Stigmata Of Recent Hemorrhage Research Articles

Risk factors of early rebleeding in the endoscopic management of colonic diverticular bleeding.

The risk factors for early rebleeding following the management of colonic diverticular bleeding (CDB) are unclear. This study aimed to determine the risk factors for early rebleeding following initial colonoscopy. Overall, 370 patients with CDB were divided as having presumptive (229) or definite CDB with stigmata of recent hemorrhage (141) on the basis of initial colonoscopy. Definite CDB cases were treated by either endoscopic clipping (EC) or endoscopic band ligation (EBL) as a first-line treatment. Time-to-event analysis for early rebleeding was performed by Kaplan-Meier methods with log-rank test between the three groups (presumptive, EC, and EBL). Multivariate Cox proportional hazards regression was used to identify risk factors for early rebleeding. There were 38 and 103 patients in the EC and EBL groups, respectively. Early rebleeding developed in 61 cases (16.5%). The cumulative incidence rates of early rebleeding at 1, 5, and 30days were 7.7%, 16.4%, and 17.9% in the presumptive group; 1.9%, 7.0%, and 9.5% in the EBL group; and 2.6%, 34.9%, and 37.7% in the EC group, respectively (log-rank test, P=0.00059). Moreover, 90.2% of early rebleeding occurred within 5days. Adjusted hazard ratio (HR) was marginally lower in the presumptive group (HR=0.50; 95% confidence interval, 0.26-1.01; P=0.052) and significantly lower in the EBL-treated group than in the EC group (HR=0.21; 95% confidence interval, 0.09-0.50; P=0.0004). Most early rebleeding occurred within 5days after initial colonoscopy. EC was less effective than EBL in terms of early rebleeding.

Over the Scope Clip to Control Major Bleeding of Gastric Adenocarcinoma

Signet ring cell carcinoma is rare and highly aggressive malignancy. We report a case of a 26 year old Colombian female who was brought to our hospital with syncope following an episode of hematemesis. Blood testing showed profound anemia. Endoscopic examination revealed a large ulcer with stigmata of recent bleeding in the gastric fundus. There was a large visible vessel within the ulcer. The ulcer appeared malignant and biopsies were obtained from the edges of ulcer and surrounding abnormal appearing mucosa with a cold forceps for histology. Then the visible vessel was injected with 10 mL of a 1:10,000 solution of epinephrine to prevent re-bleeding prior intervention. Then the ulcer edges were approximated and one over-the-scope clip (OVESCO) was successfully placed. Biopsied ulcer edges showed signet-ring cell carcinoma of the stomach and antral biopsies revealed severe chroinc active gastritis and H. Pylori infection. In this case report we review the patient clinical course and the management of cancer related gastrointestinal bleeding.1928_A Figure 1. Large gastric ulcer with visible vessel1928_B Figure 2. NodulemMucosa in the antrum1928_C Figure 3. Over the scope clip of gastric ulcer

A Rare Case of Bevacizumab and Radiation-Induced Ischemic Bowel Injury

Ischemic colitis is a poorly documented side effect of the combination of palliative radiation and targeted therapy with Bevacizumab, a recombinant and humanized monoclonal antibody against the vascular endothelial growth factor receptor.1 We present a case of acute onset of ischemic colitis in a patient with prior pelvic irradiation undergoing treatment of metastatic rectal adenocarcinoma with Bevacizumab. A 68 y/o male with microsatellite stable, KRAS-mutated Stage IVB Rectal Adenocarcinoma status post 3 months of fluorouracil, oxaliplatin, folinic acid, abdominal perineal resection with ileo-colonic anastomosis with end colostomy, and palliative radiation to pelvis and spine presented with abdominal pain and bright red blood in his ostomy bag. Hemoglobin was 5.6 g/dL on admission, with appropriate response after transfusion. Recent endoscopy showed monlial esophagitis and non-bleeding erosive gastropathy. Colonoscopy 1 year prior showed multiple benign polyps. He underwent colonoscopy via colostomy, which was remarkable for both a continuous area of non-bleeding ulcerated mucosa and a segmental area of severely friable mucosa within the distal colon, neither with stigmata of recent bleeding. Histopathology demonstrated severely active colitis with ulceration. Colorectal surgery recommended no acute surgical intervention given his poor prognosis. Conventional therapy for treatment of metastatic colorectal cancer includes a fluoropyrimidine-based therapy with or without the use of targeted therapy and/or palliative radiation. Bevacizumab inhibits tumor neovascularization, which has proven beneficial when treating solid tumors by restricting tumor growth and metastatic ability.1 Radiation amplifies this effect by free radical formation, which promotes cell death. Results of a retrospective study looking at 33 patients undergoing therapy with Bevacizumab and prior radiation showed a 9% incidence of severe bowel complications, including acute ischemic colitis and bowel perforation.2 Ischemic colitis, a rare and minimally reported risk of therapy with Bevacizumab and radiation, should be considered in patients presenting with sudden onset of abdominal pain and hematochezia.1487_A Figure 1. Previously normal appearing descending colon1487_B Figure 2. Friability with absence of bleeding in distal colon1487_C Figure 3. Ulceration of distal colon

Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping

Very few prospective studies with over 100 samples have evaluated the long-term outcomes of endoscopic therapy for colonic diverticular bleeding (CDB). This study sought to elucidate the recurrent bleeding risk of endoscopic band ligation versus clipping for definitive CDB based on stigmata of recent hemorrhage (SRH). Patients emergently hospitalized for acute lower GI bleeding and examined by high-resolution colonoscopy were enrolled. Better visualization of SRH from a diverticulum was obtained using a water-jet device. Endoscopic band ligation or clipping was performed as first-line treatment, and patients were prospectively followed after discharge. No statistical difference was found between the ligation (n= 61) and clipping (n= 47) groups in baseline characteristics or follow-up period. The probability of 1-year recurrent bleeding was 11.5% in the ligation group versus 37.0% in the clipping group (P= .018). No patients required surgery or experienced perforation. One patient in the ligation group experienced diverticulitis the next day. In patients with recurrent bleeding within 7 days, the recurrent bleeding site was the same diverticulum, and ulceration was found in the ligation group on repeat colonoscopy. In patients with recurrent bleeding after 2 months, repeat colonoscopy identified that the recurrent bleeding site was different, and scar formation was seen in the ligation group. The left side of the colon was an independent predictor for recurrent bleeding in the ligation group but not in the clipping group. Band ligation for definitive CDB has better outcomes than clipping during long-term follow-up after endoscopic therapy, probably because of complete elimination of the diverticulum. CDB can recur at the same diverticulum in the short term but at a different diverticulum in the long term.

Role of Diagnostic Preoperative Upper Gastrointestinal Endoscopy in Radiologically Confirmed Gastric Volvulus.

Gastric volvulus (GV) is a life-threatening condition that warrants prompt diagnosis and treatment. GV is a radiologic diagnosis. The role of preoperative upper gastrointestinal endoscopy (UGIE) for individuals with radiologically confirmed GV is poorly defined. Our objective was to assess the diagnostic yield of UGIE in the preoperative evaluation of patients presenting with radiologically confirmed GV. Retrospective review of all adult patients undergoing surgery for GV between July 1996 and August 2016 has been carried out. We performed analyses evaluating diagnostic yield of preoperative UGIE and compared outcomes in patients who did and did not undergo preoperative UGIE. Outcomes were diagnostic yield of preoperative UGIE, length of hospital stay, postoperative complications, and mortality at 30days and 1year. In the preoperative UGIE group, the diagnostic yield was 34.6% (27/78). The most common endoscopic findings were erosive esophagitis (13/27) and clean based gastric or duodenal ulcers (5/27). There were no cases of esophago-gastric malignancy. Three patients had ulcers with stigmata of recent bleeding, and three patients had features suggestive of gastric ischemia. Endoscopic findings did not influence surgical management. There was no statistically significant difference in mortality between patients who did and did not undergo preoperative UGIE, both at 30days (0 vs. 2.5%) and 1year (3.8 vs. 7.5%). Among patients with radiologically confirmed GV, preoperative UGIE rarely demonstrates clinically significant findings and can potentially delay definitive surgical intervention.

A multicenter, randomized controlled trial comparing the identification rate of stigmata of recent hemorrhage and rebleeding rate between early and elective colonoscopy in outpatient-onset acute lower gastrointestinal bleeding: study protocol for a randomized controlled trial

BackgroundThe clinical benefit of early colonoscopy within 24 h of arrival in patients with severe acute lower gastrointestinal bleeding (ALGIB) remains controversial. This trial will compare early colonoscopy (performed within 24 h) versus elective colonoscopy (performed between 24 and 96 h) to examine the identification rate of stigmata of recent hemorrhage (SRH) in ALGIB patients. We hypothesize that, compared with elective colonoscopy, early colonoscopy increases the identification of SRH and subsequently improves clinical outcomes.MethodsThis trial is an investigator-initiated, multicenter, randomized, open-label, parallel-group trial examining the superiority of early colonoscopy over elective colonoscopy (standard therapy) in ALGIB patients. The primary outcome measure is the identification of SRH. Secondary outcomes include 30-day rebleeding, success of endoscopic treatment, need for additional endoscopic examination, need for interventional radiology, need for surgery, need for transfusion during hospitalization, length of stay, 30-day thrombotic events, 30-day mortality, preparation-related adverse events, and colonoscopy-related adverse events. The sample size will enable detection of a 9% SRH rate in elective colonoscopy patients and a SRH rate of ≥ 26% in early colonoscopy patients with a risk of type I error of 5% and a power of 80%.DiscussionThis trial will provide high-quality data on the benefits and risks of early colonoscopy in ALGIB patients.Trial registrationUMIN-CTR Identifier, UMIN000021129. Registered on 21 February 2016; ClinicalTrials.gov Identifier, NCT03098173. Registered on 24 March 2017.

Esophageal Squamous Cell Carcinoma of the Distal Esophagus and Gastroesophageal Junction

The following case demonstrates a rare site of esophageal squamous cell carcinoma, the distal esophagus and gastroesophageal junction. A 51 year-old-male presented to the emergency department with a three week history of dysphagia. The patient's past medical history was most notable for a sixty pack-year smoking history. He reported progressive dysphagia to both solids and liquids over the time period, as well as a “sticking” sensation in his chest with PO intake. On the day of presentation, he experienced an episode of a choking sensation after drinking water, followed by oral and nasal regurgitation. He reported an associated unintentional 15-pound weight loss over a six-month period. An EGD performed showed a large, ulcerated circumferential mass with friable mucosa extending from the distal esophagus to the gastroesophageal junction. There were no stigmata of recent bleeding in the lower third of the esophagus. The mass partially obstructed the esopahgeal lumen. Biopsies demonstrated squamous cell carcinoma of each sampled portion of this mass. Following staging workup, the patient was determined to have stage 3 esophageal squamous cell carcinoma and was initiated on curative intent chemoradiation. The US incidence of esophageal squamous cell carcinoma has decreased over the past three decades, while the incidence of esophageal adenocarcinoma has increased considerably. Known risk factors for esophageal squamous cell carcinoma include tobacco and alcohol use with dysphagia and weight loss being frequent presenting symptoms. Squamous cell carcinoma is most often located in the proximal two thirds of the esophagus, with adenocarcinoma being more common in the distal region surrounding the gastroesophageal junction. While this patient's tobacco use is a common risk factor and his symptoms of dysphagia and weight loss are consistent with presenting symptoms, this case illustrates an uncommon location for esophageal squamous cell carcinoma, the distal esophagus and gastroesophageal junction.

Development of Bleeding Gastric Arteriovenous Malformations in a 23-year-old Man 3 Months After Normal Endoscopy

Gastric arteriovenous malformations (AVMs) are extremely rare. AVMs can develop in the stomach, large and small intestine. They are typically seen in elderly patients and are most commonly found in the large intestine. They are a significant cause of lower gastrointestinal bleeding in elderly patients. AVMs are more common in patients with end-stage kidney disease, Von Willebrand disease and have been found to be associated with aortic stenosis. A 23 year-old Caucasian male was brought in to the hospital by his mother after he had an episode of coffee ground emesis associated with fever and a low oxygen saturation level measured at home by his caretaker. He has a past medical history of an anoxic brain injury from a childhood drowning accident at age 4, with a gastrojejunostomy tube for feeding. In the emergency room, he was found to have hypoxia and was admitted to the hospital. His physical exam revealed blood pressure of 73/51 and an oxygen saturation of 85%. Admission labs revealed hemoglobin of 15.3 g/dl, hematocrit of 43.8%, MCV 94.2 and WBC 8,900. A chest x-ray performed during hospitalization revealed a left lung consolidation suspicious for possible aspiration pneumonia. Blood work on the following day showed his hemoglobin had dropped to 7.9 g/dl with a hematocrit of 23% and he continued to have episodes of coffee ground emesis. An endoscopy was performed that revealed several medium-sized angiodysplastic lesions with stigmata of recent bleeding in the gastric body and underneath the g-tube bumper. Hemostasis was achieved with argon laser and the patient did not have any further episodes of hematemesis. The patient had a previous endoscopy that was performed 3 months prior to hospitalization evaluating for reflux esophagitis which had revealed normal gastric and duodenal mucosa. No AVMs were seen at that time. In this case, a young male patient developed gastric AVMs in a span of 3 months that were associated with significant bleeding, leading to aspiration pneumonia. The patient does not have end-stage renal disease, aortic stenosis or Von Willebrand disease. The pathogenesis of AVMs of the gastrointestinal tract is not well understood. In this patient, it is possible that previous hospitalization with significant hypoxia may have led to the increased expression of angiogenic factors which may be the underlying reason for the development of arteriovenous malformations of the stomach in a short period of time.Figure: Endoscopic view of multiple a/v malformations in patient's stomach.Figure: Endoscopy performed 3 months ago.

An Interesting Case of Melena: Gastric Neuroendocrine Tumor

We present an atypical cause of melena secondary to a gastric neuroendocrine tumor successfully managed by endoscopic submucosal dissection (ESD). A 66-year-old male with a history of hypertension, gastritis and peptic ulcer disease presented with three days of melena. EGD showed an ulcerated, protruding mass at the lesser curvature of the stomach. EUS confirmed a hypoechoic, homogeneous mass measuring 16 mm originating from the muscularis mucosa with an intact muscularis propria. ESD was performed with successful en bloc resection of the gastric mass. Pathology revealed a well-differentiated neuroendocrine tumor (NET) without associated atrophic gastritis. The tumor was classified as intermediate grade 2 with a Ki-67 index of 3-4%. Of note, there was involvement of the deep margin in the resected specimen. CT of chest, abdomen, and pelvis showed no evidence of other masses or metastases. Given the positive deep margin, a subsequent EGD with full-thickness resection of the ESD site was performed with the help of an over-the-scope clip. Pathology showed gastric mucosa with chronic focal inflammation, negative for tumor, with no evidence of NET. A post-resection octreotide scan showed no areas of pathologic uptake of radio-labeled octreotide. No complications were encountered during resection and the patient has had no recurrence on follow up surveillance endoscopy. Gastrointestinal NETs are relatively rare tumors, with carcinoid tumors being the most common type. Gastric involvement is rare, representing 7% of all carcinoid tumors within the GI tract. Gastric carcinoids can be divided into 3 types, differing in behavior and prognosis. Type I (>80%) are associated with chronic atrophic gastritis and pernicious anemia. Type II (< 5%) carcinoids are associated with hypergastrinemia due to gastrinomas. Both type I and type II gastric carcinoids are generally indolent with little malignant potential. Type III (20%) carcinoids are sporadic tumors in the absence of any gastric pathology. Type III tumors have a high rate of metastasis and carry a worse prognosis. Due to their aggressive nature, type III tumors are usually treated with partial or total gastrectomy. We report a case of a type III carcinoid tumor that presented with melena due to mucosal ulceration. Our case highlights the successful management of a type III carcinoid tumor with ESD with no signs of recurrence on follow up.Figure: EGD showing an ulcerated, protruding mass with stigmata of recent bleeding at the lesser curvature of the stomach.Figure: EUS showing a hypoechoic, homogeneous mass measuring 16 mm originating from the muscularis mucosa with an intact muscularis propria.Figure: Site of endoscopic submucosal dissection (ESD) with successful en bloc resection of the gastric mass.

A Rare Cause of Gastrointestinal Bleeding: Metastatic Renal Cell Carcinoma

This is a case of metastatic renal cell carcinoma to the small bowel as a cause of GI bleed. A 60-year-old man with known renal cell carcinoma metastatic to the lung s/p right nephrectomy, was admitted with anemia. He reported fatigue and melena for one week. He denied hematemesis, hematochezia, hematuria, epigastric pain, reflux symptoms, and did not use NSAIDs. Physical exam was notable for normal vital signs, conjunctival pallor, a soft non-tender abdomen, and rectal exam was negative for melena. Labs were significant for hemoglobin 6.8 (baseline 10), MCV 101, normal BUN, baseline creatinine 1.6. Upper endoscopy revealed a large ulcerated mass in the first portion of the duodenum with stigmata of recent bleeding. There were no additional abnormalities or sources for bleeding found during the procedure. Pathology from the mass confirmed metastatic renal cell carcinoma. The patient had a good response to blood transfusion and was discharged in stable condition. He underwent systemic therapy with ipilimumab and nivolumab. Hemoglobin remained stable without further GI bleeding. While malignancy is an uncommon cause of gastrointestinal bleeding (GIB) in the general population, it is the most common cause of GIB in oncologic patients (5% vs 23%). Patients with primary GI malignancies comprise a large proportion of those with tumor related bleeding. In contrast, those with malignancy outside of the GI tract are most likely to bleed from causes similar to that of the general population. In a retrospective study of 147 oncologic patients with an identified source of GIB, common sources of GIB in those with malignancies outside of the GI tract included ulcers, erosive disease, and varices. Only 10.9% percent of this group had malignancy related bleeding. A more recent study describing the epidemiology of GIB due to malignancy found that of the 71 GI bleeds due to tumors, only 5 cases (7%) were due to metastatic disease. Renal cell carcinoma is metastatic in 25-30% of patients at the time of diagnosis with common sites including the lung, liver, bone and brain. Metastatic disease to the small bowel is exceedingly rare, with only a few cases reported in the literature. Presenting symptoms are variable and can include abdominal pain, intussusception, obstruction, and GI bleed. Metastasis to the duodenum is thought to arise from primary tumors of the right kidney given the close proximity, as in our patient who underwent right nephrectomy.Figure: duodenal mass.Figure: duodenal mass.Figure: duodenal mass.

EUS-Guided Coil Embolization and Glue Injection in the Management of Bleeding Gastric Varices

Endoscopic cyanoacrylate injection is the standard primary intervention for management of large gastric varices due to benefits seen in hemostasis and rebleeding rates when it is compared to sclerotherapy or with band ligation. This case demonstrates a the role of EUS guided coil embolization and glue injection utilizing Tornado coils and Cyanoacrylate glue in the management of such large bleeding gastric varices. The patient is a 55-year-old Hispanic male with a past medical history of a twenty-year alcohol intake and peptic ulcer disease who presented with hematemesis and melena. Physical exam of the patient was non contributory. He was started on a proton pump inhibitor, octreotide, and ceftriaxone. An initial EGD demonstrated moderate sized esophageal varices without stigmata of recent bleeding and large gastric varices with red wale marks. The patient underwent repeat EGD and EUS with Doppler imaging which demonstrated visualization of large gastric varices in the fundus. Doppler ultrasound techniques demonstrated large flow within the gastric varices. A Tornado coil and Cyanoacrylate glue were loaded into a Cook 19 gauge EchoTip needle. The large varices were injected with the Tornado coil and 3 cc of Cyanoacrylate glue leading to embolization and cessation of blood flow as demonstrated through Doppler investigation. The patient had no subsequent gastrointestinal bleeding and was discharged home on a proton pump inhibitor, propranolol, ceftriaxone, and Carafate with a plan to follow up in clinic in one week. Utilization of tornado coil's synthetic fibers in conjuntion with cyanoacrylate injection allows for a space occupation effect of the coil and cyanoacrylate retention leading to obliteration of the varix lumen with the added benefit of the need for less volume of cyanoacrylate. The techniques demonstrate the novel ability to manage large gastric varices specifically, with tornado coil and cyanoacrylate glue embolization through EUS guidance.Figure: EUS scope visualization of the gastric varices including Doppler views demonstrating large varices with turbulent flow.Figure: A FNA 19 gauge needle can be visualized puncturing the large cluster of gastric varices and the coil was introduced through the stylet followed by an injection of 3 ccs of cyanoacrylate glue.Figure: Doppler visualization post injection demonstrating decreased flow in the gastric varices post embolization.

E‐Poster Presentations – A2) Gastric and Duodenal

E‐Poster Presentations – A2) Gastric and Duodenal

What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding?

There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).

Rebleeding Risk Is Lower in Oozing Peptic Ulcers

The risk for rebleeding from peptic ulcers can be predicted by the presence of endoscopic stigmata of recent hemorrhage (SRH) as defined by the Forrest

Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage

For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy's lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n= 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n= 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P= .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143-0.8565) and the number needed to treat was 7. In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers orother lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).

Reassessment of Rebleeding Risk of Forrest IB (Oozing) Peptic Ulcer Bleeding in a Large International Randomized Trial.

Our aims were to assess risks of early rebleeding after successful endoscopic hemostasis for Forrest oozing (FIB) peptic ulcer bleeding (PUBs) compared with other stigmata of recent hemorrhage (SRH). These were post hoc multivariable analyses of a large, international, double-blind study (NCT00251979) of patients randomized to high-dose intravenous (IV) esomeprazole (PPI) or placebo for 72 h. Rebleeding rates of patients with PUB SRH treated with either PPI or placebo after successful endoscopic hemostasis were also compared. For patients treated with placebo for 72 h after successful endoscopic hemostasis, rebleed rates by SRH were spurting arterial bleeding (FIA) 22.5%, adherent clot (FIIB) 17.6%, non-bleeding visible vessel (FIIA) 11.3%, and oozing bleeding (FIB) 4.9%. Compared with FIB patients, FIA, FIIB, and FIIA had significantly greater risks of rebleeding with odds ratios (95% CI's) from 2.61 (1.05, 6.52) for FIIA to 6.66 (2.19, 20.26) for FIA. After hemostasis, PUB rebleeding rates for FIB patients at 72 h were similar with esomeprazole (5.4%) and placebo (4.9%), whereas rebleed rates for all other major SRH (FIA, FIIA, FIIB) were lower for PPI than placebo, but the treatment by SRH interaction test was not statistically significant. After successful endoscopic hemostasis, FIB patients had very low PUB rebleeding rates irrespective of PPI or placebo treatment. This implies that after successful endoscopic hemostasis the prognostic classification of FIB ulcers as a high-risk SRH and the recommendation to treat these with high-dose IV PPI's should be re-evaluated.

An Uncommon Cause of Chronic Portal Vein Thrombosis, Large Varices, and Massive Splenomegaly

A 68-year-old female presents to hepatology for further management of chronic portal vein thrombosis (PVT). She was diagnosed with mesenteric vein thrombosis in 1995 after she developed acute onset of severe abdominal pain. She required exploratory laparotomy at which time the diagnosis was made and was treated with warfarin for six months. She underwent hypercoagulable workup which was negative. In 2003, she was noted to have extension of the superior mesenteric vein (SMV) thrombus into the portal vein. She was restarted on warfarin which she remains on. She has a history of esophageal and fundal varices on propranolol 600 mg daily. The varices were never treated endoscopically and she denies history of gastrointestinal bleeding. She has not had prior liver biopsy. Family history is negative for venous thromboembolism. Social history is negative for alcohol use. She has two healthy children and no history of miscarriage. Review of systems is negative for jaundice, icterus, pruritus, encephalopathy, ascites, or peripheral edema. On exam, abdomen is distended but soft and nontender. Splenomegaly is present and there is no obvious ascites. There are no chronic liver disease stigmata. Labs are significant for a platelet count of 80, normal liver function tests, normal albumin, and elevated INR in the setting of warfarin. MRI of liver with elastography reveals cavernous transformation of the intra- and extrahepatic portal veins with a prominent system of pericholecystic collaterals. Massive splenomegaly of 25 cm length is noted and the SMV is patent. There are no suspicious liver lesions. Stage III to IV liver fibrosis is noted. Transjugular liver biopsy shows extramedullary hematopoiesis without evidence of cirrhosis. Upper endoscopy with endoscopic ultrasound reveals grade III esophageal varices and type 1 gastroesophageal varices without stigmata of recent bleeding. No further intervention is recommended by surgery or interventional radiology and her beta blockade and anticoagulation are continued. Patient is referred to hematology due to liver biopsy finding of extramedullary hematopoiesis. Bone marrow biopsy reveals hypocellular bone marrow with marked myelofibrosis and molecular analysis is positive for JAK2 V617F mutation, consistent with a diagnosis of primary myelofibrosis. This case illustrates the importance of keeping in mind myeloproliferative neoplasms as a potential etiology of PVT, noncirrhotic portal hypertension, and massive splenomegaly.

Endoscopic Appearance of Oropharyngeal and Upper GI Kaposiʼs Sarcoma in an Immunocompromised Patient: A Case Report

Introduction: Kaposi's Sarcoma (KS) usually manifests as a cutaneous disease but GI mucosal manifestation are often rare. It is associated with human herpes virus-8 infection (HHV-8) and often seen in immune-compromised patients. In the USA, the widespread use of highly active anti-viral therapy (HAART) as drastically reduced the incidence of KS in HIV-infected patients. Here we present a case of oropharyngeal manifestations of Kaposi Sarcoma in a patient with HIV Case Report: A 65 year old male with history of human immunodeficiency virus (HIV) was admitted to the intensive care unit (ICU) after having a cardiopulmonary arriest secondary to hyperkalemia 7.5 meq/L. Following the placement of orogastric and endotracheal tube (ETT), significant amount of blood was noticed in the ETT. Hemoglobin was found to have trended downwards from 9.6 mg/dL to 6.7 mg/dL over the following five days. Stool guaiac was found to be positive for occult blood. Esophagogastroduodenoscopy (EGD) was initially performed and revealed multiple large hyper-vascularized violaceous submucosal nodular lesions with stigmata of recent bleeding seen on the soft palate, pharynx and within the crico-pharyngeal area close to the vocal cords. No active bleeding was noted. Examination of the distal esophagus revealed a severe ulceration with a small hiatal hernia. Biopsy of soft palate lesions showed proliferation of neoplastic spindle shaped cells arranged in bundles with slit-like capillary spaced containing erythrocytes which is consistent with Kaposi sarcoma. Biopsy was also positive for HHV-8. Colonoscopy was unremarkable for similar lesions, polyps or diverticulosis. There were no cutaneous manifestations of the disease. Conclusion: GI involvement of Kaposi sarcoma must be considered in immune-compromised patients and can be confirmed by endoscopic methods.

An “Obscure” Presentation of Early Cirrhosis: Bleeding Jejunal Varices as Initial Presentation of Cryptogenic Cirrhosis

Introduction: Isolated small intestinal varices are an uncommon manifestation of portal hypertension. Although uncommon, small intestinal variceal hemorrhage can be life-threatening. We report a case of isolated small bowel variceal hemorrhage in a man with previously undiagnosed cirrhosis. Case: An 82 year-old man presenting with 5 weeks of melena and anemia (hemoglobin 5.7 g/dL) was admitted to the hospital. Two months prior, he had undergone coronary artery bypass graft surgery. His post-operative course was complicated by new-onset atrial fibrillation; he was started on therapeutic anticoagulation with apixaban. His past medical history was otherwise notable for a history of chronic kidney disease secondary to hypertension requiring kidney transplant fourteen years prior. Inpatient EGD was normal. Colonoscopy with examination of ileum was normal except for colonic diverticulosis without active or stigmata of recent bleeding. A CT of the abdomen and pelvis without contrast revealed no abnormalities of the liver or spleen. The patient was instructed to stop apixaban and was discharged with stable hemoglobin level of 8.0 g/dL and platelet count 158,000. He had no further episodes of melena while inpatient. An outpatient capsule endoscopy revealed the presence of blue tinged nodules in the distal jejunum. Double balloon enteroscopy confirmed the presence of jejunal varices without evidence of active bleeding or other high-risk stigmata (Figure 1). The patient underwent liver ultrasound, which showed liver contour nodularity and mildly enlarged splenic vein and spleen. There was normal flow through hepatic and portal veins and hepatic arteries.Figure 1Discussion: We present a case of small intestinal varices in a patient with no previous diagnosis or manifestations of portal hypertension. Small intestinal varices are uncommon and are rarely reported to cause gastrointestinal hemorrhage, but can cause significant blood loss when hemorrhage does occur. Small intestinal variceal bleeding can present subtly with occult gastrointestinal hemorrhage or dramatically with hypovolemic shock, hematochezia and/or hematemesis. Small intestinal varices are most often caused by portal hypertension in the setting of liver cirrhosis or portal vein thrombosis, but have also been associated with adhesions from previous abdominal surgeries or other vascular anomalies. Prompt identification and treatment, if necessary, are essential in the management of small intestinal varices.

PTH-030 How Does Delivery of Appropriate Endotherapy at Index Endoscopy Affect Outcome in Patients with Non-Variceal Bleeding?

Introduction NICE recommends that patients with non-variceal acute upper gastrointestinal bleeding (AUGIB) and stigmata of recent haemorrhage (SRH) are offered endoscopic treatments (combination or mechanical method).1 We audited the appropriateness and outcomes of endoscopic therapy in patients with non-variceal bleeding in a University Hospital with a dedicated consultant led out of hours endoscopy service. Methods AUGIB patients who underwent an emergency endoscopy (OGD) were identified from endoscopy, theatre and electronic records between 01.01.15 and 30.04.15. Our electronic clinical database was used to ascertain clinical details and outcomes. Results A total of 116 patients received an emergency OGD. Rebleeding occurred in 18 (15.5%) and 30 day mortality was 11%. 24 patients had non-variceal bleeding with SRH. 22 (92%) of these patients received endotherapy. Haemostasis was achieved after endotherapy in 20 (91%) patients.Two patients required CT angiography/embolization of the gastroduodenal artery. Two received no therapy. 19/24 (79%) patients received at least dual endoscopic therapy with 9/24 (37.5%) patients >2 modalities. 5/24 (9%) patients did not receive minimal recommended therapy; 3 patients (13%) received single (non-mechanical) modality. 2 patients received no treatment. In patients with endoscopic therapy, haemostasis was achieved in 13/22 (59%) patients at first OGD, 5/22 (27%) at second OGD and 2 (9%) at third OGD. In the two patients who failed endoscopic therapy, haemostosis was achieved at CTA. 7/22 patients (32%) did not achieve haemostasis at index endoscopy and required repeat endoscopy. Of these patients 5 (71%) had suboptimal endoscopic therapy at index endoscopy. In the 15 patients who achieved haemostasis 3 (20%) had suboptimal therapy at index endoscopy. (p = 0.05, Fisher’s exact test) Conclusion In this audit he failure to deliver effective endoscopic therapy at the index endoscopy led to ongoing bleeding in patients with non-variceal bleeding and SRH. In this audit we found 37% of patients needed triple endoscopic therapy to achieve haemostasis. The impact of such intensive endotherapy requires further study. Reference 1 NICE: https://www.nice.org.uk/guidance/gs38 Disclosure of Interest K. Waddell: None Declared, G. White: None Declared, A. Stanley Conflict with: Cook Medical, Boston Scientific, A. Morris Conflict with: Cook Medical, Boston Scientific.