Proton Pump Inhibitor Infusion Research Articles

Ketosis-prone Diabetes Presenting with Acute Esophageal Necrosis or “Black Esophagus”: An Intriguing New Clinical Association

Background:: Ketosis-prone diabetes (KPD) is an intermediate subtype of diabetes mellitus, usually affecting Afro-American adults, presenting with diabetic ketoacidosis (DKA), without the classic phenotype of autoimmune type 1 diabetes. Patients require insulin therapy at onset for the acute decompensation, then usually remain insulin-free for prolonged periods with diet alone or with other antidiabetic drugs. DKA can be rarely complicated by upper gastrointestinal bleeding and mucosal necrosis, a severe complication named acute esophageal necrosis (AEN) burdened by high mortality. The association of KPD presenting with DKA complicated by AEN is here reported for the first time, to the knowledge of the authors, in the medical literature. Case Presentation:: Here we report an interesting case of middle-aged African woman, newly diagnosed with KPD, presenting with DKA hematemesis. The patient was first treated at Intensive Care Unit for the ketoacidosis with intravenous fluids combined with continuous insulin infusion, and then switched to subcutaneous regimen. At the same time, esophagogastroduodenoscopy (EGD) was performed to diagnose acute esophageal necrosis, which was promptly managed with proton pump inhibitors infusion, fasting, and parenteral nutrition. After the correct clinical evaluation, the patient was switched to oral antidiabetic and basal insulin at discharge and an EGD follow-up was scheduled. Conclusions:: KPD remains an under-recognized and under-diagnosed type of diabetes which can present as DKA. Since DKA could be a possible trigger of AEN, a rare but potentially lifethreatening condition, that clinicians should be aware of, in patients presenting with upper gastrointestinal bleeding and ketoacidosis. The prompt management and classification of DKA, combined with the EGD execution for early AEN diagnosis and follow-up, is essential.

Life-threatening upper gastrointestinal hemorrhage from a Cameron ulcer

Introduction: Acute upper gastrointestinal bleeding can be life-threatening; however, Cameron lesions are an uncommon etiology. These lesions should be suspected with a previous history or endoscopic evidence of hiatus hernia. Case Report: A male in his 60s presented to the emergency department with hematemesis and melena for two days. He had no prior medical, surgical, or endoscopic history and took no regular medications. He was resuscitated with packed red blood cell transfusion and treated with proton pump inhibitor infusion then transferred to operating theaters for endoscopic hemostasis. Cardiac arrest occurred after anesthetic induction and airway intubation, return of spontaneous circulation was achieved after cardiopulmonary resuscitation and further blood transfusion. At endoscopy a Cameron ulcer was noted in the hiatus hernia with overlying blood clot with no active hemorrhage, treated with Hemospray®. Conclusion: Patients presenting with acute upper gastrointestinal hemorrhage and shock need urgent upper gastrointestinal (UGI) endoscopy. Topical hemostatic agents are successful in controlling bleeding when challenging anatomy precludes use of banding or clip application.

S709 Proton-Pump Inhibitor Infusion Misuse in the Community Hospital Setting

Introduction: Proton pump inhibitors (PPIs) are the most potent acid suppressants available. Several studies have shown that in hospitalized patients with acute upper gastrointestinal (GI) bleeding from peptic ulcer disease, high-dose PPI therapy via continuous infusion reduces the rate of high-risk bleeding lesions (active bleeding, visible vessel, adherent clot) on initial endoscopy. While the benefits of PPI infusions have been clearly described for these specific indications, they are often over-prescribed to inpatients. Our study aim was to determine the rate of misuse in a tertiary care community hospital setting. Methods: A retrospective cohort study was conducted at Lankenau Medical Center, a 370 bed community hospital. The usage of pantoprazole infusion was determined among hospitalized patients between March 1, 2018 and March 1, 2021 through review of the EPIC electronic medical record system. Appropriate candidates for pantoprazole infusion were defined as patients with hematemesis, melena, coffee-ground emesis, or hematochezia with hemodynamic instability. All other indications were categorized as inappropriate. Variables including age, sex, race, serum hemoglobin at the time of PPI infusion initiation, and antiplatelet use were collected. The rate of PPI infusion misuse was determined. Factors which significantly affected utilization of PPI infusion were determined through multivariate analysis. Results: A total of 348 pre-endoscopic PPI infusions were ordered during the three-year period. Approximately 35% of these prescriptions were ordered without an appropriate indication. The mean age of patients who were prescribed PPI infusions was 68.8 years. 48.6% were on an antiplatelet agent. The only significant variable between patients who were given a PPI infusion for an appropriate versus inappropriate indication was age, where the mean patient age was 68.8 compared to 71.1 years (p=0.04). Patient sex, race, antiplatelet use, and hemoglobin value did not significantly affect PPI infusion use. (Table) Conclusion: Pre-endoscopic PPI infusion was prescribed inappropriately in 34.8% of patients in a community hospital setting. Misuse of this drug leads to unnecessary healthcare costs and reflects poor understanding among prescribers of its appropriate clinically indicated uses. While PPIs are generally regarded as safe, misuse can increase the risk of adverse side effects. A follow-up study looking at a quality improvement intervention will follow this study. Table 1. - Characteristics and Multivariate Analysis of PPI Infusion Misuse Inappropriate PPI Infusion No Yes Total p-value n = 227 n = 121 n = 348 Age (Mean/SD) 67.6 (14.8) 71.1 (15.1) 68.8 (15.0) 0.04 Sex 0.571 Male 131 (57.7%) 66 (54.6%) 197 (56.6%) Female 96 (42.3%) 55 (45.5%) 151 (43.4%) Race 0.705 White 104 (46.0%) 59 (48.8%) 163 (47.0%) Black 112 (49.6%) 55 (45.5%) 167 (48.1%) Other 10 (4.4%) 7 (5.8%) 17 (4.9%) Ethnicity 0.12 Not Hispanic 225 (99.6%) 116 (97.5%) 341 (98.8%) Hispanic 1 (0.4%) 3 (2.5%) 4 (1.2%) Total Number of Antiplatelets 0.629 0 121 (53.3%) 58 (47.9%) 179 (51.4%) 1 70 (30.8%) 41 (33.9%) 111 (31.9%) 2 36 (15.9%) 22 (18.2%) 58 (16.7%) Antiplatelet Type (n = 169 Yes Only) Aspirin 103 (45.4%) 61 (50.4%) 164 (47.1%) 0.37 Clopidogrel 36 (15.9%) 23 (19.0%) 59 (17.0%) 0.456 Ticagrelor 4 (1.8%) 4 (3.3%) 8 (2.3%) 0.456 Prasugrel 1 (0.4%) 0 1 (0.3%) 1 Last Hemoglobin (Mean/SD, g/dl) 8.9 (2.6) 8.6 (2.9) 8.8 (2.7) 0.344 Missing Hemoglobin 19 8 27 Transfusion Units (median/IQR) 2 (0-6) 2 (0-4) 2 (0-5) 0.478

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A retrospective study.

To compare the effectiveness of intermittent and continuous proton pump inhibitors (PPIs) infusion on the outcomes of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). The study was a single-centred retrospective study in adult patients with active upper gastrointestinal bleeding who received intermittent or continuous PPI infusion at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2013 to October 2019. The outcomes assessed were rebleeding, length of hospital stays and mortality within 30 days of admission, and were compared between the treatment groups. A statistically significant p-value was set at 0.05. The study involved 97 patients with NVUGIB treated with intermittent (n=56) and continuous (n=41) PPI infusions, with mean (±SD) ages of 66.0±16.1 and 58.0±19.5 years, respectively. The baseline and clinical characteristics between the 2 treatment groups; age (p=0.116), gender (p=0.345) and comorbidities (p=0.401), were comparable. There were no significant differences in rebleeding rates within 30 days (5 [8.9%] versus 1 [2.4%], p=0.396), length of hospital stays (4 vs 5, p=0.067), and mortality rate (1 [1.7%] vs 3 [7.3%], p=0.308) between the 2 groups. The management of NVUGIB with intermittent and continuous PPI infusions demonstrated comparable outcomes in reducing rebleeding rate, length of hospital stays, and mortality rate among patients attending the university hospital in Saudi Arabia.

QUELS SONT LES FACTEURS PREDICTIFS DECHEC DU TRAITEMENT ENDOSCOPIQUE DES ULCERES HEMORRAGIQUES?

Ulcerative gastrointestinal bleeding is the most frequent emergency in digestive endoscopy. Management is based on the initiation of an infusion of proton pump inhibitors as soon as the diagnosis is mentioned. Upper endoscopy should be performed as quickly as possible under the best technical conditions. Two combined techniques of endoscopic hemostasis, most often by injection of reduced adrenaline and placement of clips, allow hemostasis in most situations. In case of failure, a new endoscopy can be proposed. Surgery and interventional radiology have a place in second or even third line treatment. A retrospective study was carried out on 80 patients over an extended period from 2009 to 2019. Including all patients presented to the emergency department for upper gastrointestinal bleeding regardless of the mode of exteriorization and who were reinforced with endoscopic treatment. risk of surgery and death. The objective of our work is to evaluate the effectiveness of endoscopic management and to deduce the predictive factors of failure of endoscopic hemostasis.

Cost-effectiveness and clinical outcomes of intermittent/continuous proton pump inhibitors infusion in high bleeding risk of ulcers: A retrospective observational cohort study.

The purpose of this study was to evaluate the clinical outcomes, including patient prognosis and medication expense, of proton pump inhibitors administered by high-dose continuous infusion (HDC, 80 mg loading dose, then 8 mg/h for 72 hours) or non-high-dose intermittent infusion (NHDI, 40 mg qd or 40 mg q12 h, for 3 days) regimens in high-risk patients with bleeding peptic ulcers.In this retrospective cohort study, patients with peptic ulcers and endoscopic hemostasis between January, 2013 and December, 2015 were included. The primary endpoints were rebleeding and mortality rates within 7 days. The secondary endpoints were length of stay (LOS), transfusion units of packed red blood cells (PRBCs), and the number needed to treat.A total of 335 patients met the inclusion criteria during the 3-year follow-up period. The cumulative incidence of rebleeding within 7 days was 20.4% and 11.2% in the HDC and NHDI groups, respectively, with a significant difference (P = .021). The mortality rate was 12.1% and 7.3% in the HDC and NHDI groups, respectively, with no significant difference (P = .136). Univariate Cox proportional hazards model analysis showed that the risk of rebleeding within 7 days in the HDC group was higher than that in the NHDI group. The hazard ratio for HDC vs. NHDI was 1.93 (P = .021). There were significant differences in LOS (P = .034) and PRBC units (P = .005) for risk of rebleeding within 7 days, as well as in transfusion units of PRBCs for mortality rate analysis (p < 0.001), between the HDC and NHDI groups. The results showed that the NHDI regimen could reduce the risk of rebleeding within 7 days in 1 of 11 patients (number needed to treat = 11) and could reduce medication cost by US$ 400 to 800.The NHDI regimen showed a lower risk of rebleeding within 7 days, shorter LOS, and fewer PRBC units than that of the HDC regimen. Receiving NHDI has better cost-effective outcomes than that of HDC for patients with high-risk bleeding peptic ulcers.

The Additive Effect of Platelet-Rich Plasma in the Treatment of Actively Bleeding Peptic Ulcer.

Background/AimsPeptic ulcer bleeding is the most common cause of upper gastrointestinal tract bleeding. Platelet-rich plasma (PRP) enhances tissue repair, and is therefore used in various medical treatments. A combination of mechanical or electrothermal hemostasis has been recommended for upper gastrointestinal tract bleeding treatment. This study evaluated the additive efficacy of PRP in bleeding peptic ulcer hemostasis and recovery. MethodsEighty patients with peptic ulcer bleeding were initially treated by hemoclipping, and were randomly chosen for either additional PRP (n=40) or additional epinephrine (n=40) injections. Both groups were compared with regard to achieving hemostasis and the frequency of complications. ResultsHemostasis was immediately achieved in both groups. Two patients (5%) in the PRP group and 8 (20%) patients in the epinephrine group experienced rebleeding after 15.9±2.8 and 12.3±3.7 days, respectively. They were managed by PRP injection in addition to proton pump inhibitor infusion. Hemoglobin was substantially increased in the PRP-treated group with full recovery occurring in 60.5% compared to 31.3% of patients in the epinephrine group (p=0.001). There was no recurrent bleeding in the PRP group, but 4/32 (12.5%) patients in the epinephrine group exhibited rebleeding. ConclusionsPRP showed additional benefit in reducing peptic ulcer bleeding with no reported significant complications. Clinical trial (NCT03733171).

PGI30 Assessment of Prescription Use and Patterns of Drug Related Problems in Patients with Peptic Ulcer Disease in Southern India.

The aim of the study is to assess the usage of drugs in the management of peptic ulcer and to identify the association of drug-related problems(DRPs). A prospective observational study was conducted over a period of nine months in the department of gastroenterology among both in-patients and out-patients. Patients diagnosed endoscopically with Peptic Ulcer Disease (PUD) were enrolled in the study after obtaining inform consent form. Descriptive statistics were applied to this study. A total of 180 patients were included in the study with 108 (60%) out-patients and 72 (40%) in-patients. Clarithromycin based triple therapy [n= 104 (57.77%)] with Esomeprazole based Helicobacter Pylori (HP) kit [n=90 (86.53%)], Pantoprazole based HP kit [n=14 (13.46%)] were started as fixed drug–dose combination therapy and monotherapy in 45% of the patients. The average maintenance treatment with proton pump inhibitors lasted for 42.12 ± 5.94 days. In-patients with complicated Peptic Ulcer Disease were administered with proton pump inhibitor (PPIs) 80mg bolus followed by PPI infusion 8mg/hr. for a period of 19.5±6.69 hours. A total of 138 (76.66%) participants encountered at least one drug-drug interactions(DDIs) and drug interactions accounted for 71.64% of overall drug related problems. Among 235 DDI’s, minor interactions were 149 (63.40%), the interactions to be monitor closely were 74 (31.49%) and serious interactions were 12 (5.10%). Overall, 10 (3.08%) experienced adverse drug reaction (ADR) as a DRP. Among 108 (60%) ambulatory patients, 10 (9.25%) experienced ADR. The H-pylori kit is popular clarithromycin-based therapy used in H-pylori eradication. Proton pump inhibitor was the most common therapy used in combination or alone, and use of esomeprazole was safe and compliant with the American College of Gastroenterology guidelines. In-patients the prophylactic use of antibiotics was seen due to complicated ulcers. DRPs encountered was DDIs followed by sub-therapeutic dose and failure to receive maintainance dose of PPI.

430 BALLOON TAMPONADE UTILIZATION FOR SEVERE ESOPHAGITIS CAUSING HEMORRHAGIC SHOCK

Abstract Esophagitis as a cause of upper gastrointestinal bleeding (UGIB) is a difficult entity to treat and is associated with significant morbidity. Epidemiologic studies note a 7-18% incidence of significant hemorrhage due to esophagitis. Current existing treatment options for UGIB complicated by hemorrhagic shock secondary to severe esophagitis are limited when there is a lack of response to proton pump inhibitor (PPI) medical therapy. Methods We present a case series of two patients who developed hemorrhagic shock from esophagitis, underwent endoscopic evaluation revealing limited treatment options, and ultimately required balloon tamponade resulting in successful resolution of bleeding and improvement in hemodynamics. A 55-year-old male with history of alcoholism complicated chronic pancreatitis and esophagitis presented with seizures. On admission he experienced hemorrhagic nasogastric tube output, anemia unresponsive to transfusions and hemodynamic instability. A 44-year-old patient with decompensated alcoholic cirrhosis was initially admitted for renal failure, and during the hospitalization developed melena and hemorrhagic shock requiring transfusions and vasopressors. The patients were promptly started on PPI infusion. Results Both patients underwent esophagogastroduodenoscopy revealing severe bleeding esophagitis extending from the gastroesophageal junction to the proximal esophagus and no varices. Active bleeding was not amenable to endoscopic therapy and both patients underwent balloon tamponade placement. The first patient required inflation of both the esophageal and gastric balloons for control of hemorrhage for 6 hours whereas the second patient required just gastric balloon inflation for 12 hours. Bleeding, transfusion requirement, and hemodynamics improved in both patients. Second look endoscopy demonstrated resolution of bleeding and hemostatic spray was applied to the esophagus prophylactically. Neither patient had recurrence of bleeding during the hospitalization. Conclusion UGIB secondary to esophagitis is difficult to control due to the highly vascularized nature of the esophagus. Endoscopic therapies are limited in extensive mucosal injury and risks of complications such as perforation are high. Other therapeutic options such as angiography are restricted due to vascular collateralization and surgical interventions have high morbidity and mortality. Balloon tamponade provides a viable treatment option for severe UGIB secondary to esophagitis that is not responsive to medical therapy.

Skipping the Drip: Intravenous Proton Pump Inhibitor Bolus Therapy Leads to Poor Outcomes in High-Risk Bleeding.

Background and AimThe aim of this study was to evaluate the impact of a change in our institute’s protocol from continuous intravenous (IV) proton pump inhibitor (PPI) therapy to bolus IV PPI therapy for the treatment of peptic ulcer-related bleeding on patient outcomes. Current guidelines recommend PPI therapy through high-dose IV bolus followed by continuous infusion for bleeding ulcers. Conflicting data have been reported regarding the practice shift to intermittent IV PPI therapy.MethodsA retrospective record review was conducted of patients treated at West Virginia University between 2017 and 2018 for peptic ulcer related bleeding who underwent endoscopy and had high-risk stigmata. Relevant variables were identified. Outcomes were compared between groups based on PPI strategy. The primary endpoint was any poor outcome defined as rebleeding, need for embolization or surgery, or mortality during hospital stay.ResultsA total of 130 patients were included, with a mean age of 62.18 years. Continuous PPI infusion was used in 39.23%, whereas bolus IV PPI was used 60.76%. Poor outcome was encountered in 11 (21.57%) patients in the continuous and 33 (41.77%) patients in the bolus group (p = 0.028). On multivariable analyses, bolus PPI strategy was independently linked to poor outcome (Wald’s odds ratio: 2.8; 95% CI: 1.21-6.84; p = 0.019) and an increased need for embolization/surgery (OR: 4.12, 95% CI: 1.14-19.99; p = 0.046).ConclusionsIV bolus therapy showed worse outcomes compared with continuous IV PPI therapy for patients with peptic ulcer bleeding with high-risk features. More robust data are needed before a practice shift to bolus PPI may be appropriate.

1791 Esophageal Nikolsky’s Sign: A Rare Finding in a Patient With Bullous Pemphigoid

INTRODUCTION: Bullous pemphigoid (BP) is a chronic relapsing autoimmune blistering disease characterized by circulating antibodies directed against specific epitopes of hemidesmosomes involved in anchoring the epidermis to the dermal layer. We report a case of acute onset esophageal bullae identified in a patient with active skin BP seen only upon withdrawal of the upper endoscope, not present on insertion. This sign is analogous to Nikolsky’s sign where pressure or shearing results in formation of new bullae. CASE DESCRIPTION/METHODS: 57-year-old Caucasian female with Type II DM, BP, CKD stage 3a presented to hospital for 5-6 episodes of melanotic stools for two days. She was diagnosed in September 2017 with BP by skin biopsy and direct immunofluorescence (Figure 1). At the time of presentation, she was normotensive, afebrile, heart rate 102 beats/min and respiratory rate of 14 breaths/min. Skin examination revealed tense bullae on upper extremities (Figure 2). Abdominal exam was notable for tenderness to palpate in the epigastric region. Digital rectal exam revealed melena. Laboratory findings showed hemoglobin 5.7 mg/dl, hematocrit 17.5 mg/dl. The patient received 1 unit of packed RBC, started on a proton pump inhibitor infusion and continued on mycophenolate with oral prednisone. She underwent an upper gastrointestinal endoscopy which revealed segments of sloughing mucosa in the esophagus. Additionally, a large bulla ranging from 20 to 25 cm was seen only upon withdrawal of the endoscope and not during initial insertion (Figure 3). She was discharged home on a high dose oral proton pump inhibitor, mycophenolate, prednisone, and topical steroid. DISCUSSION: Bullous Pemphigoid (BP) is the most common type of acute bullous dermatoses (ABD) affecting older adults without gender predilection. Esophageal manifestations of BP are rare and range from dysphagia, hematemesis or melena. Nikolsky sign is a specific skin finding of autoimmune blistering diseases but is only seen in 56% of the cases. The use of esophagogastroduodenoscopy can be challenging in these patients because of bullae formation after light contact between esophageal mucosa and the endoscope. Only gentle advancement and withdrawal of the endoscope is advised to prevent adverse events such as blood blisters, frank bleeding, or perforation. In cases of significant gastrointestinal bleeding and/ or hemodynamic instability, therapeutic endoscopy can be used to achieve hemostasis.

1966 Jejunal Submucosal Hemangioma as a Cause of Massive Gastrointestinal Bleeding: A Case Report

INTRODUCTION: Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery. CASE DESCRIPTION/METHODS: An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy. DISCUSSION: Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.

2037 Intestinal Spirochetosis: An Unexpected Cause of Massive Gastrointestinal Bleed

INTRODUCTION: Human intestinal spirochetosis (HIS) is a condition characterized by the presence of spirochetal microorganisms attached to the apical cell membrane of the colorectal epithelium leading to chronic diarrhea. The invasive form of this disease is more often seen in HIV patients or homosexual individuals. Here, we present a rare case of HIS presenting as lower gastrointestinal (GI) bleed and abdominal pain in the absence of diarrhea. CASE DESCRIPTION/METHODS: A thirty-year-old male with a history of peptic ulcer disease (PUD) and HIV (CD4 &gt;250) presented to the emergency department with a two-days duration of severe, generalized abdominal pain and bleeding per rectum. On presentation, the patient was hypotensive (mean arterial pressure &lt; 65) and tachycardic (heart rate 120). Physical examination revealed generalized abdominal tenderness with normal bowel sounds but no rebound tenderness or guarding. Labs were significant for anemia (Hemoglobin 6.5 g/dl; baseline &gt;14 g/dl). The rest of his labs including serum chemistry, white blood cells, amylase, lipase levels, were within normal limits. Due to the patient’s significant history of PUD and concern for rapid GI bleed, aggressive fluid resuscitation and proton pump inhibitor infusion were initiated. He also received two units of packed red blood cells with good toleration. CT scan of the abdomen/pelvis did not reveal any acute intraabdominal pathology. Despite the achievement of hemodynamic stability, the patient continued to have bright red blood per rectum. Extensive infectious workup (including blood cultures and stool tests such as stool culture, ova, and parasites) were negative. Esophagogastroduodenoscopy was performed and revealed well healed PUD without any signs of bleeding. Colonoscopy, however, revealed pan-colonic ulcers, most pronounced in the descending colon. Histopathology revealed spirochetal microorganisms attached all the way from the ascending colon to the rectum consistent with invasive HIS. Metronidazole was initiated with significant clinical improvement and he was subsequently discharged home with appropriate outpatient follow up. DISCUSSION: Most cases of HIS are asymptomatic and often diagnosed during screening/surveillance colonoscopy. Thus, data regarding symptomatic patients is scant. The few cases describing affected patients generally associate infection with chronic watery diarrhea, acute appendicitis or intermittent hematochezia. Metronidazole is an effective treatment of choice in symptomatic patients.

3130 Unexplained Thrombocytopenia Associated to the Use of PPI in a Patient With a Bleeding Peptic Ulcer Disease

INTRODUCTION: Proton pump inhibitors (PPIs) are used to suppress acid production and to promote hemostasis, which significantly reduces the risk of rebleeding in upper gastrointestinal bleeding [1]. Accumulating evidence indicates an association between PPIs and thrombocytopenia in patients treated for upper gastrointestinal bleeds [2-4]. CASE DESCRIPTION/METHODS: A 38-year-old male with no significant past medical history presented to the hospital complaining of coffee ground emesis, hematochezia, dark stools and three episodes of syncope in the setting of daily naproxen use for one month. Vital signs revealed orthostasis without tachycardia or hypotension. Physical exam revealed a soft, non-tender, non-distended, abdomen with normoactive bowel sounds. Rectal exam was positive for melena but negative for hemorrhoids or any palpable masses. Initial laboratory workup was significant for a hemoglobin of 7.8, platelet count of 163, and BUN of 27. Intravenous (IV) PPI was administered for management of suspected bleeding PUD. The patient received packed red blood cells (PRBCs) with appropriate response to transfusion. Upper endoscopy revealed a pre-pyloric non-bleeding ulcer that was successfully treated. A significant drop in platelet count was noted on hospital day four which continued to decrease from 163 to 107. PPI route of administration was changed from IV to oral, resulting in an increase in platelet count to 116 by hospital day 7. DISCUSSION: PPIs are widely used for the treatment of PUD, GERD, Barrett esophagus, esophagitis, and gastritis. As the main medication used in the treatment of upper gastrointestinal bleeding, it is crucial to understand the effect of PPI therapy on platelets. Literature review suggests an association between thrombocytopenia and the use of PPIs [2-4]. However, further studies are needed to establish a direct association between PPIs and thrombocytopenia. In our case, thrombocytopenia was noted on hospital day 3 of PPI infusion. Route of administration of PPI was changed from IV to oral and thrombocytopenia improved steadily. Although the exact mechanism linking PPI therapy to thrombocytopenia remains unknown, it is important to be aware of this possibility. Close monitoring of platelet count is recommended upon initiation of PPI therapy.

419 The Costly Case of Proton Pump Inhibitors: A Single Center Experience

INTRODUCTION: Proton pump inhibitors (PPI) are one of the cornerstones in the management of upper gastrointestinal bleed (UGIB) with the standard practice being initiating a continuous PPI infusion (CPI). In the recent years, several studies and meta-analysis have shown that there was no significant difference in major outcomes such as re-bleeding rates when using intermittent intravenous PPI (IIP) as compared to a CPI in non-variceal UGIB (2). However, most places in the USA still largely favor using the continuous infusion. Our study aimed to show the difference in patient costs of administering a CPI vs. IIP if evidence based practice was utilized in a single community hospital. METHODS: We retrospectively identified 212 CPI using our Electronic Health Record (EHR) and pharmacy database that were ordered at a community hospital in Ohio from June 2018 to May 2019 for patients who were admitted with a diagnosis of non-variceal upper GI bleed. A simple cost comparison analysis was done by Excel 2016 to compare the patient cost between CPI and IIP for the similar duration of use. RESULTS: Out of the 212 patients that were started on CPI, 54% were ordered by gastroenterologists as compared to 46% of which were started by all other physicians including internists, intensivists and ED physicians (Figure 1). The duration of the CPI tended to be longer (3.47 days) in adults &gt;50 years as compared to adults &lt; /= 50 years (2.58 days). There was a major difference in the cost of administering a CPI as compared to using IIP for a similar duration (Figure 2). The cumulative cost of CPI was 326,262 USD versus 108,810 USD for IIP (Figure 3). CONCLUSION: Although recent studies have showed that there was no difference in major outcomes in non-variceal upper gastrointestinal bleed when using intermittent PPI as compared to a continuous PPI infusion, this has changed neither the guidelines nor our practice of using a CPI. CPI is significantly more expensive as compared to an IIP for a similar duration of administration averaging up to $310 more per day. Our study showed that 217,452 USD could have been saved in 1 year by using IIP instead of CPI. A recent quality improvement study showed a significant reduction in costs when they used IIP instead of CPI in the management of non-variceal UGIB. Further studies comparing the cost effectiveness between CPI and IIP for non-variceal UGIB along with RCTs comparing the two might help revise the guidelines regarding their usage in the future.

Mucosal healing after high dose pantoprazole in acute corrosive injury of esophagus

INTRODUCTION : The ingestion of corrosive agents is still an important public health issue in our country. The GIT injuries caused by caustic agents can range from minor to fatal, or can lead to chronic disease with poor quality of life. Corrosive agents with a pH level less than two or more than twelve can rapidly penetrate the layers of the oesophagus and result in necrosis and scar formation in the mucosa. Acidic agents produce coagulation necrosis and eschar formation that may limit tissue penetration and may even spare the oesophagus when the transit is rapid. On the other hand, Alkaline agents when ingested produce liquefaction necrosis and can cause serious oesophageal injury by penetrating to deep muscle layers. The basic histopathologic reaction of tissue subjected to caustic burn is the synthesis, deposition and remodelling of collagen. Following full-thickness injuries to the oesophageal wall, the normal oesophagus is replaced by dense connective tissue. Collagen overproduction has been estimated to cause stenosis in half of the patients suffering severe burns. Consequently, when treating caustic burn injuries, it is necessary to prevent stenosis by inhibiting collagen synthesis or changing the properties of the deposited collagen. The optimal management protocol in the treatment of severe caustic injury remains controversial. The main goal of medical treatment is to inhibit inflammatory reaction or stricture formation secondary to oesophageal burning. Stricture formation is thought to be overcome by suppressing fibroplasia and scarring. Many agents directed at wound healing and stricture prevention have been used in several experimental studies in past. Results of such treatment protocols including steroids, antibiotics, heparin, indomethacin, sucralfate, vitamin E, as well as total parenteral nutrition are all controversial in treatment of corrosive burns. Randomised control trials on the role of proton pump inhibitors in caustic injuries of GIT are lacking. A few experimental studies have investigated the relationship between proton pump inhibitors and corrosive burns and has shown that proton pump inhibitors can reduce inflammation in early phase of caustic injury. Proton pump inhibitors, by decreasing gastric acid secretion and thereby GER can prevent worsening of corrosive injury. In addition proton pump inhibitors has also been shown to have anti-inflammatory and antioxidant properties. A prospective study from turkey on 13 patients have showed that omeprazole can be used effectively in treatment of acute corrosive injury of esophagus. There are no studies from India which have attempted to assess the usefulness of proton pump inhibitors in treatment of acute corrosive injury of esophagus. This prompted us to study the usefulness of pantoprazole in the treatment of patients presenting with acute corrosive injury of the oesophagus. AIM OF THE STUDY : To study the efficacy of high dose pantoprazole in causing mucosal healing after acute corrosive injury of esophagus. CONCLUSION : Treatment of corrosive injury is controversial and there are no definitive protocols. Intravenous proton pump inhibitors are widely used in treatment of corrosive injuries despite lack of evidence. Our study has demonstrated that effective mucosal healing can be achieved by intravenous proton pump inhibitor infusion. Though majority of patients in our study had minor grade of injury, 27% of the patients included in the study had 2b and 3a injury. When analysis is confined to these patients, 53% showed improvement by 1 grade, 33.3% showed improvement by 2 grades and 13.3% did not show improvement. Therefore it is evident from above that high dose pantoprazole is also beneficial in patients with higher grade of injury and may prevent late complications in these patients. A larger randomised placebo controlled trial in patients with higher grade of oesophageal injury is needed to determine if high dose pantoprazole should form standard of care in treatment of patients with acute corrosive injury of oesophagus.

Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding

This trainee-led quality improvement study evaluates the use of the Culture, Oversight, Systems Change, Training framework to reduce inappropriate proton pump inhibitor infusions in patients with upper gastrointestinal bleeding.

Management of non-variceal upper gastrointestinal bleeding in the Gaza Strip: survey of evidence-based practice

BackgroundEarly recognition, comprehensive assessment, and evidence-based care are crucial to reduce morbidity and mortality due to non-variceal upper gastrointestinal bleeding (UGIB). The aim of this study was to compare the present treatment of non-variceal UGIB in Gaza hospitals with the best available, evidence-based recommendations. MethodsWe distributed 47 questionnaires to doctors in medical departments of three hospitals (Naser Hospital, Alshifa Hospital, and the European Gaza Hospital) about current management strategies for non-variceal UGIB in two hospitals in the Gaza Strip—the European Gaza Hospital and the Shifa hospital. The questions covered target haemoglobin for blood transfusion, duration of proton pump inhibitors (PPI) infusion after endoscopic therapy, use of nasogastric tubes, and use of endoscopic stigmata of recent haemorrhage for therapeutic decisions. Answers from both hospitals were compared with the best available evidence from guidelines by the American College of Gastroenterology (ACG), published in 2012. Findings47 questionnaires were completed and returned. Only ten (20%) of responders considered the ACG-reccommended 7 g/100 mL as the best threshold for transfusion (most used a higher dose), and only 12 (25%) followed the evidence with respect to the dose and duration of intravenous infusion of PPIs after endoscopic therapy. By contrast, 42 (90%) respondents complied with ACG recommendations of not to routinely use nasogastric tubes, and 38 (80%) used endoscopic stigmata of recent haemorrhage to guide treatment decisions for patients. Finally, only 25 (53%) respondents matched the ACG guidelines about the optimum time to reuse aspirin after non-variceal UGIB. InterpretationOverall, about half of the responses matched that stated in ACG guidelines, which suggests that only half of the decisions about treatment of non-variceal UGIB made by doctors in Gaza hospitals are based on the best available evidence. A potential limitation of our study was that our questionnaire only covered common and relevant aspects of management, not all aspects of therapy. FundingNone.

Inappropriate Use of Proton Pump Inhibitor (PPI) Infusion in Upper Gastrointestinal Bleeding (UGIB) Patients and the Impact of Proper Physician Education on Outcome: An Experience in Two Community Hospitals

Introduction: UGIB remains a major health care burden in the United States. Recent ACG guidelines for ulcer bleeding supports no improvement in clinical outcome with pre-endoscopic PPI treatment in UGIB patients. However, if endoscopy is delayed or can't be performed or patient is hemodynamically unstable, IV PPI is recommended to reduce further bleeding. In addition to that, patients with suspected variceal bleeding might be benefited with pre-endoscopic PPI infusion along with vasopressin/octreotide infusion. Aim: To identify the prevalence of inappropriate use of pre-endoscopic PPI infusion in UGIB patients. To educate physicians about appropriate use of pre-endoscopic PPI infusion in UGIB and evaluate the change in clinical outcomes following education. Methods: A retrospective study was conducted in patients admitted with UGIB from July 2015 to May 2016. Physicians were educated via emails & posters about the appropriate use of pre-endoscopic PPI infusion in UGIB patients in January 2016. PPI infusion use was defined appropriate prior to endoscopy if patients were hemodynamically unstable, or EGD was delayed or could not be performed or in patients with history of cirrhosis in which variceal bleeding was suspected. Patients who did not meet the criteria for appropriate use of PPI infusion received PPI intermittent bolus. Patients were divided in two groups: Pre-education cohort and post-education cohort. Data was collected in each group to assess patients' demographics, laboratory values at the time of presentation, length of stay, cost, blood transfusion, complications and death. Results: Of 419 patients admitted with UGIB, 73 patients (17.4%) received PPI infusion prior to endoscopy. Inappropriate use of PPI infusion was reduced in post-education group compared to pre-education group. (35% vs 71%, p value 0.0069) (Table 1). Pre-education group was associated with higher length of stay and higher cost compared to post-education group. There was no difference in mortality, re-bleeding rate, and requirement of blood transfusion between two groups. (table 2).Table 1: Effect of education on inappropriate use of PPI infusion in UGIB patientsConclusion: Inappropriate use of pre-endoscopic PPI infusion in UGIB patients is very prevalent in our hospitals. Proper physician education leads to decrease in the inappropriate use of PPI infusion and was associated with reduce length of stay and hospital cost, without change in mortality, re-bleeding rate and requirement of blood transfusion. Further studies are warranted to support our data.Table 2

Second-Look Endoscopy vs. High-Dose PPI for Bleeding Peptic Ulcers

Although some data suggest that routine second-look endoscopy (SLE) can reduce rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB), most are from studies that were conducted prior to the routine use of proton-pump inhibitor (PPI) infusions. To compare the efficacy of SLE and PPI infusion in preventing rebleeding after endoscopic therapy for PUB, investigators in Hong Kong randomized 305 consecutive patients …