Oral Pantoprazole Research Articles

Comparison of Vicious Effect of Oral Pantoprazole and Famotidine on New Bone Formation in Patients With Lumbar Spine Fusion Surgery: A Randomized Control Trial

Background and Aim: Due to the increasing use of proton pump inhibitors (PPIs) and their side effects for bone repair and the high percentage of therapy failure in lumbar fusion surgery, especially in various animal studies, the goal of this study was to appraise the consequence of pantoprazole and famotidine on new bone formation in patients experiencing spinal fusion surgery. Methods and Materials/Patients: In this double-blind clinical trial, eighty patients participated based on the inclusion and exclusion criteria, of whom 40 cases received pantoprazole (group P) and 40 received famotidine (group F) for eight weeks. They were followed up for three, six, and twelve months after surgery for cage subsidence, screw loosening, and visual analogue scale (VAS), Oswestry disability index (ODI), Brantigan, Steffee, Fraser (BSF), and Lenke classification for grading their bone formation. A P<0.05 was considered significant. Results: The rate of fusion based on the Lenke score was lower in the group receiving pantoprazole six and 12 months after the surgery compared to group F (the frequency of Lenke grades C and D were 35% and 25% compared to the famotidine group 12.5% and 12.5%, respectively; P=0.042). The VAS Mean±SD score in group F was lower than group P after 12 months (2.48±1.06 and 1.83±0.55, respectively; P=0.008). There was no pharmacologically significant association between subsidence (P=0.43), loosening (P=0.13), ODI (P=0.31), and BSF (P=0.77) 3, 6 and 12 months post-operation. Conclusion: Affording to the preliminary conclusions of this study, the use of pump inhibitors, such as pantoprazole is more destructive for the ossification process in candidates for spinal fusion requiring the chronic use of drugs for controlling their gastric acid secretion, and H2-blocking drugs, such as famotidine are preferable in this situation after further investigations.

Oculomotor nerve palsy caused by imidacloprid at initial diagnosis: A case report.

Amid the pervasive deployment of imidacloprid, the incidence of poisoning from this compound has risen markedly. Those afflicted with imidacloprid poisoning typically exhibit symptoms ranging from headaches, dizziness, nausea, and abdominal pain, to impaired consciousness and breathlessness, yet instances of ocular paralysis induced by this toxin have not previously been documented. When the pesticide spray inadvertently made contact with the patient's eyes, they were seared with a burning sensation and discomfort. Subsequent to this incident, on the second day, the individual began to experience diplopia in the right eye and found it arduous to elevate his eyelids, indicating a challenge in achieving full extension. Based on the medical history, symptoms, and signs, the patient was diagnosed with oculomotor nerve palsy caused by imidacloprid. The treatment involved intravenous dexamethasone to reduce inflammatory response in the eye tissue; oral pantoprazole enteric-coated tablets to suppress acid production and protect the stomach; Xuesaitong administered intravenously to improve blood supply to the eye and promote metabolism of toxins; vitamin C, cobamamide, and vitamin B1 for nerve nutrition and antioxidant effects; local application of tobramycin-dexamethasone eye drops for anti-inflammatory purposes; and repeated flushing of the conjunctival sac with saline. Finally, the patient improved and was discharged. After active treatment, the patient finally improved diplopia and ptosis. This report marks the first documentation of oculomotor nerve palsy induced by imidacloprid, featuring diplopia, and blepharoptosis without substantial limitation of ocular motility. Following therapeutic intervention, the patient showed marked improvement and was discharged from the hospital, providing a point of reference for the treatment of analogous cases in future clinical practice. It also serves as a reminder for the public to take appropriate precautions when using imidacloprid.

Anaesthetic management of parturient posted for elective caesarean section with cerebral arteriovenous malformation

Sir, Cerebral arteriovenous malformation (AVM) has a prevalence of 0.01–0.05%.[1] We present a case of a 25-year-old primigravida at 37 weeks gestation, a known case of left frontoparietal AVM and epilepsy posted for elective cesarean section. Five years ago, she presented with weakness of the right upper and lower limbs. She was diagnosed with left frontoparietal AVM [Figures 1 and 2]. She had multiple seizure episodes and was started on T. levetiracetam 500 mg BD, T. lacosamide 200 mg BD, T. clobazam 10 mg BD, and T. phenytoin 100 mg OD.Figure 1: MR venogram showing large draining veins joining superior sagittal sinusFigure 2: MRI of the brain showing numerous flow voids along the left frontoparietal lobe and atrophy of neuroparenchyma in the left cerebral hemisphereA pre-anesthetic evaluation was done. She gave a history of seizure attacks 4 days back. She was premedicated with oral pantoprazole 40 mg and metoclopramide 10 mg 1 h before surgery and kept nil per oral for 6 h. All antiepileptic drugs were continued. In the operating room, the wedge was placed under her right hip. Standard pre-induction monitors were attached and intravenous (IV) access was secured. The cesarean section was done under general anesthesia. Rapid sequence induction was performed with IV thiopentone 5 mg/kg and rocuronium 1.2 mg/kg. The patient was intubated with a 7 mm internal diameter endotracheal tube after 1 min. Anesthesia was maintained with oxygen, air, and isoflurane. After delivery of a live female baby of 2.2 kg, IV fentanyl 2 mg/kg, midazolam 2 mg, ondansetron 4 mg, and oxytocin infusion were given. The patient was hemodynamically stable and the postoperative pain was managed with an ultrasound-guided bilateral transverses abdominis plane block. The parturient was extubated and shifted to the intensive care unit (ICU). She had an uneventful postoperative period. Cerebral AVM usually presents with intracranial hemorrhage, seizures, focal neurologic deficits, and headaches.[2] The symptoms of AVM may be mistaken with pregnancy-associated disorders such as eclampsia. computed tomography (CT) and magnetic resonance imaging (MRI) (with abdomen shielding) help to confirm the diagnosis. It is mandatory to document the neurological deficits, optimize antiepileptics, counsel regarding the potential complications, and the need for neurosurgery. The neurosurgeon and intervention radiologist were alerted regarding the patient’s delivery plan and the neurologist’s opinion was taken to optimize the antiepileptics. There are no conclusive data regarding the risk of AVM hemorrhage during pregnancy.[3,4] AVM hemorrhage during pregnancy is associated with 28% maternal and 14% neonatal mortality. Most centers prefer elective cesarean sections even though normal vaginal deliveries do not increase the risk of AVM hemorrhage. Uterine contractions during normal labor may increase the stress on the abnormal veins. Hence, if vaginal delivery is planned, epidural labor analgesia and assisted instrumental vaginal delivery are recommended. For cesarean section, general anesthesia is preferred over regional anesthesia to avoid neurological complications. cerebrospinal fluid (CSF) release with subarachnoid block causes a sudden change in the transmural pressure across the AVM predisposing it to rupture. An accidental intravascular injection of local anesthetic containing epinephrine test dose during the initiation of the test dose following epidural anesthesia could predispose to the rupture of AVM. The main aim of anesthetic management is to maintain the mean arterial and intracranial pressure within the normal range to reduce the risk of hemorrhage and cerebral hypoperfusion. Hypertensive responses to laryngoscopy and extubation should be obtunded. Thiopentone is the preferred induction agent.[5] Ketamine is avoided as it can increase blood pressure and intracranial pressure. Suxamethonium has to be avoided and a high dose of rocuronium 1.2 mg/kg is used for rapid sequence induction.[6] General anesthesia with controlled ventilation is used to keep PaCO2 at a low normal range to minimize cerebral vasodilatation and rise in intracranial pressure. Hypotension during surgery is avoided by optimal fluid resuscitation and vasopressors. Supine hypotension is avoided by the use of a wedge under the hip. Thus, multi-disciplinary care involving an obstetrician, intervention radiologist, neurologist, neurosurgeon, and obstetric anesthesiologist is required to ensure good pregnancy outcomes in these high-risk parturients. Declaration 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.

PMON40 A Rare Etiology of Chronic Diarrhea: Zollinger-Ellison Syndrome

Abstract Introduction Zollinger-Ellison Syndrome (ZES) is a rare etiology of chronic diarrhea caused by a gastrin-secreting neuroendocrine tumor. Early suspicion can prevent multiple readmissions for recurrent diarrhea thus improving clinical outcomes through prompt diagnosis and treatment, as the following case highlights. Case presentation A 74-year-old African-American female with hypertension and chronic atrial fibrillation presented to the ED complaining of watery, non-bloody diarrhea for the past 3 weeks. She reports her symptoms worsened after completing a course of amoxicillin for pharyngitis one week prior. On further questioning, she reported intermittent diarrhea for over 20 years lasting approximately two days per episode. She denied recent travel, sick contacts, pet reptiles, and recent ingestion of undercooked meat. On arrival, she was afebrile and hemodynamically stable. She was admitted for an acute kidney injury with an elevated creatinine of 3.23 mg/dL (N: 0.6-1.1 mg/dL) due to dehydration. Her renal function improved with fluids, but she developed bloody diarrhea for which gastroenterology was consulted. Stool studies were negative for Shiga-toxin, C. difficile, lactoferrin, and parasites. Computed Tomography of the abdomen showed enteritis with fluid noted throughout the colon consistent with colitis. Unprepped colonoscopy revealed blood throughout the length of the colon, suggestive of an upper gastrointestinal bleed. Esophagogastroduodenoscopy (EGD) revealed multiple bleeding duodenal ulcers controlled with hemostasis. Her symptoms improved and she was discharged home on oral pantoprazole, and told to follow up outpatient. Two weeks later, she denied any new episodes of diarrhea, and a random serum gastrin level was elevated at 413 pg/mL (N: <180 pg/mL). Repeat gastrin level off pantoprazole for 7 days was also elevated at 678 pg/mL, and a serum Chromogranin A level was elevated at 629 pg/mL (N: <390 pg/mL). Repeat EGD found her Gastric pH to be 1 with multiple non-bleeding duodenal ulcers. Somatostatin receptor scintigraphy revealed a high intensity signal consistent with a duodenal gastrinoma causing ZES. She elected for surgical resection, and was discharged home on high dose pantoprazole. Three months later, she stated that her diarrhea had completely resolved. Conclusion This case confirms ZES as a rare cause of chronic diarrhea in the setting of multiple duodenal ulcers refractory to proton pump inhibitors. Diagnosis can be made with a fasting serum gastrin level >1000 pg/mL or >400 pg/mL with a gastric pH <1. A Secretin Stimulation Testing can also be used. Treatment starts with high dose proton pump inhibitors, octreotide for hormonal regulation, and surgical resection if necessary. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Collagenous gastritis presenting as chronic heartburn in a patient with psoriatic arthritis

Collagenous gastritis is a rare cause of heartburn in adults. Histopathological examination of gastric mucosal biopsy from the stomach shows submucosal collagen deposition. The pathophysiologic mechanism is unknown, and collagenous gastritis cases have been associated with certain drugs, such as olmesartan and non-steroidal anti-inflammatory drugs, and certain medical conditions, such as common variable immunodeficiency, primary IgM deficiency, autoimmune disorders, and psoriatic arthropathy. Here we report a case of collagenous gastritis in a 29-year-old woman with psoriatic arthropathy who presented with persistent heartburn. She was successfully treated with oral pantoprazole.
 
 Key words: heartburn, collagenous gastritis,

Pharmacoeconomics and Utilization of Intravenous Proton Pump Inhibitors in a Tertiary Care Hospital

Background: Proton pump inhibitors (PPIs) are one of the most frequently prescribed class of drugs worldwide contributing to the increase in economic burden on the healthcare system. To study the utilization of intravenous proton-pump-inhibitors (PPIs) according to its indications, comorbidities and related pharmacoeconomics in a tertiary care teaching hospital
 Methods: A prospective-observational study was conducted over 3 months. Case-records of 300 indoor patients were reviewed for IV (intravenous) pantoprazole prescription, as it was the only PPI available at the hospital in IV as well as oral formulations and relevant data was procured.
 Results: Amongst 300 patient records, 72% were males whereas 28% were females and mean age was 41.18 years (S.D. ± 15.91). 37.33% of the patients were prescribed PPIs for Stress ulcer prophylaxis and 62.66% for non-stress ulcer prophylaxis. 62.66% patients were prescribed IV PPIs inappropriately and 74% were found to be potential candidates for oral pantoprazole therapy without affecting patient outcomes. Utilisation of PPIs was found to be 0.87 defined daily dose (DDD)/100 bed days. The cost of administration for intravenous pantoprazole therapy per patient per day accounted to INR 64.34 and that for oral formulation of the same summed up to INR 1.36. The percentage reduction in the cost of administration of PPI therapy per patient in potential candidates for oral PPI therapy was found to be 97.8%. Antimicrobials (36%) were the most common drugs prescribed concomitantly followed by antiemetics (25%).
 Conclusion: Subtle changes like shifting the patient to oral formulations when clinically permissible can make a significant positive contribution in resource limited settings without negatively impacting patient outcomes. This will effectively reduce the economic burden on the patients and the healthcare system which is of utmost importance in a resource limited setting like tertiary care hospitals.

S3718 A Rare Case of Invasive Ductal Carcinoma of the Breast With Metastases to the Stomach

Introduction: The most common type of breast cancer is invasive ductal carcinoma (IDC) followed by invasive lobular carcinoma (ILC). Both histologic subtypes have the potential to metastasize to distant sites, but each demonstrates different metastatic tendencies. IDC metastasizes more often to the bone, lung, and liver, while ILC metastasizes more frequently to the peritoneum and gastrointestinal tract. Gastric metastases are a rare occurrence and are predominately seen in patients with ILC. Here, we present an unusual case of IDC of the breast with metastases to the stomach. Case Description/Methods: A 77-year-old female with a history of estrogen and progesterone receptor negative, HER2 positive IDC of the breast with metastases to the liver, brain, and lung on palliative chemotherapy presented to our hospital with one month of abdominal pain and melena. On evaluation, the patient was hemodynamically stable with an abdominal exam revealing moderate tenderness in the epigastric region. Lab tests showed acute normocytic anemia with a hemoglobin 8.2 g/dl. The patient underwent esophagogastroduodenoscopy demonstrating a 1.5 cm ulcer at the gastric cardia with surrounding erythema and friable tissue. Pathology from gastric ulcer biopsy showed poorly differentiated adenocarcinoma in the deeper aspect of the lamina propria with immunohistochemistry positive for GATA-3, BRST-2, E-cadherin and HER2 consistent with metastatic breast IDC. The patient was discharged to home with oral pantoprazole and iron supplements. She was later seen in oncology clinic with labs showing improvement in her anemia and palliative chemotherapy was resumed. (Figure) Discussion: Gastric metastases are an infrequent discovery. When detected, the most common primary source is breast cancer and more often the ILC histologic subtype. Our patient’s breast cancer initially followed the typical pattern of IDC with metastases to the liver, brain, and lung. Her disease then progressed to involve the stomach, which is rarely seen in HER2 positive IDC. Gastric metastases may present as a single ulcerative lesion on endoscopy, which may be difficult to differentiate from primary gastric cancer as seen in this case. The immunohistochemistry of our patient’s gastric ulcer biopsy revealed positive biomarkers for metastatic IDC thereby confirming the diagnosis. Physicians should consider the possibility of metastasis to the stomach in patients with breast cancer presenting with symptoms of a gastric ulcer even in those with the IDC histologic subtype.Figure 1.: [A] H and E shows gastric mucosa with expansion of the lamina propria by malignant cells (10x). [B] The malignant cells are positive for GATA-3 immunostain which supports metastasis from patient’s known breast primary (10x). [C] 1.5 cm ulcer at the gastric cardia with surrounding erythema and friable tissue.

Impact of Intravenous Pantoprazole versus Oral Pantoprazole on Gastric pH in Pediatric Intensive Care Unit: A Randomized Trial

Impact of Intravenous Pantoprazole versus Oral Pantoprazole on Gastric pH in Pediatric Intensive Care Unit: A Randomized Trial

Proton pump inhibitor utilisation and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study

ObjectivesThis study aimed to characterise the prescribing patterns and evaluate the appropriateness of the prescribed proton pump inhibitors (PPIs) in adult patients via a review of electronic medical records in...

Evaluation of the prescribing of proton pump inhibitors as stress ulcer prophylaxis for non-ICU patients in a Malaysian tertiary hospital

Proton pump inhibitors (PPIs) are widely prescribed in hospital settings. Several reports have highlighted concerns about the inappropriate use of PPIs as stress ulcer prophylaxis (SUP) in patients outside the intensive care unit (ICU) setting. Little is known about this phenomenon in Malaysian hospitals. This study aimed to evaluate the appropriateness of PPI prescribing as SUP for patients admitted to the general medical wards of a Malaysian tertiary hospital and to determine the rate of unnecessary prescription of PPI for discharged patients. This was a retrospective cross-sectional study conducted in a tertiary hospital in Pahang, Malaysia. We reviewed the information held on electronic databases for patients admitted to the general medical wards from January to September 2019. Appropriateness of PPI prescribing was assessed using the criteria for SUP from predefined clinical guidelines. Of 660 screened patients admitted to the general medical wards, 200 were prescribed PPIs as SUP. Oral pantoprazole was the most frequently prescribed PPI (51.5%). Only 61 (30.5%) PPIs were prescribed according to current recommendations for the use of PPI for SUP. Sex, age, number of medications, length of hospital stay, and receiving PPI at discharge were not significantly associated with appropriateness of PPI prescribing. Half of the patients continued receiving PPIs at discharge without a documented indication. Our findings indicated a high prevalence of inappropriate prescribing of PPIs as SUP for non-ICU patients. Interventions to reduce the unnecessary use of PPIs in Malaysian hospital settings are desperately required. The need for national criteria that address the proper indications and dosing regimens for PPIs as SUP in ICU and non-ICU patients is high.

Is Adjunctive Alginate Therapy Beneficial in the Treatment of Laryngopharyngeal Reflux Disease in a Rural Indian Population? A Prospective Randomized Study.

To assess the benefit of adjunctive alginate therapy in the treatment of laryngopharyngeal reflux disease (LPRD) in a rural population in south India, by comparing the outcome of alginate plus proton pump inhibitor (PPI) therapy versus PPI monotherapy. 100 consenting adults of both sexes, with LPRD symptoms for ≥ 1month, with both Reflux Symptom Index (RSI) > 13 and Reflux Finding Score (RFS) > 7, were included in a randomised prospective analytical clinical study. Patients were randomised into two treatment groups for 8weeks. Group A received oral pantoprazole (40mg, twice a day),and Group B received oral pantoprazole (40mg) and oral alginate (500mg/10ml) twice a day each. Treatment outcome was assessed with RSI and RFS at 4 and 8weeks. On follow-ups, both groups showed significant improvement in RSI. At 4weeks, significant improvement in RFS was seen in Group B, but not in Group A; both groups showed improvement at 8weeks. The improvement was significantly better in Group B RSI and RFS on both follow ups. On analysis of each RSI item at 8weeks, choking sensation showed no significant improvement in Group A. All other items showed significant improvement in both groups, with all items except difficulty swallowing and choking sensation showing significantly better improvement in Group B. Analysis of each RFS item at 8weeks, showed significant improvement in Group B but not in Group A. The addition of alginate to PPI shows greater definitive improvement in both symptoms and signs of LPRD within a short period of 8weeks, compared to PPI monotherapy, making it a feasible treatment option with good results in routine practice in a rural set-up. Adjunctive alginate therapy enhances the resolution of clinical features of LPRD and is thus beneficial in its routine treatment in all populations.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy.

IntroductionPerforation, obstruction, and bleeding remain the most frequently encountered complications of peptic ulcer disease (PUD). Bleeding may be in the form of hematemesis or melena. The treatment of choice in patients with a bleeding peptic ulcer is endoscopic ligation to maintain the hemostatic balance followed by the administration of proton pump inhibitors (PPIs). This study focuses on the evaluation and comparison of intravenous (IV) and oral PPIs in terms of prevention of re-bleeding after successful endoscopy for peptic ulcers.MethodsA prospective, comparative study was conducted in a tertiary care hospital in Pakistan from January 1, 2018 to June 30, 2019. The trial included known cases of PUD admitted with active upper gastrointestinal bleeding (UGIB). They were randomly divided into two groups: one received oral pantoprazole and the other was administered IV pantoprazole. The outcomes for both groups were compared. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) software version 23.0 (IBM, Armonk, NY)ResultsThere were 96 (48%) patients in the IV pantoprazole group and 104 (52%) in the oral group. From 24 hours after the medication onwards, the IV pantoprazole group showed a significant improvement in hemoglobin (Hb) levels (p: 0.01); the group also showed improvement in supine systolic BP at 48 hours (p: 0.04) and in diastolic BP at both 12 and 48 hours as compared to the oral pantoprazole group (p: 0.05). The mean duration of hospital stay, need for blood transfusion and repeat endoscopy, re-bleeding, and mortality rates were similar for both groups (p: >0.05).ConclusionWe could not find any statistically significant difference between oral and IV routes of pantoprazole administration in the prevention of rebleeding when used after successful therapeutic endoscopy in patients with bleeding PUDs.

Double pylorus

A 56-year-old male presented with progressive upper abdominal pain for 5 days at our department. He had neither undergone endoscopy nor recently used non-sterodial anti-inflammatory drugs. He underwent his first upper gastrointestinal endoscopy, showing two openings, which were separated by a bridge, between gastric antrum and duodenal bulb (Fig. 1A, upper panel). A closer endoscopic observation also demonstrated an ulcer in one of the two openings (Fig. 1A, lower panel). Thus, a diagnosis of double pylorus with an ulcer in the gastroduodenal fistula was diagnosed. Oral pantoprazole and aluminium phosphate gel were prescribed. Since then, his abdominal symptoms gradually disappeared. Fifteen days later, he underwent a second upper gastrointestinal endoscopy, confirming the diagnosis of double pylorus (Fig. 1B upper panel) and showing that the ulcer in the gastroduodenal fistula was healed (Fig. 1B, lower panel). At that time he was in a stable condition without any other complaints.

1984 Helicobacter pylori-Negative MALT Lymphoma Presenting as Massive Recurrent Gastrointestinal Hemorrhage

INTRODUCTION: Extranodal marginal zone lymphoma or low-grade B cell lymphoma of mucosa-associated lymphoid tissue (MALT), an uncommon type of non-Hodgkin lymphoma (NHL), accounts for 5–10% of NHL in the US (18.3 cases per 1 million person-years1). It usually presents as gastro-esophageal reflux, nausea, anorexia, weight loss or occult GI bleeding2. Massive GI bleeding is unusual and rare. CASE DESCRIPTION/METHODS: Here we present a 68-year-old woman who presented with weakness and syncope after large volume hematemesis. Physical exam showed tachycardia, hypotension and conjunctival pallor. Her hemoglobin and hematocrit on admission were 8.5 g/dL and 25.6 %. She was managed with IV fluids, packed RBC transfusion and Pantoprazole and Octreotide infusions. An EGD within 24 hours showed erythematous, friable, spontaneously oozing mucosa with neovascularization in gastric fundus which was treated with bipolar cautery. A biopsy was not obtained due to recent bleeding. She was discharged on oral Pantoprazole. Two days later she was readmitted due to severe recurrent hematemesis with similar findings on repeat EGD. Bleeding was controlled with APC and biopsies were obtained from the gastric fundus. Due to the recurrent bleeding, an angiogram was performed. Active bleeding could not be seen. Prophylactically, left gastric artery was embolized. Biopsies revealed low-grade B cell MALT lymphoma with negative H.pylori. She was treated with 20 fractions of radiotherapy with the intention to cure. She did not experience further episodes of bleeding and has remained in remission since. DISCUSSION: Studies show the indolent nature of GI MALT lymphoma3, but our case illustrates the life-threatening presentation of a rare low-grade B cell MALT lymphoma as massive and recurrent hematemesis with negative underlying H.pylori infection or autoimmune process45. H.pylori positive localized MALT lymphoma is treated with the eradication of infection. H pylori negative, localized and recurrent disease is treated with radiotherapy6. Chemotherapy and/or immunotherapy is given when patients fail to respond to radiotherapy or develop metastasis. Long term endoscopic and laboratory follow up is needed as gastric MALT lymphoma is associated with a significant risk of gastric adenocarcinoma8 and increased incidence of gastric cancer and residual NHL. Our case emphasizes the importance of early diagnosis and timely intensive radiotherapy of a localized but aggressive gastric MALT lymphoma which induced remission and cessation of GI bleeding.

1918 A Case of Recurrent Pneumatosis Intestinalis and Portal Venous Gas

INTRODUCTION: Mesenteric ischemia (MI) is caused by inadequate blood flow through the mesenteric vessels resulting in ischemic bowel. The most serious cases cause gangrenous bowel, leading to pneumatosis intestinalis (PI) and portal venous gas (PVG), often an ominous sign. CASE DESCRIPTION/METHODS: This is a case of a 63-year-old male who presented to the hospital with hematemesis and severe anemia. After massive transfusion, an EGD revealed actively bleeding gastric ulcers, requiring serial EGDs for successful control of bleeding. A CT revealed gastric distention with thickening of the duodenum and bilateral femoral vein opacities, later confirmed as deep vein thromboses. An IVC filter was subsequently placed, as he was not a candidate for anticoagulation. The patient was subsequently discharged on oral pantoprazole. Of note, there was no history of NSAID use or evidence of H. pylori. Repeat EGD 2 months later noted mild gastritis, but no ulcers were seen. A screening colonoscopy at the time noted only diverticulosis. He was continued on pantoprazole. 3 months later he presented to the hospital with acute onset nausea, vomiting, and diarrhea. A CT revealed PI at the gastric fundus, as well as PVG. An infectious work-up was negative, lactate was normal, and his symptoms resolved quickly. A subsequent repeat CT noted resolution of the PVG and reduction in PI. He represented to the hospital 1 month later again with nausea, vomiting, and diarrhea. A CT noted small bowel dilatation with air fluid levels, PI at the esophagus, stomach, and jejunum, and significant PVG. The initial lactate level was mildly elevated and his symptoms resolved quickly after bowel decompression. A subsequent CTA noted a significant reduction in PVG without evidence of vascular occlusion. A follow up EGD showed diffuse subepithelial hemorrhages without any evidence of recurrent ulcers. A subsequent CTE noted a thrombus above the IVC filter and an evolving hepatic infarction. He was asymptomatic at the time, however, he was admitted to the hospital for anticoagulation. He has since remained on warfarin without any recurrence of symptoms, PI, or PVG. A follow-up CTA showed a full resolution of venous thromboses. DISCUSSION: Previous case reports have described the development of PI and PVG secondary to underlying MI. This case highlights an example of MI secondary to an increase in the resistance of mesenteric blood flow due to venous thromboses. When investigating IP and PVG, underlying venous thromboses should always be considered.

3091 Squamous Papilloma of the Esophagus

INTRODUCTION: Squamous esophageal papillomas are rare epithelial lesions typically discovered incidentally during esophagoduodenoscopy (EGD). The occurrence in patients undergoing EGD is less than 0.45 percent and the prevalence in the general population inferred from autopsy is less than 0.04 percent. Most patients are asymptomatic unless the lesion is large. The most common symptom is dysphagia. A majority of these lesions are found in the distal one third of the esophagus. They have not been demonstrated to progress to esophageal carcinoma. CASE DESCRIPTION/METHODS: Our patient was a 53 year old male with history of alcohol abuse who presented with new-onset seizure/syncope, six painless maroon stools, and coffee-ground emesis. The patient admitted to frequent diclofenac use. He was found to be anemic with a hemoglobin of 7.9 G/dL and had an elevated INR of 1.2. He was transfused two units of packed red blood cells and was started on a pantoprazole drip. Initial endoscopy revealed an island of tissue growth in the mid-esophagus and a bleeding duodenal ulcer that was injected with epinephrine, cauterized with gold probe, and clipped. Biopsy of the esophageal lesion was deferred to outpatient follow-up given the severity of the patient's presenting condition. Following the procedure, he was continued on the pantoprazole drip with transition to oral pantoprazole 40 mg daily. He had no further signs of gastrointestinal bleeding. Two weeks later, an EGD was performed. Biopsies were taken of the stomach mucosa and mid-esophageal mass. Gastric biopsy demonstrated mild chronic gastritis without dysplastic changes or helicobacter pylori. Esophageal biopsy demonstrated findings consistent with squamous papilloma. DISCUSSION: Squamous papilloma of the esophagus is a rare but benign lesion. Its macroscopic appearance is similar to other, less benign growths (verrucous squamous cell carcinoma, granulation tissue, or papillary leukoplakia). The etiology is unclear. Chronic mucosal irritation from GERD or esophagitis is the prevailing theory of pathogenesis, but HPV – strongly associated with cervical, anal, and oropharyngeal cancers (depending on viral serotype) – has been detected in some lesions. Thus, the gold standard for evaluation is biopsy. There are various proposed therapies for squamous papillomas including resection, cautery and radiofrequency ablation. Future research is needed in regard to treatment and surveillance for these lesions.

Hereditary Hemochromatosis and Dieulafoyʼs Lesion - A Plausible Association

Hereditary hemochromatosis (HH), is an autosomal recessive disorder most commonly due to mutations in the HFE gene. The condition's pathophysiologic predisposition to increased iron uptake can lead to the development of life-threatening complications of liver disease, heart disease, and diabetes. A Dieulafoy's lesion is a dilated aberrant submucosal vessel that erodes the overlying epithelium in the absence of a primary ulcer. The lesions are usually located in the proximal stomach along the lesser curvature, although they have been found in all areas of the gastrointestinal tract, including the esophagus, duodenum, and colon. Here, we present a case of a 68-year-old man with HH that presented with melena of 2 weeks duration associated with a Hemoglobin drop from 14 to 8.8 g/dL. He reported increasing fatigue, weakness, and dyspnea on exertion. He denied hematemesis, bright red blood per rectum, use of iron or bismuth supplements. On physical exam his abdomen was soft, non-distended, with normoactive bowel sounds. Rectal exam showed no fissures, normal rectal tone, no palpable masses. Some flecks of brown and black stool were present. He was stabilized and taken for endoscopy the following day. Endoscopy showed a Dieulafoy's lesion at the duodenal sweep, which was actively oozing blood. Even after multiple attempts to electrocauterize and place a hemoclip, there was still residual bleeding. The patient was subsequently transferred to interventional radiology for gastroduodenal artery embolization. Unfortunately, despite multiple intraoperative angiograms, the vessel was unaccessible. His vitals and hemoglobin were monitored, as dark stool transitioned to brown. He was continued on oral pantoprazole twice a day and scheduled with close follow up. We propose that there may be an association between HH and Dieulafoy's lesions. The etiology of Dieulafoy's lesion is not well understood. Patients who bleed from Dieulafoy's lesions are typically men with comorbidities including cardiovascular disease, hypertension, chronic kidney disease, diabetes, alcohol abuse, NSAID use, and advanced liver disease. Many of these comorbidities are inherently present in individuals with HH, as a part of the disease process. The patient mentioned above had cardiovascular disease, diabetes, and liver disease secondary to HH. He also had chronic kidney disease stage 3B secondary to diabetes and hypertension. He did not use NSAIDs or alcohol.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy.

BACKGROUND Proton pump inhibitors (PPIs) are now widely prescribed for the management of patients with acute upper gastrointestinal bleeding; although its optimal dose and route of administration has remained a controversial issue. The aim of this study was to assess the clinical effectiveness of high dose oral versus intravenous (IV) PPI after successful endoscopic therapy in patients with bleeding peptic ulcer disease. METHODS 178 patients with active upper gastrointestinal bleeding due to a peptic ulcer with stigmata of high risk for re-bleeding entered the study. After successful endoscopic hemostasis, they were randomized to receive either high dose oral pantoprazole (80 mg stat and 80 mg twice daily for 3 days) or high dose intravenous pantoprazole (80 mg IV infusion within 30 minutes and 8 mg per hour for 3 days). After the 3rd day, the patients in both groups received oral pantoprazole 40 mg twice daily for one month. The end points were comparing the rate of re-bleeding or mortality, and the need for blood transfusion or surgery during the first month between the two groups. RESULTS There were not significant statistical differences between the two groups in the volume of blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates. However, the rates of re-bleeding were 2.3% (2:88) in the IV group and 3.3% (3:90) in the oral group (p = 0.6). CONCLUSION According to our findings, it seems that high dose oral PPI can be a good alternative to high dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding. Due to the lower cost and the availability of oral PPIs, their use can be economically much more affordable.

A Black Esophagus

A 54-year-old woman with type II diabetes mellitus presented with a 3-day history of vomiting and mild abdominal pain. She was afebrile, tachycardic and severely hypertensive. Her abdomen was non-tender and without guarding. Laboratory evaluation revealed hyperglycemia, acidosis, acute kidney injury and elevated troponin. She was admitted with a diagnosis of diabetic ketoacidosis and hypertensive emergency. Overnight, she developed melena. Upper endoscopy revealed an esophagus with black necrotic tissue from 23cm to 32cm from the incisors, ending abruptly at the gastroesophageal junction. The patient was kept nothing per mouth and started on intravenous pantoprazole. Repeat endoscopy 6 days later showed healing of the esophageal necrosis and ulceration. Her diet was advanced, and she was switched to oral pantoprazole. Two weeks later, repeat endoscopy revealed LA class D esophagitis, which appeared substantially improved. Acute esophageal necrosis (AEN) is a rare condition with prevalence between 0.001 to 0.2%. It is characterized by circumferential black mucosa in the esophagus. It most commonly manifests as upper gastrointestinal bleeding, but it can also cause dysphagia, chest pain, or epigastric pain. Risk factors include male sex, age, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, and hypercoagulable state. Diagnosis is based on the findings of upper endoscopy with the appearance of black necrotic tissue, mostly in the distal esophagus, and terminates at the gastroesophageal junction. Histology is not required for diagnosis, but it can be helpful to rule out other causes. Etiology is multifactorial, including tissue hypoperfusion due to an ischemic insult, impaired local barrier defenses, and acid reflux. Management is conservative with bowel rest, acid suppression, and hydration with restoring hemodynamic stability. Treating the coexisting medical condition is crucial, as AEN has been associated with different medical conditions, including diabetic ketoacidosis. Complications include esophageal stricture, mediastinitis, infection or abscess, and esophageal perforation. Death has been reported, with a mortality rate of 6% due to AEN, and as high as 32% due to the underlying medical condition. Therefore, high clinical suspicion and appropriate diagnosis and management are important to save the patient's life.FigureFigureFigure

Granular Cell Tumor of the Duodenum: A Rare Entity

A 49 year old female with past medical history of depression and osteogenic sarcoma of the jaw in remission presented with shortness of breath, atypical chest pain and fatigue of one week duration. Initial vital signs revealed a normal pulse rate and elevated blood pressure of 158/102. Acute coronary syndrome was ruled out. The patient was noted to be anemic with hemoglobin of 8.7 g/dL compared with baseline of 13 g/dL. The patient endorsed only dark stools with no visible blood. She denied hematemesis and hemoptysis. Menstrual cycles were regular and without menorrhagia or intermenstrual bleeding. Hemoglobin remained low (7-9 g/dL) but stable. She was begun on oral pantoprazole and GI consult was requested. She underwent EGD which revealed a 3 cm well-circumscribed mass in the body of the stomach covered with normal mucosa and a 3 cm ulcerated mass in the duodenal bulb. Biopsies of the duodenal mass were consistent with granular cell tumor of the duodenum. Biopsies of the stomach lesion revealed chronic and focal gastritis. H. pylori testing was negative. CT scan of the abdomen and pelvis was significant for a duodenal bulb mass, a large pedunculated fibroid, and two hepatic lucencies of uncertain etiology. Fine needle aspiration of the liver lesions was negative for malignancy. Gynecologic evaluation revealed an asymptomatic fibroid uterus. General surgery recommended outpatient follow up for consideration of duodenal mass resection versus conservative management. The patient was discharged to home with outpatient follow up. Granular cell tumor (GCT) of the duodenum is an exceedingly rare entity, with only three cases reported in the medical literature. Of these three cases, only one presented with GI blood loss. Most cases of granular cell tumors of the GI tract are asymptomatic and found incidentally. Malignant GCTs are characterized by distinctive pathologic features, such as invasion of adjacent organs, nuclear and cellular pleomorphism, and mitotic figures. While surgical excision is recommended for malignant GCTs, benign appearing tumors may be managed conservatively. GCT of the GI tract is not uncommon but GCT of the duodenum is rare. The extent to which these lesions present with significant anemia is not well defined. This case provides further evidence that GCT of the duodenum can cause significant anemia and should be considered as a rare but reported cause of GI blood loss.