Mallory-Weiss Research Articles

Efficacy and safety of transcatheter arterial embolization for active arterial esophageal bleeding: a single-center experience.

The study aimed to evaluate the safety and clinical efficacy of transcatheter arterial embolization (TAE) for the treatment of arterial esophageal bleeding. Nine patients (8 male, 1 female; mean age, 62.3±7.5 years) who underwent TAE for arterial esophageal bleeding between January 2004 and January 2020 were included. Preceding endoscopic treatment was unsuccessful in five patients and was not attempted in four patients due to the non-cooperation of the patients in endoscopic treatment. The etiologies of bleeding were esophageal cancer (n=4), Mallory-Weiss syndrome (n=3), erosive esophagitis (n=1), and esophageal ulcer (n=1). Technical and clinical success, recurrent bleeding, procedure-related complications, and clinical outcomes were retrospectively reviewed. The angiographic findings for bleeding were contrast media extravasation (n=8) or tumor staining without a definite bleeding focus (n=1). The bleeding focus at the distal esophagus (n=8) was the left gastric artery, whereas that at the middle esophagus (n=1) was the right bronchial artery. Technical success was achieved in all patients. The embolic agents were n-butyl cyanoacrylate (NBCA, n=5), gelatin sponge particles (n=2), microcoils (n=1), and NBCA with gelatin sponge particles (n=1). Clinical success was achieved in 77.8% of cases (7/9); two patients with recurrent bleeding one day after the first TAE showed culprit arteries different from the bleeding foci at the first TAE. One patient who underwent embolization of both the left and short gastric arteries died of gastric infract/perforation one month after TAE. TAE can be an alternative to the treatment of arterial esophageal bleeding. TAE can be attempted in the treatment of recurrent bleeding, but there is a risk of ischemia/infarct in the gastrointestinal tract involved.

Gastric Mallory–Weiss tear after cardiopulmonary resuscitation

Abstract Mallory–Weiss tear is a rare complication that could result following cardiopulmonary resuscitation, leading to vigorous upper gastrointestinal bleeding. We illustrate a case of an 84-year-old male patient, admitted to the hospital for investigation of lung nodules and bilateral pleural effusion. The patient developed cardiac arrest during pleural aspiration, and cardiopulmonary resuscitation was done, which was followed shortly by an attack of acute upper gastrointestinal bleeding. Urgent upper endoscopy revealed a mucosal tear with submucosal oozing of blood and two large vessels in its floor, which were successfully managed endoscopically with both injection and hemoclips. This case report emphasizes the importance of considering this potential complication, especially after performing a successful cardiac resuscitation.

Gastrointestinal Bleed After Total Pancreatectomy With Islet Autotransplant.

Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB. Prospectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes. Sixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055). Twelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).

Treatment of Kyphosis Arising Secondary to Laminectomy and Irradiation in the Pediatric Population.

The effects of radiation therapy and laminectomy on the growing spine have been well documented. Due to compromised bone quality after irradiation, spinal fusion has a high failure rate. The aim of this study was to evaluate treatment of post-laminectomy and post-irradiation kyphosis in children using a vascularized rib graft (VRG) to augment anterior spinal fusion and posterior spinal fusion. Data were collected retrospectively from electronic medical records for all patients treated at a single institution for post-laminectomy and post-irradiation kyphosis who underwent VRG to augment spinal fusions done between December 2003 and August 2015. Five patients were included in the analysis. Imaging studies were analyzed by 2 senior pediatric orthopedic surgeons and a pediatric orthopedic surgery fellow. The outcome for all 5 patients who underwent VRG were considered successful at most recent clinical follow-up. Success was defined as the following: complete fusion evident through computed tomography scan, no implant failure, and no kyphosis progression. Follow-up ranged from 21 to 63 months. One patient experienced 2 complications: esophageal tear and deep infection. Spinal fusion with a VRG is a viable treatment option for children who have developed kyphosis following laminectomy and irradiation. On long-term follow-up, there has been no evidence of progression of kyphosis for patients who were treated with VRG in either the primary fusion procedure or in subsequent revision procedures. A VRG provides a non-irradiated, vascularized bone graft to bridge the irradiated segments, increasing the stability of the spine. [Orthopedics. 2021;44(4):e563-e569.].

A case of intractable Mallory-Weiss syndrome

A case of intractable Mallory-Weiss syndrome

The Use of the Hemostatic Agent Zhelplastan in Combination with a Granulated Sorbent in the Treatment of Patients with Mallory-Weiss Syndrome

Background: Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal bleeding. The aim of our research was to develop a method for the treatment of MWS, which would improve the efficiency of local hemostasis, reduce the risk of re-bleeding and shorten the treatment time. Methods and Results: The study involved 102 patients with MWS. All patients were divided by random sampling into two groups: the main group (MG) and control group (CG). Patients of both groups were comparable in age, gender, concomitant diseases, type of bleeding, size of bleeding defect, and duration of observations. The MG included 52 patients, who were given the developed method of MWS treatment. Patients with ongoing bleeding were treated with a combined method of endoscopic hemostasis: active bleeding was initially stopped by infiltration or coagulation (argon-plasma coagulation was preferred), and then to increase the reliability of hemostasis and prevent the resumption of bleeding, powdered Zhelplastan 0.2g was applied to the rupture area with an insufflator, followed by Sephadex G-25 0.3g (Patent RF №2633925). In patients with signs of unstable hemostasis, the developed method of cytoprotective action on a clot or thrombosed vessel was used by applying a local hemostatic, Zhelplastan 0.2g, to the defect area in combination with a granular sorbent, Sephadex G-25 0.3g, during therapeutic endoscopy to prevent the resumption of bleeding. In patients with stable stopped bleeding, a hemostatic powdered Zhelplastan was applied to the defect area using an endoscope in combination with Sephadex G-25, according to the developed method. In the CG (n=50), well-known methods of arresting endoscopic bleeding (pricking with aminocaproic acid, vasoconstrictors, argon-plasma coagulation, etc.) were used without local hemostatics and granular sorbents. Summing up the results of patients with Mallory-Weiss syndrome in the compared groups, in the MG final hemostasis was performed in 51(98.1%) patients. In the MG, bleeding resumed in 1(1.9%) patient. There were no emergency operations or deaths. In the CG, the bleeding was finally stopped in 43(86%) patients, and it resumed in 7(14%) patients. Emergency surgery was required for 1(2%) patient. In the CG, the mortality rate was 4%. Conclusion: In MWS, the use of the developed method of endoscopic treatment, including pneumoinsufflation of a powdered hemostatic agent in combination with a granular sorbent, against the background of conservative therapy, improved the results of treatment, increased the reliability of local hemostasis, reduced the number of recurrent bleedings, and excluded emergency operations.

The prevalence and risk factors for Mallory-Weiss syndrome: a systematic review and meta-analysis

Mallory-Weiss syndrome (MWS), characterized by tearing and blood from mouth and stool, is a complication of gastro esophageal tract. The prevalence varies and there are a number of risk factors associated with MWS development. The present study is a systematic review and meta-analysis to determine the prevalence and various risk factors associated with Mallory-Weiss syndrome development. We systematically searched literature using specified keywords, reviewed it, and selected articles based on the inclusion and exclusion criteria. Qualitative data was presented in tables and the quantitative data was used to draw forest plots. Percentage was used to determine overall effect size for prevalence and OR and 95% CIs was used to determine overall effect size of risk factors. Our analysis of 21 studies showed that the overall effect size for prevalence was 15.46% with 95% CI of 13.63-17.29. The pooled effect size for hiatus hernia as risk factor was found to be OR 1.96 with 95% CI of 1.96 (1.73-2.22). The pooled effect size for alcohol as risk factor OR 0.81 with 95% CI of 1.96 (0.63-1.05). Finally, we found the pooled effect size for hiccups as risk factor OR 1.04 with 95% CI of 1.96 (0.78-1.39). Mallory-Weiss syndrome is not widely prevalent in various populations. There are a number of risk factors for MWS and hiatus hernia is most significant. Alcohol consumption is not strong predictor and hiccups are an emerging risk factor. There is a need for new studies with large number of subjects and controlled conditions.

English

BACKGROUND Upper gastrointestinal bleeding (UGIB) is one of the common medical emergencies throughout the world that may require hospital admission and results in high patient morbidity and mortality. The presentation of UGI bleeding depends on the amount and location of haemorrhage. Upper gastrointestinal endoscopy (UGIE) is the preferred investigative procedure for UGIB because of its accuracy, low rate of complication, and its potential for therapeutic interventions. The present study has been carried out to evaluate the different aetiological causes of UGIB in a tertiary care centre in the North Eastern part of India and compare the same with other studies done globally. METHODS This was a hospital based observational study with cross sectional design carried out in the Department of Medicine at Tripura Medical College & DR BRAM Teaching Hospital, Agartala. Total 376 patients were selected for this study for over a period of 2 years from January 2017 to December 2018. Upper GI endoscopy was performed in all patients after hemodynamic stabilisation. Rockall scoring system was used in non-variceal cases to predict the mortality in patients with upper GI bleeding. RESULTS A total of 376 patients had endoscopy for UGIB which included 260 (69.1 %) males and 116 (30.9 %) females, and the mean age was 47.9 (± 17.0) years. The most common cause of UGIB was peptic ulcer disease (duodenal ulcer and gastric ulcer) consisting of 31.38 %, followed by erosive gastritis (23.94 %), oesophageal varix (11.17 %), portal hypertensive gastropathy (10.64 %), duodenitis (8.51 %). Gastrointestinal malignancy (gastric and oesophageal cancers) was reported in 3.98 % and rare causes of UGIB were Mallory-Weiss syndrome (1.86 %), and esophagitis (1.60 %). Among them 4.26 % of the patients had normal endoscopy findings. CONCLUSIONS In the present study, peptic ulcer disease was the most common cause of upper gastrointestinal bleeding, followed by erosive gastritis. Rockall score of more than 4 was numerically associated with increased incidence of mortality. KEYWORDS Upper Gastrointestinal Bleeding (UGIB), Upper Gastrointestinal Endoscopy (UGIE

Endoscopic Profile of Acute Upper Gastrointestinal Bleed in Adults

Background: Acute upper gastrointestinal bleeding (UGIB) is one of the most common causes of medical emergencies and associated with high morbidity and mortality in adults. Although there is decline in peptic ulcer bleed as an etiology of acute UGI bleed due to discovery of proton pump inhibitors, the Emergency Room (ER) visits for UGI bleed are increasing due to other etiologies including variceal bleed and drug-induced gastrointestinal (GI) bleed. This study was designed with the aim to assess the endoscopic profile of UGIB presenting to our tertiary care center in south India. Materials and Methods: This was a prospective analytical study. It was done over a period of 6 months from January 2020 to June 2020. All adult patients presenting with acute hematemesis and/or melena were included in the study. All included patients underwent detailed history, clinical examination, blood tests, and upper GI endoscopy. Results: One hundred and eighty-two patients were included in the study. Out of 182 patients, 76% were males. The most common age group was 51–60 years contributing to 34%. The commonest presentation was hematemesis than that of melena. Out of all patients, 69% of patients were hemodynamically stable and 31% patients were unstable at the time of admission. The causes of bleed included esophageal varices, gastric varix, peptic ulcer, portal hypertensive gastropathy (PHG), Mallory-Weiss tear, gastric cancer, drug-induced gastritis, and esophageal tear. Variceal bleed was the most common cause of UGI bleed comprising 34.16% of cases. Conclusions: From our study, we conclude that the most common cause of upper GI bleed in our part of India is portal hypertension related bleeding which included esophageal varices, gastric varices, and severe PHG. This was in contrary to most of the studies from other part of the country as peptic ulcer is far more common than variceal bleed in other studies.

Current Trends in Etiological Profile of Acute Upper Gastrointestinal Bleeding in Northern India: A Retrospective Analysis of 5-Year Endoscopic Data

Abstract Introduction The etiological spectrum of acute upper gastrointestinal bleeding (AUGIB) varies from region to region. This study was performed to find out the latest etiological spectrum of the AUGIB in a tertiary care hospital in North India and to compare it with etiological spectra from a previous study from the same center and from the other regions of India. Methods Clinical notes and endoscopic data of all consecutive patients who had presented with AUGIB in Indira Gandhi Medical College Shimla, Himachal Pradesh, from May 2015 to December 2019, were analyzed retrospectively with the objective of finding out the various endoscopic etiologies that lead to AUGIB. The findings were compared with the previous study from the same center and with the data from the other regions of the country. Results A total of 1,513 patients were enrolled and majority were males (74.6%) with male:female ratio of 2.9:1. Majority were 41 to 60 years (46.46%) of age. Melena was the presenting complaint in 93.98% and hematemesis in 46.06%. Peptic ulcer disease (PUD; 46.19%) was the commonest cause of AUGIB followed by portal hypertension (26.23%). Other less common causes were erosive mucosal disease, erosive esophagitis, neoplasm, Mallory–Weiss tear, gastric angiodysplasia, anastomotic site ulcers, and Dieulafoy’s lesion. Conclusion PUD was still the commonest cause of AUGIB followed by portal hypertension. This is in agreement with the previous report from the same center and in contrast to the reports from other studies from Northern and Western India that create the impression that portal hypertension related bleeding is the most common cause of AUGIB in India.

Sudden Chest Pain Due to Esophageal Intramural Dissection

Sudden Chest Pain Due to Esophageal Intramural Dissection

Experience of Emergency Cervical Tracheal Repair after Non-Iatrogenic Injury

Non-iatrogenic cervical tracheal injury is very rare and challenging for emergency critical care, early diagnosis, and immediate repair. So, emergency repair after early definitive diagnosis is the mainstay to avoid mortality and morbidity. A retrospective, observational, cohort study is undertaken with collected data on 50 patients with emergency cervical tracheal repair after non-iatrogenic injury between January 2011 to January 2020 at our accident and emergency department in Minia and South Valley Universities. The non-iatrogenic injury of the cervical trachea is more common in adult males (98%), and blunt trauma (70%) is the predominant type of injury. Subcutaneous emphysema (SE) is the most common presentation (99%). There are associated comorbidities like vascular (4%), maxillofacial (6%), head injury (2%), and esophageal tear (8%). Successful intubation is lifesaving, and early diagnosis and repair avoid complications. Early diagnosis is a cornerstone for the successful management of cervical tracheal injury, in which successful intubation is a mainstay to reduce mortality. Emergency surgical repair reduces mortality and complications.

Endoscopic treatment for gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40–100%; however, APC needs several treatment sessions, with a high recurrence rate of 10–78.9%. The endoscopic success rates of RFA and EBL are 90–100% and 77.8–100%, respectively; and their recurrence rates are 21.4–33.3% and 8.3–48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory–Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.

Findings of Esophagogastroduodenoscopy in Patients Suspected of Upper Gastrointestinal Bleeding Referred to the Main Endoscopy Unit at King Fahad Specialist Hospital.

IntroductionUpper gastrointestinal bleeding (UGIB) is defined as any blood loss originating from the esophagus, stomach or the proximal duodenum above the ligament of Treitz. Ethnic trends regarding the causes of UGIB have been reported. The aim of this study was to identify the most common causes of UGIB among patients residing in Tabuk city, Saudi Arabia.MethodsWe have conducted a retrospective descriptive cohort study at King Fahad Specialist Hospital (KFSH), Tabuk, Saudi Arabia. All adult patients above the age of 18 years who were suspected of UGIB and referred for esophagogastroduodenoscopy (EGD) were included. The collected data included age, sex, nationality, complaint, EGD, and histopathologic findings.ResultsBetween January 1, 2017 and December 31, 2019, 73 patients were included. 83.6% were Saudi, and 64.4% were males. Hematemesis was the main complaint (65.8%). Esophagogastroduodenoscopy was normal in 6.84% of cases; however, it showed UGIB due to esophageal and gastric varices (9.57%) as well as non-variceal causes (83.56%). The most frequent non-variceal findings which represent about two-thirds of the cases were duodenal ulcer (20.53%), antral gastropathy (13.68%), gastric ulcer (12.32%), antral gastritis (10.94%), and duodenal/gastric mass (9.57%), whereas much less frequent findings representing a total of 16.39% of cases included Cameron gastropathy, gastropathy/duodenopathy, esophagitis/gastritis, gastritis/duodenitis, gastroesophageal reflux disease (GERD), and Mallory-Weiss tear.ConclusionNon-variceal causes showed higher prevalence as causes of UGIB than variceal causes in the Tabuk area. Furthermore, chronic duodenal and gastric ulcers were the most common culprits of bleeding, whereas duodenitis, gastritis, esophagitis, and Mallory-Weiss syndrome were the least common non-variceal causes.

Gastrointestinal Bleeding

Gastrointestinal bleeding occurs when a pathologic process such as ulceration, inflammation, or neoplasia leads to erosion of a blood vessel. Bleeding can occur in the upper gastrointestinal tract (50%) or the lower gastrointestinal tract (40%) or may be obscure (10%), meaning that no definitive source is identified. Gastrointestinal bleeding is common, with major bleeding leading to 1 million hospitalizations every year in the United States. This review details the pathophysiology of gastrointestinal bleeding and the stabilization and assessment, diagnosis, treatment, and disposition and outcomes of patients with gastrointestinal bleeding. Situations requiring special consideration are also discussed. Figures show how gastrointestinal bleeding occurs when a pathologic process causes erosion of the mucosa and exposes a submucosal blood vessel; an ulcer with a raised, red, variceal spot; a Mallory-Weiss tear; the formation of varices; vascular ectasia; treatment of esophageal varices with balloon tamponade; and a wireless capsule. Tables list the major causes of gastrointestinal bleeding, terms relating to gastrointestinal bleeding and their definitions, Blatchford score, substances that interfere with occult blood testing, clinical factors differentiating gastrointestinal bleeding placed in descending order of likelihood ratio, and a summary of American College of Radiology recommendations for angiography in nonvariceal gastrointestinal bleeding. This review contains 8 figures, 15 tables, and 107 references. Key Words: gastrointestinal bleeding, inflammation, occult blood testing, UGIB, LGIB, Blatchford score, angiography, wireless capsule endoscopy (WCE)

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references

S0416 Is Mallory-Weiss Syndrome Associated With Hiatal Hernia?

INTRODUCTION: Mallory Weiss Syndrome (MWS) has an incidence rate of up to 15% among patients presenting with upper gastrointestinal bleeding. It has been proposed that retching increases the potential for mucosal laceration by creating a higher-pressure gradient in the hiatus hernia (HH) as compared with the rest of the stomach. In this abstract, we aimed at determining the association between MWS and HH, before and after HH repair. METHODS: We used the 2009 to 2014 nationwide inpatient sample database (NIS) for this study. NIS is the largest publicly available all-payer inpatient database in the United States with more than seven million hospital stays each year, as a part of the Healthcare Cost and Utilization Project (HCUP). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for WMS, unrepaired HH, and repaired HH, were obtained (appendix 1). Logistic regression was used to model the association between MWS and HH before and after repair. Participants included in this study were aged 18 and above. RESULTS: We identified 38,036 patients with MWS. The mean age of MWS diagnosis was 56 years. The male to female ratio was 1.6:1. Most of the patients were white (65.2%), had Medicare insurance (43.6%), and were from urban, non-teaching hospitals (85.1%). There was a significant association between MWS and HH before and after repair (P < 0.001). Using logistic regression, HH is significantly and positively associated with MWS, while repaired HH has a statistically significant negative association with MWS, independent of age, sex, and race (Table 1). CONCLUSION: The pathogenesis of MWS is not completely understood. HH was reported in up to 80% of patients with MWS in case series, however, one study involved 2342 concluded no significant association between MWS and HH. In this study, we found a significantly high prevalence of MWS in patients with unrepaired HH. Compared to unrepaired HH, repaired HH was associated with a significantly lower MWS prevalence. This difference in MWS prevalence between repaired and unrepaired HH populations suggests HH as a potential risk factor for MWS. Further prospective research is needed to illustrate this relationship.Table 1.: Factors associated with Mallory Weiss syndromeFigure 2.: Appendix.

S3422 Candida Esophagitis and Heavy Alcohol Consumption

INTRODUCTION: Candida esophagitis (CE), a common infection in the immunocompromised, also affects immunocompetent patients. Several retrospective and case control studies of patients without human immunodeficiency virus (HIV) infection and diagnosed with CE have observed its association with different risk factors, such as diabetes mellitus, malignancy, corticosteroids and antibiotic therapy. In this case, we examine heavy alcohol consumption as an independent risk factor for CE, and the need to consider it to prevent or treat CE and its potential complications. CASE DESCRIPTION/METHODS: 50 year old male with a history of alcohol abuse presents with 2 days of severe epigastric abdominal pain with hematemesis and melena. He reports binge drinking 2 liters of whiskey every 1-2 weeks, with his last drink 2 days prior to admission. He occasionally takes ibuprofen for back pain. On examination, his abdomen was soft, but tender in the epigastrium. Blood work showed normocytic anemia, anion gap metabolic acidosis and lactic acidosis, and was negative for HIV, elevated pancreatic enzymes and diabetes mellitus. Computed tomography showed thickening of the esophageal wall. Endoscopy revealed candida esophagitis in the middle and distal third of the esophagus, and a Mallory-Weiss tear at the gastroesophageal junction. The patient was discharged on a course of proton pump inhibitor and antifungal agent, and counseled on alcohol avoidance. DISCUSSION: CE results from colonization of the esophagus by Candida species, followed by invasion of the epithelium. Candida is known to colonize the esophagus even in healthy adults and normally exists in a complex symbiotic relationship with the host and commensal bacteria. However, colonization and virulence can be promoted by exposure to factors that alter esophageal microbiota and damage the mucosa. Heavy alcohol consumption has been linked to increased oropharyngeal colonization by Candida, and has been revealed as a major risk factor for CE. Candida species exacerbate inflammation and delay healing of mucosal lesions. This further promotes Candida colonization and leads to a vicious inflammatory cycle, with studies showing increased risk of ulcer perforation. Physicians should be wary of heavy alcohol consumption as a potential risk factor for the development of CE in immunocompetent patients. Alcohol avoidance and early treatment of CE can break the cycle of inflammation perpetuated by Candida colonization and reduce morbidity and mortality.Figure 1.: Endoscopic image of middle third of esophagus revealing numerous whitish plaques consistent with diagnosis of Candida Esophagitis.

S1530 A Catastrophic Complication of Pancreatic Adenocarcinoma

INTRODUCTION: Gastrointestinal bleeding (GIB) is often times a medical emergency. Determining the source of bleed is important for management and treatment. Some common causes of upper GIB are known as peptic ulcers, Mallory-Weiss tears, esophageal varices, and gastric cancer. A less frequent cause of GIB occurs due to an extremely rare disease called hemosuccus pancreaticus (HP), defined as bleeding from ampulla of Vator through the pancreas. HP is caused by pancreatitis, arterial pseudoaneurysms, and pancreatic tumors causing bleeding from the pancreatic duct or adjacent vessels such as the splenic or gastric artery. We present a rare case of HP causing massive upper GIB in a patient with known pancreatic adenocarcinoma. CASE DESCRIPTION/METHODS: We describe a case of a 79 year old male with history of melena and stage IV pancreatic adenocarcinoma who presented to the hospital for fatigue. Upon arrival the patient was hypotensive and tachycardic. He complained of extreme generalized weakness above his baseline. He appeared pale with icteric sclera and conjunctival pallor. Intravenous fluids were started. Significant lab values showed hemoglobin 7.4 g/dL, which was 2 grams less from outpatient labs 1 day prior. Therefore, 1 unit of packed red blood cells was initiated. During the interview, he had sudden onset of profuse hematemesis and systolic pressure decreased to 60 mmHg. Patient was started on massive transfusion but blood pressure continued to fall and he went into cardiac arrest requiring cardiopulmonary resuscitation. Return of systemic circulation was achieved after 8 minutes. After stabilization, an esophagogastroduodenoscopy revealed active bleeding from the duodenal papilla, requiring endovascular treatment. Notably, there was recent sonographic evidence of tumor invasion into the celiac trunk likely causing rupture of a splenic pseudoaneurysm into the pancreatic duct causing HP. Despite interventional embolization, hemodynamic compromise continued leading to demise. DISCUSSION: HP remains a clinical and diagnostic challenge. The acuity of bleed can be massive and mortality rate remains high. The importance of this report is to include HP as a differential diagnosis, especially in patients with known pancreatic adenocarcinoma. A common manifestation of HP is melena, and if detected early in these patients, prior to massive bleeding with hemodynamic instability, it can allow safe intervention and life saving measures. The gold standard for diagnosis and treatment of HP remains angiography.Figure 1.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.Figure 2.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.