Symptoms Of Upper Gastrointestinal Bleeding Research Articles

A Case Report of a Gastric Schwannoma on the Lesser Curvature of the Stomach Presenting with Upper Gastrointestinal Bleeding

Introduction: Gastric schwannomas are extremely rare mesenchymal tumors that represent only 0.2% of all gastric neoplasms. These tumors arise from the Auerbach or Meissner’s plexus and are most commonly found incidentally. Of those presenting with a gastric schwannoma only 12.8% of patients will present with upper gastrointestinal bleeding. Case Presentation: In this report, we present the case of a 51 year old female with signs and symptoms of upper gastrointestinal bleeding from a gastric schwannoma. The patient’s computed tomography revealed a 6.4 x 5.7 cm mass on the lesser curvature of the stomach near the pylorus. She subsequently underwent esophagogastroduodenoscopy with endoscopic ultrasound and fine needle aspiration revealing SMMS-1, Pankeratin, CD34, DOG-1, and CD117 negative immunohistochemical stains, which suggested a spindle cell neoplasm. The patient’s tumor was surgically resected two weeks later via laparoscopic distal gastrectomy with gastrojejunostomy. On immunohistochemistry, the tumor stained positive for S100, suggesting a gastric schwannoma. The patient’s postoperative course was complicated by possible early dumping syndrome which resolved in one week with dietary changes. She is tolerating regular food on follow-up and doing well. Discussion: With only a handful of reported cases, the need for inclusion of gastric schwannomas to the differential diagnosis of a bleeding gastric mass is essential. From these figures the likelihood of a patient with a gastric mass and upper gastrointestinal bleeding being caused by a gastric schwannoma is 0.026%. This points to the fact that this patient presentation is extremely rare but that gastric schwannomas do occur and need to be on the differential diagnosis of a patient with a gastric mass and signs of upper gastrointestinal bleeding.

The Constellation of Upper Gastrointestinal Symptoms and Associated Endoscopic and Histologic Features in Patients Receiving Immune Checkpoint Inhibitors

Introduction: Background: Immune checkpoint inhibitors (ICPIs) have demonstrated high effectiveness in treating advanced malignancies. Gastrointestinal (GI) adverse events involving the lower GI tract are commonly reported, however, very limited data is available about upper GI tract toxicities. We aimed to describe clinical, endoscopic and histological characteristics of upper GI tract injury related to ICPI treatment. Methods: We studied consecutive patients who developed upper GI symptoms requiring esophagogastroduodenoscopy (EGD) within 6 months of ICPI treatment (4/2011—3/2018). Results: Sixty patients met inclusion criteria; 92% Caucasians, 68% males with mean age of 59 years. The proportion of patients on CTLA—4 based therapy was comparable to that of PD—1/L1 (Table 1). The most common presenting symptoms were nausea and vomiting (78%). Eleven patients suffered from symptoms of upper GI bleeding. Mean time from ICPI initiation to onset of injury was 5 months. Endoscopically, mucosal ulceration was evident in 7 (12%) patients and non—ulcerative inflammation in 34 (57%). Histologic inflammation of the stomach was evident in 83% of patients, and of the duodenum in 38%. Risk factors for gastritis such as chemotherapy, radiotherapy, and non—steroidal anti—inflammatory drugs within 3 months of onset were recorded in 42 patients. Patients without these risk factors had isolated gastric involvement on endoscopy (Table 2). The rate of ulceration was the same in the cohorts with and without other risk factors (11% vs. 12%). Among patients with concurrent colonoscopies, endoscopic inflammation involving both upper and lower GI tract was detected in 21 (Table 3). Upper GI injury was treated with proton pump inhibitors or H2—blockers (n = 54), steroids (n = 25), and infliximab or vedolizumab (n = 14). Nine (15%) patients had recurrence of symptoms with a mean follow—up duration of 2 years. Conclusion: ICPIs might cause upper GI toxicity that is severe enough to require immunosuppression and hospitalization. Gastric involvement was evident more often than duodenal involvement on endoscopic and histological level. Patients without other risk factors for gastritis had isolated gastric involvement on endoscopy, although histologically duodenal inflammation was evident in 39%. Ulceration was more frequently found in isolated upper GI toxicities than concurrent upper and lower GI toxicities.1231_A Figure 1 No Caption available.1231_B Figure 2 No Caption available.1231_C Figure 3 No Caption available.

Primary Esophageal Diffuse Large B-Cell Lymphoma With Barrettʼs Esophagus: A Case Report and Literature Review

Diffuse large B-cell lymphoma (DLBCL) is the most common type of NHL in United States and accounts for 40% of NHL worldwide. GI lymphomas are rare and primarily located in the stomach, small intestine, and colon with esophageal being the rarest location. We present a rare case of rapidly growing esophageal lymphoma arising in the background of long segment Barrett's esophagus. A 76-year-old Caucasian male presented to our facility for poor oral intake and weight loss of 40 pounds in four months. Abdominal CT demonstrated circumferential distal esophageal wall thickening (Figure 1). EGD demonstrated erythematous and circumferentially nodular mucosa in the distal esophagus.1739_A Figure 1. CT scan showing distal esophageal thickening.Biopsies revealed Barrett's esophagus with erosive esophagitis but was negative for malignancy. Esophageal brushings showed candida esophagus. A 3-week course of fluconazole was prescribed. Repeat EGD in 4 weeks demonstrated salmon colored mucosa without nodules. Distal esophagus had ulcerated, granular and friable mucosa covered with exudates. (Figure 2). Biopsies from this region returned positive for high grade B-Cell lymphoma with C-MYC and BCL-2 rearrangements. Immunoperoxidase studies showed neoplastic B cells positive for CD20, PAX-5, BCL-6 and CD10. C-MYC was positive in 60% cells and KI-67 positive in 80% cells. PET scan demonstrated marked uptake in the distal esophagus without any evidence of regional or distal metastatic disease. Bendamustine and rituximab was initiated for treatment of diffuse large B cell lymphoma. The patient had an uneventful hospital course and was discharge home to continue chemotherapy. He continues to do well on follow up clinic visit.1739_B Figure 2. Distal Esophagus: Ulcerated, granular and friable mucosa with exudatesGastrointestinal lymphoma accounts less than 20% of extra nodal lymphomas with primary esophageal lymphoma accounting for less than 1% of GI lymphomas. Our patient satisfies Dawson's criterion of primary GI lymphoma which includes an absence of peripheral lymphadenopathy, absence of mediastinal adenopathy, lack of liver or spleen involvement, and normal peripheral blood count. Primary esophageal lymphomas are most commonly found in the distal esophagus, may present with dysphagia, weight loss, odynophagia or symptoms of upper gastrointestinal bleeding. To our knowledge this is the first reported case of esophageal lymphoma arising in background of long segment Barrett's esophagus. We hope that our description of this patient's esophageal DLBCL contributes to the limited data available.

Bitlis İlinde Acil Servise Üst Gastrointestinal Kanama İle Başvuran Hastaların Endoskopik ve Demografik Verilerinin Değerlendirilmesi

Giriş ve Amaç: Üst gastrointestinal sistem kanamaları acil servise başvuruların önemli bir nedeni olup, erken tanı ve tedavi gerektirmektedir. Bu çalışmanın amacı Bitlis ilinde üst gastrointestinal sistem kanaması tanısı alan hastaların özelliklerini değerlendirmektir. Gereç ve Yöntem: Ocak 2014-Aralık 2017 tarihleri arasında Bitlis Devlet Hastanesi acil servisi kliniğine üst gastrointestinal sistem kanaması nedeni ile başvuran hastaların verileri retrospektif olarak incelendi. Bu hastaların klinik özellikleri ve kanamaya yol açabilecek etiyolojik nedenler değerlendirildi. Bulgular: Çalışmaya toplam 54 hasta alındı. Hastaların çoğunluğunu erkekler (%59.3) oluşturmaktaydı. En sık başvuru şikayeti hematemezdi. Hastaların %22.8’inde kanamaya predispozan olabilecek ilaç kullanımı mevcuttu. Hastaların ortalama yatış süresi 5.6±3.6 gün idi. Etiyolojik açıdan en sık neden duedonum ve mide ülseri olarak saptandı. Sonuç: Bitlis ilinde üst gastrointestinal sistem kanaması olan hastaların genel özellikleri ülkemizde bu konu ile ilgili yapılan diğer çalışmalar ile uyum göstermekteydi.

Feasibility of predictive model by clinical and laboratory parameters for risk stratification of geriatric abdominal pain

Background: Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis. Objective: Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments. Methods: This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician. Results: In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%). Conclusion: Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.

Outcomes in Upper Gastrointestinal Bleeding by Type of Hematemesis

The presenting symptoms of upper gastrointestinal bleeding may predict clinical outcomes. Investigators in six countries prospectively assessed

Limited Benefit of Additional Inpatient Diagnostic Evaluation in Patients With Upper Gastrointestinal Bleeding and a Negative Initial EGD

Introduction: Upper gastrointestinal bleeding (UGIB) is a common reason for hospitalization and is associated with significant costs and resource utilization. For patients with a negative initial esophagogastroduodenoscopy (EGD) it is unclear if further inpatient testing affects clinical outcomes. Aims: To evaluate whether additional in-hospital diagnostic testing affect outcomes in patients with UGIB and a negative initial EGD. Methods: We conducted a prospective observational cohort study of consecutive adult patients admitted to an academic medical center from April 2016 to April 2017 with melena, hematemesis or coffee ground emesis and who underwent EGD. The cohort was divided between those with diagnostic and non-diagnostic EGDs and between those who underwent further inpatient testing or did not. Further testing included repeat EGD, colonoscopy, flexible sigmoidoscopy, capsule endoscopy, enteroscopy, and CT or IR angiogram. In-hospital outcomes included endoscopic intervention, re-bleeding, ICU admission, transfusion requirement, number of red cells transfused, length of stay (LOS) and in-hospital mortality. Two-tailed Students T test and Fisher's exact test were used to compare the two groups. Results: One hundred and ninety four patients underwent EGD for symptoms of UGIB, 113 (58%) had source of bleeding identified on initial EGD, and 58 (30%) underwent endoscopic intervention. Patients with a positive EGD had lower initial hemoglobin, higher BUN, higher heart rate, and higher Glasgow Blatchford scores (see Table 1). They were more likely to require ICU stay, red cell and plasma transfusion (P values 0.007, 0.01, 0.05; percent difference 20, 19, 12). Of those with negative initial EGD, 50 (62%) patients underwent additional inpatient testing. A source of bleeding was identified in 17 (34%) patients (11 with colonic source including 3 diverticular bleeds, 4 with small bowel source including 2 AVMs, and 2 gastric ulcers missed on initial EGD). Two patients with small bowel AVMs and 1 with a colonic ulcer underwent endoscopic intervention. There were no significant differences in re-bleeding, ICU stay, red cell transfusion requirement, or mortality whether patients underwent additional inpatient testing or not (P values 0.15, 0.82, 0.07, 1.00; percent difference 17, 4, 21, 2).Table: Table. Baseline characteristics and outcomes of cohort and those with source identified or not identified on index EGDConclusion: Among patients with UGIB and non-diagnostic initial EGD further inpatient diagnostic testing did not impact outcomes.Table: Table. Comparison of baseline characteristics and outcomes of those who underwent EGD only (with no source identified) and those who underwent additional inpatient diagnostic studies after negative EGDFigure: Intervention and source identification flowchart for patients presenting with UGIB and who underwent EGD.

Metastatic Renal Cell Carcinoma Leading to Upper Gastrointestinal Bleeding

Introduction: Renal cell carcinoma (RCC) is the most common urological malignancy and usually diagnosed after it has already metastasized to other organs. RCC most commonly metastasizes to lungs, soft tissue, bone, brain and rarely spreads to stomach. Here, we present a rare case of upper gastrointestinal bleeding secondary to metastatic renal cell carcinoma. Case report: A 75-year-old African American male with the history of stage IV renal cell carcinoma with metastasis to lungs, COPD, HTN, and DVT on enoxaparin presented to the hospital with the complaint of shortness of breath. He admitted to having dark brown stools on multiple occasions over the last month. Physical examination was benign. Laboratory evaluation revealed normocytic anemia with hemoglobin of 5.9. EGD revealed multiple ulcerated lesions with heaped up margins in mid-gastric body with a single large ulcer in the duodenum (FIg, 1, 2). Biopsies of the gastric ulcers were consistent with renal cell carcinoma (Fig. 3), clear cell type with PAX8 immunohistochemical stain showing strong nuclear positivity in the clear cells. Discussion: Malignant metastasis to stomach is commonly associated with breast cancer and lung cancer with very few reported cases of RCC. To date, only 45 cases (including this one) has been reported in the literature describing renal cell carcinoma metastasis to the stomach [1]. The most frequent presentation of gastric metastasis is melena or hematemesis indicating an upper gastrointestinal bleed, with abdominal pain and dysphagia being less common. It typically presents as a single polypoid lesion with reported incidence of 71.5%, and most commonly involves the gastric body, however, multiple small lesions have also been reported in 8 of 45 cases [1]. Presentation of gastric metastasis ranges from 1 to 24 years [2] from initial diagnosis of RCC and can even present after complete resolution and treatment of initial disease. Clear cell type is the most common form of RCC associated with gastric metastasis. Treatment depends on the extent of disease and includes endoscopic therapy for the single polypoid lesion, cauterization of bleeding vessel, gastrectomy and/or chemotherapy for widespread disease. Overall gastric metastasis has been linked with poor prognosis. It is very important to consider gastric metastasis in patients presenting with signs and symptoms of upper gastrointestinal bleeding with a history of renal cell carcinoma, even after remote and stable disease.Figure 3Figure 1Figure 2

Comparison of Glasgow-Blatchford score and full Rockall score systems to predict clinical outcomes in patients with upper gastrointestinal bleeding.

BackgroundVarious risk scoring systems have been recently developed to predict clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). The two commonly used scoring systems include full Rockall score (RS) and the Glasgow-Blatchford score (GBS). Bleeding scores were assessed in terms of prediction of clinical outcomes in patients with UGIB.Patients and methodsTwo hundred patients (age >18 years) with obvious symptoms of UGIB in the emergency department of Rasoul Akram Hospital were enrolled. Full RS and GBS were calculated. We followed the patients for records of rebleeding and 1-month mortality. A receiver operating characteristic curve by using areas under the curve (AUCs) was used to statistically identify the best cutoff point.ResultsEighteen patients were excluded from the study due to failure to follow-up. Rebleeding and mortality rate were 9.34% (n=17) and 11.53% (n=21), respectively. Regarding 1-month mortality, full RS was better than GBS (AUC, 0.648 versus 0.582; P=0.021). GBS was more accurate in terms of detecting transfusion need (AUC, 0.757 versus 0.528; P=0.001), rebleeding rate (AUC, 0.722 versus 0.520; P=0.002), intensive care unit admission rate (AUC, 0.648 versus 0.582; P=0.021), and endoscopic intervention rate (AUC, 0.771 versus 0.650; P<0.001).ConclusionWe found the full RS system is better for 1-month mortality prediction while GBS system is better for prediction of other outcomes.

Similar Efficacy of Proton-Pump Inhibitors vs H2-Receptor Antagonists in Reducing Risk of Upper Gastrointestinal Bleeding or Ulcers in High-Risk Users of Low-Dose Aspirin

It is not clear whether H2-receptor antagonists (H2RAs) reduce the risk of gastrointestinal (GI) bleeding in aspirin users at high risk. We performed a double-blind randomized trial to compare the effects of a proton pump inhibitor (PPI) vs a H2RA antagonist in preventing recurrent upper GI bleeding and ulcers in high-risk aspirin users. We studied 270 users of low-dose aspirin (≤325 mg/day) with a history of endoscopically confirmed ulcer bleeding at 8 sites in Hong Kong and Japan. After healing of ulcers, subjects with negative results from tests for Helicobacter pylori resumed aspirin (80 mg) daily and were assigned randomly to groups given a once-daily PPI (rabeprazole, 20 mg; n= 138) or H2RA (famotidine, 40 mg; n= 132) for up to 12 months. Subjects were evaluated every 2 months; endoscopy was repeated if they developed symptoms of upper GI bleeding or had a reduction in hemoglobin level greater than 2 g/dL and after 12 months of follow-up evaluation. The adequacy of upper GI protection was assessed by end points of recurrent upper GI bleeding and a composite of recurrent upper GI bleeding or recurrent endoscopic ulcers at month12. During the 12-month study period, upper GI bleeding recurred in 1 patient receiving rabeprazole (0.7%; 95% confidence interval [CI], 0.1%-5.1%) and in 4 patients receiving famotidine (3.1%; 95% CI, 1.2%-8.1%) (P= .16). The composite end point of recurrent bleeding or endoscopic ulcers at month 12 was reached by 9 patients receiving rabeprazole (7.9%; 95% CI, 4.2%-14.7%) and 13 patients receiving famotidine (12.4%; 95% CI, 7.4%-20.4%) (P= .26). In a randomized controlled trial of users of low-dose aspirin at risk for recurrent GI bleeding, a slightly lower proportion of patients receiving a PPI along with aspirin developed recurrent bleeding or ulcer than of patients receiving an H2RA with the aspirin, although this difference was not statistically significant. ClincialTrials.gov no: NCT01408186.

Comparison of Risk Stratification Scores for Patients Presenting with Symptoms of Upper Gastrointestinal Bleeding in the Emergency Department

Objective To compare four scoring systems to predict outcomes in patients with symptoms of upper gastrointestinal bleeding presenting to the emergency department. Method A single centered prospective cohort study. All adult patients presenting to the emergency department of the studying centre with haematemsis or tarry stool or coffee ground vomiting or coffee ground aspirate from nasogastric tube were included from February 2012 to April 2012. The outcome variables include mortality, length of stay in hospital, blood product transfusion and interventions for bleeding control. The AIMS65 score, pre-endoscopic Rockall score, Glasgow Blatchford Score (GBS) and the modified Glasgow Blatchford Score (mGBS) were evaluated. Diagnostic characteristics were presented and areas under the receiver-operating-characteristic (AUROC) curve were compared. Results A total of 129 patients were included in the study. 81 of them (62.8%) had upper endoscopy performed. The mortality rate was 3.1%. Initial haemoglobin level of &lt;10 was an important factor in risk stratification. Validation of the 4 scoring systems showed GBS had highest sensitivities (98.3-100%) and negative predictive values (90-100%) for all outcome variables but could not achieve a good specificity and positive predictive values against the outcomes. Both GBS and modified GBS outperformed the other two scoring systems in the AUROC curves in predicting composite high-risk outcome, length of stay in hospital and blood transfusion. Conclusion GBS appeared the best scoring system in the emergency department for screening purpose and to stratify those high risk patients for admission and low risk patients for out-patient management. (Hong Kong j.emerg.med. 2016;23:199-209)

Upper Gastrointestinal Bleeding in Caracas Hemorragia Digestiva Superior en Caracas

Materials and Methods: The aim of this research is to describe endoscopic findings in patients with acute Upper Gastrointestinal bleeding. The sample consisted of 131 patients with signs or symptoms of Upper Gastrointestinal Bleeding during the first half of 2012. Non-experimental, descriptive and prospective research. Mean, mode and median for numerical variables and percentages were used. Results and Discussion: During the first half of 2012 were performed 2602 endoscopies, a total of 136 endoscopies were maid whose indication was upper digestive bleeding. Endoscopy was performed on 131 patients, 52.2% were female, 36.8% of endoscopies were performed in people of 60 year or older. 48.9 % of patients had no comorbidity. 80.1 % of patients received no medication. The most frequent endoscopic finding was Peptic Ulcer Disease (44.1%). In 70.6% of cases no endoscopic therapy was applied. Conclusions: Study findings are similar to those described in the national and international literature, differences were observed by increased frequency of neoplasms, increased use of argon plasma coagulation and low recurrence of bleeding. This research extended several recommendations.

Gastrointestinal Involvement of Systemic Amyloidosis

Introduction: Amyloidosis presents with multiple organ system involvement at an annual incidence of approximately 3,000 cases in the U.S. It usually involves multiple organ systems, with the most common being renal and cardiac manifestations. Gastrointestinal (GI) system involvement is rare, occurring in approximately 3% of cases. Presentation may include hepatomegaly with or without splenomegaly and GI bleed; however, patients rarely present with GI bleed as the primary or sole symptom. We present a case of a patient who presented with symptoms of upper GI bleeding leading to esophagogastroduodenoscopy (EGD) and resultant biopsy diagnostic for amyloidosis. Case Report: A 72-year-old white male with PMH significant for peptic ulcer disease and coronary artery disease presented with 2 weeks of melena, fatigue, lower extremity edema, and increasing abdominal girth. In the emergency department, fecal occult blood testing was positive and the patient was admitted for suspected GI bleeding. EGD with biopsy was done, which revealed gastritis and polyps in fundus and body of stomach. Symptoms progressed to include acute renal failure with creatinine peaking at 1.6 mg/dL. Urinalysis showed nephrotic range proteinuria (>500 mg/dL). Pertinent labs included: AST 111 IU/L (5.0-34 IU/L), alkaline phosphatase 645 IU/L (40-150 U/L), serum albumin 1.5 g/dL (3.5-5.0 g/dL), and INR 1.3. Abdominal ultrasound showed ascites with a normal-appearing liver and normal-sized spleen. Ascitic fluid analysis resulted in a SAAG of 1.5 and protein of 0.8 g/dL, suggestive of portal hypertension. Gastric biopsy revealed amyloid deposits, positive for Congo red stain with apple green birefringence by polarized light. The patient underwent trans-jugular liver biopsy, which revealed near complete replacement of hepatic parenchyma with amyloid deposition confirming the diagnosis. The patient is currently being evaluated for further characterization, and pending studies include SPEP, UPEP, flow cytometry, skeletal survey, and bone marrow biopsy, which will dictate mode of treatment. Discussion: Amyloidosis is a systemic disease that may present with a constellation of symptoms. GI tract involvement with amyloid may result in occult bleeding in 45-75% of patients, which may be from ulceration, erosions, vascular fragility, and lack of vasomotor response. When present in the liver, amyloid may lead to portal hypertension and liver failure. In an infiltrative process such as amyloid, the elevation of alkaline phosphatase is most prominent. This is a rare case in which the presenting symptom of amyloidosis was GI bleeding and diagnosis was initially made by endoscopic biopsy.

Esophageal submucosal tumor-a red flag in patients receiving thoracic aortic aneurysmal stent-graft.

A 75-year-old man presented to our hospital with symptoms of fever, abdominal pain, intermittent hematemesis and melena for 2 days. The patient underwent stent-graft placement for a thoracic aortic aneurysm (TAA) 6 months prior to this presentation. Seven days ago, he suffered from dyspepsia; an upper gastrointestinal (UGI) endoscopy indicated a submucosal tumor (Fig. 1A, arrow) in the middle portion of the esophagus. Endoscopic biopsy was then conducted, which disclosed inflammatory cells. Upon hospitalization, laboratory data indicated marked anemia with a hemoglobin of 6 g/dL. Chest radiography revealed a widening of the mediastinum and a TAA stent-graft (Fig. 1B, arrow) in place without unusual mediastinal air. Emergent UGI endoscopy was performed due to intermittent hematemesis and anemia. It demonstrated an ulcerative hole located in the middle portion of the esophagus (Fig. 1C, arrow indicates the ulcerative hole). Due to fever of an unknown focus, contrast-enhanced computed tomography (CT) of chest was done in order to rule out any occult infectious process associated with the stent-graft, showing a gas-forming peri-stent-graft abscess formation with posterior mediastinal extension (Fig. 1D, pre-contrast CT; Fig. 1E early-phase CT; Fig. 1F, reconstructed image; Fig. 1E to F, white star indicates the abscess and white arrow indicates the nasogastric tube). The radiographic and endoscopic findings were consistent with an aortoesophageal fistula formation (AEF). The patient was put on broad-spectrum antibiotics, but succumbed to sepsis before emergent operation. Fig. 1 Aortoesophageal fistula is a rare complication after thoracic endovascular aortic repair. The rate of incidence is around 1.9%.1) AEF formation after thoracic endovascular aortic repair is probably associated with the erosion of the esophageal wall by an infected stent-graft, pressure necrosis caused by the direct compression of a self-expanding stent-graft, or a compromised blood supply of the esophageal wall.1),2) Presentations of AEF include new-onset fever, chest pain or symptoms of UGI bleeding, such as hematemesis or melena.3) Contrast-enhanced CT is a useful imaging modality if AEF is suspected clinically. When a new heterogeneous mass with some air bubbles inside is found on the CT, subsequent UGI endoscopy can be performed to confirm the diagnosis. Endoscopic findings vary from submucosal tumor, ulceration, small defect of esophagus or direct visualization of a stent-graft. The mortality rate of AEF is extremely high if treated conservatively.3) Surgical intervention is challenging and important for the management of this devastating complication.

Esophageal Involvement of Pemphigus Vulgaris Associated with Upper Gastrointestinal Bleeding

Esophageal involvement of pemphigus vulgaris is rare, and when present, the most common presenting symptoms reported in the medical literature are odynophagia and dysphagia. Here, we present two cases of pemphigus vulgaris presenting with upper gastrointestinal hemorrhage because of esophageal involvement of the disease. In case 1, a 41-year-old female patient with a prior diagnosis of pemphigus vulgaris presented with hematemesis. Esophagogastroduodenoscopy showed diffuse mucosal exfoliation and oozing bleeding of the oropharynx and esophagus. The patient recovered after the administration of high-dose corticosteroids and immunosuppressants. In case 2, a 30-year-old female patient with known pemphigus vulgaris also presented with hematemesis, showing similar endoscopic findings to the first case. She also responded to the same treatment. Esophageal involvement of pemphigus vulgaris responds to high-dose corticosteroids and immunosuppressants. Thus, in patients with pemphigus vulgaris with signs or symptoms of upper gastrointestinal bleeding, an early endoscopy for the evaluation of esophageal involvement is beneficial.

“Heavy metal – heavy heart” — An unusual cause of refractory chest pain

A 48-year-old man presented to our institution with acute onset central chest pain radiating to both his left shoulder and neck. Although he was somewhat reticent about his prior medical history, he described prior long-standing symptoms of upper gastrointestinal bleeding, chest pain and chronic back pain. Upon examination a 12-lead electrocardiogram revealed widespread T-wave inversion throughout the precordial leads (Fig. 1), and given an elevated initial high-sensitive troponin assay of 21ng/L (normal range: 1–13ng/L), he was treated for acute coronary syndrome.

Effects of early oral feeding on relapse and symptoms of upper gastrointestinal bleeding in peptic ulcer disease

Peptic ulcer is the most common cause of upper gastrointestinal bleeding (GIB) and nutritional support is a helpful strategy in malnutrition prevention during treatment. As early oral feeding in patients with GIB may shorten hospital stay and decrease costs and risk of infection, the present study was carried out to investigate the effects of early oral feeding on relapse and symptoms of upper GIB. The present clinical trial was conducted with the participation of 100 patients with upper GIB due to gastric or duodenum ulcer at Emam Reza University Hospital in Tabriz. Subjects were randomly allocated to two groups (n=50). In one group, patients received oral diet from day 1 and in other group patients were nil by mouth until day 3 and then received oral diet. Endoscopic and clinical findings of patients were recorded from day 1 to 3. The mean age of subjects was 57.6±1.7 and 63% were male. Sclerotherapy was used in most cases as a hemostasis treatment. There was no significant difference in laboratory findings and rebleeding between the two groups. In the group with early oral feeding, the time of hospital stay was significantly shorter than in the control group (P<0.001). Although early oral feeding had no significant effects on electrolyte balance and treatment outcomes in patients with upper GIB who were treated with endoscopic hemostasis, it could effectively shorten the hospital stay. Consequently, early oral feeding in these patients enables early discharge and reduces the costs of treatment.

PMO-207 Changing trends in upper and lower gastrointestinal bleeding over a 13-years period

IntroductionAcute gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality and morbidity. Recent studies suggest that the incidence of upper GI bleeding (UGIB) has decreased mainly due...

Can Pre-Endoscopic Assessment Predict Active Upper Gastrointestinal Bleeding? A Retrospective Study in Patients with Symptoms of Upper Gastrointestinal Bleeding Outside Regular Working Hours

To evaluate the usefulness of pre-endoscopic assessment for predicting active up-per gastrointestinal bleeding (UGI-B) at emergency esophagogastroduodenoscopy (E-EGD, within 6 hours). We retrospectively analysed the medical records of patients that had an E-EGD performed outside working hours and considered 15 pre-endoscopic variables in a univariate analysis. Active UGI-Bat E-EGD was taken as end-point. Of 228 E-EGD performed during 75 months, 195 were motivated by the suspicion of UGI-B. We excluded 83 cases as they were hospitalised at the time of first symptoms of bleeding. Thus, 112 cases were included. The following clinical signs triggered E-EGD: hematemesis (56/50%),melena (55/49.1%), hematochezia (20/17.8%), anae- mia (7/6.2%). Patients' age was 65.5+14.2 years. Sixty nine (61.6%) cases were male. The relative risk and p-value of the variables for the presence of active bleeding at E-EGD were as follows: hematemesis: 1.54/0.3; malignancy and cirrhosis: 1.73/0.07; haemoglobin <8g/dL: 1.38/0.3; white blood count >12,000/tL: 1.18/0.6;systolic blood pressure (SBP) <100 mmHg: 0.53/0.03;pulse >100/min: 1.42/0.2; platelets <14000/nL:1.5/0.2; INR >1.17: 1.89/0.049. In the multivariate analysis none of these variables independently predicted UGI-B. No relevant pre-endoscopic variables for the prediction of active UGI-B at E-EGD could be found. Our data suggest that pre-endoscopic evaluation cannot replace rapid endoscopy.

External validation of the Glasgow-Blatchford Bleeding Score and the Rockall Score in the US setting

BackgroundThe Glasgow-Blatchford Bleeding Score (GBS) and Rockall Score (RS) are clinical decision rules that risk stratify emergency department (ED) patients with upper gastrointestinal bleeding (UGIB). We evaluated GBS and RS to determine the extent to which either score identifies patients with UGIB who could be safely discharged from the ED. MethodsWe reviewed and extracted data from the electronic medical records of consecutive adult patients who presented with signs or symptoms of UGIB (hematemesis and/or melena) to an academic ED from April 1, 2004, to April 1, 2009. The primary outcome was need for intervention (blood transfusion and/or endoscopic/surgical intervention) or death within 30 days. ResultsWe identified 171 patients with the following characteristics: mean age of 69.9 years (SD, 17.0 years ), 52% women, 20% with a history of liver disease, and 22% with history of gastrointestinal bleeding. Ninety (52.6%, 95% confidence interval, 44.9-60.3) patients had the primary outcome. GBS outperformed pre-endoscopy RS [area under the receiver operating characteristic curve (AUC) = 0.79 vs 0.62; P = .0001; absolute difference, 0.17]. The prognostic accuracy of GBS and post-endoscopy RS was similarly high (AUC, 0.79 vs 0.72; P = .26; absolute difference, 0.07). The specificity of GBS and RS was suboptimal at all potential decision thresholds. ConclusionsAlthough GBS outperformed pre-endoscopy RS, the prognostic accuracy of GBS and post-endoscopy RS was similarly high. The specificity of GBS and RS was insufficient to recommend use of either score in clinical practice.