Stigmata Of Recent Hemorrhage Research Articles

Independent risk factors of 30-day outcomes in 1264 patients with peptic ulcer bleeding in the USA: large ulcers do worse.

Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeds (PUBs) are essential indicators because of significant morbidity and mortality rates of PUBs. However those have been infrequently reported since changes in medical therapy (PPI, proton pump inhibitors) and application of newer endoscopic haemostatic technique. To determine: (i) independent risk factors for 30-day rebleeding, surgery, and death and (ii) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB after successful endoscopic haemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists - H2RAs). A large prospectively followed population of patients hospitalised with severe PUBs between 1993 and 2011 at two US tertiary care academic medical centres, stratified by stigmata of recent haemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors for each outcome (rebleeding, surgery and death) up to 30 days were analysed. Effects for medical treatment (H2RA patients 1993-2005 vs. PPIs 2006-2011) were also analysed. A total of 1264 patients were included. For ulcers ≥10 mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95% CI 1.02-1.10, P = 0.0053). Other risk factors for 30-day rebleeding were major SRH, in-patient start of bleeding, and prior GI bleeding. Major SRH and ulcer size≥10 mm were predictors of 30-day surgery. Risk factors for 30-day death were major SRH, in-patient bleeding, and any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and out-patient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95% CI 1.02-1.14, P = 0.0095). Ulcer size was a significant independent variable for both time periods. Ulcer size is a risk factor for worse outcomes after PUB and should be carefully recorded at initial endoscopy to improve patient triage and management.

Atypical Aortoesophageal Fistula with Atypical and Delayed Presentation and Negative Imaging Studies.

A 59-year-old man with past medical history of thoracic aortic aneurysm treated with thoracic endovascular aortic repair presented with melena for 2 weeks. Initial EGD did not reveal the source of bleeding and showed normal esophagus; abdominal arteriogram did not reveal a fistulous communication and initial CTA showed normal position of the aortic graft stent without endoleak. The sixth EGD revealed a submucosal tumor-like projection in the upper esophagus and stigmata of recent bleeding. Another thoracic endovascular aortic repair with stent was placed over the old graft for presumed aortoesophageal fistula. Poststent upper gastrointestinal series with contrast showed extravasation of the contrast from the esophagus and CTA showed fistulous tract between aorta and esophagus. The patient refused definitive surgical repair despite having infected aortic graft; jejunostomy tube was placed and life-long suppressive antibiotic treatment was given and the patient is doing well at 2-year follow-up.

A Case of Hemorrhagic Pancreatic Pseudocyst as a Complication of Chronic Pancreatitis

Chronic pancreatitis can be associated with a variety of complications the most common being the formation of a pseudocyst. Hemorrhagic complications such as bleeding into a pseudocyst or from a pseudoaneurysm are rare but are associated with a significant mortality and therefore merit consideration in the right clinical scenario. A 54 year old woman with a history of chronic pancreatitis with pseudocyst and alcoholic cirrhosis presented to the emergency department with acute right upper quadrant abdominal pain. Initial work up included an ultrasound, which revealed cholelithiasis without any signs of cholecystitis. Diagnostic paracentesis was negative for an intraperitoneal infection. During the hospitalization, the patient was noted to have a gradually downtrending hemoglobin with reported dark stools. Upper endoscopy was performed, revealing a large submucosal bulging mass in the body of the stomach with a small overlying superficial ulcer and stigmata of recent bleeding. A hemostatic clip was placed over the ulcer. On endosonographic examination, a heterogenous mass of about 4 cm was seen abutting the posterior wall of the stomach. Computed tomography revealed the pancreatic pseudocyst which had increased in size from 4.1x3.2 cm a year ago to 7.0x5.4 cm with evidence of active bleeding into the cyst. An emergent splenic arteriogram was performed which showed no active bleeding and no pseudoaneurysm. A prophylactic coil embolization of the distal left splenic artery was performed. Hemoglobin was stable after embolization. Hemorrhagic pancreatic pseudocysts are rare late complications of chronic pancreatitis occurring either from a pseudoaneurysm or venous and capillary bleeding, the latter often escaping angiographic detection. In a retrospective review of 1,910 patients who had undergone radiologic evaluation of pancreatitis, 1.3% were found to have hemorrhagic complications. Hemorrhagic pseudocysts accounted for 19.5% of these complications. Common treatment options include arterial embolization or surgical intervention with arterial ligation and resection. However, the latter is reserved for unstable patients or for those in whom the culprit vessel is not visualized angiographically or embolization cannot be performed. Hemorrhagic complications are an important consideration in the patient with chronic pancreatitis presenting with unexplained abdominal pain or bleeding.Figure 1Figure 2Figure 3

Doppler Ultrasound Stratification of High-Risk Stigmata in Peptic Ulcer Bleeding

Stigmata of recent hemorrhage (SRH) have long been used to stratify the risk for rebleeding in patients with peptic ulcer bleeding (PUB). Could use of

Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding

For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB). Prospective cohort study of 163 consecutive patients with severe PUB and different SRH. All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05). (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis

Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata--none after hemostasis--and there was no rebleeding. (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred.

Acute Anemia in a Patient With Hepatocellular Carcinoma

Question: A 64-year-old man presented with syncope. He had been diagnosed with a multifocal hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer stage D 2 months before admission. He denied prodromes, hematemesis, melena, or abdominal pain, and there was no recent history of abdominal trauma. At admission, he was pale and tachycardic, presented with grade 3 ascites (International Ascites Club Classification) and the neurologic examination was unremarkable. Laboratory data revealed de novo normocytic and normochromic anemia (hemoglobin, 4.3 g/dL; normal range, 11.5–18.0) and prothrombin time of 60% (normal, 70%–100%). Upper gastrointestinal endoscopy revealed only small esophageal varices with no stigmata of recent hemorrhage. Paracentesis revealed a bloody fluid with serum–ascites albumin gradient of 1.4 consistent with portal hypertension, 2.4 g/dL of proteins, and 500 cells/mL with predominance of lymphocytes and mesothelial cells, erythrocyte count was not available. Cytology was negative for malignant cells. CT angiography (Figure A) was performed. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage

Background and study aims: Endoscopic band ligation (EBL) has been used for hemostasis of colonic diverticular hemorrhage. However, early rebleeding (< 30 days after EBL) has been reported in some cases. The aim of this study was to elucidate risk factors for early rebleeding after EBL in treatment of colonic diverticular hemorrhage. Patients and methods: A total of 101 patients with definite diverticular hemorrhage treated using EBL from June 2009 to October 2014 were included in the retrospective cohort study and divided into rebleeding and non-rebleeding groups, depending on the presence or absence of early rebleeding. Patients’ ages, comorbid diseases, stigmata of recent hemorrhage (SRH) [active bleeding (AB), non-bleeding visible vessel (NBVV), or adherent clot (AC)], locations of bleeding diverticula, and eversions of the diverticula after EBL were retrospectively evaluated in each group. Results: Early rebleeding occurred in 15 cases. The median time (range) of early rebleeding occurrence was 5 days (range, 2 h to 26 days). Early rebleeding could be managed conservatively and/or endoscopically, except in one case in which surgery was done. Multivariate analysis revealed that age under 50 (adjusted OR, 8.7; 95 % CI 1.6 – 52.5; P = 0.014) and AB (adjusted OR, 4.21; 95 % CI 1.15 – 18.1; P = 0.03) were shown to be significant risk factors. The right side of the colon carried less risk than did the left side (adjusted OR, 0.21; 95 % CI 0.04 – 0.84; P = 0.028). Conclusions: Younger age, AB of SRH, and leftsided lesions were identified as the risk factors for early rebleeding after EBL in the treatment of colonic diverticular hemorrhage.

Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding.

The aim of this study was to identify predictors for the identification of stigmata of recent hemorrhage (SRH) on colonic diverticula. Several factors influence the identification of SRH in the diagnosis of colonic diverticular bleeding. A total of 396 patients hospitalized for lower gastrointestinal bleeding were analyzed. Comorbidities, medications, timing of colonoscopy [<24 h (h); urgent, 24 to 48 h, >48 h], preparation, expert colonoscopist, use of a cap, use of a water-jet scope, total colonoscopy, and procedure time (over 60 min) were assessed. A multivariable logistic regression model was used to estimate odds ratio (OR) and 95% confidence interval (CI). Two hundred fifteen patients were diagnosed with colonic diverticular bleeding and 37 (17%) were identified with SRH. Urgent colonoscopy (OR, 8.4; 95% CI, 2.3-30; P<0.01), expert colonoscopist (OR, 3.0; 95% CI, 1.2-7.3; P=0.02), use of a cap (OR, 3.4; 95% CI, 1.4-8.0; P=0.01), and use of water-jet scope (OR, 5.8; 95% CI, 2.3-15; P<0.01) were found to be independent predictive factors for SRH. The accuracy of these factors in combination was 0.90 (95% CI, 0.85-0.96) as measured by area under the receiver operating characteristic curve (ROC-AUC). SRH identification rate was higher in the urgent (22%) than in the 24 to 48 hours (2.9%, P<0.01) and >48 hours groups (1.0%, P<0.01), showing a tendency to decrease with time (P<0.01 for trend). Factors of urgent colonoscopy, expert colonoscopist, use of a cap, and use of water-jet scope are useful for identifying SRH diverticula.

Sinistral Portal Hypertension and Anastamotic Varices Secondary to Splenic Vein Thrombosis After a Whipple Procedure

Introduction: A 70-year-old Pakistani woman with a past medical history of coronary artery disease status post recent bare metal stent x 3 (on aspirin and clopidogrel), with a remote history (1989) of a pancreaticoduodenectomy for a benign pancreatic mass that was complicated by splenic vein thrombosis, was admitted to the hospital for worsening anemia. On admission, she was noted to have a hemoglobin of 5 g per dL (9.7 grams per dL 1 month prior). Symptoms included increased fatigue and weakness, and she reported dark stools unchanged while taking oral iron. Of note she had a history of overt, obscure upper gastrointestinal bleeding with several admissions and extensive evaluations from 2001-2012, which were unsuccessful in identifying a source of bleeding. Her most recent endoscopic studies included a normal colonoscopy and an upper endoscopy that revealed post-Whipple anatomy with a widely patent gastrojejunostomy (GJ) and small type 2 gastro-esophageal varices (GOV2) without stigmata of recent bleeding. Push-enteroscopy was performed, which identified small, nonbleeding GOV2s along the fundus. The GJ anastomosis was characterized by friable mucosa and extensive vascular ectasia. The efferent jejunal limb was normal. During the procedure, active bleeding was induced by scope trauma to the GJ anastomosis requiring patient intubation and intra-procedural transfusions. A post-procedure CT angiogram revealed prominent submucosal vasculature localized to the GJ anastomosis diagnostic of anastomotic varices with additional short gastric varices between the spleen and stomach. Moreover, the spleen was enlarged (13 cm) and the splenic vein was not visualized secondary to chronic splenic vein thrombosis. There was no evidence of cirrhosis, suggesting isolated left-sided portal hypertension. Our patient was treated with splenectomy, and has not experienced recurrent bleeding during approximately 2 years of clinical follow-up. Sinistral portal hypertension, also known as left-sided portal hypertension, is hypertension confined to the gastrosplenic side of the portal venous system. To our knowledge, this is the first case of sinistral portal hypertension leading to varices at a GJ anastomosis. Sinistral portal hypertension accounts for less than 5% of all portal hypertension, and is most commonly caused by splenic vein occlusion related to pancreatic disorders. As most patients are asymptomatic, the exact incidence is unknown, but bleeding (variceal or nonvariceal) is the most common manifestation. Splenectomy decreases venous flow through collateral vessels and decompresses associated varices. Rebleeding is rare after splenectomy in various case series.

An Unusual Case of an Upper Gastrointestinal Bleed: Pharyngeal Varices

Introduction: Ectopic varices are a rare finding and cause of gastrointestinal bleeding. We report a case of upper gastrointestinal bleeding in a cirrhotic patient due to pharyngeal varices. A 53-yearold man with hepatitis C cirrhosis presented with 6 months of fatigue with episodic hematemesis and melena. He denied use of alcohol, non-steroidal anti-inflammatory drugs, anticoagulants, aspirin or iron supplementation. Physical examination revealed a pale, non-icteric man with spider angiomas and caput madusae. Laboratory findings showed: hemoglobin 6.1 gm/dl, platelets 88,000 U/L, international normalized ratio 1.36, aspartate aminotransferase 51 U/L, alanine aminotransferase 30 U/L, alkaline phosphatase 118 U/L, total bilirubin 1.62 mg/dl. The patient was started on esomeprazole and octreotide drips and was transfused with red blood cells. On esophagogastroduodenoscopy, prior to intubation of the esophagus, the pharynx showed pharyngeal varices with stigmata of recent bleeding. The patient was transferred to a tertiary care center for laryngoscopy and further treatment. Ectopic varices are considered variceal veins other than those found in the esophagus and stomach such as rectal varices. These develop from portosystemic collaterals in portal hypertension that become enlarged. Pharyngeal varices are by definition considered ectopic varices. However, unlike other ectopic varices, pharyngeal varices arise from the lingual venous system and not from the portal venous system. There is no known anastomosis between the two systems; therefore it is unclear if the formation is related to portal hypertension. The fact that these varices have been found in cirrhotic patients suggests a relationship between these two systems, but it is unknown if conventional treatment for esophageal varices including transjugular intrahepatic portosystemic shunt (TIPS) would be an option. Prior cases have reported treating pharyngeal varices with ablation using a continuous carbon dioxide laser or decompressing neck veins with a venous bypass procedure. Ectopic varices are associated with a mortality rate reaching 40%; it is unknown whether pharyngeal varices carry similar risk. Overall, both the prognosis and the optimal management of pharyngeal varices have not been elucidated.

1034 Measures of Obesity and Risk of Gastric and Duodenal Ulcers

G A A b st ra ct s the recurrence of LDA-related peptic ulcers has not been reported. We conducted a randomized, double-blind, double-dummy, active-controlled trial to assess the efficacy, doseresponse relationship and safety of rabeprazole for peptic ulcer recurrence in Japanese patients in long-term LDA therapy. Methods: Patients were eligible for the trial if they had an endoscopically confirmed gastric or duodenal ulcer scars and were receiving long-term LDA (81 mg/day or 100 mg/day) therapy for cardiovascular and cerebrovascular protection. Patients on long-term LDA therapy were also eligible if they had a previous history of endoscopically confirmed active peptic ulcers, but did not present them at baseline endoscopy. Patients were randomly segregated into three groups receiving rabeprazole 10 mg once daily (standard dose in Japan), rabeprazole 5 mg once daily or teprenone (mucosal protective agent commercially available in Japan) 50 mg three times per day as an active control. The primary endpoint was recurrence of gastric and duodenal ulcers over 24 weeks. Secondary endpoints included an occurrence of bleeding ulcers with stigmata of recent hemorrhage or drop in hemoglobin level of more than 2 g/dl, changes from baseline in the modified Lanza score (endoscopic scoring system for gastroduodenal damage) or upper gastrointestinal symptom score, and newly-developed erosive esophagitis. Results: Among 472 randomized patients, 452 patients (rabeprazole 10 mg, n=151; rabeprazole 5 mg, n= 150; teprenone 150 mg, n=151) constituted the full analysis set. The cumulative recurrence rates of gastric and duodenal ulcers over 24 weeks in the 5and 10-mg rabeprazole groups were 2.8% and 1.4%, respectively, and both were significantly lower than that in the teprenone group (21.7%). The cumulative occurrence rate of bleeding ulcers over 24 weeks in the teprenone group was 6.1%, while bleeding ulcers were not observed in the 5or 10-mg rabeprazole groups. The rates of worsening in the modified Lanza and upper gastrointestinal symptom scores in the 5and 10-mg rabeprazole groups were significantly lower than those in the teprenone group. Significantly fewer patients developed erosive esophagitis in the 5 mg rabeprazole group (2%) and 10 mg rabeprazole group (0%), compared with the teprenone group (8.6%). Rabeprazole was well-tolerated at both doses. Conclusions: Rabeprazole prevents the recurrence of gastroduodenal ulcers with no evidence of a major dose response effect in patients taking LDA, and is well-tolerated.

1033 Underestimation of Small Bowel Bleeding in Users of Nonselective Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Low-Dose Aspirin (ASA): A Prospective Study

G A A b st ra ct s the recurrence of LDA-related peptic ulcers has not been reported. We conducted a randomized, double-blind, double-dummy, active-controlled trial to assess the efficacy, doseresponse relationship and safety of rabeprazole for peptic ulcer recurrence in Japanese patients in long-term LDA therapy. Methods: Patients were eligible for the trial if they had an endoscopically confirmed gastric or duodenal ulcer scars and were receiving long-term LDA (81 mg/day or 100 mg/day) therapy for cardiovascular and cerebrovascular protection. Patients on long-term LDA therapy were also eligible if they had a previous history of endoscopically confirmed active peptic ulcers, but did not present them at baseline endoscopy. Patients were randomly segregated into three groups receiving rabeprazole 10 mg once daily (standard dose in Japan), rabeprazole 5 mg once daily or teprenone (mucosal protective agent commercially available in Japan) 50 mg three times per day as an active control. The primary endpoint was recurrence of gastric and duodenal ulcers over 24 weeks. Secondary endpoints included an occurrence of bleeding ulcers with stigmata of recent hemorrhage or drop in hemoglobin level of more than 2 g/dl, changes from baseline in the modified Lanza score (endoscopic scoring system for gastroduodenal damage) or upper gastrointestinal symptom score, and newly-developed erosive esophagitis. Results: Among 472 randomized patients, 452 patients (rabeprazole 10 mg, n=151; rabeprazole 5 mg, n= 150; teprenone 150 mg, n=151) constituted the full analysis set. The cumulative recurrence rates of gastric and duodenal ulcers over 24 weeks in the 5and 10-mg rabeprazole groups were 2.8% and 1.4%, respectively, and both were significantly lower than that in the teprenone group (21.7%). The cumulative occurrence rate of bleeding ulcers over 24 weeks in the teprenone group was 6.1%, while bleeding ulcers were not observed in the 5or 10-mg rabeprazole groups. The rates of worsening in the modified Lanza and upper gastrointestinal symptom scores in the 5and 10-mg rabeprazole groups were significantly lower than those in the teprenone group. Significantly fewer patients developed erosive esophagitis in the 5 mg rabeprazole group (2%) and 10 mg rabeprazole group (0%), compared with the teprenone group (8.6%). Rabeprazole was well-tolerated at both doses. Conclusions: Rabeprazole prevents the recurrence of gastroduodenal ulcers with no evidence of a major dose response effect in patients taking LDA, and is well-tolerated.

Non-variceal upper gastrointestinal bleeding: clinical, therapeutic and evolution aspects. Comparison between a tertiary medical center and a municipal hospital.

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies in gastroenterology practice. In recent years, the introduction of urgent upper gastrointestinal endoscopy (UGIE) and of the treatment with proton pump inhibitors (PPIs) in high doses has resulted in an improvement of the treatment outcome in patients with UGIB, but without a significant improvement in mortality rates. In our study we compared the epidemiological, clinical, therapeutic, and prognostic aspects in patients with non-variceal UGIB admitted over a period of one year in a tertiary center where urgent UGIE is a routine procedure and in a municipal hospital where UGIE with endoscopic hemostasis is not available. Patients admitted to the tertiary medical center had more clinical and endoscopic severity factors compared to those from the municipal hospital: they were older, with more frequent intake of NSAIDs, several comorbidities, some of them severe, and more severe posthemorrhagic anemia. The endoscopic examination revealed that active bleeding and stigmata of recent hemorrhage were more frequent in these patients. Urgent UGIE and, where necessary because of lesions, endoscopic hemostasis were performed in most of these patients. Patients admitted to the municipal hospital were treated more frequently with high-dose intravenous PPIs. Patients undergoing urgent UGIE and endoscopic therapy had a shorter duration of hospitalization. However, there were no differences regarding the need for surgery or mortality rates. The results of our study are consistent with the literature.

Dieulafoyʼs Lesion as a Cause of Severe UGI Hemorrhage: What Is New and How Do We Treat in the Current Era?: Presidential Poster

Purpose: Dieulafoy first described a lesion (DL) more than 130 years ago as a large focal artery without ulceration of the stomach causing massive fatal UGI hemorrhage (UGIH). Endoscopically, DL is reported in patients with severe UGIH when major stigmata of recent hemorrhage (SRH) without ulceration are seen. For endoscopically diagnosed and treated UGI DLs, our purposes were: 1) to report prevalences of SRH, 2) to compare 30-day outcomes after thermal coagulation vs. hemoclipping (HC), and 3) to describe recent changes in hemostasis of DL with Doppler probe ultrasound (DUP) monitoring. Methods: 56 patients with severe UGIH were enrolled in prospective CURE hemostasis studies. Techniques evolved from monotherapy, to combination hemostasis, to use of DUP to complete treatments. Thirty two patients before 6/2006 were treated with thermal coagulation. Twenty four other patients after 8/2006 had hemostasis with hemoclipping. Endoscopic treatments usually included epinephrine pre-injection and tattooing after hemostasis. When it became available, DUP was used for arterial blood flow detection underneath SRH in nine patients, to map the arteries, and to check for blood flow ablation to complete hemostasis. All patients were followed up to 60 days. Data were prospectively collected, entered onto computer databases, and managed with SAS. Results: For all 56 patients, prevalences of SRH were 60.7% active bleeding, 17.9% adherent clot, 2.5% non-bleeding visible vessel (NBVV), and 8.9% spot. For thermal vs. HC treated patients, there were no significant differences in 30 day outcomes: re-bleeding 25% vs. 29%; surgery 16% vs. 17%; or death 6% vs. 0%. However, the non-DUP assisted DL hemostasis group had a significantly higher 30 day re-bleed rate than the DUP assisted patients: 33% (15/45) vs. 0% (0/9). Conclusion: For 56 patients with severe UGIH from Dieulafoy's lesions: 1) SRH were active bleeding 60.7%, clot 17.9%, NBVV 12.5%, and other SRH 8.9%. 2) 30-day outcomes of re-bleeding, surgery, death were similar for thermal & hemoclip treated patients. 3) However, the 30-day re-bleeding rate of DUP assisted hemostasis patients was significantly lower than those without DUP monitoring. Acknowledgements: Partially supported by a Clinical VA Merit Review grant and NIH CURE DDRC CURE grant-Human Studies Core (AM41301).

An Unusual Presentation of Metastatic Hypopharyngeal Squamous Cell Carcinoma

Purpose: Squamous cell neoplasms of the head and neck commonly metastasize to the lungs, mediastinal lymph nodes, liver, and bone- gastrointestinal metastases (especially small bowel) are extremely rare. We report a case of hypopharyngeal squamous cell carcinoma with metastasis to the duodenum presenting with anemia. A 53-year-old male with a known history of Stage IV-hypopharngeal squamous cell cancer status post chemoradiation therapy, presented with a 3-day history of dark stools and fatigue. The patient was afebrile, and his physical examination revealed scleral pallor. Laboratory data revealed a WBC of 4.4 k/cm2, a hemoglobin of 7.1 g/dL, platelets of 207 k/cm2, an albumin of 2.4g/dL and normal electrolytes. Carcinoembryonic Antigen (CEA) was 41.1ng/mL, and CA 19-9 Antigen was 2,932 U/mL. Contrast-enhanced CT scan of the chest, abdomen, and pelvis revealed a 4-cm mediastinal mass with extensive hilar adenopathy, numerous hypodense liver lesions and extensive duodenal wall thickening. Our patient underwent upper endoscopy (EGD), which revealed a large fungating ulcerated mass with stigmata of recent bleeding in the second portion of the duodenum- this was biopsied with cold forceps and revealed a poorly differentiated squamous cell carcinoma. Immunohistochemical staining (IHC) was performed and was positive for p63 and CK5/6- supporting the diagnosis of recurrent disease. Subsequently, radial endoscopic ultrasound (EUS) demonstrated a 50 x 28 mm poorly defined mediastinal mass, numerous malignant appearing subcarinal lymph nodes, and an irregular hypoechoic 33 x 65 mm left lobe liver lesion. Examination of the duodenum revealed a 12 x 35 mm heterogeneous mass with poorly defined borders in the second portion, a 16 x 11 mm peripancreatic lymph node and a large amount of abdominal ascites. EUS-FNA was performed on the mediastinal, hepatic and duodenal masses. Immediate cytologic evaluation (ICE) revealed malignant cells and cell block subsequently demonstrated metastatic squamous cell carcinoma with extensive necrosis from all three sites. Squamous cell carcinomas of the head and neck develop distant metastases in 11-23% of patients. There are several reports of metastasis to the small bowel (most frequently the ileum) and patients usually present with abdominal pain and/or obstructive symptoms. We report a rare presentation of a 53-year-old male with recurrent squamous cell carcinoma with metastasis to the duodenum presenting with anemia. This case demonstrates how patients with squamous cell carcinoma can present atypically when distant metastases develop.

An Atypical Appearance of Gastric Antral Vascular Ectasia (GAVE) with Complete Resolution after Liver Transplant

Purpose: Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal bleeding in end-stage liver patients being considered for liver transplant, and can be difficult to recognize. The correct diagnosis has therapeutic implications for successful treatment of bleeding. A 56-yearold male with alcoholic cirrhosis, complicated by ascites and non-bleeding gastroesophageal varices, presented for liver transplant evaluation. The most severe manifestation of his cirrhosis was chronic blood loss anemia requiring transfusion of two units of blood every two weeks. He had melenic stools and required frequent hospital admissions for anemia. A pre-transplant esophagogastroduodenoscopy revealed gastroesophageal varices without stigmata of recent bleeding, diffuse GAVE in the antrum with some areas of active oozing, and a fleshy, nodular mass in the second part of the duodenum with thick folds of oozing, friable mucosa. The most active areas of bleeding were over this mass-like lesion. A biopsy of the mass showed vascular ectasias with thombosis, consistent with nodular GAVE in the duodenum. The patient had treatment with serial argon plasma coagulation, however still remained transfusiondependent. Six months after the diagnosis of GAVE, he underwent an orthotopic liver transplantation. After the immediate post-operative period, he was no longer transfusion dependent. An esophagogastroduodenoscopy performed a year after his transplant showed complete resolution of his antral GAVE, as well as complete resolution of his nodular, duodenal GAVE. The endoscopic appearances of GAVE have been described in literature as puctate-type vascular ectasias, which are more strongly associated with cirrhosis, as well as striped, erythematous lesions arranged radially from the pylorus, more commonly termed “watermelon stomach.” Both these presentations share the same histologic findings of mucosal capillary dilations, fibrin thrombi, and fibromusclar hyperplasia. In our patient, we present an atypical, nodular presentation of GAVE in the duodenum. Our case also highlights the resolution of GAVE in patients with liver disease after liver transplantation. The recognition of GAVE is necessary for successful treatment. GAVE-induced bleeding can be treated with thermal ablation or estrogen, and can be cured with liver transplantation; however, it has not been shown to be responsive to treatments with reduction in portal pressure.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for the Treatment of Anorectal Varices

Purpose: Despite the high prevalence of anorectal varices in portal hypertension, serious hemorrhage is quite rare, but may be fatal. Although several techniques for treating acute bleeding have been reported, the optimal therapeutic management has not been established. We report a patient with severe recurrent rectal bleeding from anorectal varices successfully treated by a transjugular intrahepatic portosystemic shunt (TIPS). A 53-year-old man with known history of hepatitis C-induced liver cirrhosis, listed for possible liver transplantation and prior decompensation in the form of esophageal variceal bleed maintained on beta-blockers, presented to the emergency department with the chief complaint of rectal bleeding for one week's duration, associated with weakness, dizziness, shortness of breath, and generalized abdominal pain. On admission, labs showed: WBC 1.3, hb 10.4, hct 31.4, INR 1.5, total bilirubin 1.4, alkaline phos 136, ALT 43, AST 70. CT abdomen and pelvis performed the day of admission revealed: diffuse cirrhosis without hepatic lesion, splenomegaly, large-caliber gonadal varices that extend to the pelvis and surround the rectum, as well as concentric thickening of the rectum. Due to presentation and findings, gastroenterology was consulted. EGD showed grade 2 esophageal varices without stigmata of recent bleeding, and gastric antral vascular ectasia (GAVE) without active bleeding. Colonoscopy showed very large rectal varices. One column had a small mucosal hemorrhage present, no active bleeding esd present, and a nonbleeding cecal AVM. After extensive discussion between the hepatology and GI departments about options for treatment, it was decided to pursue transjugular intrahepatic portal systemic shunt (TIPS) to relieve portal pressure causing the rectal varices. The patient underwent successful TIPS procedure, performed by the interventional radiology department. Contrast injections during the examination demonstrated hepatofugal flow in the portal vein. The patient was also noted to have splenorenal shunting, as well as massive inferior mesenteric vein filling rectal varices. A Rosen wire was placed. The tract was dilated to 8 mm. A 10-mm x 80-mm covered VIATORR stent was placed. Follow-up pressures demonstrated a mean portal pressure of 29 mmHg with a central venous pressure of 29/22, with a mean of 25 mmHg. There remained flow in the inferior mesenteric vein; however, it subjectively appeared to be slower. After the procedure, the patient was discharged to be followed closely as an outpatient. A follow-up colonoscopy was performed two months after TIPS procedure. showing one cord of rectal varices, approximately 75% improved since prior colonoscopy, and small internal hemorrhoids.

Eosinophilic Gastritis Masquerading as Recalcitrant Giant Gastric Ulcer

Background: Eosinophilic gastroenteritis (EG) is a rare condition of unknown etiology characterized by an intense eosinophilic infiltrate throughout the GI tract, and has been reported in poorly controlled asthmatics. We present a rare case of eosinophilic gastritis in a poorly controlled asthmatic that presented as a bleeding giant gastric ulcer. Case: A 70-year-old male with HTN and poorly controlled asthma presented with bloating, coffee ground emesis and melena. He was a former heavy alcohol user, took one baby aspirin daily, no recent steroid use. The patient was stable with a Hg of 13. His WBC count was 8.8 with an elevated eosinophil count (12.9%). EGD showed a 4.2cm gastric ulcer with stigmata of recent bleeding. Biopsies showed severe eosinophilic gastritis, negative for H. pylori. In the past he also had a bleeding gastric ulcer despite use of PPIs. With each presentation there was a parallel marked peripheral eosinophilia and appeared to coincide with, or shortly precede his asthma exacerbations. Discussion: EG is a very rare disease, usually presenting as abdominal pain, vomiting and distention. A diagnosis of eosinophilic gastritis is made when >30 eosinophils are seen per high power field. About 50% of patients with EG have asthma or other atopic disorders, which may be diagnosed at the same time or years beforehand. Previously reported peripheral eosinophilia to >4000/ul have been noted. These patients may have thickened gastric mucosal folds, nodularity, or ulcerations seen on radiographs, reflecting intense eosinophilic infiltrate. Endoscopy may reveal normal or edematous mucosa with prominent gastric folds or surface erosions. Treatment with systemic corticosteroids led to bronchial and abdominal symptom resolution. Conclusion: We presented an unusual case of a patient with a history of uncontrolled asthma presenting with eosinophilic gastritis manifested as a recalcitrant giant gastric ulcer. To our knowledge this is only the second case described in the literature of eosinophilic gastritis presenting this way, and highlights the importance of considering eosinophilic disorders of the GI tract in patients with severe asthma.FigureFigure

Su1917 Comparison of Clinical Outcomes of Bleeding Dieulafoy's Lesions and Peptic Ulcers With Stigmata of Recent Hemorrhage

Su1917 Comparison of Clinical Outcomes of Bleeding Dieulafoy's Lesions and Peptic Ulcers With Stigmata of Recent Hemorrhage