Severe Hematochezia Research Articles

Dual-Energy CT Evaluation of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is a potentially life-threatening condition accounting for more than 300 000 annual hospitalizations. Multidetector abdominopelvic CT angiography is commonly used in the evaluation of patients with GI bleeding. Given that many patients with severe overt GI bleeding are unlikely to tolerate bowel preparation, and inpatient colonoscopy is frequently limited by suboptimal preparation obscuring mucosal visibility, CT angiography is recommended as a first-line diagnostic test in patients with severe hematochezia to localize a source of bleeding. Assessment of these patients with conventional single-energy CT systems typically requires the performance of a noncontrast series followed by imaging during multiple postcontrast phases. Dual-energy CT (DECT) offers several potential advantages for performing these examinations. DECT may eliminate the need for a noncontrast acquisition by allowing the creation of virtual noncontrast (VNC) images from contrast-enhanced data, affording significant radiation dose reduction while maintaining diagnostic accuracy. VNC images can help radiologists to differentiate active bleeding, hyperattenuating enteric contents, hematomas, and enhancing masses. Additional postprocessing techniques such as low-kiloelectron voltage virtual monoenergetic images, iodine maps, and iodine overlay images can increase the conspicuity of contrast material extravasation and improve the visibility of subtle causes of GI bleeding, thereby increasing diagnostic confidence and assisting with problem solving. GI bleeding can also be diagnosed with routine single-phase DECT scans by constructing VNC images and iodine maps. Radiologists should also be aware of the potential pitfalls and limitations of DECT. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

The global incidence of adverse events associated with fecal microbiota transplantation in children over the past 20years: A systematic review and meta-analysis.

To understand the global incidence of the adverse events associated with fecal microbiota transplantation (FMT) in children over the past 20years. We searched PubMed, Web of Science, Embase, and three Chinese databases (CNKI, Wanfang, and Chongqing Weipu) for high-quality articles written over the past 20years and made selections based on the quality standard score. The study characteristics and incidences of adverse events were extracted from each article, meta-analysis was performed using the R.3.6.3 software, and randomized-effect or fixed-effect meta-analyses were used to determine the incidence of adverse events. Subgroup analysis was performed to determine heterogeneity. A total of 18 articles involving 681 children were included in the analysis. The total effective rate of FMT in children was 85.75% (95% CI: 76.23-93.15%), of which the overall efficacy of FMT for the treatment of Clostridium difficile infection was 91.22% (95% CI: 83.49-96.68%) and the overall adverse event rate was 28.86% (95% CI: 19.56-39.15%), with a mild to moderate adverse event rate of 27.72% (95% CI: 17.86-38.83%) and a severe adverse event rate of 0.90% (95% CI: 0.33-1.76%). The most common mild to moderate adverse events were as follows: bellyache, 14.02% (95% CI: 5.43-25.77%); diarrhea, 7.75% (95% CI: 2.69-15.11%); and bloating, 7.36% (95% CI: 1.79-16.28%). Other adverse events included fever, 2.34%; vomiting, 3.12%; nausea, 1.50%; hematochezia, 2.30%; anorexia, 1.94%; and fatigue, 0.03%. The only death reported was in a study from China, in which the patient died of sepsis and liver failure 4weeks after FMT. The other serious adverse event was an immunodeficiency patient with severe hematochezia. Another study in the United States described seven serious adverse events including one death that was not considered to be related to FMT; however, they did not describe the events in detail. There was no difference in the incidence of adverse events between the upper and lower gastrointestinal tracts (OR=0.61, 95% CI: 0.02-15.42, P=0.76). Adverse events related to FMT in children are mostly mild to moderate, of short duration, and self-limiting. Therefore, the use of FMT in children is safe and worthy of widespread promotion.

Outcomes of patients with ischemic colitis causing severe hematochezia managed medically or surgically.

To compare short- and long-term outcomes of hospitalized patients with ischemic colitis (IC) presenting with severe hematochezia and treated medically or colectomy and also those with inpatient vs. outpatient start of hematochezia. A retrospective analysis of prospectively collected data for IC patients hospitalized for severe hematochezia from two teaching hospitals was done from 1994 to 2020, with the diagnosis of IC made colonoscopically and confirmed histologically. Ninety-seven patients initially all had medical management for IC. Seventy-two (74.2%) were stable and had no further bleeding; 17 (17.5%) had colon resection; and 8 were critically ill and not surgical candidates. Surgical patients and non-surgical candidate had higher comorbidity scores; received more red blood cell (RBC) transfusion (median (IQR) 5 (3-10) vs. 4.5 (3-6.5) vs. 1 (0-4) units, p < 0.001); had significantly longer hospital and ICU days; had higher severe complication rates (35.3% vs. 100%. vs. 5.6%, p < 0.001); and had higher 30-day all-cause mortality rates (23.5% vs. 87.5% vs. 0, p < 0.001). Inpatients developing IC hemorrhage had more RBC transfusions, more complications, longer hospital stays, and higher mortality than patients whose IC bleeding started as outpatients. The majority of IC patients hospitalized for severe hematochezia were successfully treated medically. Patients who were not surgical candidate had the highest rates of severe complications and mortality. Surgical patients and those who were not surgical candidate had worse outcomes than the medical group. Patients with inpatient start of bleeding from IC had significantly worse outcomes than those with outpatient start of bleeding.

Massive lower gastrointestinal bleeding due to Dieulafoy’s lesion in sigmoid colon

Dieulafoy’s lesion is one of the rare lesions observed in endoscopy. These lesions are usually observed in upper gastrointestinal system and mostly in the stomach. Dieulafoy’s lesion in colon is very rare. Here we report a very case of dieulafoy’s lesion found in sigmoid colon of a patient presenting with severe hematochezia and successfully treated with endoclip application.

Ischemic colitis as a cause of severe hematochezia: A mini review.

Ischemic colitis (IC) is a common cause of severe lower gastrointestinal bleeding (LGIB) in the elderly. There are very few studies of patients with IC as a cause of severe LGIB in the literature. This article aims to review diagnosis, colonoscopic findings, medical treatment, and outcomes of patients with IC as a cause of severe hematochezia. The majority of IC patients with severe hematochezia can be successfully managed with medical treatment. Colonoscopic hemostasis with hemoclips is safe and feasible in treating major stigmata of recent hemorrhage in focal ischemic ulcers. Colon surgery is indicated in patients who fail medical treatment and/or have severe ongoing bleeding, clinical deterioration, or peritoneal signs. Overall, the morbidity rates in patients with IC range from 10% to 79%. Clinical outcomes in patients who need colon surgery for IC are worse than those treated with medical management. Patients who develop hematochezia from IC during hospitalization for other medical conditions have worse clinical outcomes than those with an outpatient start of bleeding. Further research is warranted for the prevention, early diagnosis, and treatment of patients with severe hematochezia from IC.

Atypical Presentation of Colonic Diverticular Disease

Hematochezia or passage of fresh blood per rectum is a relatively common finding in medical practice which mostly indicates lower gastrointestinal bleeding. The causes for lower gastrointestinal bleeding include diverticular disease, vascular ectasia, ischemic, inflammatory or infectious colitis, colonic neoplasia, hemorrhoids, anal fissures and small bowel lesions (Crohn’s disease, Vascularectasia, Meckel’s diverticulum).If a patient comes with severe hematochezia, the first and foremost task is to stabilize the patient and then find out the source of bleeding as soon as possible. Elderly patients presenting with severe hematochezia, is most likely due to colorectal malignancy but benign causes like colonic diverticulosis can also present as life threatening bleeding in rare occasions. Here we report a case of 70-years-old male patient presenting with severe painless hematochezia leading to severe anemia due to diverticulosis. Bangladesh J Medicine July 2022; 33(1) : 94-98

Meckel’s Diverticulum with Dieulafoy’s Lesion: A Cause of Severe Hematochezia

Background Meckel’s diverticulum (MD) is a remnant of the omphalomesenteric duct. Although the majority of MD are asymptomatic, it can present with severe hematochezia. Hematochezia is generally considered to result from a peptic ulcer caused by ectopic gastric mucosa in MD. However, this hypothesis has not been proved. Methods 10 cases of surgically resected MD initially presenting with severe hematochezia were histologically examined. Results Ectopic gastric mucosa was present in 9 cases, two of which also contained ectopic pancreas. No ectopic tissue was found in one case, which shows that bleeding can occur in MD without ectopic gastric mucosa. In addition, a rupture of aberrant submucosal arterioles through the overlying mucosa, a vascular abnormality called Dieulafoy’s lesion, was detected in all the 10 cases. Conclusion This study suggests that the actual cause of massive bleeding in MD is not a peptic ulcer, but Dieulafoy’s lesion.

S2424 New Diagnosis of Severe Ulcerative Colitis Immediately Following mRNA-1273 SARS-CoV2 Vaccination

Introduction: Vaccination against SARS-CoV-2 (COVID-19) has become the main tool for controlling the global pandemic. Although trials are ongoing, there have not been published safety concerns, and guidelines strongly recommend that patients with inflammatory bowel disease (IBD) receive a vaccine. We present a case of new onset, severe ulcerative colitis (UC) following the mRNA- 1273 COVID-19 vaccine series. Case description/methods: A 66-year-old female with a history of diverticulitis requiring sigmoid colectomy was referred to outpatient gastroenterology within one week after her first dose of the mRNA-1273 COVID-19 vaccine. Colonoscopy showed friable mucosa and a loss of vascular markings and histology was consistent with UC. She was treated with budesonide and mesalamine and symptoms resolved. The second dose was administered 4 weeks later, after which she immediately developed severe hematochezia and anorexia requiring hospital admission. Laboratory data was notable for c-reactive protein of 202 mg/L. Symptoms persisted despite 2 weeks of intravenous and rectal corticosteroids. Repeat colonoscopy revealed severe pancolitis. Infliximab was initiated and re-dosed after 48 hours due to concern for protein-losing enteropathy. Despite the addition of a biologic agent, a third colonoscopy showed minimal improvement. The patient underwent a total colectomy and was discharged in stable condition. Discussion: This is a clear case of a patient with UC unmasked by the hyper-inflammatory state following the mRNA-1273 vaccine, with subsequent severe flare following the second dose requiring colectomy. A safety and efficacy study reported no safety concerns amongst 15,000 volunteers and millions more have been vaccinated worldwide. Patients without specific contraindications should continue to receive vaccination against COVID-19, however following an adverse event, clinicians should think carefully about administration of the second dose. While the importance of vaccination and herd immunity cannot be understated, cases such as this are important to report, especially with regard to advice on administration of the second dose of the vaccine when an adverse event was noted following the first dose. This is especially important as many of the local and systemic reactions associated with the mRNA-1273 vaccine were more severe after the second dose.

Practical advantage of SPECT/CT image co-registration for accurate bleeding Meckel’s diverticulum localization in pediatrics: A case report

Planar scintigraphy with 99mTc-pertechnetate or Meckel scan is the gold standard in the diagnosis of a bleeding Meckel’s diverticulum (MD) for pediatrics. However, several setbacks may occur during the interpretation of a scintigram, especially in cases of an atypical MD presentation. In this report, we highlight the importance of functional and anatomical image co-registration using a hybrid SPECT/CT scanner to precisely localize a MD lesion. An 18-month-old boy presented with severe hematochezia over 4 days with declining hemoglobin levels. He underwent a conventional 60-min dynamic planar imaging of the Meckel scan. Upon review of the Meckel scan, a suspicious increase in the 99mTc-pertechnetate uptake was observed at the right upper quadrant of the abdomen. Due to its atypical location at the right kidney, we could not differentiate between a physiological uptake of the right kidney or an ectopic gastric mucosa. The patient was imaged again using single-photon emission computed tomography (SPECT) and low-dose CT protocol with a hybrid SPECT/CT scanner, and the co-registration of both SPECT and CT images was able to confirm the MD, which was located anterior to the right kidney at the right hepatic flexure region. An exploratory laparotomy was then ensued to remove the bleeding MD. The patient was discharged after 3 days with no complications. In summary, this case illustrates that hybrid imaging modality and co-registration allow for a more definitive diagnosis, as well as a more precise localization of MD.

Gastrointestinal hemorrhage caused by duodenal metastasis from a primary lung adenocarcinoma: A case report.

The present case study reported a rare case of duodenal metastasis from a lung adenocarcinoma. A 62-year-old male, who underwent radical lung cancer surgery two years ago, was readmitted to Guangzhou Red Cross Hospital complaining of epigastric pain. The esophagogastroduodenoscopy identified a 2.5x3.5 cm ulcerative lesion at the duodenum. Histopathological and immunohistochemical staining results confirmed that the lung adenocarcinoma had metastasized to the duodenum. The tumor cells were positive for cytokeratin-7, thyroid transcription factor-1 and napsin-A expression, but negative for caudal-related homeobox 2 expression. Prior to the second cycle of targeted treatment with anlotinib, the patient reported severe hematochezia. Therefore, an angiography and artery embolization were subsequently performed. However, the patient succumbed to acute kidney injury three days after the operation. The metastasis of lung cancer to the gastrointestinal tract is extremely rare and usually asymptomatic. However, when treating patients with lung cancer presenting with digestive symptoms or other distant metastatic sites, clinicians should consider the possibility of gastrointestinal metastasis so that it can be identified in a timely manner. If lesions exist, doctors should locate these and perform biopsies to conduct histopathological and immunohistochemical examinations to make a clear diagnosis.

Ischemic Colitis with Severe Hematochezia: A Comparison of 30-Day Clinical Outcomes Between Surgical and Non-Surgical Management

Wongpongsalee, Thongsak MD; Khrucharoen, Usah MD; Jensen, Dennis MD; Jutabha, Rome MD; Thibodeau, Gail DVM; Ellen Jensen, Mary MLS Author Information

S2103 Endoscopic Management of Massive Lower GI Bleeding in the Setting of Refractory Pan-Ulcerative Colitis and New Decompensated Alcoholic Cirrhosis

INTRODUCTION: Ulcerative colitis (UC) is an inflammatory disorder that affects the colonic mucosa. Treatment is based on disease severity. Surgical colectomy is considered for refractory disease. We present a case of massive, acute lower GI bleed from refractory ulcerative pancolitis (UP) in the setting of newly-diagnosed, decompensated alcoholic cirrhosis. CASE DESCRIPTION/METHODS: 32-year-old male with UP presented with a 5-day history of hematochezia, right upper quadrant pain, and jaundice. He previously failed treatment of prednisone, mesalamine, azathioprine, adalimumab, vedolizumab, infliximab, and ustekinumab. Lab work was significant for AST 361U/L, ALT 103U/L, alkaline phosphatase 211U/L, direct bilirubin 11.9 mg/dl, hemoglobin 7.4 gm/dl, and WBC count 15 × 109/L. New diagnosis of cirrhosis was suspected on computed tomography (CT) and confirmed, with acute alcoholic hepatitis, on liver biopsy. Hematochezia continued; however, prednisone was held due to infection concerns. He acutely decompensated 6 days later requiring vasopressors for multiorgan failure and shock. He developed severe hematochezia 5 days after decompensation from active sigmoid arterial (SA) bleed seen on CT angiography (Figure 1), unresponsive to transfusion and SA embolization. Emergent colectomy was considered; however, post-operative mortality risk was deemed too high due to decompensated cirrhosis (DC). Emergent flexible sigmoidoscopy (Figure 2) showed diffusely friable mucosa with actively bleeding pseudopolyps. Partial hemostasis was achieved with epinephrine and clip placement to culprit pseudopolyps. Patient clinically improved, vasopressors were weaned off and orthotopic liver transplant (OLT) evaluation was initiated. One-week after acute bleed, he underwent OLT. Total colectomy with end-ileostomy was performed 5 days after OLT. He was discharged to acute rehabilitation facility and has good liver graft function at 2-month follow up. DISCUSSION: DC and related coagulopathy caused significant UC-related pseudopolyp bleeding. With history of failed medical therapy and predilection for hemorrhage, colectomy is preferred management. However, with DC, post-operative mortality risk approached 90%. Endoscopic intervention is unlikely to alter management in severe UC bleed and poses perforation risk from insufflation. However, endoscopic management led to temporary hemostasis, which helped patient globally recover and undergo OLT. Colectomy for refractory UC was then safely performed.Figure 1.: Area of irregularity with increased density located at the rectosigmoid junction and within the rectum which demonstrates active arterial and possible venous bleeding.Figure 2.: Severe colitis throughout the sigmoid colon characterized by linear ulcerations, and friable mucosa with multiple pseudopolyps, some of which were oozing. Three pseudpolyps with active arterial oozing were treated with epinephrine and endoclips, with good effect.

Scurvy may occur even in children with no underlying risk factors: a case report

BackgroundSince ancient times, scurvy has been considered one of the most fearsome nutritional deficiency diseases. In modern developed countries, this condition has become very rare and is only occasionally encountered, especially in the pediatric population. Underlying medical conditions, such as neuropsychiatric disorders, anorexia nervosa, celiac disease, Crohn disease, hemodialysis, and severe allergies to food products may enhance the risk of developing scurvy.Case presentationWe report the case of an otherwise healthy 3-year-old white boy who developed scurvy due to a selective restrictive diet derived from his refusal to try new food. He presented to our clinic with asthenia and refusal to walk. During hospitalization he developed severe anemia and hematochezia. A diagnosis of scurvy was assessed on the basis of nutritional history, clinical features, radiographic findings, and laboratory findings. Supplementation of ascorbic acid enabled a prompt resolution of symptoms.ConclusionsScurvy is caused by vitamin C deficiency. Cutaneous bleeding, mucosal bleeding, and anemia represent typical manifestations of the disease. These symptoms are directly connected to ascorbic acid involvement in collagen biosynthesis. Some radiographic findings can be useful for the diagnosis. Treatment aims to normalize serum levels of vitamin C in order to counteract the deprivation symptoms. The present case report demonstrates that scurvy may sporadically occur in pediatric patients, even in individuals with no predisposing medical conditions and/or potential risk factors.

3055 Solitary Rectal Ulcer Syndrome: A Rare Cause of Hematochezia

INTRODUCTION: Solitary rectal ulcer syndrome (SRUS) is an uncommon rectal disorder that may result in severe rectal bleeding. The term solitary rectal ulcer syndrome is a misnomer. Endoscopic findings in patients with SRUS can range from mucosal erythema alone to single or multiple ulcers and polypoid mass lesions. Here, we present a rare case of severe hematochezia occurring secondary to a solitary rectal ulcer. CASE DESCRIPTION/METHODS: The patient is a 37 year-old male with a medical history of alcohol abuse who presented to our emergency department complaining of three episodes of hematochezia accompanied by dizziness and lightheadedness that began the night prior. Notable workup in the emergency department included a complete blood count (CBC) showing a hemoglobin of 12.5 gm/dL. A fecal occult blood test was also done which returned positive. This was followed by a repeat CBC showing an acute drop in the hemoglobin to 9.8 gm/dL. The gastroenterology service was then consulted and performed a colonoscopy. This was done and showed a large cratered ulcer about two centimeters in size and a non-bleeding visible vessel noted approximately five centimeters from the anal verge (Figure 1). These were treated with BiCAP cautery and the three hemostatic clips. Biopsies were not taken given the high risk of bleeding and emergent nature of the procedure. After the procedure the patient remained hemodynamically stable with no further drops in hemoglobin. He was then discharged with follow up appointments for repeat colonoscopy. DISCUSSION: SRUS is an oftentimes-misdiagnosed condition. The prevalence of SRUS is not clear, but has an estimated incidence of 1 in 100,000 people per year. Its diagnosis can usually be accomplished through a combination of symptomatology, endoscopy, sigmoidoscopy, and the histologic finding of fibromuscular obliteration of the lamina propria. The pathogenesis if SRUS is not well known, but various factors contribute to its development. This includes straining, self-induced trauma, paradoxical contraction of puborectalis muscle and rectal prolapse, and intussusception. Treatment of SRUS is based on the symptoms and severity. Asymptomatic patient treatment options include dietary modification, patient education, and behavioral modification. Endoscopic treatment can be applied to control bleeding and allows the clinician to obtain a biopsy specimen. Surgical treatment is recommended for those who have full thickness and rectal prolapse.

Portal vein recanalization failed to improve chronic intestinal obstruction due to extrahepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) refers to obstruction of the extrahepatic portal vein that is characterized by cavernous transformation, portal hypertension, and intestinal dysfunction. Radiological interventions on EHPVO are an extraordinary challenge, although being reported to be safe and effective in selected patients by pertinent experts. Chronic intestinal dysfunction is a rare complication of EHPVO; it is unknown whether portal vein re-canalization by radiological interventions can improve chronic intestinal dysfunction. We describe a 22-year-old male patient with chronic intestinal dysfunction due to EHPVO, which was not improved by portal vein re-canalization. The patient presented with acute abdominal pain and dyspepsia for 2 weeks without hematochezia in August 2016 and was diagnosed with EHPVO. Due to cavernous transformation, systemic anticoagulation therapy was administered, and although his abdominal pain was relieved, the patient still had dyspepsia and partial jejunum dysfunction. Intestinal segmentectomy was suggested but was refused, and the patient received catheter-directed thrombolysis in another hospital. Although the portal vein was partly recanalized, the intestinal obstruction was not alleviated. Four months after onset, an emergent enterectomy was performed due to severe hematochezia with pathological examination findings of necrosis, ulcer, and granulation formation. Unfortunately, the patient developed a serious systemic infection, severe thrombocytopenia and disseminated intravascular coagulation, which was assumed to be caused by intestinal bacterial translocation and serious malnutrition. The infection was subsequently controlled. In conclusion, in patients with chronic intestinal dysfunction due to EHPVO, portal vein re-canalization may not improve intestinal function. Timely enterectomy may prevent intestinal bacterial translocation and serious malnutrition.

大量下血を呈し緊急手術を要したサイトメガロウイルス腸炎の1例

大量下血を呈し緊急手術を要したサイトメガロウイルス腸炎の1例

Impact of cap-assisted colonoscopy on the learning curve and quality in colonoscopy: a randomized controlled trial

Colonoscopy competency assessment in trainees traditionally has been informal. Comprehensive metrics such as the Assessment of Competency in Endoscopy (ACE) tool suggest that competency thresholds are higher than assumed. Cap-assisted colonoscopy (CAC) may improve competency, but data regarding novice trainees are lacking. We compared CAC versus standard colonoscopy (SC) performed by novice trainees in a randomized controlled trial. All colonoscopies performed by 3 gastroenterology fellows without prior experience were eligible for the study. Exclusion criteria included patient age<18 or >90 years, pregnancy, prior colon resection, diverticulitis, colon obstruction, severe hematochezia, referral for EMR, or a procedure done without patient sedation. Patients were randomized to either CAC or SC in a 1:1 fashion. The primary outcome was the independent cecal intubation rate (ICIR). Secondary outcomes were cecal intubation time, polyp detection rate, polyp miss rate, adenoma detection rate, ACE tool scores, and cumulative summation learning curves. A total of 203 colonoscopies were analyzed, 101 in CAC and 102 in SC. CAC resulted in a significantly higher cecal intubation rate, at 79.2% in CAC compared with 66.7% in SC (P= .04). Overall cecal intubation time was significantly shorter at 13.7 minutes for CAC versus 16.5 minutes for SC (P=.02). Cecal intubation time in the case of successful independent fellow intubation was not significantly different between CAC and SC (11.6 minutes vs 12.7 minutes; P= .29). Overall ACE tool motor and cognitive scores were higher with CAC. Learning curves for ICIR approached the competency threshold earlier with cap use but reached competency for only 1 fellow. The polyp detection rate, polyp miss rate, and adenoma detection rate were not significantly different between groups. CAC resulted in significant improvement in ICIR, overall ACE tool scores, and trend toward competency on learning curves when compared with SC in colonoscopy trainees without prior colonoscopy experience. (Clinical trial registration number: NCT02472730.).

Endoscopic Treatment of Bleeding Diversion Pouchitis with High-Concentration Dextrose Spray

Surgical closure of stoma with the reestablishment of gut continuity is the only curative intervention available for inflammatory bowel disease patients with diversion pouchitis, proctitis, or colitis. For patients who are not candidates for surgical reestablishment of bowel continuity, the alternative nonsurgical approaches, such as topical therapy with mesalamine, corticosteroids, or short-chain fatty acids, have only shown modest efficacy. The management of massive bleeding from diversion pouchitis has not been described. We present a patient with ulcerative colitis with severe hematochezia and diffuse mucosal bleeding in a diverted ileal pouch, which was successfully treated with endoscopic spray of hypertonic glucose.

The Use of Octreotide in Refractory Gastrointestinal Bleeding Due to Crohnʼs Disease

A 36 year male with history of Crohn's disease complicated by anal stricture and anorectal fistula presented to the emergency department with one day of severe rectal bleeding. His Crohn's disease was diagnosed at age six and he underwent a left hemicolectomy at age 14. He had been treated with mesalamine, adalimumab, infliximab with 6-mercaptopurine in the past, and was currently being treated with vedolizumab. On presentation to the emergency room he was tachycardic. His abdomen was mildly distended with decreased bowel sounds. His labs were significant for leukocytosis (WBC 16.9) and anemia (Hemoglobin 10.8 g/dL). A CT scan showed nonspecific colitis and narrowing of the mid descending colon. He was treated with intravenous levofloxacin and metronidazole and after unremarkable stool cultures, intravenous methylprednisolone was added. He continued to have hematochezia and his hemoglobin continued to drop (7.4 g/dL, followed by 6.9 g/dL). He was transferred to the medical intensive care unit and was transfused four units of packed red blood cells. He was then started on intravenous octreotide 50 mcg/hr. After starting octreotide no further episodes of bleeding occurred. Repeat hemoglobin was 11.1 g/dL and remained stable. Colonoscopy was performed which showed skip areas of ulceration including the rectum and ileocecal valve. The intravenous octreotide was continued for a total of 72 hours. The patient was discharged home and has had no further episodes of bleeding. Octreotide is an analog of somatostatin. It is known to decrease splanchnic blood flow, and it may have a local vasoconstrictive effect. For these reasons it is a Class 1, Level A recommendation for patients with esophageal variceal bleeding (1). The effect of octreotide on other types of gastrointestinal bleeding is less clear. Andrews et al reported a patient with severe hematochezia due to CMV colitis who continued to bleed despite ganciclovir, but stopped bleeding after initiation of octreotide (2). Our case is the first reported use of octreotide to control lower gastrointestinal bleeding due to severe Crohn's colitis. Considering its safety profile, octreotide may be considered in patients with refractory lower gastrointestinal bleeding. Further randomized control trials are warranted.

A case of multiple recurrence of Clostridium difficile infection with severe hematochezia in an immunocompromised host

Clostridium difficile infection (CDI) is increasing in incidence and severity. Clinically, diarrhea frequently occurs, but severe hematochezia is rarely seen with CDI. We describe here a hematopoietic stem cell transplantation (HSCT) recipient who experienced life-threatening gastrointestinal bleeding due to severe CDI. Subsequent stool surveillance and molecular typing observed the patient who had two episodes of recurrence with a new strain of C. difficile distinct from the initial infection. We analyze C. difficile strains obtained from the patient, and also discuss the diagnosis and treatment of this case.