Persistent Vomiting Research Articles

Enhanced recovery program versus traditional postoperative care for elective open colorectal cancer surgery

Background Traditional colorectal surgeries usually require a relatively long hospital stay of ∼10 days. Inadequate pain control, intestinal dysfunction, and immobilization are the main factors associated with delay in recovery. Enhanced recovery protocols have been used to optimize the perioperative care. Objectives To study the outcome of the enhanced recovery program for selected patients with colorectal malignancies subjected to elective surgery compared with similar patients subjected to surgery with traditional perioperative care. Patients and methods This prospective study was performed at Fayoum University Hospital from April 2008 to June 2017 and involved 97 patients who had uncomplicated colorectal cancer and were planned for elective open colorectal surgeries. They were divided into two groups: group A (44 patients) was subjected to surgery based on fast-track protocol and group B (53 patients) was subjected to surgery based on traditional perioperative care. Hospital stay, perioperative morbidity, mortality data, postoperative pain, and patient satisfaction data were collected, statistically analyzed, and recorded. Results In groups A and B, respectively, the mean±SD age was 47.3±5.1 and 43.7±6.1 years, the number of males was 31 and 44, whereas the number of females was 13 and nine. According to American Society of Anesthesiologists (ASA) score, 43.2 and 54.7% of patients were ASA I and 56.8 and 45.3% were ASA II in groups A and B, respectively. Overall, 40.9 and 43.4% underwent low anterior resection, 36.4 and 22.6% sigmoidectomy, 22.7 and 28.3% right colectomy, and 0 and 5.7% left colectomy in groups A and B, respectively. The mean±SD length of postoperative hospital stay was 3.58±0.24 and 8.84±1.87 days in groups A and B, respectively. There was no mortality in the two groups, and overall morbidity rate was 22.7 and 22.6% in groups A and B, respectively. Overall, 4.5 and 7.5% had wound infection, 2.3 and 0% had abdominal wall dehiscence, 11.4 and 11.3% had persistent vomiting, 2.3 and 3.8% had postoperative fever in groups A and B, respectively. Moreover, one (2.3%) patient in group A required readmission and resurgery to manage anastomotic leakage and peritonitis. Conclusions Enhanced recovery program for elective colorectal cancer surgery has a very good effect on postoperative recovery, as it shortens the length of hospital stay, with high safety and good patient compliance; therefore, we strongly recommend the application of such protocols, provided the availability of well-trained and adequately experienced personnel in well-equipped centers.

Generalized Spherical Fuzzy Soft Sets in Medical Diagnosis for a Decision

In the present communication, we introduce the theory of generalized spherical fuzzy soft set and define some operations such as complement, union, intersection, AND and OR. Notably, we tend to showed De Morgan’s laws, associate laws and distributive laws that are holds in generalized spherical fuzzy soft set. Also, we advocate an algorithm to solve the decision making problem based on generalized soft set model. We introduce a similarity measure of two generalized spherical fuzzy soft sets and discuss its application in a medical diagnosis problem. Suppose that there are five patients P1, P2, P3, P4 and P5 in a hospital with certain symptoms of dengue hemorrhagic fever. Let the universal set contain only three elements. That is X = {x1 : severe, x2: mild, x3 : no}, the set of parameters E is the set of certain symptoms of dengue hemorrhagic fever is represented by E = {e1 : severe abdominal pain, e2: persistent vomiting, e3 : rapid breathing, e4 : bleeding gums, e5: restlessness and blood in vomit}. An illustrative examples are mentioned to show that they can be successfully used to solve problems with uncertainties.

Reversible Wernicke encephalopathy caused by hyperemesis gravidarum in the second trimester of pregnancy: a case report

Wernicke encephalopathy is a potentially life-threatening neurologic syndrome caused by acute thiamine (vitamin B1) deficiency. It is usually associated with excessive alcohol consumption. Less frequently, this syndrome can be caused by persistent vomiting. This is a case report of a 33-year-old woman diagnosed with Wernicke encephalopathy (WE) during the second trimester of pregnancy. The presence of neurological and ophthalmological symptoms in the context of hyperemesis gravidarum led us to evoke the diagnosis of WE, and it was confirmed when specific lesions were found in the brain magnetic resonance imaging (MRI). Luckily for our patient, WE was diagnosed promptly and the signs were reversible after thiamine supplementation. In conclusion, any first line care taker or midwife must know the symptoms of Wernicke encephalopathy because prompt diagnosis and treatment can lead to recovery

Preventing Delayed Gastric Emptying after Whipple'S Procedure - Isolated Roux Loop Reconstruction with Pancreatico-Gastrostomy

Introduction: Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. Methods: All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2018 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. Results: A total of 101 patients were operated using this technique from January 2009 to December 2018. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). 5 out of the 101 (4.9 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Conclusion: Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE

Diagnóstico e tratamento da síndrome inflamatória multissistêmica temporalmente relacionada à COVID-19 em adolescente: relato de caso

In April 2020, the UK pediatric society reported to the World Health Organization the appearance of a rare syndrome, with a wide spectrum of signs and symptoms, temporarily associated with COVID-19, which mainly affected normally healthy schoolchildren and adolescents, with high lethality when not diagnosed and treated early. We present the case of a 12-year-old child who had high and persistent fever, rash and vomiting, who, after 6 days, developed acute respiratory failure, myocardial and renal dysfunction, requiring ventilatory and hemodynamic support, treated with antibiotics, intravenous immunoglobulin, and anticoagulant. The purpose of this report is to present the reader with the peculiar characteristics of the diagnosis and treatment of the syndrome and its main differential diagnoses at the hospital admission.

A young woman with persistent nausea, vomiting and hiccups.

Neuromyelitis optica is an inflammatory syndrome of the central nervous system, associated with anti-aquaporin-4 IgG antibodies. It is associated with severe neurological symptoms and risk of permanent neurological disability. The diagnosis can be established on the basis of clinical core characteristics of neuromyelitis optica, together with serological testing for anti-aquaporin-4 IgG antibodies and magnetic resonance imaging of the central nervous system. We describe the case of a young woman presenting with obstipation, persistent nausea, vomiting and hiccups. The initial diagnostic workup confirmed obstipation, but did not find any underlying gastrointestinal pathology that could explain her persistent symptoms. Her condition deteriorated, she was unable to eat or drink without inducing vomiting, and eventually she received parenteral nutrition. Further diagnostic workup included magnetic resonance imaging of the brain, which revealed a T2-hyperintense lesion in the medulla oblongata, more specifically in the area postrema. Neurological and neuroradiological assessment led to a tentative clinical diagnosis of neuromyelitis optica spectrum disorder with a well-described, but rare, presentation: the area postrema syndrome. The diagnosis was confirmed by serological testing for anti-aquaporin-4 IgG antibodies. She was successfully treated with methylprednisolone with complete remission of symptoms. Patients with neuromyelitis optica spectrum disorders frequently experience relapses of the disease if untreated, and she was therefore treated with rituximab to prevent future relapses. This case is a reminder that common gastrointestinal symptoms may be caused by diseases of the central nervous system.

Man With Persistent Vomiting

An 80-year old man with a history of hypertension and Parkinson disease presented to the emergency department with persistent vomiting and vague abdominal pain for 2 days. His vital signs were stable, and he was afebrile. An abdominal radiograph (Figure 1) showed a severely distended stomach. After decompression by nasogastric tube, a large amount of bilious material was drained. The blood tests revealed only mild anemia (hemoglobin, 11.4 g/dL) and hypokalemia (3.09 mmol/L). A point-of-care abdominal ultrasound scan was performed (Figure 2).

Knowledge, attitude and practices among pregnant women about antenatal care, danger sign during pregnancy and adopting family planning method

Introduction: The knowledge, attitude and practices (KAP) for antenatal check-up during pregnancy is a key indicator of health care facility in a community. The study was conducted in a district hospital in North Delhi of India about antenatal care among pregnant female. Materials and Methods: Total 54 pregnant females were studied about KAP during antenatal care check-up in a tertiary care hospital.The study was cross sectional in design. They were asked questions while attending the outpatient clinic in the hospital. Result: It was found that practices and positive attitude about antenatal care among pregnant females was adequate. Score for positive attitude was 93% and score for antenatal care practices was 62%. Both are more than 50%. But knowledge among them is not adequate; the score for knowledge about antenatal care was 17%, which was less than 50%. Hence periodic health education sessions have to be conducted by the doctors and health staffs. Ten pregnant females(18.5%) had faced danger signs during their previous pregnancy, these danger signs were dizziness and fainting, persistent vomiting, less movement of baby inside uterus, bleeding per vagina (for abortion), persistent vomiting, leaking per vagina and pain abdomen. Four pregnant women (7.4 %) had mentioned bleeding per vagina in their previous pregnancy. Out of 54 pregnant women nine pregnant female told that they were using condom and six not using any contraceptive methods after marriage. Conclusion: The study detected knowledge score of 17%, practice score of 62% and attitude score of 93% in pregnant female attending antenatal check-up clinic. Keywords: Antenatal care, Family planning, Danger signs, Knowledge, Attitude, Practices.

Complex intracranial vascular complications caused by essential thrombocythemia: a critical case report

BackgroundEssential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by elevated and dysfunctional platelets. ET can result in systemic thrombotic and hemorrhagic complications, and it’s a rare cause of stroke. The coexistence of multiple vascular lesions has seldom been reported in patients with essential thrombocythemia.Case presentationA young woman presented with isolated and persistent vertigo and vomiting. The CT scan indicated a hyperdense lesion in the right cerebellar hemisphere. No signs of cerebral artery malformation were observed in the CT angiography (CTA). Besides, the blood tests indicated an increase in platelet and white blood cell counts. The patient then suddenly developed a transient unconsciousness with left horizontal nystagmus when staring to the right. The subsequent cranial magnetic resonance imaging (MRI) scans indicated a diffuse and acute infarction of the pons and hemorrhage in the bilateral cerebellums. Further digital subtraction angiography (DSA) revealed a progressive and critical intracranial vertebral arterial occlusion. The patient’s clinical condition stabilized after cytoreductive therapy with interferon-α (IFN-α), even though endovascular and antiplatelet treatments were restricted because of the simultaneous presence of intracerebral hemorrhage (ICH) and ischemic stroke. A JAK2 V617F mutation was later detected through genetic testing, further confirming the diagnosis of ET. The patient was treated with a continuous regimen of IFN-α, and an antiplatelet treatment (aspirin) was added after ICH. The 1-year follow-up indicated normal platelet levels and no additional stroke event.ConclusionsThis case demonstrates that ET can be a rare cause of the cerebrovascular disease (CVD), even though the coexistence of ischemic and hemorrhagic complications. Underlying hematological system diseases should be taken into account when abnormal hemogram and CVD are concurrent in a patient. An early multidisciplinary diagnosis and intervention could significantly improve patient’s prognosis.

Prospective Pilot Study of Telehealth As Domiciliary Follow-up after Hematopoietic Cell Transplantation during the COVID19 Pandemic

IntroductionAn increased risk of mortality has been documented in transplanted patients affected by Coronavirus Disease 2019 (COVID19) with an estimated mortality rate between 20-40%. Multiple efforts are ongoing to control COVID19 pandemic, and clinical practice is being adapted at the same time as the pandemic progresses around the world. To reduce unnecessary in-person appointments has become crucial to minimize hospital exposition. Digital technologies allow us to perform real-time monitoring of patients' clinical status. A real-time patient monitoring system through the use of a smartphone application and wearable devices was implemented at our Center during the COVID19 pandemic.MethodsSince March 2020, a real time patient monitoring system was implemented at our HCT program. All consecutive adults patients transplanted between April 2020 and July 2020 were considered for the study. Vital signs and relevant clinical information were reported during 14 consecutive days after being discharged, through the online platform provided by Trilema Fundation (saludencasa.trilema.org, Fundación Trilema, Valencia, Spain). Vital signs (cardiac frequency, blood pressure, oxygen saturation) were measured with validated oxymeters (Onyx II®, Nonin Inc, Plymouth MN USA) and blood pressure monitors (iHealth Track®, Mountain View, CA USA). Temperature was measured through domiciliary thermometers. Patients were educated to measure their respiratory frequency. A checklist of clinical symptoms was filled daily. An analogue visual scale (0-10) to detect potential cases of anxiety or depressive disorders was reported daily. Scores of >6 were evaluated by a psycho-oncologist through videoconference. All the data were reported to the online platform using a smartphone app compatible with iPhone and Android systems. A direct chat between patients and physician was available through the app. Clinical information was daily supervised by an experienced HCT hematologist. Clinical interventions were arranged if significant clinical abnormalities were documented. A hematologist with experience in HCT patients revised all the patients’ data daily. Programmed alarms were set in case of any of the following situations: fever >38 oC; oxygen saturation <92%; tachicardia >125/bpm, hypotension (sytolic<90 mmHg, diastolic > 60 mmHg; altered mental status; persistent emesis or diarrhea). Patient´s satisfaction questionnaires were evaluated individually after finalizing the 14-days clinical monitoring.ResultsDuring the study period, 21 adults underwent HCT and 16 were s were eligible to be recruited into the study (80% feasibility) with team effort and without additional costs. Reasons for not being enrolled were: language incompatibility (1 patient), no consent (1 patient), not compatible smartphone (3 patients). Of the 16 enrolled patients, median age was 50 (range 22-70 years), 37% were female and 94% had lymphoid diseases. Thirty-eight percent of HCTs were autologous and 62% allogeneic.Of the 16 enrolled patients, 25% were not able to adequately use the app due to inability in using smartphone applications. Of the remaining 12 patients, adherence in reporting study data (number of days reported of the planned 14 days study period) was as follows (average):temperature 89%, oxygen saturation 90%, respiratory frequency 70%, cardiac frequency 85%, blood pressure 89%, symptoms reporting 65%, emotional distress 71%.Automatic alarms were activated only 3 times: twice for the presence of clinical symptoms and once, for emotional distress. A videoconference with the psycho-oncologist was requested by one patient only. The chat service to communicate with hospital personnel was used in 4 patients. Data collected with the digital system helped the clinician to early recognize arterial hypertension (1 patient) and acute cutaneous GVHD grade 1 (1 patient).Only two patients of the whole cohort were readmitted within 14 days from discharge due to grade 4 odynophagia due to HSV1/2 reactivation.Patients´ experiences with telehealth systems are reported in table 1.ConclusionTelehealth monitoring can potentially improve patient's follow-up in terms of both physical and psychological outcomes. Technological problems still represent a barrier to a wider application of telehealth monitoring systems in the medical setting.DisclosuresMussetti:Novartis, Gilead: Honoraria, Research Funding. Sureda Balari:Incyte: Consultancy; Janssen: Consultancy, Honoraria; Celgene/Bristol-Myers Squibb: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; BMS: Speakers Bureau; Roche: Honoraria; Takeda: Consultancy, Honoraria, Speakers Bureau; Sanofi: Consultancy, Honoraria; Gilead/Kite: Consultancy, Honoraria; Merck Sharpe and Dohme: Consultancy, Honoraria, Speakers Bureau.

Procedural Pain and Serious Adverse Events with Bone Marrow Aspiration and Biopsy: Real World Experience from India

Background: Bone Marrow aspiration and Biopsy (BMAB) is perceived by patients as a painful procedure with fearsome complications. Though informed as safe and well tolerated; there is limited data about the complications and degree of pain experienced by patients undergoing BMAB.[1] Further scarce is data from the developing world where procedural fear discourages patients from pursuing treatment and diagnosis.[2] Methods Aims: To estimate the level of pain and frequency of serious adverse eventsexperienced by patients undergoing BMAB at our center. We also attempted to identify factors associated with increased pain perception. Study setting: This study was conducted at a tertiary level teaching hospital, the Christian Medical College &amp; Hospital, Ludhiana. Ethics approval was obtained from the Institutional research committee (CMC/1495). Study period: 01 April 2015 through 30 Nov 2019 Study Design: This is a comparative cross sectional study where comparison of those with relatively more pain to those with less was done to elicit the factors associated with pain perception. Study Population: All consecutive patients who underwent a BMAB and provided informed consent which was taken pre-procedure, were included. We excluded patients who underwent the procedure under general anesthesia. Logistics of the Study: The BMAB was performed variably by Consultant Physicians, Trainee Physicians and Physician Assistants. All patients were pre-medicated with tramadol intravenous pre-procedure, and the preferred approach was from the posterior superior iliac spine (PSIS) in a left lateral decubitus under local anesthesia with lignocain. Patients were sent home or returned to their ward after upto 60 minutes of observation. A serious adverse event was considered as one requiring a prolonged observation beyond routine practice or extending to an admission to manage adverse events following and related to the BMAB. Data sources and variables Information regarding age at diagnosis, address and sex, indication to perform the BMAB, coded as malignant and non-malignant was collected from each patient. Number of prior procedures and details regarding food intake were collected as recalled by the patient. Level of pain was noted soon after the BMAB using a combined Wong-Baker grimace with numeric pain scale by the patient themselves. Statistical Analysis: Descriptive statistics were used to characterize variables. Univariate and Multivariate Logistic Regression were used to identify factors associated with higher pain severity (Score &amp;gt;2). Results: A total of 942 BMAB procedures were performed in this period. Baseline characteristics as tabulated below (Table1). Although the Mean + SD pain score was only 2.7 + 1.39, fourteen patients (1.48%) reported severe pain (&amp;gt;8). The following risk-factors were associated with increased pain on multivariate analysis: those experiencing their first BMAB procedure had very low odds of pain (OR (95 % CI): 0.23 (0.15-0.37)). However, when more than one attempt of biopsy was made, the odds of pain was much higher (OR (95 % CI): 1.62 (1.29-2.05)). Food and drink intake prior to procedure was associated only at the univariate level. Those who did not take any food prior to procedure had very high odds of pain (odds ratio (OR) 1.81 (95 % CI 1.01-3.22)). However, those who took juice had very low odds (OR (95 % CI): 0.619 (0.43-0.90)). Nine (0.95%) serious adverse events were reported. There were no deaths. The major serious adverse event was hemorrhage resulting from pseudo-aneurysm of the posterior iliac artery, which comprised 2 of the 9 serious adverse events. Other serious adverse events included persistent vomiting and severe aching pain in the ipsilateral leg. Conclusions: In our analysis BMAB is associated with a low level of procedural pain and is safe. The pain perception was not influenced by the operator. Factors associated with decreased pain perception were first procedural BMAB experience and successful completion of the procedure in the first attempt. Having at least a snack or a juice pre-procedure could reduce pain perception. Serious adverse events are rare in our experience. Disclosures No relevant conflicts of interest to declare.

WHAT BEHIND THE SCENE OF HYPEREMESIS GRAVIDARUM: AN ARTICLE REVIEW

Background:Hyperemesisgravidarum is a complicated medical condition characterized by persistent severe nausea and vomiting. The incidence of hyperemesis gravidarum is about 0.5% of live births and thought to be of higher incidence in hydatidiform mole, multiple pregnancies and other medical conditions associated with elevated hormonal levels. Objectives:The aim of this article is to provide evidence-based data that summarize the causes and treatment regimens of Hyperemesis Gravidarum. Review of literature:Hyperemesisgravidarum is a multifactorial condition with various etiological factors have been identified such as hormonal, psychological, genetic and infectious factors, the exact cause and pathogenesis still unknown. The management of this medical condition involves psychological treatment in addition to antiemetic drugs, pyridoxine and vitamin replacement. We performed this literature review with focusing on articles published over the last 10 years, to examine the recent theories of possible causes and management in hyperemesis gravidarum. Conclusion:Hyperemesisgravidarum could be a life-threatening condition that occurs during the first trimester. It is a treatable condition, mostly by supportive means such as vitamins, IV Fluids, bland diet and family support. These patients can get rapidly into shock, fluid loss or electrolyte imbalance, there for pregnant women with suspected hyperemesis gravidarum must not go on without a well-developed treatment plan.

Gastro-esophageal reflux disease: Key messages for clinicians.

Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.

Adrenal Insufficiency due to Total Primary Empty Sella Syndrome

A 64-year-old woman was transported suffering from persistent lower abdominal pain, vomiting, and low-grade fever. Magnetic resonance imaging revealed an empty sella (ES) and hormone tests revealed a disappearance of diurnal variation of cortisol, low cortisol and adrenocorticotropic hormone (ACTH) secretion especially in the morning, and poor ACTH-cortisol axis reaction, as well as normal hypothalamus-pituitary gland-thyroid or adrenal gland axis hormone reaction. The cause of ES remained unclear; however, based on a diagnosis as adrenal insufficiency due to inappropriate ACTH secretion caused by total primary ES syndrome, we started hydrocortisone (15 mg/day). Afterwards, she immediately became symptom-free and was discharged. J Endocrinol Metab. 2020;10(5):144-153 doi: https://doi.org/10.14740/jem686

A Comparative Study to Assess the Knowledge Regarding Dengue Fever and its Prevention among All Women at the Selected Urban and Rural Areas of Ratia (Fatehabad)

Dengue infection is a mosquito-borne arboviral infection. An important criterion to consider in the diagnosisof dengue infection is history of travel or residence in a dengue-endemic area within 2 weeks of the onsetof fever. The spectrum of dengue virus infection ranges from an asymptomatic or undifferentiated febrileillness to severe infection. Criteria for diagnosis of probable dengue include history of travel or residence ina dengue-endemic area, plus high grade fever of acute onset and two of the following signs and symptoms:nausea/vomiting, rash, severe aches and pains (also called ‘break bone fever’), positive tourniquet test,leukopenia, and any warning sign. Presence of any of the following warning signs–abdominal pain ortenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, restlessness, liverenlargement greater than 2 cm, and an increase in hematocrit concurrent with rapid decrease in plateletcount–will require strict observation and medical intervention.

Late diagnosis of duodenal obstruction associated with down syndrome: Similar presentation of different pathologies

Down syndrome is the most common chromosomal abnormality and is associated with a high incidence of upper gastrointestinal anomalies. Although these anomalies are commonly identified antenatally or in the early prenatal period, delayed presentation is possible. Herein, we describe two patients with Down syndrome who presented with persistent vomiting associated to a partial duodenal obstruction. Both patients presented for evaluation after a prolonged period of vomiting and severe dehydration. In both cases, gastrointestinal reflux had been suspected, resulting in inappropriate treatment. We proceeded with upper gastrointestinal radiographic series and endoscopy in both cases, which revealed classic features of duodenal obstruction, including dilation of the stomach and first/second segments of the duodenum. Laparotomy was used to confirm the diagnosis in both cases. In case one, findings of massive dilation of the esophagus and the stomach were reflective of a long-standing obstruction. In the second case, examination revealed a duodenal bulb with an annular structure and no appreciable lumen. Both patients were treated via open laparotomy, with a corrective duodeno-duodenostomy procedure performed for the patient in case one with annular pancreas and enterotomy and transverse closure performed for the patient in case 2 with an external obstruction. Both patients recovered without complications, with complete resolution of symptoms. As delayed diagnosis is associated with significant morbidities and unneeded interventions, physicians treating children with Down syndrome should have a high index of suspicion of the possibility of late presenting duodenal obstruction.

WHO 2009 Warning Signs as Predictors of Time Taken for Progression to Severe Dengue in Children

To identify WHO 2009 warning signs that can predict time taken for progression to severe dengue in a pediatric population. Prospective analytical study over 1 year and 2 months. Tertiary care center. 350 children aged 1 mo-12 y with serologically confirmed dengue without co-morbidities/co-infections; conse-cutive sampling. At admission, clinical and laboratory details were noted. Disease progression, time of onset of each warning sign, hematocrit, and platelet counts were recorded daily till discharge/ death. If progressing to severe dengue, its time of onset was noted. Time to event analysis with Log Rank test, Kaplan Meier plots and Cox Proportional Hazards Model was done. Primary outcome was time interval from onset of first warning sign to onset of severe dengue (defined as per WHO 2009 guidelines). Predictors were WHO 2009 warning signs: abdominal pain, lethargy, persistent vomiting, mucosal bleed, clinical fluid accumulation, hepatomegaly >2 cm, hematocrit ≥0.40 and platelet count <100x109/L. Among 350 children followed up completely till discharge/death, 90 developed severe dengue (event) while 260 did not (censored). Median age of study population was 7.75 y. Clinical fluid accumulation [(P=0.002, Hazard Ratio (HR) 2.19, 95% CI 1.33-3.60)] and hematocrit ≥0.40 [(P=0.009, HR (95%CI) 1.715, (1.13-2.60)] were significant in univariate analysis. Final multivariate model includes clinical fluid accumulation [(P=0.02, HR (95%CI) 1.89, (1.116-3.202)], hematocrit ≥0.40 (P=0.07), mucosal bleed (P=0.56) and persistent vomiting (P=0.32). WHO warning signs that predict time taken for progression to severe dengue in children include clinical fluid accumulation, hematocrit ≥0.40, persistent vomiting and mucosal bleed. Study results have implications in policy making and practice guidelines to triage children attending a health care facility with or without warning signs.

S2371 Endoscopic Vacuum Therapy (EVT) for the Successful Treatment of Duodenal Fistula

INTRODUCTION: Perforation is a devastating complication. The solution has always been surgical. At the Minneapolis, we have encountered a case of complicated duodenal ulcer which failed both surgical and radiology interventions. The EVT finally achieved the closure. CASE DESCRIPTION/METHODS: A 65 y/o veteran presented with persistent vomiting and weight loss. Initial CT revealed a large stomach and a duodenal wall thickening. EGD showed a large amount of bezoar, reflux esophagitis, and ulcerated duodenal stricture that only 6mm endoscope could pass. A 15 mm Axio stent was placed in the stricture. The patient’s symptoms improved and the stent was removed after 3 weeks. Two weeks later, the symptoms recurred. NPO and TPN were initiated. Repeat EGD revealed a pin point pylorus that could not be traversed. Liquid contrast was injected. A duodenal fistula between the duodenal bulb and sub-hepatic space was identified. A surgical procedure was then performed consisting of pylorus exclusion, gastro-jejunostomy (GJ), and sub-hepatic drain, Continuous bilious material via the sub-hepatic drain continued. The patient was unable to tolerate any oral intake. A PEG-J tube then was inserted by the Interventional radiology. Afterwards, the patient’s abdominal pain and drainage increased. Another EGD was performed. This time, a wide-open GJ was seen. The tube was found to pass through the suture line of the “excluded pylorus”. There were 2 additional disruptions at suture line. The PEG-J tube was repositioned into the GJ. The 3 open disruptions at the suture lines were cauterized using argon plasma and then closed using two 8mm and one 12mm Ovasco clips. Within a week, the percutaneous drain from the fistula decreased by 80%. But abdominal pain continued. A fifth EGD was performed to initiate EVT. A new PEG-J tube was inserted through the GJ into the duodenum loop. The distal tip loop string of the tube was secured onto the duodenal wall using 3 small endo-clips. High vacuum suction was applied to the J-port. Within a few days, all drainage from the fistula had ceased. A sixth EGD showed that 1 of the 3 Ovasco clips had fallen off so that standard 9mm endoscope could pass. The duodenal bulb was narrowed. The fistula resolved. The PEG-J was removed. DISCUSSION: EVT is a very effective treatment for perforation and fistula. The fundamental basis is to evacuate gastric, bile, and pancreatic secretions near the internal wound. This therapy should be considered as first-line rather than last resort.

S2881 Lupus Enteritis as the Unique Manifestation of Lupus Flare - Report of 2 Cases

INTRODUCTION: Gastrointestinal (GI) symptoms are common in patients with systemic lupus erythematous (SLE) but real GI involvement is rare. Lupus enteritis refers to either vasculitis or inflammation of the bowel wall. It is present in 0.2–5.8% of patients usually in the context of high-SLE activity. The symptoms are nonspecific and can be life-threatening especially if the treatment is delayed. We present two cases of lupus enteritis as the sole manifestation of SLE flare. CASE DESCRIPTION/METHODS: Case 1. 19-year-old female with no prior SLE diagnosis was admitted with four months of persistent diarrhea, vomiting, and epigastric pain. Workup revealed Mg 0.5 mg/dl, K 2.5 mEq/l, Hb 11.2 g/dl, CRP 1.40 mg/dl, and subnephrotic proteinuria. Infectious workup was negative. CT scan showed diffuse thickening and enhancement of the small and large bowel wall. Upper and lower endoscopy with biopsy revealed nonspecific edema and chronic inflammation. Further evaluation showed low complement levels, positive ANA ( > 1:160), anti-dsDNA ( > 300 IU/ml), SSA, SSB, anti-histone Ab, and lupus anticoagulant. IV methylprednisolone was started with marked improvement, later transitioned to hydroxychloroquine, azathioprine, and prednisone with taper dose. Case 2. 49-year-old female, SLE diagnosed in 2017, no treatment for 2 years was admitted with one month of persistent vomiting and abdominal pain. Evaluated initially with upper and lower endoscopy which revealed Barret’s esophagus. Workup revealed Na 132 mEq/L, Mg 1.6 mg/dl, lymphopenia (200 k/uL), elevated CRP (0.67 mg/dl), and subnephrotic proteinuria. Negative infectious workup. Further evaluation showed ANA ( > 1:160), Anti Smith ( > 8), anti-dsDNA (4 IU/ml), SSA ( > 8), and low complement levels. CT scan with diffuse thickening and enhancement of the small bowel and entire colon and rectum. IV methylprednisolone and a short course of IV erythromycin was started with significant improvement; later transitioned to hydroxychloroquine, azathioprine, and prednisone with taper dose. Both patients did not present recurrence of symptoms during the next 3 months. DISCUSSION: Lupus enteritis is very rare as an unique feature of SLE flare. Current knowledge is scarce. CT scan is the test of choice. It usually responds to steroids. Steroid-sparing agents are required in severe-relapsing cases. Our cases highlight the difficult diagnosis of this disease. Identifying this condition is crucial to avoid complications as bowel necrosis or perforation.Figure 1.: Contrast enhanced abdomen CT scan coronal axial views revealed “target” sign that represent circumferential thickening of the intestine wall. In this case affecting both small and large intestine.Figure 2.: Contrast enhanced abdomen CT scan showing diffuse thickening of the small and large intestine wall. "Target" sign can also be appreciated here.

S1909 Black Esophagus: A Syndrome of Acute Esophageal Necrosis

INTRODUCTION: Black esophagus, also known as acute esophageal necrosis (AEN) syndrome is a rare entity characterized by patchy or diffuse circumferential black pigmentation of esophageal mucosa from ischemic necrosis and may present with life threatening upper gastrointestinal hemorrhage (UGIH) resulting in high mortality in immunocompromised patients. CASE DESCRIPTION/METHODS: A 56-year-old female with diabetes mellitus (DM), gastroesophageal reflux disease (GERD), and alcohol abuse (8–10 drinks daily) presented with multiple episodes of coffee ground emesis and epigastric abdominal pain for two days. The pain was sharp epigastric, 10/10 in severity, non-radiating, precipitated with ingestion of oral intake, without alleviating factors. On examination, she was tachycardic (120/minute) and hypotensive (80/50 mm of Hg), had oropharyngeal erythema with white spots on its posterior wall, and significant ptyalism. She had epigastric tenderness and unremarkable digital rectal examination. Laboratory workup revealed lactic acidosis (>15 mmol/L), acute kidney injury with creatinine 2.21 mg/dL, leukocytosis (18 k/dL), and transaminitis. A computed tomography (CT) of abdomen and pelvis without contrast was unremarkable. The hospital course was complicated by hematemesis, dysphagia, and melena. After initial resuscitation, esophagogastroduodenoscopy (EGD) was performed which revealed inflammation of the epiglottis, arytenoid cartilages, and dark mucosal pigmentation of distal 2/3 of the esophagus with associated hiatus hernia (Figure 1). A biopsy of esophageal mucosa demonstrated fragments of fibrinopurulent exudate and necrotic tissue with pigment deposition (Figure 2). Evidence of helicobacter pylori, cytomegalovirus, herpes simplex virus, candida albicans infections, and malignancy was not found on further testing. She was managed with strict NPO, total parenteral nutrition, proton pump inhibitors, and analgesics. Serial EGDs showed complete resolution of the lesion in 4 weeks and was transitioned to an oral diet. DISCUSSION: In this case, vascularity of the distal esophagus was compromised due to uncontrolled DM, GERD, and binge alcohol drinking, complicated with acute UGIH due to mucosal tears from persistent vomiting. Acute UGIH is alarming for AEN in patients with multiple co-morbidities and a high index of clinical suspicion is required for pursuing EGD for early diagnosis. Early recognition and aggressive resuscitation are the fundamental principles for the management of AEN and better outcome of the disease.Figure 1.: Distal two-thirds of the esophagus showing black pigmentation of mucosa due to ischemic necrosis.Figure 2.: A biopsy of esophageal mucosa demonstrating fragments of fibrinopurulent exudate and necrotic tissue with pigment deposition (arrow).