Tarry Stool Research Articles

010. Ileus Obstruktif Letak Tinggi E.C Susp Hirschprung pada Pasien Umur 22 Tahun di RSUP Prof. Dr IGNG Ngoerah pada Tahun 2023

Background: Hirschsprung is a disease that occurs in the intestine, and cases most often appear in the colon (colon). Symptoms that usually arise are chronic constipation, failure to grow, and malnutrition. The surgical procedure approach that can be performed in this case is by carrying out an exploration laparatomy and placed a colostomy on the patient. Case: A 22-year-old male patient presents to the emergency department with abdominal pain, His pain began suddenly then dissappear gradually, accompanied by flatulence and nausea since a week ago. Other complaints such as fever and vomiting are denied. Patients with a history of defecation patterns every 2-3 days. Patients complain of difficulty defecating since last week before admitted, the stool form was a small amount of liquid, frequency is 2-3x/day. Stool with blood (-), black or tarry stool (-). Patients with a history of circumcision surgery. The results of the examination showed an increase in WBC 15.11. Based on the BOF results, the results described as a leading to paralytic ileus, Fecal material prominent as high as the pelvic cavum. In addition, based on the results of abdominal ultrasound, it is said that most of the scanning areas are covered by prominent intestinal gas, mild fatty liver. After the exploratory laparatomy, no signs of malignancy were found in the patient, but there was suspicion towards Hirschsprung where the patient did not have the flexura hepatica ligament and the lienalis flexura ligament. Conclusion: Hirschsprung requires surgical procedures that must be explained throughly to patient and families. The surgical procedure approach that can be performed in this case is by carrying out an exploratory laparatomy and the placed a colostomy on the patient. And colon in loop will be used to determine and evaluate the intestine height with aganglionic.

Effective Management of Ileocecal Hemorrhage with Super-Selective Arterial Embolization: A Case Study

Background: Acute colonic bleeding, including rectal bleeding and melena, affects approximately 36 per 100,000 people annually, with a higher incidence in the elderly. Effective management requires prompt diagnosis and intervention, especially for severe cases characterized by persistent bleeding and significant decreases in hemoglobin levels. Traditional therapeutic options include pharmacologic therapy, endoscopic coagulation, transcatheter therapy, and surgery. While percutaneous embolization is established for upper GI bleeding, its effectiveness for lower GI bleeding remains debated due to concerns over potential intestinal infarction. Methods: We present a case of a 31-year-old female with a history of severe mitral regurgitation and chronic atrial fibrillation who underwent mitral valve replacement. Post-operatively, she developed black tarry stools indicative of lower GI bleeding. Initial treatments, including proton pump inhibitors, tranexamic acid, and vitamin K, were ineffective. Gastroscopy and colonoscopy showed no active bleeding, but abdominal CT revealed contrast extravasation at the ileocecal junction, likely from the ileocolic artery. Super-selective arterial embolization was performed using a 6 Fr femoral sheath and microcatheter (2.7 Fr) with non-spherical polyvinyl alcohol (nsPVA) particles (355-500 μm) to target the bleeding source. Results: The embolization successfully halted hematochezia with no signs of peritonitis or mesenteric infarction. Post-procedure, the patient was discharged after 4 days with no abdominal pain or readmission for complications. Conclusion: Super-selective arterial embolization is a safe and effective method for managing lower GI bleeding, with no observed intestinal infarction in this case. This approach demonstrates the feasibility of embolization in controlling severe colonic hemorrhage, potentially offering a viable alternative to more invasive procedures while minimizing the risk of bowel ischemia.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review

BackgroundThe rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach.Case presentationA 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma.ConclusionsWe successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Abstract 1072: Two Filter, Or Not Two Filter: Case Report Of Rare Anatomical Variant Of Inferior Vena Cava

This case involves bilateral inferior vena caval filter placement in a 68-year-old male with a history of a recently diagnosed pulmonary embolism (PE) who presented with precipitously dropping hemoglobin and dark tarry stools after starting Eliquis. Endoscopy confirmed ulcerative esophagitis. Interventional radiology was consulted for inferior vena cava (IVC) filter placement as was indicated due to lower extremity thrombosis, PE, and GI bleed. During the procedure, cavography revealed a duplicated inferior vena cava (DIVC), prompting the placement of bilateral Denali filters infrarenally via the right and left common femoral approach. Only 16 similar cases are reported in the literature at the time of this literature review, and this case highlights the efficacy of bilateral infrarenal filter placement in addressing this anatomical variation.

A case of methotrexate-related lymphoproliferative disease showing multiple liver lesions in a patient with rheumatoid arthritis

A 66-year-old woman with rheumatoid arthritis (RA) who had been receiving methotrexate (MTX) for 2 years presented with tarry stools. Contrast-enhanced computed tomography (CT) of the abdomen revealed irregular wall thickening in the ileocecal region and multiple low-contrast masses in both lobes of the liver. Lower gastrointestinal endoscopy revealed a type 2 tumor in the ileocecal region with a semi-peripheral ulcer. Histological examination of liver and colon biopsies showed other iatrogenic immunodeficiency-associated lymphoproliferative disorder (Oi-LPD), diffuse large B-cell lymphoma type, with positivity for Epstein-Barr virus DNA. After withdrawal of MTX, the LPD lesions disappeared and the patient achieved remission. We considered this to be a sporadic case of Oi-LPD, diffuse large B-cell lymphoma type, in the liver and colon due to treatment with MTX. There has been no previous report of this condition with simultaneous hepatic and colonic lesions, and the present case is thought to be highly informative in relation to the pathogenesis.

A Case Report of Giant Splenic Artery Pseudoaneurysm with Splenic Infarctions

The splenic artery is a frequently affected site for pseudoaneurysms, abnormal bulges in the artery wall. Pseudoaneurysms of the splenic artery are typically linked to pancreatic issues, including acute pancreatitis, chronic pancreatitis, and the formation of pancreatic pseudocysts.[1,2,3,4] These pseudoaneurysms can rupture into nearby organs, leading to gastrointestinal bleeding.[5] Common symptoms associated with splenic artery pseudoaneurysms include the passage of bloody stools (hematochezia) or dark, tarry stools (melena), vomiting blood (hematemesis), abdominal pain, and a condition known as hemosuccus pancreaticus.[6] In the instance of our patient, hematemesis, anaemia, and stomach pain were observed.[6]
 The preferred imaging method for diagnosing splenic artery pseudoaneurysm is CT angiography.[7] Diagnosing a pseudoaneurysm of the splenic artery can be challenging due to its rarity. Still, splenic infarct can provide a valuable diagnostic clue, as was the case similar to our patient.[6]
 Pseudoaneurysm of the splenic artery is a relatively rare complication with associated pancreatitis.[1] While pseudoaneurysms can develop in any blood vessel near the pancreas, the splenic artery is most frequently affected, accounting for about 60% of cases due to its proximity to the pancreas.[8] In autopsy studies, the reported incidence of splenic artery pseudoaneurysms ranges from approximately 0.098% to 10.4%.[9] Identifying this less common vascular complication is crucial because it has the potential to rupture and lead to gastrointestinal bleeding.[5]

A case of hereditary hemorrhagic telangiectasia presenting with brain abscess

BackgroundHereditary hemorrhagic telangiectasia (HHT), characterized by telangiectases and arteriovenous malformations that can occur in any organ but primarily the lungs, liver, and brain, is an autosomal dominant disorder. Brain abscess, though a rare and potentially fatal complication, can be an initial presentation of this condition. Case summaryA 60-year-old man presented with anemia and black tarry stools, then developed right-sided weakness initially misdiagnosed as an ischemic stroke. Subsequent onset of headaches and high-grade fever led to the diagnosis of brain abscess, and HHT was subsequently identified. ConclusionThis case underscores that brain abscess can be an initial symptom of HHT. Prompt diagnosis and treatment are vital, which requires physicians to maintain a high index of suspicion and conduct appropriate investigations promptly.

59/m-Blood in vomit and tarry stools : Preparation for the medical specialist examination: part30

59/m-Blood in vomit and tarry stools : Preparation for the medical specialist examination: part30

Vitamin E-induced coagulopathy in a young patient: a case report

BackgroundHigh-dose vitamin E intake is known to inhibit vitamin K-derived coagulation factor synthesis, which can cause serious bleeding events such as gastrointestinal bleeding and intracranial hemorrhage. We report a case of coagulopathy induced by marginally increased levels of vitamin E.Case presentationA 31-year-old Indian man presented with oral bleeding, black tarry stools, and bruising over his back. He had been taking non-steroidal anti-inflammatory drugs for low backache and vitamin E for hair loss. He had mild anemia with normal platelet count, thrombin time, and prolonged bleeding time, activated partial thromboplastin time, and prothrombin time. Serum fibrinogen was slightly raised. Mixing studies with pooled normal plasma, aged plasma, and adsorbed plasma were suggestive of deficiency of multiple coagulation factors due to acquired vitamin K deficiency. Serum phylloquinone was normal, while prothrombin induced by vitamin K absence-II level was increased. Serum alpha-tocopherol was slightly raised. Upper gastrointestinal endoscopy showed multiple gastroduodenal erosions. A final diagnosis of vitamin E toxicity-related coagulopathy was made. The patient responded well to pantoprazole, vitamin K supplementation, multiple fresh frozen plasma transfusions, and other supportive treatments besides the discontinuation of vitamin E supplementation. The coagulation parameters normalized, and the patient was discharged with complete resolution of symptoms and remained asymptomatic during the follow-up for 6 months.ConclusionsVitamin E-related inhibition of vitamin K-dependent factors with coagulopathy may occur even at marginally increased levels of serum vitamin E. This risk becomes significant in patients receiving other drugs that may increase the risk of bleeding.

Unusual Cause of Tarry Stool: What Do You Think?

Question: A 52-year-old man, who was in good health, presented with a 4-month history of tarry stool, abdominal pain, and weight loss. The patient denied history of inflammatory bowel disese and recent antibiotic use. His abdomen was soft, with mild periumbilical tenderness. There was no organomegaly. Laboratory studies showed red blood cell count 3.02 × 1012/L (normal range 4.3–5.8 × 1012/L), leukocyte count 6.57 × 109/L (normal range 3.5–9.5 × 109/L), platelet count 347 × 109/L (normal range 125–350 × 109/L), hemoglobin 66 g/L (normal range 130–175 g/L), aspartate transaminase 15 U/L (normal range 15–40 U/L), alanine transaminase 7 U/L (normal range 9–50 U/L), total serum protein 49 g/L (normal range 65–85 g/L), and serum albumin 27 g/L (normal range 40–55 g/L). Urine tests were normal. Esophagogastroduodenoscopy was normal, with multiple biopsies showing no abnormality in histopathology. Colonoscopy revealed patchy erythema throughout the colon without active hemorrhage (Figure A). Eight biopsies were taken from the ascending colon, transverse colon, descending colon, and sigmoid colon. Contrast-enhanced abdominal computed tomography showed thickened and dilated ileal loops (Figure B). A double-balloon retrograde enteroscopy revealed numerous patchy areas of denuded and ulcerated ileal mucosa (Figure C), the outline of which was graphically outlined with methylene blue staining (Figure D). Four biopsies were taken from the ileum. Screening was negative for serum tumor markers and the following autoantibodies: anti–double-stranded DNA, anti-nuclear antibody, anti-SSA/Ro, anti-SSB/La, anti–liver/kidney microsomal type 1, anti–Scl-70, anti–smooth muscle antibody, anti–U1-snRNP, anti-mitochondrial antibodies, anti-SmD1, cytoplasmic anti-neutrophil cytoplasmic antibody, and peri-nuclear anti-neutrophil cytoplasmic antibody. Electrocardiography and chest computed tomographic (CT) scan were normal. Biopsies of the colon and small intestine (hematoxylin and eosin staining) revealed the findings shown in Figure E.

Duodenal gastric-type neoplasm with uncertain malignant potential in a lipoma.

The pathologic diagnosis of duodenal tumors is a developing field; however, its overview remains unclear. We describe a rare case of a duodenal gastric-type neoplasm in a 50-year-old woman. She visited her primary care doctor with complaints of upper abdominal pain, tarry stools, and shortness of breath on exertion. She was admitted owing to a stalked polyp with erosion and hemorrhage in the descending part of the duodenum. Endoscopic mucosal resection (EMR) was performed on the polyp. Histologically, the resected polyp was a lipomatous lesion in the submucosal layer, composed of mature adipose tissues. Scattered irregular lobules of Brunner's gland-like structures with well-preserved construction but mildly enlarged nuclei and occasional conspicuous nucleoli of the constituent cells were observed. The resection margin was negative. EMR findings of the duodenal polyp showed a gastric epithelial tumor within a lipoma, a rare histological type that has not been reported previously. This tumor may be classified as a "neoplasm with uncertain malignant potential" in a lipoma, an intermediate category between adenoma and invasive adenocarcinoma. There is no consensus on treatment, and careful follow-up is recommended. This is the first report of a duodenal gastric-type neoplasm with uncertain malignant potential in a lipoma.

Herpes Simplex Esophageal Ulcer in an Immunocompetent Adult With Hematemesis.

A 61-year-old man with pharyngitis and stomatitis for 2 months was admitted due to difficulty in swallowing solids. Laryngoscopy demonstrated multiple laryngopharyngeal ulcers with exudative laryngopharyngitis (Figure A). He had elevated IgM antibody for herpes simplex virus (HSV). Acyclovir (750 mg daily) was orally administered soon after admission. After 2 days, he had hematemesis and tarry stool. Hemoglobin level decreased to 4.9 g/dL with hemorrhagic shock and required blood transfusion. Urgent upper gastrointestinal endoscopy showed multiple erosions and ulcers with spurting bleeding in the upper esophagus (Figure B).

Diagnostic Challenge in A Young Male Patient Presenting with Feeling of Upper Abdominal Lump and Recent Onset Black Tarry Stool

Diagnostic Challenge in A Young Male Patient Presenting with Feeling of Upper Abdominal Lump and Recent Onset Black Tarry Stool

Manifestation of leech infestation as severe gastrointestinal bleeding in a 3-year-old boy: a case report and review of the literature

Leeches are a class of hermaphroditic parasites that can attach to various body parts and start sucking blood. Gastrointestinal (GI) bleeding due to leeches is a rare phenomenon that is more common in less developed countries. Common symptoms include melena, hematemesis, pallor, weakness, and fatigue. Due to the similar symptoms of this issue to the main differential diagnoses of GI bleeding in pediatrics, such as diarrhea, constipation, diverticulitis, esophagitis, and anal fissures, it is challenging to differentiate it from the rest. We present a three-year-old boy who was transferred to our center with hematemesis, tarry stool, and a drop in hemoglobin level. He finally was diagnosed with a leech in his stomach. In less developed counties, the inability to reach safe drinking water, swim in lakes or springs, and inadequate awareness of public health information among individuals can be risk factors for leech infestation.

Operative material left in the abdominal cavity during surgical procedures.

The authors present seven cases of surgical drape left in body cavities during surgical operations. The most common symptoms reported by these patients are analysed and the consequences of leaving a foreign body in the abdominal cavity are summarised. In the majority of cases, the time elapsed from the operation to the detection of the foreign body was an average of 17 months. In one case, the foreign body remained in the abdomen for 7 years. The most common symptom reported by patients was abdominal pain. Some patients also developed wound healing disorders with leakage of pus from the wound, fever, nausea and vomiting, weight loss or intermittent tarry stools. In most cases, the foreign body required reoperation to remove it. Major surgery with stoma creation or bowel resection was required. In one case described, the consequence of leaving a surgical drape was the death of the patient. In three cases, there was spontaneous expulsion of the surgical sling by the patient by natural means.

S2529 Threading the Needle: Safely Removing Double-Edged Sharp Foreign Bodies

Introduction: Foreign body ingestion is a common phenomenon among individuals with psychiatric disorders, alcohol intoxication, developmental delay, or in incarcerated individuals. Most ingested foreign bodies pass spontaneously without complication but 10-20% require endoscopic intervention. Impaction, perforation, or obstruction often occurs at angulations or narrowing. Early recognition and urgent upper endoscopy (EGD) for foreign body removal may improve clinical outcomes. Here we present a case of melena and abdominal pain secondary to foreign body ingestion. Case Description/Methods: An 83-year-old male with a past medical history of pulmonary embolism on warfarin, alcohol use disorder, and anxiety presented after 2 black, tarry stools and light-headedness. On admission his vitals were stable and labs were notable for an International normalized ratio (INR) of 3.3 and a Hemoglobin (Hgb) of 12.3g/dL. He was treated with Vitamin K and intravenous pantoprazole twice daily. The next day his Hgb was found to be 8.2g/dL and an EGD was performed revealing antral ulcerations and a 3.5cm sewing needle and thread with both ends penetrating opposite walls of the antrum (Figure A, B). Multiple attempts at removing the needle with rat tooth and jumbo forceps were unsuccessful and the procedure was aborted. Follow up computed tomography imaging did not reveal perigastric fluid or pneumoperitoneum post-procedurally. On hospital day 3 a repeat EGD was attempted and showed the needle was only perforating mucosa along one side of the gastric body; it was able to be removed via overtube and raptor device (Figure C). Discussion: Endoscopic removal of sharp ingested foreign bodies can prove to be challenging. Several risk factors including age and duration of impaction are associated with adverse events, such as laceration, perforation, and ulcers. Double pointed/sharp objects are particularly challenging given they are harder to grasp and maneuver. That, in addition to luminal contractions, likely contributed to the difficulty retrieving the needle in this case despite using recommended tools. Had the second endoscopic retrieval attempt failed, the patient would have required surgical evaluation. Overall, the benefit of further endoscopic retrieval attempts versus the risk of perforation from the foreign body or complications from the procedure itself must be weighed case by case.Figure 1.: Endoscopic Evaluation of Patient with Foreign Body A – Foreign body wedged between opposite ends of pylorus (Highlighted by top arrow) B – Full view of sewing needle with thread in gastric antrum C – Sewing needle after removal.

S3521 A Rare Case of Duodenal Leiomyoma

Introduction: Only 1–5% of gastrointestinal neoplasms are found in the small intestine. Adenocarcinomas, lymphomas, and neuroendocrine tumors are the most common malignant tumors seen in the small intestine, while gastrointestinal stromal tumors, leiomyosarcomas, and leiomyomas are uncommon. The jejunum, ileum, and duodenum are the three most common locations for leiomyomas. We are presenting a rare case of a female with duodenal leiomyoma. Case Description/Methods: A 70-year-old female presented to the hospital with complaints of fatigue and weakness. Laboratory evaluation showed iron deficiency anemia with hemoglobin 7.5g/dl and hematocrit 25.4%. The patient reported an episode of black tarry stool about a week before the presentation. The patient received one packed red blood cell transfusion, and upper gastrointestinal endoscopy (EGD) was performed to evaluate anemia. EGD revealed non-erosive gastritis and gastric erosions without any current or recent bleeding stigmata. A single large pedunculated polyp was found in the duodenum's first portion, extending into the second portion of the duodenum(a). Biopsy from the polyp revealed submucosal leiomyoma without any evidence of dysplasia or malignancy(b). The next day, a colonoscopy showed significant diverticulosis and non-bleeding internal hemorrhoids. The patient remained hemodynamically stable and was discharged home the next day. The patient presented about a month later with iron deficiency anemia again. Repeat EGD and colonoscopy performed this time showed no obvious source of bleeding. We also conducted a pill cam study, which also came back negative. (Figure) Discussion: It is unusual for leiomyomas, which are benign smooth muscle tumors, to develop in the gastrointestinal tract. Males are more likely than females to be diagnosed with duodenal leiomyomas in the 6th and 7th decades of life. The origin and pathology of these tumors in the gastrointestinal tract remain a mystery. Leiomyomas of the duodenum seldom cause symptoms. When a duodenal tumor is larger, it might cause more severe symptoms, such as bleeding, nausea, vomiting, and weakness. In our patient described above, we believe the leiomyoma caused bleeding, as no other definitive source of bleeding was found even after a complete evaluation. The case describes a rare duodenal tumor with an unusual presentation.Figure 1.: a. EGD showing a large pedunculated polyp extending from the first portion to the second portion of the duodenum. b. H&E stain showing submucosal benign spindle cell proliferation. No atypia, pleomorphism or mitotic activity.

S1790 Portal Biliopathy in a Patient Who Underwent a Whipple Procedure With Portal Vein Reconstruction

Introduction: Portal biliopathy is a condition that is defined as abnormalities in the biliary tract due to portal hypertension. Some patients may present with abdominal pain, fever, jaundice, or pruritis. Rarely, portal hypertension secondary to portal vein abnormalities cause peri-biliary varices. We report a case of a patient with a peri-biliary variceal bleed due to portal hypertension from acquired portal vein stenosis. Case Description/Methods: A 59-year-old female with a past medical history of pancreatic ductal adenocarcinoma presented to the hospital with 5 days of Black tarry stools. Two years prior, she was diagnosed with pancreatic head adenocarcinoma and underwent a pancreaticoduodenectomy with portal vein reconstruction. Subsequent CT scans demonstrated post surgical portal vein stenosis. On admission, she denied fevers, abdominal pain, or hematemesis. Labs were notable for a hemoglobin of 5.7 g/dl, INR of 1.6, and bilirubin of 1.0 mg/dl. Physical exam demonstrated an abdominal fluid wave and melena on digital rectal exam. CT abdomen showed post Whipple anatomy, severe portal vein stenosis, large volume ascites, and extensive upper abdominal collaterals including peri-portal and peri-biliary varices. Upper endoscopy revealed blood in the afferent jejunal limb. Bleeding was found to be originating from the choledochojejunostomy. Multiple large visible vessels with stigmata of recent bleeding were visualized within the common bile duct. A single hemostatic clip was placed on one of the vessels, resulting in increased bleeding. Hemostasis was achieved with cyanoacrylate injection. The patient was transferred to the interventional radiology suite, where she underwent portal venography confirming severe stenosis of the porto-mesenteric confluence. Interventional radiology performed portal vein balloon dilation and stent placement. The patient had no further bleeding following the procedure (Figure). Discussion: Bleeding from peri-biliary varices is a rare cause of upper GI bleeding. In this case, non cirrhotic portal hypertension from acquired portal vein stenosis after pancreaticoduodenectomy led to clinically significant gastrointestinal bleeding. Portal biliopathy is an uncommon and late presentation in patients with extrahepatic portal vein obstruction. In many cases, patients present with signs and symptoms of biliary obstruction. Treatment of PB should involve a multidisciplinary discussion among various subspecialties including gastroenterology, interventional radiology, and hepatobiliary surgery.Figure 1.: A. Choledochojejunostomy with visible varices. B. Hemostatic clip placement with subsequent bleeding. C. Injection of cyanoacrylate glue with hemostasis. D. Portal venography demonstrating portal vein stenosis at the porto-mesenteric confluence.

Lower Gastrointestinal Bleed Playing Hide and Seek.

A 13-year-old adolescent male presented with an episode of rectal bleed. He has had five such episodes in the past year where he witnessed black tarry stools mixed with fresh blood, painless, not associated with fever or hematemesis. Clinical examination revealed pallor and a soft, non-tender abdomen. Vitals were stable. Blood investigations revealed haemoglobin of 102g/L, WBC count of 10 X 109/L and platelet count of 165 × 109/L. The clotting screen was normal. Upper GI endoscopy and colonoscopy revealed no abnormality. The patient underwent Tc-99m pertechnetate scintigraphy to look for Meckel's Diverticulum in view of painless lower GI bleed.

S2680 A Case Report of Radiation-Induced Hemorrhagic Gastritis Successfully Treated With Bevacizumab After Failing Endoscopic and Hyperbaric Oxygen Therapies

Introduction: Radiation induced gastritis is an uncommon complication of radiation therapy. Therapies that have been attempted for this pathology include argon plasma coagulation (APC), oral prednisolone, radio-frequency ablation, hyperbaric oxygen, and surgical intervention. We present a case of radiation induced gastritis complicated by transfusion dependent anemia and melena that was successfully treated with Bevacizumab Case Description/Methods: This patient is a 65-year-old male with medical history significant for esophageal adenocarcinoma in 2014 treated with chemoradiation and subsequently esophagectomy. Several years after therapy, he started to report tarry stools, and was found to be anemic with iron studies consistent with severe iron deficiency. He had an esophagogastroduodenoscopy (EGD) that showed severe distal esophagitis. Follow up colonoscopy was unremarkable. He was started on omeprazole and iron infusions, but he needed frequent blood transfusions. He had a repeat EGD that showed diffuse erythema, friability and oozing of the gastric mucosa. This was treated with APC. A biopsy showed a single focus of intravascular fibrin thrombus concerning for radiation induced gastritis. He had transient resolution of his melena, but then had recurrence one month later. He underwent further endoscopies with thermal therapy, which failed to control his bleeding. Hyperbaric oxygen therapy was trialed. After completing multiple sessions, his symptoms persisted. Surgical evaluation was recommended but the patient declined. The patient was then started on anti-angiogenic therapy with Bevacizumab 5mg/kg every 2 weeks and his melena resolved, requiring less transfusions. He stopped taking Bevacizumab two months later as he was scheduled for hernia repair, and he had recurrence of his melena and worsening anemia post-operatively. After being restarted on Bevacizumab, his melena resolved Discussion: Hemorrhagic radiation gastritis is mainly due to mucosal injury and telangiectatic vessels from angiogenesis secondary to endothelial proliferation. Bevacizumab is an anti-vascular endothelial growth factor humanized monoclonal antibody that inhibits angiogenesis. It has been shown to be effective in treatment of hereditary hemorrhagic telangiectasia, gastric antral vascular ectasia, and small bowel angioectasia. It has also been reported to treat hemorrhagic gastritis in a few case studies. Our case demonstrates that Bevacizumab is a promising pharmacologic treatment for radiation induced hemorrhagic gastritis.