Recent Hemorrhage Research Articles

Nonvariceal Upper Gastrointestinal Bleeding

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

Nonvariceal Upper Gastrointestinal Bleeding

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

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome During Hemorrhagic Shock.

Despite overall improvements in critical care, mortality from acute respiratory distress syndrome (ARDS) remains high. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is used to rescue patients with severe ARDS. Although V-V ECMO can be life-saving, there are significant risks associated with this therapy. Hemorrhage is one of the most common complications. Therefore, some providers are reluctant to use V-V ECMO in patients with severe ARDS who concurrently have a high risk of bleeding or recent active hemorrhage. Several studies have been published detailing the safety of heparin-sparing or completely heparin-free anticoagulation strategies in patients on V-V ECMO. We present the cases of two patients with hemorrhagic shock and ongoing transfusion requirements who developed severe and refractory ARDS while in the operating room for hemorrhage control. After the massive bleeding was stopped, both patients were placed on V-V ECMO and were managed with minimal or no therapeutic anticoagulation for the duration of their course on V-V ECMO. Both patients required multiple operations and procedures while on V-V ECMO and there were no significant hemorrhagic complications. In conclusion, V-V ECMO can be considered for use in select patients with severe ARDS and high risk of hemorrhage, active hemorrhage, or ongoing transfusion requirements.

Intracranial Hemorrhage

Intracranial Hemorrhage

Healthcare Utilization and Health Related Quality of Life in Persons with Von Willebrand Disease

Healthcare Utilization and Health Related Quality of Life in Persons with Von Willebrand Disease

Favourable safety profile of S62798, a potent TAFIa (activated thrombin-activatable fibrinolysis inhibitor) inhibitor, in first-in-man study in healthy subjects

Abstract Background Thromboembolic diseases, such as venous thromboembolic diseases represent a significant public health burden. S62798, a selective and potent inhibitor of activated thrombin-activatable fibrinolysis inhibitor (TAFIa), is being developed as a fibrinolysis enhancer for the treatment of thromboembolic diseases, including pulmonary embolism. TAFIa inhibits the fibrinolysis by limiting plasmin generation. Objectives This double-blind, randomised, placebo-controlled first-in-man study was conducted to investigate the safety, pharmacokinetics (PK) and pharmacodynamics (PD) of single ascending doses of S62798 in healthy subjects. Methods Young male (18–40 years) subjects were randomised 3:1 to single ascending doses of S62798 ranging from 3.2 mg to 320 mg or placebo, administered as an intravenous bolus followed by a 7 hour 2-step infusion (part 1), or to 30 mg or 40 mg or placebo administered as a 1-min bolus (part 2). Follow-up ranged from 6 to 13 days post S62798 administration depending on cohorts. Exclusion criteria included bleeding disorders, recent bleeding, and abnormal blood coagulation parameters. Anticoagulant/antiplatelet treatments were not allowed for 30 days prior to and during the study. Safety was assessed by recording adverse events (AE), physical examination, vital signs, biochemical, haematological and haemostasis parameters (prothrombin time, activated partial thromboplastin time, thrombin clotting time, D-Dimers and fibrinogen). Plasma and urine samples for PK assessment were collected pre-dose and up to day 13 to assess the full PK profile. In part 1, ex vivo TAFIa inhibition (spiking of purified human TAFIa) and in vitro clot lysis time were assessed at pre-dose, during and after infusion. The study was performed in France in accordance with the declaration of Helsinki revised in Fortaleza. EudraCT number: 2016–002108–25. Results A total of 56 subjects were randomized to part 1 and 16 to part 2. Subjects were (mean ± SD) 29.5 ±- 5.7 years old with a BMI of 23.9±2.6 kg/m2 in part 1 and 31.4±5.2 years old with a BMI of 23.9±2.5 kg/m2 in part 2. All doses of S62798 administered as a bolus and infusion or a single bolus were well tolerated, and no serious adverse events or discontinuations resulting from AEs occurred during the study. No effects of S62798 on haemostasis parameters were observed. Cardiac safety assessed by 12-lead 24h Holter ECG showed no relevant abnormalities. Plasma exposure of S62798 increased proportionally with the dose. S62798 inhibits TAFIa activity and decreases clot lysis time (reflecting TAFIa activity inhibition) rapidly and dose-dependently in all treated groups. Conclusions S62798, a potent TAFIa inhibitor, has a favourable safety profile with a linear PK. PD results on TAFIa inhibition and clot lysis assay suggest that S62798 has relevant properties to pursue clinical development as an enhancer of endogenous fibrinolysis for the treatment of thromboembolic diseases Funding Acknowledgement Type of funding source: Private company. Main funding source(s): IRIS

Stroke prevention strategies in high-risk patients with atrial fibrillation.

Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.

Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report.

Coronavirus disease (COVID-19) has a wide spectrum of clinical manifestations. In this case report, we describe our first case of COVID-19 pneumonia that was complicated by cerebral venous thrombosis and bleeding in a patient with polycythemia vera. Madam A, a 72-year-old lady with polycythemia vera, ischemic stroke, hemorrhoids, diabetes mellitus, hypertension, and dyslipidemia was admitted to the hospital for COVID-19 pneumonia. She was treated with hydroxychloroquine and lopinavir/ritonavir as per hospital protocol. She continued taking hydroxyurea and aspirin for her treatment of polycythemia vera. Subsequently, she developed rectal bleeding when her platelet count was 1247 × 103/μl, even though she was not on an anticoagulant. Her aspirin was withheld. One week later, she was readmitted to the hospital for cerebral venous thrombosis and her D-dimer was 2.02 μg/ml. She was commenced on a therapeutic dose of low molecular weight heparin. Following that, her D-dimer level showed a decreasing trend and normalized upon her discharge. Patients with polycythemia vera are prone to develop thrombotic and bleeding complications. Management of this group of patients has become more complex with COVID-19 infection. It is crucial for us to decide when to start an anticoagulant especially when there is a history of recent bleeding. We need to balance the risks of further bleeding versus potentially fatal thrombotic events. Studies have shown that D-dimer can be used as a clinical marker to predict thrombotic events in COVID-19 infection. Patients with COVID-19 infection and polycythemia vera will benefit from both pharmacological thromboprophylaxis and close monitoring for bleeding.

S2384 Post-TIPS Hemolytic Anemia Due to Polytetrafluoroethylene Stent

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are performed to decrease the complications of portal hypertension in cirrhosis including salvage for variceal bleeds, medically refractory ascites, and hepatic hydrothorax. Although generally well-tolerated, encephalopathy and liver failure are major complications which can occur after the procedure. One of the lesser known complications of TIPS, however, is a transient hemolytic anemia, which we discuss here. It occurs in approximately 10% of cases. CASE DESCRIPTION/METHODS: A 65-year-old male with history of alcoholic cirrhosis decompensated by esophageal and gastric varices was referred to our facility after recent gastrointestinal hemorrhage to evaluate for a TIPS procedure. After being deemed a candidate, a 90 mm total length (70 mm covered / 20 mm uncovered) Viatorr (GORE, Flagstaff, AZ, USA) polytetrafluoroethylene (PFTE) stent-graft was successfully placed, and the portosystemic gradient decreased from 16 mmHg to 5 mmHg. Post-procedure, however, the patient developed worsening jaundice. Laboratory data demonstrated anemia with hemoglobin of 6.0 gm/dL, reticulocytosis with a reticulocyte index of 7.9%, hyperbilirubinemia with up-trending total bilirubin from 6.5 mg/dL to 18.9 mg/dL and an indirect bilirubin of 8.0 mg/dL, and findings consistent with hemolysis with an elevated LDH of 254 units/L, low haptoglobin of < 15 mg/dL, and a negative Coomb’s test. Peripheral smear showed anisocytosis, Burr cells, and target cells; no schistocytes were observed. This led to a diagnosis of non-immune hemolytic anemia. During the remainder of the patient’s hospital course, his hyperbilirubinemia slowly improved prior to discharge. DISCUSSION: Hemolytic anemia is one of the lesser known complications following TIPS. It was first described in the 1990s when bare metal stents (BMS) were commonly used. Literature refers to the hemolytic process with BMS as the “Naked Stent” syndrome due to injury of red blood cells after colliding with the exposed mesh of the stent. In order to improve stent patency and decrease complications, PFTE stents were introduced; however, hemolytic anemia may still occur as described in our case. The pathogenesis remains the same due to stent-related trauma to red blood cells as the covered PFTE stents have areas which remain exposed. With complete endotheliazation of the stent, the hemolytic anemia generally resolves without further intervention in 8–12 weeks.

Role of percutaneous catheter-directed thrombolysis in acute limb ischemia: predictors of outcome

Objectives Acute thrombotic ischemia is a very dangerous limb-threatening and life-threatening disease. It is better treated by catheter-directed thrombolysis. Now, tissue plasminogen activator like alteplase is safer than streptokinase or urokinase. The current study is designed to show its efficacy and safety and to investigate variables that correlate with outcome. Patients and methods This is a prospective cohort study. It included patients with acute thrombotic limb ischemia. Excluded ones were acute ischemia due to embolism, trauma, arterial dissection, complicated aneurysm, bleeding risk, history of recent intracranial bleeding, massive gangrene, or uncontrolled hypertension. The study is approved by ethical committee of Beni-Suef University. Primary end points were technical success, clinical success, and limb salvage. Secondary end points were procedural complications. Results A total of 36 patients were enrolled in the study from March 2019 to February 2020 in Beni-Suef University Hospital. It included 21 (58.33%) male patients. The patients’ mean age was 58.42 years and mean BMI was 31.56 kg/m2. Risk factors were smoking in 15 (41.67%) patients, diabetes mellitus in 16 (44.44%) patients, hypertension in 15 (41.67%) patients, ischemic heart disease in nine (25%) patients, and hyperlipidemia in 14 (38.89%) patients. Clinical presentation showed that 16 (44.44%) patients were in Rutherford IIa category and 20 (55.56%) patients were in Rutherford IIb category. Limb salvage was achieved in 14/16 (87.5%) of patients in Rutherford IIa category and 12/20 (60%) of patients in Rutherford IIb category. Statistical analysis showed a correlation of BMI and severity of ischemia with outcome. Moreover, the frequency of risk factors was correlated with outcome. Conclusion Catheter-directed thrombolysis using alteplase is effective and safe to treat acute thrombotic limb ischemia. Its outcome is better with lower BMI, less severe ischemia, and less or no comorbid disease.

EMERGENT THROMBECTOMY OF HIGH RISK PE

SESSION TITLE: Fellows Pulmonary Vascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Some physiologic consequences of high risk pulmonary emboli (PE), such as shock and refractory hypoxemia, require urgent reperfusion therapy. Delaying management in those cases may lead to catastrophic consequences including hemodynamic collapse. However, comorbid conditions often limit treatment options complicating management. Here we present two cases of acute onset severe hypoxemia attributable to PE. Neither patient was a candidate for pharmacological thrombolysis due to recent or active GI bleeding. CASE PRESENTATION: Patient A, a 52-year-old male with prior colectomy due to ulcerative colitis, was admitted with duodenal perforation and post-ERCP pancreatitis with one day of significant dyspnea and hypoxemia. He underwent testing with a computed tomography pulmonary angiogram (CTPA) which revealed pulmonary emboli. Despite intubation, FiO2 of 100%, recruitment maneuvers, and inhaled vasodilator therapy with epoprostenol, he had persistent and refractory hypoxemia (Table). After the initiation of heparin, he had recurrent gastrointestinal hemorrhage and required vasopressors. Patient B, a 71-year-old female with multiple myeloma and on chemotherapy with pancytopenia and lower GI bleed two weeks prior, presented with acute onset of dyspnea for less than one day and high oxygen requirements and labile hemodynamics with signs of hypoperfusion (Table). CTA confirmed pulmonary emboli. Point of care ultrasonography demonstrated signs of right heart strain. DISCUSSION: Both patients had bilateral pulmonary emboli and filling defects in distal left main pulmonary artery extending into left upper and lower lobar arteries and lobar and segmental arteries on the right. After rapid discussion with a multidisciplinary PE response team, percutaneous aspiration thrombectomy via the FlowTriever System was utilized in both patients. The FlowTriever System is a large bore catheter device which is FDA approved for mechanical thrombectomy in the pulmonary arteries. Both patients were successfully treated with acute clinical and technical success, with intraprocedural improvements of mean pulmonary artery pressures of > 25%. Patient A had immediate improvement of hypoxemia. Patient B had improvement in her hemodynamic stability and organ perfusion. Both patients did require packed red blood cell transfusions. This is partially attributed to both patients having active GI bleeding, but can be exacerbated aspiration of blood during thrombectomy if multiple passes are required. CONCLUSIONS: Percutaneous thrombectomy is an alternative treatment option in critically ill patients with high risk of hemodynamic collapse or refractory hypoxemia, especially in those with contraindications to thrombolysis. One limitation is the possibility of intraprocedural blood loss which should be anticipated and address with volume expansion with or without transfusion. Reference #1: Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med. 2011;26(5):275-294. doi:10.1177/0885066610392658 Reference #2: Wible BC, Buckley JR, Cho KH, Bunte MC, Saucier NA, Borsa JJ. Safety and Efficacy of Acute Pulmonary Embolism Treated via Large-Bore Aspiration Mechanical Thrombectomy Using the Inari FlowTriever Device. J Vasc Interv Radiol. 2019;30(9):1370-1375. doi:10.1016/j.jvir.2019.05.024 DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response Consultant relationship with Bellerophon Please note: $1001 - $5000 Added 06/01/2020 by Roger Alvarez, source=Web Response, value=Travel Advisory Committee Member relationship with United Therapeutics Please note: $1001 - $5000 Added 06/01/2020 by Roger Alvarez, source=Web Response, value=Consulting fee No relevant relationships by Adhiraj Gosine, source=Web Response No relevant relationships by Susanna Leonard, source=Web Response

S2231 Successful Endoscopic Therapy of Acute Lower GI Bleeding From Serosal Vessel Within a Contained Perforation Abscess Cavity

INTRODUCTION: We present a case of successful colonoscopic therapy of bleeding from a serosal vessel within a contained perforation cavity. CASE DESCRIPTION/METHODS: A 66 year old woman developed severe necrotizing post ERCP pancreatitis with walled off necrosis, multiple abdominal abscesses, and duodenal and colon perforation. She was transferred for evaluation of recurrent lower gastrointestinal bleeding which had been managed with transfusions due to her severe comorbidities. CT showed multiple abdominal collections with the dominant peripancreatic collection communicating with the descending colon. Colonoscopy showed large amount of blood clots and ischemic looking ulcers from 30-35cm from the anus. The scope could not be passed beyond 35cm due to stricture. A cavity was seen at 30cm which corresponded to the perforation from the peripancreatic collection seen on CT. This was filled with large amount of clots. The patient was managed conservatively and discharged back to the nursing facility. She was transferred back 6 weeks later with worsening bleeding. Repeat CT showed worsening abdominal abscesses and a drainage catheter was placed in to the loculated collection near the descending colon. CT angiogram showed bleeding from the stomach. Endoscopy was unremarkable. Sigmoidoscopy showed the known cavity at 30cm which was filled with clots and red blood. The drainage catheter was seen within the cavity. Once blood was cleared a stigmata of recent hemorrhage was seen and obliterated with hemostatic forceps. The bleeding stopped and patient was discharged back to the nursing home. DISCUSSION: Our patient presented with lower gastrointestinal bleeding from a non-gastrointestinal source since her bleeding occurred from a vessel outside of the colon. The blood drained through the colon through the perforation which is why she did not have significant bleeding nor fluid output through her drain since they drained preferentially through the large colonic fistula. Recognition of the stigmata of recent hemorrhage within the abscess cavity and hemostasis resolved the bleeding. It is safe to endoscope cavities communicating with the gut, especially when they are chronic and also have external drainage as in our patient since any CO2 insufflation or irrigation would drain outside of the body. Therefore such cavities including peripancreatic walled off necrosis, abscess, or contained perforation could be evaluated for cause of bleeding which can be safely treated using conventional hemostasis.Figure 1.: Blood clots (triangle) filling the perforated abscess is seen on the left and colon lumen (arrow) on the right.Figure 2.: Stigmata of recent hemorrhage (arrow) seen after clots cleared.Figure 3.: Percutaneous drain (triangle) is seen on the left and obliterated stigmata (arrow) on the bottom.

S1298 Identification and Treatment of Gastrointestinal Angiodysplasia With Stigmata of Recent Hemorrhage May Reduce Rebleeding in Patients Admitted for Suspected Small Bowel Bleeding

S1298 Identification and Treatment of Gastrointestinal Angiodysplasia With Stigmata of Recent Hemorrhage May Reduce Rebleeding in Patients Admitted for Suspected Small Bowel Bleeding

S2185 “Red Nipple Sign”: A Precursor to “White Nipple Sign”

INTRODUCTION: Cirrhosis affects approximately 3.6 out of every 1000 adults in North America and leads to about 32,000 deaths annually. Variceal hemorrhage occurs in 25–40% of patients with cirrhosis and is a major cause of cirrhosis related morbidity and mortality, associated with up to 20 percent mortality. Additionally, those patients who survive a variceal hemorrhage have a 70 percent chance of recurrent variceal hemorrhage within one year. CASE DESCRIPTION/METHODS: We present a case of a 70-year-old male with past medical history of alcoholic cirrhosis, hypertension and rheumatoid arthritis (taking nonsteroidal anti-inflammatory drugs [NSAIDs]) admitted with hematochezia and hematemesis. The patient was started on a proton pump inhibitor (PPI), octreotide and ceftriaxone, and underwent an emergent esophagogastroduodenoscopy (EGD). Two columns of large esophageal varices were identified extending from Z-line to mid-esophagus (Figure 1). One of the varices was noted to contain two adjacent red spots which appeared similar to stigmata labeled as “white nipple sign” but red in color (Figure 2). A decision was made to perform band ligation and one band was deployed to each variceal column base resulting in excellent decompressive effect. One additional band was then deployed over both “red spots,” which during suctioning into the bander cap began to actively spurt heme, however, bleeding resolved after band deployment. The sites of previous “red spots” were then noted to have classic “white nipple sign” appearance (Figure 3). The patient tolerated the procedure well, was monitored as inpatient and subsequently discharged home with follow-up in a hepatology clinic. DISCUSSION: Variceal hemorrhage is a gastrointestinal emergency with prognosis reliant on achieving hemostasis and preventing future hemorrhage. Therefore, it is extremely important to recognize endoscopic features of high-risk stigmata for future hemorrhage. The most commonly reported features are often described as “red signs,” and include red wales marks, cherry red spots and hematocystic spots. One stigma of recent hemorrhage is known as “white nipple sign,” which owes its appearance to the platelet-fibrin plug overlying a varix. On literature review, we found this to be the first case of showing endoscopic transition of a red spot (“red nipple sign”) into a “white nipple sign,” demonstrating likely pathogenesis from a finding significant for high risk of hemorrhage to the finding consistent with post hemorrhage state.Figure 1.: Two columns of large varices extending from z-line to mid-esophagus.Figure 2.: Close up endoscopic image of red spot overlying varix.Figure 3.: Site of previous red spot, subsequently noted to have "white nipple sign" after band ligation of varix.

S3175 Gastrointestinal Bleeding and Endoscopic Evaluation Within 90 Days of Acute Cardiac Event

INTRODUCTION: Patients are at increased risk of gastrointestinal bleeding (GIB) after acute coronary syndrome (ACS). The diagnosis and management of GIB in this setting is challenging as the risk of endoscopic intervention and sedation increases after ACS. The risk of sedation increases multifold with increasing ASA status. Re-vascularization of coronary lesions via stenting or CABG should theoretically decrease this risk by restoring blood flow to the ischemic myocardium. Data regarding safety of endoscopic evaluation before and after a myocardial infarction remains sparse in the literature. METHODS: We reviewed the chart of a sample of 119 patients admitted for GIB within 90 days before and after an ACS event between 2008 and 2019. Patients were identified through ICD billing codes for myocardial infarction, angina, and GIB. We collected data on 61 of these patients who met the inclusion criteria for this study. Descriptive statistics was used to tabulate the findings. RESULTS: Our cohort included 41 men (67%) with an average age of 71 +/- 23.2 years. 32 patients (52%) were receiving dual anti-platelet therapy at the time of GIB and 16 (26%) were receiving anticoagulation at the time of bleeding. Majority of these patients, 49 (80%) underwent endoscopic evaluation within 3 months after cardiac event, while 8 patients (13%), underwent endoscopic evaluation within 3 months prior to ACS. A source of bleeding could be identified in 36 (59%) of patients with 16 (26%) exhibiting signs of active bleeding or stigmata of recent bleeding at the time of evaluation. 22 (37%) patients were diagnosed with peptic ulcer disease, while angioectasias were the second most common finding. Rebleeding was observed in 9 (15%) of patients with all but one occurring in the first month after the incident bleed. At least 4 patients did not undergo evaluation for GIB given cardiac arrest, refractory cardiogenic shock and anticipated imminent death. All-cause mortality was 18% at 1 year, however, none of the deaths occurred during or within 24 hrs of endoscopic evaluation and all were attributed to non-GI causes. CONCLUSION: GIB occurs commonly in patients after ACS often in a setting of anti-platelet, anti-coagulant therapy. While endoscopic evaluation is high risk after ACS, it remains safe in most patients following appropriate revascularization. However, mortality in patients with ACS and GIB is high within 1 year of the events, mostly attributed to non-GI etiology.Table 1Table 2

S2777 Metastatic Cervical Adenocarcinoma: A Rare Cause of Upper GI Bleeding

INTRODUCTION: Primary small bowel neoplasms are rare, accounting for 1–5% of all gastrointestinal (GI) tract malignancies. Metastatic small bowel lesions are more common than primary and typically arise from malignant melanoma and adenocarcinomas from the lung, kidney and colon. Distant metastasis from cervical adenocarcinoma is extremely rare, most often seen with advanced stages. We report the case of a young female with known cervical cancer presenting with acute abdominal pain and melena secondary to metastatic ulcerated duodenal mass. CASE DESCRIPTION/METHODS: 43-year-old female with stage IIIB cervical adenocarcinoma status post pelvic radiation, human immunodeficiency virus (HIV) on antiretroviral therapy, and right upper extremity deep vein thrombosis on Eliquis presented with mild diffuse abdominal pain and intermittent melena over four weeks. On admission, she was afebrile and hemodynamically stable. Laboratory findings were significant for acute blood loss anemia with hemoglobin 3.3 g/dL (7.6 g/dL two months prior). Computed tomography abdomen and pelvis showed a heterogenous cervical mass near the sigmoid colon without signs of obstruction or perforation. Three units of packed red blood cells were transfused, proton pump inhibitor drip was initiated, and anticoagulation was held. Esophagogastroduodenoscopy revealed a large, infiltrative, ulcerated and friable mass within the second portion of the duodenum (Figure 1), occupying 50% of the luminal circumference with stigmata of recent bleeding. Duodenal mass biopsies confirmed metastatic cervical adenocarcinoma (Figures 2 and 3). She had no further bleeding throughout her course and was discharged home with palliative oncology care. DISCUSSION: Cervical cancer is the second most common gynecologic malignancy. Up to half of stage III cervical cancer patients present with distant metastases, most often to liver, lungs and bone marrow; however, only approximately 8% have GI tract metastases, often to the rectosigmoid secondary to local extension. Isolated metastases to the small bowel are exceedingly rare. Clinical presentations include small bowel obstruction, anemia, abdominal pain and, less commonly, overt GI bleeding. Early diagnosis of such an unusual pattern of metastasis related to cervical cancer is vital for optimal therapeutic management and prediction of prognosis.Figure 1.: Ulcerated mass at second portion of the duodenum.Figure 2.: Medium-power view demonstrating reactive duodenal mucosa on the top and poorly-differentiated carcinoma growing up from the submucosa (H&E, 100x).Figure 3.: High-power view demonstrating marked pleomorphism, 'bubbly' cytoplasm, apoptotic bodies and numerous atypical mitotic figures (H&E, 400x).

S3013 The Two Challenges in Management of Gastric Glomus Tumors

INTRODUCTION: Gastric glomus tumors (GGTs) are rare gastrointestinal lesions originating from the neuromuscular arterial canal or vascular lumen which share many overlapping features with other stromal lesions. Even though most cases of GGTs are benign, there is lack of reliable histological features predictive of tumor behavior. CASE DESCRIPTION/METHODS: A 42-year-old male with hypertension and gastroesophageal reflux disease presented with a history of intermittent left upper quadrant pain and non-bloody, non-bilious emesis. He was afebrile and had a soft, non-distended abdomen. Labs were notable only for mild iron deficiency anemia. Contrast-enhanced computed tomography (CT) of the abdomen showed a 3.2 × 2.7 × 3.1 cm soft tissue mass with central calcification and vascularity along the lesser curvature of the stomach. Esophagogastroduodenoscopy (EGD) demonstrated a 3 cm submucosal ulcerated mass at the incisura (Figure 1). Endoscopic ultrasonography (EUS) showed a well-defined hypoechoic lesion arising from the muscularis propria, with maximum diameter of 3.3 cm (Figure 2). Further investigation with fine needle aspiration (FNA) of the lesion demonstrated – small, round and uniform cells intermixed with capillary-sized vessels along with in-tumor-calcification, mild pleomorphism, and sparse Ki67 staining, but no evidence of mitotic activity (Figure 3A) which demonstrated positivity for smooth muscle actin and synaptophysin and weak stained for placental alkaline phosphatase suggestive of a glomus tumor (Figure 3B). The tumor cells lacked markers more indicative of an epithelioid gastrointestinal stromal tumor including: CD117, CD34, Desmin, S-100, and DOG1. After discussing surveillance versus endoscopic/surgical resection options with the patient, surgical wedge resection of the tumor was performed for definitive management. Pathology of excision specimen was consistent with a benign gastric glomus tumor. DISCUSSION: GGTs pose two challenges: 1) differentiation from more common stromal/mesenchymal tumors and 2) prediction of tumor behavior. In our patient, although EUS and FNA showed small benign cells, given the patient’s young age, symptomatic presentation, ulcerated lesion appearance and neovascularity, we proceeded with resection after shared decision making. Given the rarity of GGTs, this case highlights the importance of establishing an accurate diagnosis and the various factors that must be taken into consideration to best determine malignant potential.Figure 1.: A) EGD of pre-pyloric stomach showing multiple, small non-bleeding erosions near the antrum (yellow arrows). B) EGD showing a large, submucosal mass with no bleeding and no stigmata of recent bleeding was found at the incisura (yellow arrows).Figure 2.: EUS showing a hypoechoic mass in the stomach incisura angularis (yellow arrows).Figure 3.: A) Hematoxylin and Eosin (H& E) staining of FNA (30x magnification). B) Smooth muscle actin (SMA) stain on FNA specimen which is characteristically positive in glomus tumors (16x magnification).

S2143 Hepatic Artery Pseudoaneurysm Due to Aortic Dissection: An Unusual Cause of Portal Hypertension and Bile Duct Compression

INTRODUCTION: Hepatic artery pseudoaneurysm is rarely seen as a result of aortic dissection. Life-threatening gastrointestinal bleeding requiring urgent therapeutic intervention can occur as a complication of pseudoaneurysm formation. CASE DESCRIPTION/METHODS: A 66 year-old male with a history of a type A aortic dissection which was repaired four years prior to presentation was evaluated in the the emergency department for multiple episodes of melena. He was previously treated at another institution for a biliary stricture with a metal stent. On physical exam, he was hemodynamically stable and had scleral icterus. Initial labs revealed hemoglobin 8.7 gm/dl, platelets 240 K/CUMM, aspartate aminotransferase 192 U/L, alanine aminotransferase 161 U/L, alkaline phosphatase 380 U/L, total bilirubin 21 mg/dl, and INR 1.6. ERCP revealed a patent stent in the common bile duct and no evidence of hemobilia. Subsequent esophagogastroduodenoscopy revealed three columns of large, non-bleeding esophageal varices with stigmata of recent bleeding. Endoscopic band ligation was performed. After completion of the procedure, abdominal aortic angiography revealed interval enlargement of a fusiform aneurysm of a false lumen of the common hepatic artery as well as resultant central compression of the adjacent portal venous system and intrahepatic bile ducts. The patient then had an episode of hypotension and tachycardia and required transfusion of four units of red blood cells. Interventional radiology emergently performed catheter-directed embolization of the common and right hepatic artery pseudoaneurysms, and the patient did not experience any further episodes of gastrointestinal bleeding. DISCUSSION: Our evaluation of this clinical case revealed two interesting points. In retrospect, the biliary stricture was the result of direct compression of the bile duct by the pseudoaneurysm, which may not have been appreciated by the endoscopist performing the initial procedure. Second, the etiology of this patient's portal hypertension was also a direct result of compression of the portal vein by the aneurysm. On his initial presentation, we did not make these associations, but further cross-sectional imaging led us to the correct answer. The patient benefited from early involvement of vascular interventional radiology, who were able to provide a therapeutic intervention via catheter-directed coil embolization. In cases where interventional radiology is unable to intervene, surgical management with vascular surgery may be necessary.Figure 1.: Aneurysmal dilation of the false lumen of the common hepatic artery (1.9 cm in diameter) causing extrinsic compression of the adjacent biliary tract and portal venous system.

S2561 Successful Treatment of Splenic Vein Thrombosis-Induced Gastric Varices During Pregnancy

INTRODUCTION: Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by excessive platelet production leading to a prothrombotic state. Thrombosis of the portal venous system has been well-established in patients with ET and can cause life-threatening complications in certain situations. In pregnant females, ET alone has been associated with higher rates of fetal demise and treatment options for acute complications may be limited. We report a unique case in which a 28-week pregnant female with ET complicated by splenic thrombosis was successfully treated for life-threatening bleeding gastric varices. CASE DESCRIPTION/METHODS: A 28-week pregnant, 38-year-old female with a previous history of obstetric complications (intrauterine growth restriction, HELLP syndrome) requiring preterm C-sections, and ET complicated by splenic vein thrombosis and marked splenomegaly presented with hematemesis and melena. Upon admission, she was found to have a hemoglobin of 7.5g/dL (baseline 13g/dL pre-pregnancy). Following stabilization, an urgent EGD was performed noting large, non-bleeding gastric varices within the gastric cardia and fundus with stigmata of recent bleeding (Figure 1). Follow-up magnetic resonance venography confirmed presence of current splenic vein thrombosis. To prevent recurrent bleeding, and possible obstetric complications, an empiric splenic artery embolization followed by open splenectomy was performed. No complications were encountered in either the mother or baby. Post-operatively, her hemoglobin stabilized, and she was discharged in stable condition. DISCUSSION: Abdominal thrombotic complications in ET has been well established. Thrombosis of the portal venous system, in-particular the splenic vein, can lead to the formation of gastric varices which can cause life-threatening bleeding. Splenectomy has been referred as the treatment of choice in these situations however its role during pregnancy has not been well-reported. We report a successful case in which an open splenectomy was safely performed in a 28-week pregnant patient for the treatment of bleeding gastric varices.Figure 1.: Large gastric varices within the gastric fundus and cardia on retroflexed view.

S2121 Overt Small Bowel Bleeding From a Jejunal GIST

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare causes of gastrointestinal malignancies. Herein we describe a cause of upper GI bleeding from a jejunal GIST. CASE DESCRIPTION/METHODS: A 58-year-old male with history of chronic hepatitis B, hypertension and hyperlipidemia presented to the hospital with melena and lightheadedness. The patient was hemodynamically stable with an elevated BUN/creatinine ratio and initial hemoglobin of 11.5 g/dL. His repeat CBC twelve hours later revealed down trend of hemoglobin to 8.5 g/dL. Review of the patient’s past admission and outpatient history revealed the patient was admitted two years prior for GI bleed requiring multiple blood transfusions. At that time, upper endoscopy, colonoscopy and CT scan of the abdomen/pelvis were unrevealing as was a 99 Technetium bleeding scan. He was discharged and scheduled for outpatient small bowel video capsule but was lost to follow up. He returned to the clinic one year later and repeat upper endoscopy and colonoscopy were performed. Upper endoscopy revealed mild gastritis and colonoscopy revealed medium sized hemorrhoids but he had a poor colon bowel prep. Small bowel video capsule endoscopy revealed AVM's in the proximal small bowel but the study was also poor due to bile obscuring most of the small bowel mucosa. Due to concern for possible small bowel AVM bleed, we opted to perform upper endoscopy with push enteroscopy. A large ulcerated friable nodular mass with stigamata of recent bleeding was identified in the proximal jejunum. Bite on bite biopsies were obtained to evaluate the mass and a tattoo was placed for identification purposes. Despite the deep biopsies, pathology later returned as normal small bowel mucosa. A CT enterography was obtained revealing a 3.5 × 3.6 × 3.5 cm hyperenhancing mass arising from the proximal jejunum with adjacent wall thickening. Surgical consultation was obtained and the patient underwent laparoscopic resection of the mass. Pathology demonstrated low grade spindle-cell type gastrointestinal stromal tumor. DISCUSSION: Although an uncommon cause for GI bleeding overall, GISTs are a common cause of small bowel bleeding. Obtaining a thorough history and evaluation of the patient’s prior outpatient records proved useful in identifying the cause of bleeding in this case even though it was different from what was suspected.Figure 1Figure 2