Source Of GI Bleeding Research Articles

Computed Tomography Angiography and Conventional Angiography for the Diagnosis and Treatment of Non-variceal Gastrointestinal Bleeding at a Tertiary Cancer Center.

To evaluate the diagnostic value of computed tomography angiography (CTA) and conventional angiography (CA) and the therapeutic value of transarterial embolization for acute gastrointestinal bleeding in patients with malignancy. A retrospective review of 100 patients who underwent CTA and/or CA for gastrointestinal bleeding at a comprehensive cancer center between the years 2011-2021 was performed. Clinical and patient outcome data were collected and analyzed using Kruskal-Wallis tests for continuous variables and chi-square tests or Fisher's exact tests (whichever is appropriate) for categorical variables in univariate analysis. All tests were two-sided at a significance level of 0.05.Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Fifty-two percent of our patients underwent CTA alone, 29% underwent CA alone, and 19% underwent both procedures. Overall, CTA was positive in 11.3% (8/71) of patients and CA was positive in 22.9% (11/38) of patients. Of patients who underwent both studies, 52.6% (10/19) were positive for both. ICU admission was associated with CTA and/or CA positivity (p=0.015). Of 48 patients with data for embolization, 50% of patients underwent transarterial embolization for bleeding, 11 patients had identifiable bleeding on CA, and 13 patients underwent prophylactic embolization at the site of suspected bleeding.Rebleeding following embolization was found in 33.3% (8/24) of patients, including six patients who underwent prophylactic embolization and two patients who were treated for visualized bleeding. CTA and CA are two critical studies for patients with GI bleeding and a history of malignancy. Neither alone can effectively exclude an identifiable source of bleeding. In patients with a history of malignancy, transarterial embolization may be an effective treatment of both angiographically visible and occult sources of GI bleeding.

Diagnostic utility of CT angiography compared with endoscopy in patients with acute GI hemorrhage

Because it is minimally invasive, CT angiography (CTA) has emerged as an attractive diagnostic tool for investigation of acute GI hemorrhage. This study examined patients with acute GI bleeding who underwent CTA. CTA was the initial diagnostic examination in 177 patients, identifying upper and lower GI bleeding lesions in 16 and 27 patients, respectively. In 103 patients with an initial negative CTA, 78 had endoscopy (32 EGD and 46 colonoscopy/flexible sigmoidoscopy), of whom 52 (67%) had a bleeding lesion identified, including 23 with a high-risk bleeding lesion requiring therapy. Peptic ulcer disease and diverticular bleeding were the most commonly identified bleeding lesions. With endoscopy as a criterion standard, the sensitivity of CTA for the detection of a source of GI bleeding was 20%. CTA has very poor sensitivity for identification of a GI bleeding source or lesion, suggesting that CTA should not be used as an initial diagnostic test.

Spray coagulation as an alternative to argon plasma coagulation for bleeding portal hypertensive gastropathy

Spray coagulation as an alternative to argon plasma coagulation for bleeding portal hypertensive gastropathy

S2128 Rectal Ischemia in a Patient After EVAR and COVID-19

Introduction: Ischemic proctitis is a rare, but serious, source of GI bleeding as mortality rates approach 20-40%. Patients for which ischemia should be considered are those with previous surgery, older patients, and those with known peripheral arterial disease. Case Description/Methods: 80-year-old male with history of hyperlipidemia and hypertension presented to the hospital for shortness of breath secondary to COVID-19 pneumonia. His respiratory status continued to decline requiring mechanical ventilation and ICU admission. During his admission, he was found to have acute left lower extremity ischemia requiring stenting of his superficial femoral artery and abdominal endovascular aneurysm repair (EVAR). He was started on anticoagulation with heparin infusion. His hospital course was further complicated large volume maroon-colored stools concerning for lower GI bleed. Colonoscopy was performed at the bedside to further evaluate. In the rectum, there were circumferential ulcerations with inflammation and exudate, extending 10 cm from the anal verge. Biopsies were consistent with rectal ischemia. Unfortunately, soon after the patient developed worsening acidosis requiring CVVHD and increased requirement for pressor support. The family ultimately decided to pursue comfort care and the patient was palliatively extubated (Figure). Discussion: Rectal ischemia is rare as the rectum has blood supply from the inferior mesenteric and bilateral iliac arteries. In our patient, during EVAR graft repair, the IMA was occluded by a stent, the iliac arteries however, remained intact providing the middle rectal and pudendal artery as sources of collateral blood supply. It is hypothesized that a hypercoagulable state caused by COVID-19 infection coupled with ongoing hypotension in the setting of critical illness in our patient with significant peripheral arterial disease led to the low flow state in bilateral iliac arteries causing ischemic proctitis. Rectal ischemia must be considered early in patients because, while most cases of lower GI bleeding can be treated conservatively, rectal ischemia is an indication for prompt surgical intervention. Surgical intervention is required to remove necrotic bowel and potential sources of infection causing septic shock.Figure 1.: Circumferential rectal ischemia as seen by colonoscopy.

S2176 Small Bowel Varices: A Covert Source of Overt Bleeding

INTRODUCTION: Alcoholic cirrhosis is one of the most common causes of liver failure, accounting for millions of hospitalizations each year. Although esophageal, gastric, and rectal varices are extensively described as a result of portal hypertension, small bowel varices (SBV) are rarely implicated as a source of GI bleeding. This report describes a unique case of isolated SBV resulting in overt GI hemorrhage. CASE DESCRIPTION/METHODS: A 54-year-old female with a history of alcoholic cirrhosis decompensated by esophageal varices, hepatic encephalopathy, and abdominal ascites (MELD-Na 19) presented to the ED after multiple episodes of melena and hematochezia. The patient had previously undergone transjugular portosystemic shunting (TIPS) for recurrent variceal bleeding. The patient underwent an EGD which showed mild portal hypertensive gastropathy but no gastric or esophageal varices. Her colonoscopy was unremarkable. Given ongoing bleeding, the patient underwent a capsule endoscopy which revealed fresh blood with clots two-thirds (65%) of the way through the jejunum. A CT angiography revealed a portosystemic shunt between the superior mesenteric vein and the common femoral vein near the jejunum. Interventional radiology performed a catheter guided coil and glue embolization of the venous malformation and created a new portosystemic shunt. The patient’s melena and hematochezia ceased, and she was safely discharged home. DISCUSSION: Caused by portal hypertension, SBV are rare and infrequently implicated in significant GI hemorrhage. This case is unique in that the patient had no gastric, esophageal, or rectal varices. Isolated SBV are described anecdotally in the literature and extremely unlikely to manifest clinically. In addition, this case highlights the potential utility for inpatient video capsule endoscopy (VCE). In a patient with persistent GI bleeding with normal endoscopy and colonoscopy should certainly be considered for a deeper luminal exam. Furthermore, the definitive management of SBV is not well defined. While the mainstay of treatment is supportive care, minimally invasive vascular interventions provide an exciting option for management.

S2117 The GIST of It: A Rare Presentation of Neurofibromatosis Type I

INTRODUCTION: Neurofibromatosis Type 1 (NF1) is an autosomal-dominant disease with an incidence of 1 in 2500–3000 individuals. NF1 confers up to a four-fold increase in overall malignancy risk compared to the general population, and patients are 34 times more likely to develop gastrointestinal stromal tumors (GIST). GIST are rare mesenchymal tumors involving the gastrointestinal tract (GI) and their increased incidence has been associated with the history of NF-1. We present a case of a patient with NF-1 associated with an unusual presentation of GIST. CASE DESCRIPTION/METHODS: 42 years old female with past medical history of NF-1 initially presented to the ED for maroon-colored stools for 2 days. She endorsed infrequent use of ibuprofen with last use being 3 months ago. Initial physical exam was significant for mild hypotension responding to fluid resuscitation, and rectal exam negative for blood. The hemoglobin in the ER was 7.9 g/dL (baseline 11.3 g/dL) with an elevation of BUN: Creatinine ratio (24 mg/dL, 0.65 mg/dL). An EGD was performed which demonstrated mild duodenitis. An ileocolonoscopy was performed and blood clots were in the entire colon including the terminal ileum. No source of active bleeding in the colon seen after extensive suctioning done. The patient underwent a video capsule endoscopy (VCE) and an abdominal CT with contrast. VCE demonstrated a endophytic mass with active bleeding. CT revealed numerous exophytic and endophytic masses with the largest mass at the anterior wall of the ileum measuring 2.4 cm × 2.2 cm, which was noted to have a brisk active arterial bleeding. Surgery was consulted and she underwent emergent exploratory laparotomy with surgical resection of the ileal segment containing the actively bleeding mass. Histopathologic staining was positive for receptor tyrosine kinase (C-KIT) and DOG-1, consistent with GIST. Patient was initiated on imatinib therapy and has remained symptom free. DISCUSSION: Our novel case describes life-threatening GI bleeding from GIST in a patient with NF-1. GISTs are 34 times more common in patients with NF-1. In NF-1 patients presenting with GI bleeding, Small bowel GISTs should be considered as a differential and clinicians must have a low threshold for obtaining abdominal imaging by CT, VCE or nuclear imaging in case endoscopy does not detect the source of GI bleeding. Emergent surgery stands alone as a curative form of therapy for actively bleeding GISTs in patients with NF-1.Figure 1.: CT Abdomen with IV contrast : A lobulated endophytic avidly enhancing mass is identified in the Ileum, which measures approximately 2.4 × 2.2 cm. This lesion demonstrates brisk active arterial bleeding into the intestinal lumen.Figure 2.: CT abdomen with IV contrast: There is a round partially exophytic avidly enhancing mass measuring approximately 1.6 × 1.5 cm in the 4th portion of the duodenum, favored to represent a GIST. This lesion is without evidence of active bleeding on the current exam.Figure 3.: Capsule endoscopy – Brisk active bleeding lesion noted on the capsule endoscopy.

Predictors of myocardial injury in patients with cirrhosis presenting with upper gastrointestinal bleeding

BackgroundMyocardial injury in conditions other than coronary artery disease (CAD), known as type 2 myocardial infarction, is mostly related to mismatch between myocardial oxygen supply and demand. Cirrhotic patients with acute upper gastrointestinal bleeding (UGIB) are usually hemodynamically unstable. Hypovolemia, hypotension, and decreased oxygen-carrying capacity as consequences of UGIB may precipitate subclinical heart failure and myocardial injury.Aim of workAssessment of the prevalence and potential risk factors of myocardial injury in patients with liver cirrhosis with acute UGIB.Patients and methodsThe study was conducted on 132 patients diagnosed with liver cirrhosis presenting by UGIT bleeding at Mansoura University Hospitals during one year. Patients were divided into 2 groups: group 1 (76 patients) with myocardial injury or ischemic heart disease and group 2 (60 patients) without.ResultsThe incidence of myocardial injury in this study (elevated troponin levels above cutoff value and/or ECG changes) was 55% of patients. Troponin I was positive in 25% of patients. ECG ischemic changes were found in 36.3% of patients in the form of ST-segment deviation or T-wave inversion. On univariate analysis, predictors of myocardial injury in patients with UGIB included MELD score and variceal source of GI bleeding. On multivariate analysis variceal source of GI bleeding is an independent predictor of myocardial injury. Variceal bleeding was found in 95 % of the ischemic group versus 63% in the other group.ConclusionMore than half of the study patients presented with UGIB have suffered from unnoticed subclinical myocardial injury. Variceal source of GI bleeding was found to be an independent predictor of myocardial injury.

2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature

INTRODUCTION: Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy. CASE DESCRIPTION/METHODS: A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia. DISCUSSION: IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.

Is Blood Urea Concentration an Independent Predictor of Positive Endoscopic Findings in Presumed Upper Gastrointestinal Bleeding?

Background: The test characteristics of blood urea concentration in the identification of upper gastrointestinal bleeding (UGIB) or high-risk endoscopic lesions have not been clearly determined. This study aimed to elucidate if urea independently correlates with the presence of positive endoscopic findings in cases of presumed UGIB and understand the diagnostic value of this parameter when assessing a patient with potential UGIB. Methods: A retrospective cohort study was conducted at Hamilton Health Sciences hospitals examining patients who had upper endoscopy for presumed UGIB. Contingency tables were generated to determine the test characteristics of urea at different thresholds for prediction of UGIB. A crude OR was calculated for odds of bleeding being identified on endoscopy based on varying thresholds of urea, and adjusted ORs were calculated using logistic regression modelling. Results: Variables significantly associated with detecting a source of GI bleeding at endoscopy included increase in urea (OR 1.06, 95% CI 1.01–1.09), male gender (OR 2.02, 95% CI 1.08–3.77), presence of melena (OR 2.37, 95% CI 1.06–5.33), and hematemesis (OR 3.88, 95% CI 1.70–8.83), when adjusted for other covariates. The odds of identifying UGIB at endoscopy in patients with urea ≥10 mmol/L was 3.73 (95% CI 1.90–7.31) times higher than for patients with urea <10 mmol/L. Conclusion: Urea level is an independent predictor of positive endoscopic findings in presumed UGIB, and urea ≥10 mmol/L may be a useful threshold to help guide clinicians towards clinically significant bleeding that could warrant early endoscopic evaluation.

Getting the GIST of Small Bowel Bleeding

Gastrointestinal stromal tumors (GISTs) account for 1-3% of all GI malignancies and, of these, 20-25% occur in the small intestine. Although small bowel GISTs are rare, GI bleeding is a frequent presentation of symptomatic GISTs.1 We present a case of overt GI bleeding due to a jejunal GIST. A previously healthy 61-year-old woman was admitted for a syncope initially attributed to bradycardia until, after another syncopal episode, the patient had melena and a drop in hemoglobin from 11.4 to 7.9 g/dL. Initial EGD was unremarkable and colonoscopy was planned for the next day as she was hemodynamically stable. Overnight, she became hypotensive with a transient vasopressor requirement, and could not tolerate bowel preparation. In light of her continued melena and elevated BUN/creatinine ratio, a more distal GI bleed was suspected. A push enteroscopy was performed at which time adherent clot was visualized distal to the furthest extent of the colonoscope. Examination with an enteroscope demonstrated a large (3-5 cm) serpiginous, pulsatile mass with an overlying ulceration. No active bleeding was seen and the site was tattooed at either extent of the lesion. Biopsies were not performed due to concern for inciting significant bleeding. A CT angiogram demonstrated a 58 x 72 mm hypervascular right pelvic mass adjacent to a loop of small bowel. She underwent exploratory laparoscopy with resection of a segment of the jejunum and the adjacent 9 cm mass. Pathology demonstrated an intermediate to high risk GIST (pT3N0) and the patient was started on adjuvant imatinib. Although small bowel GISTs are rare and the small bowel is an uncommon source of GI bleeding, GISTs may be overrepresented as a cause of small bowel bleeding. In a case series of capsule endoscopy for diagnosis of small bowel bleeding, GISTs accounted for 18.75% of bleeding among 40 to 64 year olds, second only to vascular lesions.2 This underscores the importance of keeping this otherwise rare entity on the differential in small bowel bleeding, particularly in this age group. GISTs are primarily extraintestinal and cross-sectional imaging may be beneficial as in this case.1965_A Figure 1. Endoscopic image of the jejunum with a large (3-5 cm) serpiginous, pulsatile mass with overlying ulceration.1965_B Figure 2. CT Angiogram demonstrating a 58 x 72 mm hypervascular right pelvic mass adjacent to a loop of small bowel1965_C Figure 3. Exploratory laparoscopy revealed a 9cm GIST adjacent to the jejunum

Metastases from lobular breast cancer as an unusual source of GI bleeding.

e12557 Background: With the exception of malignant melanoma, metastases to the GI tract are rare, especially as a first presentation of malignancy. We report a series of patients with GI metastases from lobular breast carcinoma as an unusual source of symptomatic GI bleeding. Methods: We conducted an electronic database search to identify solid tumour patients (excluding melanoma) with metastases to the GI tract. We then analysed the database by tumour type. Results: 3 cases of proven metastasis to the GI tract were identified. All had lobular breast cancer metastases. The database contained 240 patients with breast cancer, identifying 63 with infiltrating lobular carcinoma, 2 with micropapillary and 175 with invasive ductal carcinoma The 1st case had had invasive ductal breast carcinoma 6 years previously and presented with fatigue and shortness of breath from anaemia. Colonoscopy revealed a polyp which was removed. Histopathology showed metastatic lobular breast carcinoma. Further investigation then confirmed an occult breast mass with identical pathology. The 2nd case presented with 18 months of abdominal pain, previous colonoscopy was normal. After onset of anaemia and 25kg weight loss, upper GI endoscopy showed a markedly thickened stomach with evidence of recent bleeding and biopsies confirmed metastatic lobular breast carcinoma. The 3rd case presented with abdominal pain, subsequent blood tests showing a raised CA125 with omental and ovarian masses. Surgical debulking showed metastatic lobular breast carcinoma, though no primary breast lesion was detectable with mammography, ultrasound and MRI. 3 years later, investigation of anaemia with colonoscopy showed a caecal polyp with histology confirming lobular breast carcinoma. Conclusions: Despite all common tumour types being represented in the database it is notable that all 3 cases with mucosal GI metastases had lobular breast cancer. Previous evidence suggests a long latent period from initial diagnosis of breast cancer to development of GI metastases however our report suggests it can occur earlier in the illness. Clinicians should consider this as a rare cause of GI bleeding and further research to understand the mechanism of mucosal metastasis in lobular breast cancer is needed.

Pharmacologic provocation combined with endoscopy in refractory cases of GI bleeding.

The source of GI bleeding may elude us despite exhaustive testing in some cases. Bleeding in these cases is often related to a vascular lesion that is discernible only when actively bleeding. The objective of this study was to determine the efficacy and safety of endoscopy combined with the administration of antiplatelet and/or anticoagulant agents to stimulate bleeding in order to define a source. A retrospective review of a database of device-assisted enteroscopy (DAE) procedures was completed to identify cases in which provocation with antiplatelet or anticoagulant agents was used as part of a GI bleeding evaluation. Procedures were divided into 3 groups based on the method of provocation: patients with a history of bleeding associated with an antiplatelet/anticoagulant (provocation-experienced); patients naïve to these medications (provocation-naïve); and cases of recurrent, overt GI bleeding in which a combination of clopidogrel and intravenous heparin was administered for provocation (Lousiana State University [LSU] protocol). A review of 824 DAE procedures was completed to identify a total of 38 instances in which provocation was attempted in 27 patients. These cases were subdivided into 13 provocation-experienced procedures, 18 provocation-naïve procedures, and 7 LSU protocol procedures. The diagnostic yield of provocative testing per procedure was 53% in the provocation-experienced group, 27% in the provocation-naïve group, and 71% in the full protocol group. Provocative testing was revealing in 15 of 27 patients; angioectasias and Dieulafoy lesions were the most common pathologies. Provocative testing was not beneficial in 4 patients who were eventually diagnosed with bleeding caused by intestinal angioectasias (3) and an aorto-enteric fistula (1). There were no adverse events. Provocative testing combined with endoscopy can be justified as an option in the diagnostic algorithm of complex cases of GI bleeding when intermittent bleeding related to a vascular lesion, such as an angioectasia or Dieulafoy, is suspected. However, this novel technique should be considered only after standard management has failed to define a bleeding source, and bleeding continues to recur. This is the first reported case series of provocative testing combined with endoscopy.

Resolution of Constipation, Anal Stricture, and Fe Deficiency Anemia After Iron Infusion: An Analogy With Plummer Vinson Syndrome: Presidential Poster

Introduction: Anal stricture is an uncommon and disabling condition which can be unresponsive to conservative management and the complications of dilatations and Anoplasty make it a formidable treatment challenge. Here we report the case of a patient with constipation, anal stricture and iron deficiency anemia (IDA) where the triad resolved with IV iron treatment over 3 months. Case Report: A 69-year-old male presented to us with chronic constipation, rectal pain and easy fatigability. Physical examination revealed conjunctival pallor and laboratory findings were consistent with microcytic hypochromic anemia with iron deficiency (Ht- 31.6, Labs-Table 1). An upper endoscopy, CT Abdomen and Capsule endoscopy did not reveal any source of GI bleeding. Celiac panel was normal and there was no evidence suggestive of any other cause of anemia. Digital rectal examination (DRE) could not be completed because of severe rectal pain and markedly narrow anal canal. Under propofol sedation, Colonoscopy with GIF-Q 180 OLYMPUS scope, confirmed anal stricture with non-specific colitis. Conservative management with laxatives, high fiber diet and local anesthetics was initiated but the patient continued to have symptoms. Patient was referred to the hematologist for an evaluation of anemia and was started on IV Iron infusions. After 3 months of treatment, patient's anemia and all of the symptoms resolved (Ht- 38.3, Table 1). A repeat DRE was painless and the anal stricture had resolved.Table 1: Lab Values Pre and Post Iron Replacement TherapyDiscussion: The triad of Constipation, Anal Stricture and IDA in this patient paints a similar picture as PVS which presents as Dysphagia, Esophageal webs and IDA. The patient's symptoms of constipation and anal stricture resolved with iron treatment which has for long been known to resolve dysphagia and esophageal webs in PVS. Iron deficiency leading to loss of iron-dependant enzymes causes web formation and cancer development of the gastrointestinal tract. Tissue iron has been known to play an important role in the proliferation of epithelial cells. The epithelial layer of the alimentary tract is especially susceptible to iron deficiency because of its high cell turnover. Therefore, Iron replacement may provide a promising medical treatment benefit in high cell turnover GI tract and resolve rectal strictures along with the symptoms associated with them. The cause of PVS still remains a mystery. This analogy with PVS serves as a subject of further research and presents as an intriguing intellectual challenge in front of our medical fraternity.

Obscure Overt GI Bleed: A Case of CMV Ileitis in an Immunocompetent Patient

Obscure GI bleeding is an unidentified source of GI bleeding after a negative EGD, colonoscopy and barium small bowel follow-through. Up to 75% of these patients have a bleeding source in the small intestine. We present a patient with recurrent severe hematochezia, with negative upper endoscopy, colonoscopy and visceral angiogram, who was found to have bleeding Ileal ulcers on video capsule endoscopy with retrograde balloon enteroscopy showing bleeding vessels and pathology consistent with Cytomegalovirus. A 52-year-old male with history of Granulomatosis with Polyangiitis (GPA) and end stage renal disease (ESRD) presented with five episodes of Hematochezia. He was off immunosuppression for more than four years. Colonoscopy showed large amount of blood in the colon with moderate diverticuli but no active bleeding. A subsequent EGD was negative. Over the next 2 days, patient had multiple episodes of hematochezia. He underwent a tagged RBC scan, which showed blood in the terminal ileum but the visceral angiogram was negative for active bleeding. A video capsule endoscopy showed ulcerations in proximal to mid ileum. Retrograde balloon push enteroscopy showed ulcers at 135 cm from entry site in Ileum and two bleeding vessels were clipped. Results of ulcer biopsy showed intracellular inclusion bodies suggestive of Cytomegalovirus (CMV), which was confirmed with Immunostains and patient was started on oral Valganciclovir. CMV is known to cause severe infections in immunocompromised patients, but is usually mild and self-limiting in immunocompentent patients. CMV can involve any segment of the gastrointestinal tract, but most commonly involves the colon and small bowel involvement is rare. Most common presenting symptoms include fever, abdominal pain, diarrhea and bleeding per rectum, however massive transfusion dependent GI bleeding, intestinal perforation and intestinal obstruction have been reported. Diagnosis of CMV enteritis is usually made by histopathology which shows intracellular granules combined with Immunostains positive for CMV. Viral cultures and PCR are also helpful. Differential diagnosis of CMV enteritis involves colitis caused by C. difficile, ischemia, colonic malignancies and inflammatory bowel diseases. Treatment involves administration of IV Ganciclovir or oral Valganciclovir. It has been suggested that immunocompetent patients usually tend to recover spontaneously and do not need treatment. However it is hard to define the criteria of immunocompetency. In our case the patient was off immunosuppressant's for over four years, although it can be argued that presence of comorbidities like GPA and ESRD creates a state of relative immunosuppression. Our case highlights the diagnostic dilemma in patients with obscure GI bleed and additionally, is a rare presentation of CMV ileitis in a immunocompetent patient.Figure 1Figure 2Figure 3

An Unexpected Encounter at the Hepatic Bifurcation

Clinical Presentation: A 45-year-old African-American female presented with melena and acute anemia 1 week after an endoscopic sphincterotomy and biliary stent placement for bile duct obstruction. An upper GI endoscopy revealed fresh blood and clots in the second portion of the duodenum, likely coming from the major papilla. After epinephrine injection, ERCP with selective biliary cannulation and balloon sweeps yielded fragments of stones, clots, and debris. On cholangiogram, a large filling defect was also at the hepatic bifurcation. The patient was discharged several days later in stable condition. The patient returned 3 months later with nausea, vomiting, and abdominal pain consistent with acute pancreatitis, with lipase >14,000, ALP >600, and normal bilirubin. An abdominal contrast-enhanced CT scan and ultrasound showed a 3 x 3-cm mass in the CBD extending into the left and right hepatic ducts with biliary dilation. The patient responded to conservative therapy but extensive investigation was continued to identify the cause of the biliary lesion. ERCP with cholangioscopy as well as EUS with FNA revealed the lesion to be a biliary intraductal papillary mucinous neoplasm (B-IPMN). Given her age and the possible malignant potential of B-IPMNs, the patient was referred for local resection, which was performed successfully. Discussion: B-IPMNs have been increasingly recognized over the last 10 years. Due to common embryologic origins, it was postulated that B-IPMN may behave similarily to pancreatic IPMNs. Others theorized that they may follow a more benign course similar to biliary papillomas. Analysis of histopathologic subtypes and type-specific mucin expression patterns of B-IPMN seem to indicate a closer link to the main duct pancreatic IPMN lesions, with associated malignant potential favoring primary resection as the preferred modality of treatment. Several recent studies revealed carcinoma association with B-IPMN lesions ranging between 68-83%, with 5 year survival of 38% after resection. Conclusion: Persistent evaluation of an underlying biliary abnormality first noted during ERCP and on repeat imaging tests to help explain the source of GI bleeding and acute pancreatitis led to the diagnosis of a biliary lesion with malignant potential. Biliary IPMN seem to be a unique clinical entity which warrants further evaluation which may lead to better understanding of biliary malignancies.

Role of CT enterography in obscure gastrointestinal bleeding

BackgroundObscure gastrointestinal bleeding is a radiological challenge where in almost half of the patients; the origin of the blood loss remains unexplained. AimTo highlight the use of dual phase CT enterography for the detection of obscured gastrointestinal bleed. Patient and methodsTwenty consecutive patients (11 men and 9 women) with OGIB were included in this study; their age ranged from 28 to 67years (mean age 45.6years). CT enterography was performed first with a non-contrast scan, followed by biphasic contrast-enhanced CT at 35 and 70s at a rate of 4mL/s. ResultsOn CT enterography, 12 patients (60%) were negative while 8 patients (40%) had positive findings as follows: one patient (5%) had celiac disease, 1 patient (5%) had active Crohn’s disease and another patient (5%) had ischemic bowel changes. Five patients (20%) had small bowel neoplasms as follows: (1 patient had ileal angiolipoma, 1 patient had ileal hypervascular GIST, 1 patient had duodenal GIST, 1 patient had duodenal carcinoid and 1 patient had jejunal villous adenoma). ConclusionMDCT enterography has a good diagnostic accuracy in the evaluation of patients with OGIB and can reliably indicate the source of GI bleeding and guide subsequent therapy.

A duplication cyst masquerading as a meckel's diverticulum

Gastrointestinal tract duplication cysts are rare congenital malformations, usually presenting in infancy or early childhood with a variety of symptoms within the GI tract. Sources of GI bleeding can present a diagnostic dilemma despite conventional radiological & endoscopic investigations. We present an unusual case of a 13 year old boy, who presented with an acute abdomen and malaena with contrasting radiological and operative findings. A 13 year old boy was referred to our hospital with a 2 week history of severe central abdominal pain and 2 episodes of malaena. On assessment he appeared well and was haemodynamically stable. On physical examination his abdomen was tender centrally. Digital rectal examination was normal. Blood tests revealed a Haemoglobin of 7.2 with a MCV of 58.3. Abdominal X-ray showed faecal loading. An ultrasound scan of his abdomen found an abnormally dilated fluid-filled loop in the right iliac fossa extending into the pelvis. An MRI scan with Haste sequences was undertaken for additional clarity, and this favoured a Meckel9s appearance. A laparotomy revealed a large 30 cm long cystic lesion in the mesentery of the ileum. The ileum was extremely adherent to this cyst, thus en bloc ileal resection was performed with primary anastomosis. The boy was discharged uneventfully on post-operative day 3. Histology confirmed a congenital duplication cyst with heterotopic gastric glands. This demonstrated an area of haemorrhage subserosally. Alimentary tract duplications are rare childhood anomalies, but may cause intestinal obstruction, intussusception, haemorrhage or perforation. They are most commonly located in the ileum, but can occur anywhere from pharynx to rectum. They are lined by intestinal tract mucosa and share a common smooth muscle wall and blood supply with adjacent bowel wall, with which they can communicate. Malignant change has rarely been reported in adults, in particular within rectal duplication cysts. The duplication cyst attached to this boy9s ileum revealed gastric mucosa, which contains acid-secreting parietal cells resulting in peptic-ulcer type ulceration and bleeding. Intestinal duplication cysts should be considered in the differential diagnosis of GI bleeding in children. Complete excision is the treatment of choice.

Ectopic Ileal Varices Diagnosed by Bleeding Scan and Wireless Capsule Endoscopy

Purpose: Ectopic varices are an unusual cause of gastrointestinal bleeding; it accounts for 1-5% of all variceal bleeding. We report a case of ectopic ileal varices presented as obscure gastrointestinal bleeding. The diagnosis was clinically suspected, supported by bleeding scan and wireless capsule endoscopy, and confirmed on surgery. Case Report: A 56-year-old woman with history of HIV and Hep C cirrhosis was admitted to our hospital with painless hematochezia. Her past medical history was significant for esophageal variceal band ligation 1 year ago and Total Abdominal Hysterectomy and Bilateral Salpingo Oopherectomy (TAHBSO) 9 years ago. Upper endoscopy, colonoscopy, and enteroscopy did not reveal the source of GI bleeding. CT abdomen revealed dilated mesenteric veins. Due to poor renal function, mesenteric angiogram could not be performed. Subsequent bleeding scan was positive for extravasation in the right lower quadrant. This finding was further supported by wireless capsule endoscopy, which showed questionable submucosal vessel in distal ileum with fresh blood clot. Based on these findings, patient underwent exploratory laparotomy which confirmed ileal varices as source of obscure GI bleeding. 12 inches of distal ileum were resected. Unfortunately, patient progressed into hepatorenal syndrome and expired postop day 4. This case report highlights the importance of clinical suspicion, bleeding scan, and wireless capsule endoscopy in the diagnosis of obscure GI bleeding secondary to ectopic ileal varices.

Bleeding Meckelʼs Diverticulum with a Negative Meckelʼs Scan - Uncommon Feature of an Uncommon Entity

Purpose: Case: A 30-year old male presented with a 13-month history of obscure GI bleeding. He initially presented elsewhere after a single episode of maroon colored stools. He had been previously healthy, and used NSAIDs rarely. He was adopted and of Korean descent; his family history was unknown. He denied easy bruising or epistaxis. Initial workup elsewhere revealed iron-deficiency anemia. EGD and colonoscopy were negative. He was advised to avoid NSAIDs, which he did. Two weeks later, he had recurrent bleeding. A capsule enteroscopy, single balloon enteroscopy (SBE), tagged red blood cell scan and Meckel's scan were negative. At our institution, a repeat antegrade SBE showed a single non-bleeding jejunal vascular ectasia that was cauterized. He was well for 9 months, then again developed maroon stools. He denied NSAID use. Workup included a SBE that was unremarkable, a triple-phase CT enterography (CTE) showing a Meckel's diverticulum, a Meckel's scan which was again negative, and a capsule enteroscopy revealing a mid-ileal ulcer. Due to ongoing bleeding, a retrograde double balloon enteroscopy (DBE) was done and revealed a large mid-ileal diverticulum with a 2 cm ulcer at its rim containing a flat pigmented spot, treated endoscopically. Persistent bleeding led to surgical resection of the diverticulum. Pathology confirmed a Meckel's diverticulum, with circumferential ulceration around its neck and a thrombosed artery in the ulcer base. Histologic sampling of the entire diverticulum failed to reveal ectopic gastric mucosa. Discussion: Meckel's diverticulum is the most common congenital anomaly of the GI tract. It affects 2% of the population, but only 2% develop complications, often before age 2. Complications include bleeding (most commonly), obstruction, diverticulitis, intussusception and perforation. Up to 90% of bleeding diverticula contain ectopic gastric mucosa. Our patient had a triple-phase CTE demonstrating a Meckel's diverticulum, and a DBE localizing it as the bleeding source, despite negative Meckel's scans. Histologic evaluation of the surgical specimen failed to reveal ectopic gastric mucosa, ruling out acid-mediated ulceration. The pattern of ulceration suggested the diverticulum had bled from repetitive inversion and eversion of the diverticulum into the ileal lumen, leading to ulceration in the neck. This putative mechanism has not been reported in the literature. This case highlights that a Meckel's diverticulum may be a source of GI bleeding despite absence of ectopic gastric mucosa.

Yield of Antegrade Deep Enteroscopy Includes Many Significant Upper GI Findings, Even in Patients Prescreened with Capsule Endoscopy

Purpose: To determine the frequency, type and significance of UGI findings found on antegrade deep enteroscopy (Double Balloon (DBE) and Spiral) performed for evaluation of obscure GI bleeding at a referral center after EGD, colonoscopy and capsule endoscopy for patient selection. Methods: Patients referred to our center who underwent antegrade deep enteroscopy for obscure GI bleeding were included. All had undergone EGD and colonoscopy and all had capsule studies re-read, with findings warranting deep enteroscopy. Per our protocol, antegrade DBE and Spiral enteroscopy were done under GA, avoiding narcotics, and after transfusion to Hgb 10. Data analyzed included patient demographics, type and extent of exam, overall findings in upper GI territories (gastric, D1, D2, D3, D4 and ligament of Treitz) and type of finding (angioectasia, ulcers, GAVE, other). Clinical significance of UGI findings was judged based on type of lesions, number and size of UGI lesions relative to distal findings and presence of active bleeding. Results: One hundred nineteen deep enteroscopy procedures (110 DBE and 9 Spiral) for obscure GI bleeding indications were performed on 119 patients (Mean age 66.8 years; 50 M, 69 F). Mean depth of insertion was estimated at 250 cm beyond the pylorus (range 60 to 550). Overall, 73% (87/119) of deep enteroscopy exams had significant lesions found. Notably, 46% (55/119) had UGI lesions found well within push enteroscopy territory (gastric, D1, D2, D3, D4 and ligament of Treitz) with 31% (37/119) of lesions within typical EGD territory (G, D1 and D2). 75% (41/55) of exams with UGI lesions had angioectasias only, while 25% (14/55) had other lesions including GAVE (3), ulcers (6) and other (5). Clinical significance of these UGI lesions was judged as: Predominant source of bleeding 10, significant contributor 25, possible contributor 15, not significant 4. Conclusion: In our series, 46% of antegrade deep enteroscopy exams had lesions found within reach of push enteroscopy and 31% had lesions within reach of standard EGD. These UGI lesions, mostly angioectasias, were judged to be a predominant or significant source of GI bleeding in 29% of exams overall (35/119). We consider that this relatively high frequency of UGI findings may be in part due to improved detection of angioectasias by avoidance of narcotics and transfusion to Hgb 10. Our data also reinforces the value of “second look” EGD or push enteroscopy in evaluation of obscure GI bleeding. Disclosure: Dr Brown, Speakers Bureau: Given Imaging (Capsule Endoscopy).