Recurrent GI Bleeding Research Articles

Retrospective study on endoscopic findings of gastritis in children attending the gastrointestinal tract endoscopic unit of Assiut University Children Hospital over a 15-year-period

Background: Children with gastritis typically exhibit recurrent stomach pain and dyspepsia or vomiting.Objectives: To assess the frequency, clinical manifestations, endoscopic pictures, aetiology and outcome of gastritis in children who visited the gastrointestinal tract (GIT) endoscopic unit of Assiut University Children Hospital.Method: This was a retrospective, crosssectional study conducted at Assiut University Children Hospital GIT Endoscopic Unit from 1st January 2005 to 31st December 2019.Results: Upper GI endoscopy, done in all cases, showed that 66 (8.1%) had erythematous gastric mucosa, 106 (13%) had nodular gastric mucosa, 212 (25.9%) had erythematous gastric mucosa and hyperaemia, 147 (18%) had erythematous gastric mucosa and nodularity, 156 (19.1%) had hyperaemic mucosa and petechiae, 77 (9.5%) had hyperaemic mucosa and erosion, and 53 (6.5%) had multiple erosions and ulcers.Conclusions: Gastritis represented 9.4% of children who underwent upper GI endoscopy. Helicobacter pylori was the commonest cause with high recurrence. Patients presented with recurrent GI bleeding, and those with erythematous hyperaemic mucosa on endoscopy showed recurrence compared to their counterparts.

S2998 Heyde Syndrome Associated With Recurrent GI Bleeding, Severe Aortic Stenosis & Acquired Von Willebrand Deficiency

S2998 Heyde Syndrome Associated With Recurrent GI Bleeding, Severe Aortic Stenosis & Acquired Von Willebrand Deficiency

S3150 When It Bleeds, It Pours: Esophageal Dieulafoy as a Rare Cause of Recurrent GI Bleeding

S3150 When It Bleeds, It Pours: Esophageal Dieulafoy as a Rare Cause of Recurrent GI Bleeding

Evaluation of Endoscopic Mucosal Band Ligation for Treatment of Portal Hypertensive Gastropathy in Cirrhotic Patients

Background: Portal hypertensive gastropathy (PHG) is a clinical condition that can lead to chronic gastrointestinal (GIT) hemorrhage in cirrhotic patients, presented by chronic anemia. The diagnosis is based on the endoscopic features. The aim of the study was to evaluate the safety and efficacy of the use of endoscopic mucosal band ligation for treatment of portal hypertensive gastropathy in cirrhotic patients.
 Patients and methods: This prospective study included 80 cirrhotic anemic patients. They divided into four equal groups: Group (A) included patients who were treated with drugs as beta-blockers. Group (B) included patients treated with argon plasma coagulation (APC). Group (C) included patients treated with endoscopic mucosal band ligation and Group (D) included patients treated with combined endoscopic mucosal band ligation and APC in subsequent sessions.
 Results: There was statistical significant decrease in TIBC throughout follow up in the four studied groups. And there was statistical significant increase in Hb, and serum ferritin throughout follow up in the four studied groups.
 Conclusion: after 2nd follow-up in managing PHG, we have found that there is significant increase in Hb, serum ferritin and significant decrease in recurrent GI bleeding among all groups.

Long Term Follow-up of an Investigator-Initiated Phase 2 Study of Ruxolitinib in MPN-Associated Splancnic Vein Thrombosis (SVT-RUXO)

Background. Splanchnic vein thrombosis (SVT) is a frequent onset manifestation of an underlying myeloproliferative neoplasm (MPN), or can appear during the disease course. We reported primary results of an investigator-initiated Phase 2 study (SVT-RUXO: Eudract 2012-002253-30) with ruxolitinib (RUX) in 21 patients (pts) with MPN-associated SVT (Pieri L, AJH 2017; 92:187). The treatment proved safe and effective in reducing spleen volume by >35% by NMR at the planned primary analysis at 24 weeks (w) in 29% of the pts, and a >50% spleen length reduction by palpation at any time to 24w was obtained by 62% of the pts. Pts who completed the 24w core study and well tolerated the drug and had evidence of clinically-significant improvement were allowed to enter an extension phase up to w72, then entered a long-term FU (see below for pt disposition). Aim. Herein we present long-term follow up (FU) of the SVT-RUXO study after a median of 104 months, range 6.2-9.8y. Study details. The promoter of the study was the AGIMM group of Italian investigators supported by Assoc Italiana per la Ricerca sul Cancro-AIRC. The drug was provided free by Novartis, that had no role in trial design and data analysis. Safety data were reported as cumulative incidence of adverse events (CTCAE v4.03). Clinical responses were defined according to ELN and IWG-MRT criteria. After primary endpoint at 24w, spleen response was assigned by >50% reduction of spleen length by palpation. Results. Patients disposition. A total of 21 pts (38% PMF, 24% PV, 19% ET, 14% PPV-MF, PET-MF 5%) were enrolled and completed the 24w core study for primary end point. Eighteen pts (86%) were still on study at the 72w extension phase time point, and entered a long-term FU until loss of benefit and/or toxicity, or until shift to commercial RUX. The latter pts were continued to be followed under routine care, and data were collected. One pt died at w252 (sepsis), 1 pt entered another trial after 101 mo and 1 received stem cell transplant after 66 mo for loss of response. As by June 30th 2022, 15 (71%) pts are still receiving ruxo, 7 ongoing in the study and 8 receiving commercial drug. Safety. In the post-72w period, the number of AE ranged 0-20/pt. G3 events were thrombocytopenia (n=2), increase of CPK (n=1). All other events were G<2 and included anemia (56%), thrombocytopenia (44%), leukopenia (39%). Four pts (26%) had G2 H. zoster reactivation. SAE included second cancer (1 pheochromocytoma and 1 prostate adenocarcinoma), and one each pneumonia, pleural effusion, encefalopathy, inguinal ernial repair, abdominal pain, sepsis, INR increase in a pt receiving coumadin. Two pts developed COVID-19, with full resolution and under continued ruxo administration. Efficacy. At latest FU, 11 pts (73%) had a maintained spleen response (defined according to IWG-MRT criteria), the remaining 4 had stable spleen volume, in no pt splenomegaly progressed. No pt had disease-related symptoms. Median Hb was 12.7 g/dL (10.0-14.3), Hct 39.8% (31.3-42.4%), platelet count 136x109/L (46-349), leukocyte count 6.5 x109/L (2.2-43.0), neutrophil count 4.43 x109/L (1.3-38.0). Five pts (33%) were in clinical CR (no spleen/liver, no symptom), 12 pts (80%) had hematologic CR. There was no gastrointestinal or other site bleeding episodes and no thrombotic event. One pt required positioning of a TIP for increased portal hypertension with ascites. Exploratory endpoint. Fourteen of 15 pts were JAK2V617F mutated, and serial measurements of JAK2VAF VAF in granulocytes were available in 10 pts up to latest cutoff date. Mean JAK2V617F at baseline was 51.7% (+21.1) and 36.5% (+34.5) at 8+1y. According to IWG-MRT response criteria, 4 pts achieved partial molecular response (PMR; ie, >50% reduction from baseline), 5 pts were not responders; one pt had a deep molecular response (DMR) from VAF 15% to <2%, stable since 5+y. A spleen response was present in all pts with PMR+DMR, 4 had hematologic response, while the remaining one pt with PMR had 63x109/L platelets with normal Hb and leukocyte count. Conclusions. After a median follow-up of 8.6 years, 71% of pts enrolled in the SVT-RUXO study continue to be on drug with substantial efficacy on symptoms and splenomegaly, and no recurrent thrombosis nor GI bleeding events. There was no novel safety signal. Molecular responses were noted in half of pts with serial measurements of JAK2V617F VAF and were associated with hematologic and clinical improvement.

Recurrent bleeding duodenal and colonic ulcers due to post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplantation as the result of immunosuppressant medications. Epstein-Barr virus (EBV) has been implicated in most of these cases, specifically with B-cell predominant lymphoma. This case report describes a 24-year-old female who presented with recurrent GI bleed within 6months post-orthostatic heart transplant. Endoscopic evaluations including video capsule study, push enteroscopy, and colonoscopy revealed multiple ulcerated lesions in duodenum, jejunum, and colon secondary to Epstein-Barr Virus-associated monomorphic PTLD. Despite continuation of rituximab after discharge, she returned to the hospital for recurrent GI bleed requiring additional endoscopic intervention. PTLD is a devastating disease of the post-transplant population. Due to a high risk of recurrent GI bleeding, patients with PTLD may benefit from careful monitoring by gastroenterology as an outpatient with a low threshold for repeat endoscopic evaluation despite being on immunotherapy or chemotherapy.

S1949 An Unusual Case of Chronic Pancreatitis Presenting With Recurrent Obscure Gastrointestinal Bleeding

Introduction: Chronic pancreatitis (CP) is a sequela of repeated pancreatic injury resulting in loss of exocrine and endocrine function of the pancreas. In most cases, CP presents with chronic abdominal pain and patients usually have either clinical and radiological features of CP, with gastrointestinal bleeding (GIB) as a very rare occurrence. Herein is a presentation of recurrent obscure GIB caused by chronic pancreatitis. Case Description/Methods: A 48-year-old male with a prior history of PUD and recurrent GIB episodes for several years presents with dark red bleeding per rectum for two days. Of note, the patient had undergone several endoscopies and the most recent endoscopies done six months prior were all unremarkable. He denied hematemesis, NSAIDs, or anticoagulant use. Denied liver or pancreatic disease but endorsed a prior history of moderate alcohol intake. Physical examination was unremarkable except for tachycardia and epigastric tenderness. He was mildly anemic with leukocytosis. The abdominal and pelvic CT scan was unremarkable. EGD revealed a small gastric oozing site (Figure) suspected to be an AVM or dieulafoy's lesion and clipped. He continued to have a frank bloody stool and developed hemorrhagic shock requiring multiple transfusions and vasopressors. Findings on two additional EGDs were unremarkable. He had mesenteric angiography performed with ligation of the gastroduodenal artery empirically. Despite the intervention, he continued to bleed. Abdominal CTA (Figure) noted active extravasation in the 2nd segment of the duodenum. Explorative laparotomy revealed an edematous head and uncinate portion of the pancreas with venous engorgement. There was erosion into the duodenum with acute hemorrhage (Figure). A duodenotomy and Roux-en-y (duodenojejunostomy and jejunojejunostomy) were performed. On account of the above findings, a tissue biopsy was not obtained. Following surgery, he remained hemodynamically stable and got discharged. Discussion: Massive obscure GIB due to complications of pancreatitis rarely does occur. A few cases reported are due to complications resulting from hemosuccus pancreaticus, pseudoaneurysm from a vascular supply, or erosion into adjacent viscus in the setting of known pancreatitis. Our patient represents an unusual presentation in which his recurrent obscure massive GI bleeding was the initial presentation of CP. We present this case to broaden our knowledge that obscure GI bleeding can be a complication of CP and the only manifestation of the disease.Figure 1.: The image on the left shows an EGD with the gastric oozing site with clips, and the middle image shows CTA with extravasation in the second segment of the duodenum. The image on the right shows the posterior aspect of the head of the pancreas, the uncinate, and venous engorgement.

Multifocal Small Bowel Angioectasias: Managed with Innovative, Nonresectional Surgical Procedure

Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.

Pre-operative sarcopenia is predictive of recurrent gastrointestinal bleeding on left ventricular assist device support: A multicenter analysis.

Whether pre left ventricular assist device (LVAD) sarcopenia is associated with higher incidence of gastrointestinal bleeding (GIB) on LVAD support remains unknown. To study the association between preoperative sarcopenia and post LVAD GIB events, we performed a retrospective, multi-centered study including patients with chest CTs performed ≤ 3 months prior to LVAD implantation at the University of Minnesota (n=143) and Houston Methodist Hospital (n=133). To quantify sarcopenia, unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHUm) were measured on pre-operative chest CT scans. Negative binomial regression analyses were performed to determine the association between pectoralis muscle measures and number of GIB events to 2 years of LVAD support. The study cohort included 276 LVAD recipients with 43 % designated as bridge to transplant at the time of LVAD implantation. High pectoralis muscle mass and tissue attenuation were both protective against GIB events. Each 5 unit increase in PHUm was associated with an adjusted 19 % reduction in the incidence rate of GIB (95 % CI 7-29 %, p=0.002). Each unit increase in PMI was associated with an adjusted 17 % reduction in the incidence of GIB (95 % CI 1- 29 %, p=0.04). The models were adjusted for age, sex, INTERMACS profile, bridge to transplant status, creatinine, albumin and implanting center. Preoperative sarcopenia, as quantified by pectoralis muscle size and attenuation, was associated with the development of recurrent GI bleeding after LVAD implantation. These CT quantitative measures appear to predict not only early mortality but morbidity on LVAD as well.

S2384 Recurrent GI Bleeding From Colo Pancreatic Fistula – A Rare Entity

Introduction: Acute pancreatitis is an acute inflammatory condition affecting the pancreas. Colonic complications rarely occur with acute and chronic pancreatitis. Localized ileus, obstruction, colonic ischemia, hemorrhage and fistula formation have been reported together with acute pancreatitis. Colo-pancreatic fistula occurs at a rate of 3% to 10% in patients with severe acute pancreatitis. Here, we discuss the case of a patient with recurrent GI bleeding from a colo-pancreatic fistula. Case Description/Methods: A 62-year-old White male with past medical history of COPD, CAD s/p PCI, history of paroxysmal atrial fibrillation on Eliquis, diabetes presented with complaints of bleeding per rectum. He denied any other complaints. MRI abdomen showed pancreatic pseudocyst with possible fistulization of the pancreatic pseudocyst to the proximal descending colon (Fig 1A). Patient underwent EGD and colonoscopy. Colonoscopy showed evidence of pancreatico enteric fistula distal to the splenic flexure, the remnants were cleared on lavage and patient was discharged once stable (Fig 1B). One month later patient presented with another episode of recurrent GI bleeding he required 2 units of PRBC given the prior findings on the colonoscopy, patient was referred to pancreatic surgeon for further intervention of the colo-pancreatic fistula. Discussion: CPF is a rare condition associated with high mortality in patients with acute pancreatitis. Abdominal CT with or without contrast is often used for diagnosis; however, colonoscopy is also used to detect CPF. Given the anatomical proximity of the left part of the colon to the pancreas, CPF is commonly seen on the left side. Patients present with symptoms such as nausea, abdominal pain, vomiting and gastrointestinal bleeding. In contrast to other pancreatic enteric fistulas, CPF is associated with a high risk of severe hemorrhage, perforation or infection. Unlike other pancreatic enteric fistulas CPF do not close spontaneously, surgery is often the recommended treatment; however, less invasive endoscopic interventions, such as those using conventional hemoclips or over the scope clip, have been reported to have successful outcomes.Figure 1.: Fig 1A: MRI Abdomen showing pancreatic pseudocyst (shown by two blue arrows). Fig 1B: Colonoscopy showing fistulous opening in the descending colon distal to splenic flexure (shown by black arrow).

S3610 Low Hemoglobin? What GAVE?

Introduction: Learning objectives were 1) to recognize Gastric Antral Vascular Ectasia (GAVE) as a cause of recurrent GI bleeding and 2) Understand appropriate evaluation and management of GAVE syndrome. Case Description/Methods: A 60-year-old female with a PMH of systemic lupus erythematosus, rheumatoid arthritis, hypertension and diabetes presented for abnormally low hemoglobin during routine lab work. Patient reported intermittent tarry stools, epigastric discomfort, and shortness of breath for the last few days. No history of hematemesis or rectal bleeding was noted. She had no NSAID or anticoagulant use. Physical exam: P 87, BP 114/67, R 20; not orthostatic, no acute distress; pale conjunctiva, heart: regular, II/VI systolic ejection murmur; lungs: clear; abdomen: soft and nontender; neurologic: nonfocal. Labs: stool heme positive, WBC 3.45k, Hgb 7.2 g/dl; MCV 82, platelets and liver function tests were normal. Hospital course: patient treated with IV pantoprazole and given 1 unit PRBCs with minimal change in Hgb initially prompting further transfusions. EGD revealed gastric ectasias in the antrum and argon plasma coagulation was performed. Patient responded well and was discharged on a PPI and PO iron and planned for a repeat EGD in one month. Discussion: Upper GI bleeding is a very common admitting diagnosis and is most often due to peptic ulcer disease, esophageal varices or erosive esophagitis. While up to 4% of upper GI hemorrhage is due to various angiodysplasias, GAVE is an uncommon form of angiodysplasia that is also known as watermelon stomach. The classic case of GAVE is an adult female presenting with abdominal pain, recurrent occult blood loss, and transfusion-dependent chronic iron deficiency anemia. The diagnosis is made by EGD as there is a pathognomonic endoscopic pattern which resembles a watermelon and unique histologic findings. Though the exact pathophysiology is not understood, the leading theory is that antropyloric motility dysfunction develops due to vagal loss and sympathetic overstimulation causing partial prolapse of the distal gastric mucosa through the pylorus forming ectasias. Repeated treatment of ectatic vessels with endoscopic argon laser can control GI bleeding in these patients although ongoing PPI and iron are also used. CONCLUSION: Physicians should include angiodysplasias and GAVE in their differential of patients with GI bleeding as accurate diagnosis and unique laser treatment can be very beneficial for these patients.

Gastrointestinal mucormycosis due to Rhizopus microsporus following Streptococcus pyogenes toxic shock syndrome in an HIV patient: a case report

BackgroundGastrointestinal (GI) mucormycosis is a rare and often deadly form of mucormycosis. Delayed diagnosis can lead to an increased risk of death. Here, we report a case of GI mucormycosis following streptococcal toxic shock syndrome in a virologically suppressed HIV-infected patient.Case presentationA 25-year-old Thai woman with a well-controlled HIV infection and Grave’s disease was admitted to a private hospital with a high-grade fever, vomiting, abdominal pain, and multiple episodes of mucous diarrhea for 3 days. On day 3 of that admission, the patient developed multiorgan failure and multiple hemorrhagic blebs were observed on all extremities. A diagnosis of streptococcal toxic shock was made before referral to Siriraj Hospital – Thailand’s largest national tertiary referral center. On day 10 of her admission at our center, she developed feeding intolerance and bloody diarrhea due to bowel ischemia and perforation. Bowel resection was performed, and histopathologic analysis of the resected bowel revealed acute suppurative transmural necrosis and vascular invasion with numerous broad irregular branching non-septate hyphae, both of which are consistent with GI mucormycosis. Peritoneal fluid fungal culture grew a grayish cottony colony of large non-septate hyphae and spherical sporangia containing ovoidal sporangiospores. A complete ITS1–5.8S-ITS2 region DNA sequence analysis revealed 100% homology with Rhizopus microsporus strains in GenBank (GenBank accession numbers KU729104 and AY803934). As a result, she was treated with liposomal amphotericin B. However and in spite of receiving appropriate treatment, our patient developed recurrent massive upper GI bleeding from Dieulafoy’s lesion and succumbed to her disease on day 33 of her admission.ConclusionDiagnosis of gastrointestinal mucormycosis can be delayed due to a lack of well-established predisposing factors and non-specific presenting symptoms. Further studies in risk factors for abdominal mucormycosis are needed.

S3453 Cavernous Hemangioma: A Rare Cause of Massive Lower Gastrointestinal Bleeding

INTRODUCTION: Hemangiomas are benign vascular tumors that rarely occur in the gastrointestinal tract. However, only 37 cases of small intestine hemangioma were reported from 2000 to 2018. Small bowel hemangiomas may cause massive lower gastrointestinal bleeding. In this report, we present a case of massive, and recurrent lower GI bleeding caused by a cavernous hemangioma of the small intestine. CASE DESCRIPTION/METHODS: A 32-year-old man came to the ER frequent episodes of large bloody bowel movements with a drop of Hb level, and he was transferred to MICU. The upper and lower endoscopy showed a large amount of blood with clots throughout the colon with no source of bleeding. A massive transfusion (of a total of 34 units) was given. Surgery and interventional radiology recommended Superior mesenteric artery arteriography, which demonstrated brisk bleeding from a jejunal branch overlying the left upper quadrant. Embolization of the bleeding jejunal branch was performed. A few days after, the patient developed other episodes of rectal bleeding. Capsule endoscopy revealed active small bowel bleeding, originating most likely from the proximal and mid-small intestine. Small intestine resection was performed, and the specimen analysis showed a cavernous hemangioma, measuring 1.2 × 1 × 0.8 cm. DISCUSSION: Hemangiomas are benign vascular neoplasms that can appear anywhere in the body, including the GIT, and it is considered as 0.05% of all gastrointestinal tumors. The jejunum is the most common site of occurrence. Hemangiomas may be solitary or multiple. Multiple hemangiomas are usually associated with the presence of similar lesions in other organs, such as liver and skin. Hemangiomas of GIT typically originate from the submucosal vascular plexus and extend from the submucosa to the muscular layer of the intestinal wall and they may extend beyond the serosa, involving the mesenteric, retroperitoneal, or pelvic fat. Histologically, hemangiomas classified into capillary, cavernous, and mixed. Initial investigations usually include upper and lower endoscopy. However, in most cases, these investigations are normal. CT angiography, MRI, radionuclide imaging, selective angiography, double-balloon enteroscopy, and capsule endoscopy could be used to identify the lesion. Surgical resection has conventionally been used for the treatment of intestinal hemangiomas. In recent years, less invasive therapeutic interventions, such as non-surgical endoscopic treatment and minimally invasive laparoscopic surgery, have become more common.

Spontaneously resolving duodenal obstruction after balloon-occluded retrograde transvenous obliteration–assisted endoscopic Histoacryl injection in duodenal varices

A 46-year-old woman with cirrhosis presented with recurrent upper GI bleeding. EGD revealed small esophageal varices and large ectopic varices in the second part of the duodenum without any active bleeding (A). CT portovenogram revealed a branch of superior mesenteric vein as afferent and right gonadal vein as efferent for the varices (B). Balloon-occluded retrograde transvenous obliteration (BRTO) was done with the balloon inflated in the right gonadal vein. Because superselective cannulation of the ectopic varices could not be achieved, BRTO-assisted endoscopic injection of 12 mL N-butyl-2-cyanoacrylate (Histoacryl) and lipoidal (1:2 ratio) was done into the varices to minimize systemic embolization. Two weeks after discharge, the patient presented with repeated vomiting. EGD revealed partial occlusion of the duodenal lumen by the Histoacryl cast (C). Her symptoms resolved on conservative management (nothing by mouth, nasogastric drainage, and intravenous fluids). She continued to experience intermittent vomiting for the next 2 months. Because spontaneous expulsion of Histoacryl casts after variable intervals is known and each episode of duodenal obstruction subsided with conservative management, we did not plan any surgery. After about 2 months, she became asymptomatic. EGD after 2 months showed no residual Histoacryl cast (D).

3:54 PM Abstract No. 253 Single transplant center’s experience with transjugular intrahepatic portosystemic shunt creation in patients with portal venous thrombosis

To characterize the creation of TIPS in patients with difficult anatomy due to portal venous thrombosis including indications for TIPS, technical feasibility, and adjunctive techniques. An internal database at a single transplant institution was queried for all patients with primary TIPS creation between January 2014 and June 2019. This patient list was then filtered for patients with presence of portal venous thrombosis demonstrated on cross-sectional imaging prior to TIPS creation. The charts of these patients were searched for preprocedural patient characteristics including etiology of portal venous thrombosis, indications for TIPS creation, procedural details including use of adjunct techniques, and technical success of TIPS creation. A total of 89 patients were identified in our retrospective review. Patients ranged in age from 12 years to 89 years. The top 3 locations for venous thrombosis in patients were the main portal vein (58%), superior mesenteric vein (52%), and splenic vein (21%). 25 patients had occlusive thrombosis of the portal system with cavernous transformation. Etiology of portal system thrombosis was most often secondary to NASH cirrhosis (25%), alcoholic cirrhosis (16%), and HCV cirrhosis (15%). The most common indications for TIPS placement were refractory thrombosis (37%), refractory ascites (33%), and recurrent upper GI bleeding (16%). 79 patients underwent technically successful TIPS creations (89%); of these 79 cases, 13 cases required splenic venous access via direct transsplenic needle puncture, 11 cases utilized the “Gunsight” technique for TIPS creation. Average fluoroscopic time for TIPS creation was 42.3 minutes. 19 patients in this study received liver transplantation following the successful placement of a TIPS. Portal venous thrombosis may present a technical anatomic challenge in patients presenting for TIPS creation. Use of intraprocedural adjunct techniques such as splenic access or gunsight technique can help increase technical success of TIPS creation in this patient population to treat a variety of symptoms secondary to portal hypertension and portal venous clot burden.

Distal Splenorenal Shunt (DSRS) in Children with Extrahepatic Portal Hypertension.

Portal hypertension (PH) is infrequent in children as compared to adults. Currently, repetitive endoscopic ablation of varices is standard treatment. However, endoscopic facilities are not readily available in resource-limited settings. We reviewed the indications, operative morbidity, mortality, shunt patency and re-bleeding episodes in nine patients (age range 6-16 years, M:F 6:3) who had DSRS for recurrent GI bleeding not responding to endoscopic treatment and hypersplenism. DSRS is a safe and effective treatment alternative in resource limiting setting for preventing bleeding and improving hypersplenism in children with extrahepatic portal hypertension.

1974 Seeing Isn’t Always Believing! Recurrent Hematemesis Due to Factitious Disorder

INTRODUCTION: Gastrointestinal bleeding is a common inpatient diagnosis with a cost &gt;$5 billion in the US. Typically patients undergo endoscopic evaluation, capsule studies, CT imaging with/without embolization and in severe bleeding, surgical management may be pursued. We present a case of recurrent GI bleeding due to factitious disorder. CASE DESCRIPTION/METHODS: 52-year-old female veterinary tech with a complex surgical history presented to the ER for acute recurrent hematemesis with bright blood seen in ER. In 2017, she developed recurrent upper GI bleeding. Previous EGD showed Dieulafoy lesions that were clipped and she underwent partial gastrectomy. Physical examination showed normal vitals and diffuse mild abdominal tenderness. Labs showed stable normocytic anemia (Hgb 9-10), normal iron stores, LFTs, INR, and platelets. She underwent extensive workup including angiogram, multiple endoscopies, and multiple CTA A/P with no identifiable source of bleeding. Given ongoing visualized bleeding and almost weekly hospitalizations she underwent remnant gastrectomy for definitive management and pathology confirmed Dieulafoy lesions. During the hospitalization, she was found to have 2 blood-filled syringes in her pillowcase. She had multiple concerning signs for a psychiatric disorder: "la belle indifference", no active bleeding on endoscopy, no melena, persistent bleeding despite gastrectomy, stable Hgb, female with medical training, and no further bleeding after sitter placed. Psychiatry team was consulted and discovered she had been ingesting blood drawn from a PICC line to stimulate bleeding. A diagnosis of Munchausen’s disorder was made. DISCUSSION: Munchausen’s disorder occurs when patients intentionally produce physical or psychiatric symptoms (usually of dramatic nature), allowing them to assume a sick role and gain medical attention. This is a difficult diagnosis and often results in the excessive use of medical resources. Risk factors include a serious illness/trauma during childhood, loss of a loved one, personality disorder, and being a healthcare worker. The motive is mainly to gain sympathy and attention. Physicians should confront patients with the diagnosis if a good therapeutic relationship has been established and patients benefit from psychotherapy and close medical and psychiatric follow up. Prognosis tends to be poor however, with most patients refusing psychiatric evaluation and leaving AMA. This case adds to literature suggesting factitious disorder with hematemesis is not as rare as expected.

1967 Unexplained Massive Recurrent Upper GI Bleeding: A Case of Missed Connection

INTRODUCTION: Erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures leads to formation of Aortoenteric fistula (AEF). It occurs after months to years after aortic surgery and may be related to graft infection and can result in torrential Gl bleeding. Here we present a case of recurrent GI bleeding, the cause of which initially remained obscure despite repeated endoscopies. CASE DESCRIPTION/METHODS: 61 y old male with PMH of peripheral vascular disease and femoropopliteal bypass on ASA and Eliquis presented with 3 days of passing black-tarry stools and dizziness. Initial hemoglobin was 7 gm/dL (normal baseline). Urgent EGD up to 2nd part of duodenum revealed clot in the stomach without any lesion or source of bleeding. EGD was repeated the next day due to ongoing melena, which again was nonrevealing. CTA also did not show any active bleeding. Eliquis was discontinued and the patient was discharged. 2 days later, he presented with ongoing melena and dizziness. EGD, however, this time revealed aortic graft eroding into 3rd part of the duodenal wall. He was transferred to a tertiary care center for repair of the fistula. DISCUSSION: AEF is an uncommon but life-threatening complication of aortic reconstructive surgery. Due to the anatomic proximity, most cases involve the duodenum, with the proximal suture line of an aortic prosthesis. It is imperative to inquire about the history of aortic reconstruction patients presenting with Upper GI bleeding, as these patients are considered to have an AEF until proven otherwise. In our case, the remote history of aortic reconstructive surgery was not put in the clinical perspective and aortic graft was overlooked on the CT scan. Both MRI and CT can fail to diagnose AEF and EGD has 50% sensitivity. Endoscopy should include the fourth portion of the duodenum. Prompt recognition and repair of fistula in highly critical for patient survival.

577 Randomized Controlled Trial (RCT) of Over-the-Scope Clip (OTSC) as Initial Endoscopic Treatment of Severe Non-Variceal Upper Gastrointestinal Bleeding (NVUGIB)

INTRODUCTION: Recurrent GI bleeding from peptic ulcers (PUB's) &amp; Dieulafoy's lesions is common in high risk patients. In our recent RCT, patients treated with Standard Hemostasis- RX (e.g. hemoclips &amp;/or multipolar probe with epinephrine pre-injection) for severe NVUGIB had a 30 day rebleed rate of 26.3 % (Gastro 2017;152:1310). OTSC obliterates arterial flow underneath stigmata of hemorrhage (SRH) of PUB's more effectively than Standard RX &amp; residual blood flow correlates with rebleed risk (DDW 2019). No one has reported an RCT of OTSC as primary, initial treatment compared to current Standard RX. Therefore, we performed this RCT. METHODS: The RCT was conducted at 2 academic medical centers after IRB approvals &amp; Clinicaltrials.gov registration (NCT03065465). After informed consent for emergency endoscopy (EGD), patients &amp; their caregivers (general GI, ICU &amp; primary care) were blinded as to EGD Rx &amp; the latter MD's made all management decisions about medical treatment, RBC transfusions, or ordering repeat EGD or angiography (IR) for rebleeding. Patients who met clinical &amp; EGD criteria for PUB's or UGI Dieulafoy's lesions (with major SRH or spots with arterial blood flow) were randomized in a 1:1 allocation to either Standard RX (as described in above RCT) or OTSC. All patients received high dose PPI's after randomization &amp; were followed prospectively for 30 days. Clinical outcomes data were collected on standard forms, de-identified, entered onto computer files, managed with SAS, &amp; analyzed by a biostatistician (JG). RESULTS: 49 RCT patients were well matched in demographics, risk factors, lesion type &amp; SRH (Table 1). In contrast, the proportion of patients with 30 day rebleeding was significantly higher with Standard RX - 28% (7/25) - compared to OTSC Rx – 4.2% (1/24) - P = 0.0285 by Chi square (P = 0.022 by log rank test – See Figure 1). The OTSC rebleed rate was 85% lower than Standard group (Relative Risk 0.149 with 95% confidence intervals of 0.006, 0.863). The number needed to treat (NNT) was 4.2. See Table 2 for other outcomes. CONCLUSION: In patients with severe UGI bleeding from PUB's or Dieulafoy's lesions, primary endoscopic treatment with a large over the scope hemoclip resulted in significantly lower rates of rebleeding &amp; severe complications, &amp; fewer RBC transfusions than standard endoscopic hemostasis. Results appear to relate OTSC's superior ability to obliterate arterial blood flow underneath SRH &amp; thereby reduce lesion rebleeding.

1977 A Rare Cause of Small Bowel Bleeding From a Duodenal Varix

INTRODUCTION: Ectopic varices are rare and by definition occur outside of the esophagus and stomach. They can be found in the rectum, duodenum or be peristomal. An estimated 2–5% of variceal bleeds are due to ectopic varices with the majority occurring either in the rectum or duodenum. The diagnosis of ectopic duodenal varices can be challenging given their location. There is a paucity of data regarding optimal diagnosis and management of bleeding duodenal varices. CASE DESCRIPTION/METHODS: A 46 year old woman with a history of cirrhosis from alcohol and nonalcoholic steatohepatitis was referred to our center for ongoing small bowel bleeding. Previous endoscopic evaluation included an unremarkable EGD, colonoscopy revealed blood through the colon without lesions, and capsule endoscopy showed blood in the proximal small bowel (at less than 30% small bowel transit time). We performed a push enteroscopy which showed a submucosal bulge with overlying ulceration and intermittent active bleeding in the third portion of the duodenum. Hemostasis was achieved with two hemoclips and the location was marked with tattoos. On initial discovery, the lesion was most consistent with a submucosal tumor such as a GIST (Figure 1) and she was referred for surgical resection. However, surgery was unsuccessful because of dense adhesions from a prior unrelated surgery. A repeat examination of the lesion 6 weeks later with endoscopic ultrasound showed a large varix (Figures 2 and 3). The patient has otherwise been doing well without any recurrent GI bleeding. DISCUSSION: Varices typically appear as bluish enlarged vessels or bulges and are commonly tortuous and easily compressed with instrumental pressure. Ectopic varices can be confused with thickened folds or submucosal lesions as in this case. Differentiation of these lesions is paramount in choosing appropriate management. It is important to consider ectopic varices on the differentials of both GI hemorrhage and submucosal lesions. EUS is the preferred test to characterize such lesions. Varices typically appears as round anechoic structures arising from the lamina propria or submucosa. Color Doppler is used to detect blood flow, which will confirm the vascular nature of the structure. Options of endoscopic hemostasis of bleeding duodenal varices include hemoclips, sclerotherapy, TIPS, balloon-occluded retrograde transvenous obliteration or surgical resection.