significantly less in LLIS in comparison to open LIS. None of the patients presented with the flatus or stool incontinence who had undergone LLIS while in Open LIS, 12% of patients presented with flatus incontinence, and 2% of patients presented with stool incontinence during follow-up in 2–6 weeks.

Platelet-rich fibrin therapy as an adjuvant treatment in the management of metastatic Crohn’s disease: A case series

Abstract Metastatic or cutaneous Crohn’s disease (MCD) is a rare manifestation of Crohn’s disease and presents with ulcers, nodules, edema, fissures, and fistula. The genital involvement is seen in almost 50% patients and linear ulcers (knife-cut ulcers) are characteristic clinical features. The histopathological findings of skin lesions are similar to gastrointestinal involvement and is diagnostic. The treatment options for the management of MCD include topical and oral steroids, oral metronidazole, as well as immunosuppressants such as methotrexate, azathioprine, cyclosporine, and tumor necrosis factor alpha inhibitors. We present three cases of MCD who were treated with platelet-rich fibrin therapy as adjuvant and resulted in rapid healing of ulcers.

Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study.

Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients. We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis. In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions. Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.

STRESS-PROTECTIVE ACTIVITY OF THE COMPLEX REMEDY IN ACUTE IMMOBILIZATION STRESS

Relevance. The range of medicinal remedies in the traditional Tibetan medicine contains several tens of formulae named bchud len. They are multicomponent remedies of natural origin having a stimulating non-specific effect on the human body. The analysis of such formula under the name ‘Rejuvenating-35’ has been presented in the paper. The complex remedy on the base of this formula was developed. Its composition includes 14 species of the plants and chitosan as a source of mineral substances. Previous phytochemical studies have revealed that the given remedy contains a wide spectrum of biologically active substances, namely triterpene saponins, flavonoids, ether oils, tannins, polysaccharides, etc. The aim of the present work was to evaluate stress-protective activity of the complex remedy in acute restraint stress. Material and methods. Experiments were carried out on white Wistar rats. The acute stress was simulated by immobilization of animals in supine position for 18 hours. The tested remedy was introduced in the form of decoction for 7 days before exposure to stress. Results. It has been established that the course administration of the complex remedy decreases the manifestation of the Selye’s triad signs: 26% decrease of adrenal glands hypertrophy, 45% and 60% decrease in involution of thymus and spleen respectively as compared to the data in the control group of animals. Besides, its administration prevents the development of rough destructions in the stomach mucosa in the form of erosions and linear ulcers. Against the background of the complex remedy administration there was noted twofold decrease of TBA-active products concentra-tion, fourfold increase of superoxide dismutase activity, 30% increase of catalase activity and the content of the reduced glutathione was 30% in-creased as compared to the data in the control. Conclusions. The preventive administration of the complex remedy has stress-protective effect against the background of acute restraint stress. Molecular-cell mechanisms of its anti-stress effect are connected with the inhibition of free-radical oxidation processes and the increased activity of the endogenic antioxidant system.

A223 UNMASKED OR INDUCED COLITIS: COULD IT BE SECUKINUMAB?

Abstract Background Spondyloarthropathies (SpA), such as Ankylosing Spondylitis (AS) are inflammatory disorders which have coheritability with inflammatory bowel disease (IBD). Secukinumab is a monoclonal antibody inhibitor of IL-17A used to treat SpA, but has also been reported to cause de novo and exacerbations of known IBD. Rare reports of Secukinumab induced microscopic colitis have also been documented. Purpose To present and discuss the diagnostic challenges in a case of undifferentiated colitis in a patient with AS treated with Secukinumab. Method Case report and literature review. Result(s) Case Report: A 62-year-old male with a history of AS was admitted to hospital with acute on chronic diarrhea. The patient’s AS was unresponsive to Infliximab, Methotrexate, and Adalimumab, although the latter improved his diarrhea at the time. A Colonoscopy completed 14 years earlier for chronic diarrhea was endoscopically normal with biopsies of the left colon notable for mild patchy inflammation and fibrosis. A subsequent Colonoscopy with random biopsies 8 years later showed normal mucosa while he was treated with Adalimumab. He was started on Secukinumab 4 months prior to hospitalization noting progressive watery diarrhea and weight loss of 15kg. Investigations were notable for microcytic anemia (Hemoglobin 120 g/L, MCV 78 fL), elevated CRP (33 mg/L), and a creatinine of 508 µmol/L. Negative tTg antibodies and normal IgA levels ruled out celiac disease. Stool studies were unremarkable. Colonoscopy showed several linear ulcerations in the descending colon and rectum with a normal terminal ileum, transverse, and ascending colon. Biopsies from the endoscopically normal mucosa showed thickened subepithelial collagen band suggestive of microscopic colitis while the ulcerated regions showed cryptic rupture with associated granuloma representing possible Crohn’s colitis versus drug-induced injury. Stains were negative for CMV. Secukinumab was stopped and he was started on Budesonide with significant improvement in symptoms. Literature Review Almost half of all patients with SpA have microscopic intestinal inflammation and of these, 7% eventually develop IBD. Shorter symptom duration, higher SpA activity and male sex are known risk factors for underlying intestinal involvement. However, the exact role of microscopic intestinal inflammation in SpA has yet to be determined. Secukinumab is an inhibitor of IL-17A with significant efficacy in the treatment of SpA but has been associated with exacerbations of Crohn’s disease and de novo cases of IBD. Thus, the role of IL-17 in IBD remains uncertain and may suggest a protective effect rather than an inflammatory one seen in SpA. The long half-life of Secukinumab (24-31 days) presents challenges when considering treatment with other biologics, such as anti-TNFs, which may cause excessive immunosuppression. Image Conclusion(s) New onset colitis is a described but rare entity in patients treated with Secukinumab presenting several diagnostic and treatment challenges. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

GUT-BIOME MODULATION WITH HUMAN MILK OLIGOSACCHARIDE (HMO) BASED SYNBIOTIC FOR A COMPLETE AND DEEP REMISSION IN CROHN’S DISEASE: A CASE STUDY

Abstract BACKGROUND Gut microbiome plays a crucial role in modulation of inflammatory and immune pathways. Diverse bacterial species from gut microbiota feed on specific prebiotics (non-digestible dietary fibers) producing metabolites, such as short chain fatty acids (SCFA). These metabolites beneficially affect the intestinal mucosa with their role in metabolic and immunologic homeostasis, and gut barrier integrity. Recently gut-biome modulation and use of metabolites gained interest as potential targets for therapeutic development, for instance in Inflammatory Bowel Disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC). HYPOTHESIS Nourishing the gut-biome thru synbiotic formulation can enhance the interspecies synergy with production of metabolites and improved gut barrier integrity more naturally. This is a superior and holistic approach to reduce gut-inflammation. METHODS (CLINICAL CASE) An 11 year old male with refractory iron deficiency anemia, fecal calprotectin at 1375 µg/g, on video capsule endoscopy showed discrete linear and serpiginous ulcers with surrounding erythema in duodenum and proximal jejunum. Biopsy of colon showed multiple granulomas in terminal ileum and entire colon suggesting CD (Inflammatory phenotype). Exclusive Enteral Nutrition (EEN) with polymeric formula proved unsustainable. To nourish the gut-biome and its ecosystem a synbiotic formulation (Gastrosyn) that has a blend of specific prebiotics with HMO and complimentary probiotic blend with strains of Lactobacilli and Bifidobacterium was administered and followed for 20 weeks. Formulation also contained powerful antioxidant for synergistic effect in reducing inflammation. RESULTS After 4 weeks on synbiotic, fecal calprotectin dropped to 665ug/g which further dropped to 110 ug/g by week 12. Complete and deep remission was observed by 15 weeks as analyzed by endoscopy/colonoscopy (images), histology and lab tests results repeated several times (Calprotectin 65ug/g by week 15). Anemia also improved significantly, and patient continued to tolerate solid foods with no relapse even after 1year. CONCLUSIONS Synbiotics utilizing prebiotics that are specific to probiotic strains used is crucial for successful engraftment and biome modulation as established in recent literature. HMO based Synbiotic formulation has proven to nurture the ecosystem, and foster interspecies interactions, cross feeding, and generation of metabolites (SCFAs), providing a holistic and superior approach for remission in IBD.

TOPICAL GLYCERYL TRINITRATE VERSUS LATERAL ANAL SPHINCTEROTOMY IN THE MANAGEMENT OF FISSURE-IN-ANO

An anal ssure is a linear ulcer or crack that may extend from the mucocutaneous junction to the dentate line in the squamous lining of the anal canal. The most frequent beginning trigger is trauma to the anal canal, which typically manifests as the passage of a sizable, hard faecal matter. By encircling the borders of the ulcer and obstructing sufcient drainage, the internal sphincter's spasm may delay healing. The traditional procedure for treating this ailment has been a lateral anal sphincterotomy. Recently, topical glyceryl trinitrate (0.2%) has been used to lessen sphincter spasms, which helps the ssure heal. The 1 purpose of this study is to compare the two methods .

Trigeminal Trophic Syndrome.

Trigeminal trophic syndrome (TTS) is a rare cause of facial ulceration resulting from self-manipulation of skin following peripheral or central injury to the trigeminal system. The average period between the trigeminal nerve injury and the onset of ulcer varies from several weeks to many years.[1] The syndrome is characterized by a triad of anesthesia, paresthesia, and a secondary persistent or recurrent facial ulceration. The common dermatological causes are Hansen’s disease and herpes zoster.[2,3] Timely recognition of TTS will promote its correct diagnosis and better management. The condition has been reported to be associated with Alzheimer’s disease and meningioma.[4] We describe TTS in a 70-year-old male who was presented with a persistent linear ulcer on the forehead and severe scarring involving the forehead, upper eyelid, and left nose [Figure 1], following an episode of herpes zoster affecting the ophthalmic division of the trigeminal nerve 1 year ago.Figure 1: Linear ulcer on the forehead and scarring involving the forehead upper eyelid and left side of the noseDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

S2517 Pill Prep Problems? Erosive Gastritis and Peptic Ulcers due to Sodium Sulfate-Based Tablet Bowel Prep

Introduction: SUTAB is the second ever tablet formulation for bowel preparation. It became FDA approved in 2020 based on 2 randomized studies in which SUTAB provided noninferior bowel cleansing when compared to other commonly used FDA approved preparations. These randomized studies focused only on colonoscopies, possibly ignoring SUTAB’s effects on the upper GI tract. Endoscopists have recently been noticing significant adverse side effects from SUTAB, notably erosive gastritis and peptic ulcers in patients scheduled for same day bidirectional endoscopy. These findings were not noted by the studies used for FDA approval. SUTAB is a sodium sulfate based tablet composed of 3 main active ingredients: sodium sulfate, magnesium sulfate, and potassium chloride. SUTAB is taken as a 2-day split dose regimen of 24 tablets with large volumes of water. The most common adverse side effects published for SUTAB include nausea, abdominal distension, vomiting, and abdominal discomfort. Any mention of mucosal ulcerations focused on colonic ulcerations in patients with suspected inflammatory bowel disease or in concurrence with the use of stimulant laxatives. Case Description/Methods: 5 cases of same day bidirectional endoscopy were examined from 9/2/2021 to 11/15/2021. Indications for upper endoscopy included a history of Barrett’s esophagus and/or gastroesophageal acid reflux disease and all patients used SUTAB as the sole bowel preparation. In all cases there was no previous history of erosive gastritis or peptic ulcer disease, however, all upper endoscopies noted signs of moderate to severe erosive gastritis. Two of the cases also noted similarly appearing linear gastric ulcers with black eschars. All patients were subsequently placed on antacid therapy and follow-up endoscopies were performed to assess ulcer healing, which was noted at the time. Discussion: SUTAB is a relatively new bowel preparation on the market with very little published data on its known side effects. The convenience of a tablet formulation for a bowel preparation that achieves successful bowel cleansing attracts patients and doctors, but it comes with the cost of possible adverse side effects in the upper GI tract. The ingredients in SUTAB are corrosive agents, specifically, potassium chloride has been linked to erosions that are found in the mucosa of the GI tract with prolonged exposure. To better understand this recently noted phenomena, more research is needed to help prevent these unwanted and potentially dangerous side effects.

Conglomeration of Symptomatic Crohn’s Disease and Celiac Sprue: a Case Report from Western India and Review of the Literature

Background: Background: Celiac diseases are found to be associated with other autoimmune diseases such as autoimmune thyroiditis, type I diabetes, Addison’s disease, primary biliary cirrhosis, and inflammatory bowel disease (IBD). In literature, only a few cases were described simultaneously presenting both conditions in the same patient. Case Presentation:: A 23-year-old Indian male presented with a one-month history of loose motion 10-12 times per day, having watery stool, and nocturnal diarrhea. The patient had pallor, weakness, fatigability, and anorexia/weight loss. The patient also had a history of periumbilical pain abdomen and black-colored stools. In our study, both conditions are clinically symptomatic in the same patient, as proved by endoscopic changes and histopathologically. Esophagogastroduodenoscopy (EGD) examination shows severe scalloping of duodenal folds and nodularity, indicating celiac disease changes. A colonoscopy examination was performed, which revealed multiple linear longitudinal ulcerations, friability, erosions and absent vascularity, which indicates Crohn’s disease. Duodenal biopsy shows celiac disease (Marsh IIIa), and Colonic biopsy shows Crohn’s disease. The patient was treated with improvement in abdominal pain, weight, and anemia. Conclusion: Celiac and Crohn’s both conditions are clinically symptomatic in the same patient, as proved by endoscopic and histopathological changes.

Multiple linear leg ulcers in an adolescent girl.

Multiple linear leg ulcers in an adolescent girl.

Endobronchial tuberculosis with unusual linear ulceration from tracheal to right upper lobar bronchi.

The complications of endobronchial tuberculosis (TB) include bronchostenosis and fistula. We highly recommend that a TB test be included in the diagnosis of endobronchial lesions.

Intestinal Peripheral T-Cell Lymphoma in a Patient with Ankylosing Spondylitis Under Treatment with Infliximab: A Case Report and Review of the Literature.

Background:Recent literature involves many cases with lymphoma and ankylosing spondylitis (AS) with or without the use of TNF inhibitors. Herein, we report a patient, a 56-year-old Human Leukocyte Antigen-B27 (HLA-B27) positive man with four years history of AS who was still under treatment with infliximab with clinical remission. He was admitted with a new-onset, 6-week history of bloody diarrhoea with mucus, abdominal pain, fever, and weight loss. An ileocolonoscopy showed linear ileocecal valve ulcers. Histopathological findings of ileocecal valve ulcers revealed peripheral T-cell lymphoma of the small intestine. Infliximab was interrupted because of the possible progression of the lymphoma.Methods:We aimed to emphasize the underlying potential pathogenic mechanisms and to review the related literature. A literature search was conducted in the PubMed database between January 1980 and November 2020. The keywords including ‘ankylosing spondylitis’ and ‘lymphoma’ were used.Conclusion:TNFi use, immunosuppression, and chronic inflammation may be related to the development of lymphoma in chronic inflammatory diseases. Ileocecal valve involvement should not be interpreted as inflammatory bowel disease, infection, or vasculitis in the presence of red flags.

S3713 Pre-Pyloric Gastric Ulcer Leading to Stenosed Pylorus, Obstruction of Gastric Outlet and Pseudo-Gastroparesis

Introduction: Gastric outlet obstruction (GOO) is a syndrome manifested with combination of early satiety, abdominal pain, postprandial vomiting and weight loss. The usual etiology is either mechanical (benign or malignant) or motility related. Most common cause of benign obstruction is peptic ulcer disease. Here we discuss a case of pre-pyloric ulcer with significant stenosis that mimics gastroparesis causing acquired GOO. Case Description/Methods: 58 year old female with history of migraines, anxiety and chronic pain presented with generalized weakness and epigastric pain. She had been taking 2 pills of aspirin and Advil each every 3 hours for past 2 weeks for her toothache. She also reported melanotic stools. In the ER, she was vitally stable but had hemoglobin of 5.5. CTA of abdomen pelvis noted abnormal duodenum with diffuse mural thickening and mildly prominent lymph nodes. She was transfused 2 units of PRBC. EGD done revealed linear antral ulcer occupying two-thirds of pre-pyloric area measuring 4 cm extending into the pylorus with minimal oozing on contact. Pylorus was severely narrowed and ulcerated; it could not be traversed with adult scope. XP scope was then used which passed with ease through the pylorus into the duodenal bulb which appeared to be severely ulcerated. Rest of the duodenum was normal. Patient subsequently had Gastrografin follow through study to evaluate for gastric outlet obstruction which showed suspected mild stenosis &/or edema in pylorus secondary to ulcerative dislocation; however no bowel obstruction was noted since the contrast passed through the duodenum. Biopsy ruled out malignancy & H. pylori infection and was consistent with chemical gastropathy. Gastrin level was also noted to be normal. Patient was on placed on clear liquid diet initially and later transitioned to full liquids since she was unable to tolerate solid foods. She had a repeat EGD 4 weeks later while on Pantoprazole 2 times daily and eventually showed partial resolution of ulcerated lesions. Discussion: Pre-pyloric ulcers are the most common form of peptic ulcer disease leading to GOO. Most common site is the pyloric channel or duodenal bulb which was the case in our patient. Acute ulcers usually cause inflammation and edema that leads to tissue deformation and obstruction especially with solid food particles getting lodged into the ulcer. Despite these, obstruction usually occurs in 2% of the cases of peptic ulcer disease and is the least common complication contributing to gastroparesis like symptoms.Figure 1.: Figure 1). Pre-pyloric stomach ulcer 2). Pre-pyloric stomach ulcer 3). Pylorus with food residue/Bezoar stuck in the stenosed pylorus 4). Pre-pyloric stomach ulcer after 4 weeks of Protonix therapy 5). Ulcer at 11-1 o clock 6). Ulcer at 12 o clock.

S1839 Colonic Mucosal Bridging in Previously Conjoined Twin

Introduction: Mucosal bridges are infrequently encountered connections across lumens of the gastrointestinal tract that may be found in any site from the esophagus to the colon. Colonic mucosal bridges are especially rare and while they are sometimes seen as sequelae of IBD, they can also be seen in asymptomatic patients with no clear pathophysiology. Case description/methods: We present a 49 year old patient with hepatitis C cirrhosis who was scheduled for an EGD for variceal screening, as well as a screening colonoscopy. EGD showed no abnormalities, but colonoscopy was notable for bridging mucosa seen in the rectum (Figure 1), which appeared as normal, non-inflammatory colonic mucosa under narrow band imaging. When findings were discussed with the patient, she revealed that she was a conjoined twin and is status post abdominal separation complicated by small bowel obstruction and adhesions. Discussion: Colonic mucosal bridging is infrequently associated with an inflammatory state of the colon such as IBD, but may also be seen in ischemic colitis, necrotizing enterocolitis (NEC), or inflammatory pseudopolyposis. Our patient did not have known inflammatory risk factors for mucosal bridging, but it may be due to her history of being a previously conjoined twin and surgery for abdominal separation. Omphalopagus conjoined twins are joined at the abdomen and most often share the liver. However, up to one third of patients involve sharing of the GI lumen (usually the jejunum or ileum), with the colon less commonly shared. In cases where the GI tract is shared, there are case reports of NEC as a complication. The post-inflammatory healing of NEC may give rise to future mucosal bridges and adhesions. It has been suggested that these bridges arise due to sub-mucosal coalescence of linear ulcers seen in inflammatory states, which eventually heal, regenerate epithelium, and create a bridge that traverses and covers both ends of the colonic wall with healthy mucosa. Symptoms of mucosal bridging are often difficult to isolate from associated inflammatory conditions, but can include bloating and abdominal pain in severe cases. Management in symptomatic patients should target the underlying inflammatory state. Biopsies from bridges generally reveal normal colonic mucosa and have not been shown to carry malignant potential. If symptoms exist with no evidence of colonic inflammation, endoscopic intervention may be an option, as some endoscopic resection techniques have been successful in treating upper GI mucosal bridges.Figure 1.: 1a: Forward view of the rectum 1b: Rectum viewed in retroflex 1c: Forward view of the rectum.

Large Hiatal Hernia Associated with Cameron Ulcers and Consecutive Sideropenic Anemia: Case Presentation

BACKGROUND: Cameron lesions are seen in 5.2% of patients with hiatal hernia who undergo esophagogastroduodenoscopic examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernial sac, with an increased prevalence in the larger-sized sac. In about two-thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. AIM: The aim of this case report is to present the patient with Cameron ulcers associated with hiatal hernia. CASE PRESENTATION: Our patient presented with postprandial retrosternal pain, especially immediately after eating, vomiting, dyspnea, weight loss, fatigue, signs, and symptoms of severe hypochromic microcytic anemia without signs of acute gastrointestinal bleeding. No history of gastroesophageal disease. Colonoscopy was done and eliminate colic cause of anemia. The endoscopy showed a large hiatal hernia and linear erosions and ulcerations at the level of gastrodiaphragmatic contact (Cameron ulcers) and one non-sanguinant subcardial elipsoid ulceration. After conservative and operative treatment, there was significant clinically and laboratory improvement definitively, after 6 months. Cameron lesion is a rare cause of refractory sideropenic anemia. Diagnosis is very difficult in developing countries, where iron deficiency anemia is more common. A history of disease, clinical course, and laboratory findings are the important facts for diagnosis. CONCLUSION: Endoscopy is the gold standard for diagnosis, although it is not uncommon to overlook these lesions due to their unique location. There are two modalities for the treatment of Cameron lesions: Medical or surgical, which should be individualized for each patient. By severe refractory anemia and large hiatal hernia, associated with clinical signs, surgical approach is very important.

Linear papules, plaques, and ulcers in a boy.

Linear papules, plaques, and ulcers in a boy.