Venous Engorgement Research Articles

Haemorrhoids among Patients Visiting the Department of Surgery in a Tertiary Care Military Hospital of Nepal: An Observational Study

Introduction: Haemorrhoids is a common issue in the anorectal region and involves venous engorgement in the region. It greatly diminishes the overall quality of life of affected individuals by disrupting their physical and mental health. This descriptive cross-sectional study aimed to ascertain the prevalence of haemorrhoids and the associated risk factors among patients visiting a tertiary care center's surgery department. Methods: A descriptive cross-sectional study was conducted in the Department of Surgery of a tertiary care center from July 2023 to November 2023 after obtaining ethical approval. Convenience sampling method was used. The total sample size included in the study was 385. The data was analyzed in IBM SPSS Statistics software. Point estimate was calculated at 95% confidence interval. Results: Among 385 patients included in the study, haemorrhoids was prevalent in 53 (13.76%, 95% CI: 8.76%-18.76%). Internal haemorrhoids was most prevalent with 30 (56.60%) cases. 22 (41.51%) cases presented with Grade 1 haemorrhoids. The most prevalent symptoms were bleeding in 29 (54.72%) cases, perianal pain in 25 (47.17%) cases, itching in 28 (33.96%) cases and burning sensationin 15 (28.30%) cases. Conclusions: The prevalence of haemorrhoids in our center was found to be higher as compared to similar studies done in Southeast Asian region but similar with studies done in other region.

Exploration of the Conditions for Occurrence of Photoplethysmographic Signal Inversion above the Dorsalis Pedis Artery.

Inversion of the photoplethysmographic (PPG) signal is a rarely reported case. This signal anomaly can have implications for PPG-based cardiovascular assessments. The conditions for PPG signal inversion in the vicinity of the dorsalis pedis (DPA) artery of the foot were investigated. Wireless multi-wavelength PPG sensing with skin-probe contact pressure and local skin temperature were studied at different sensor positions, and the occurrence of inversion (OOI) was investigated. Twelve healthy adult volunteers were studied over four LED wavelengths at three levels of contact pressure for 11 probe positions. A novel algorithm quantified the proportion of inverted samples with respect to the abovementioned variables. Our algorithm classifying inverted vs. non-inverted pulses achieved 98.3% accuracy. Ten of the participants had at least one inverted signal identified. The impact of interindividual variation on inversion prevalence was large, but different LEDs, relative position to the DPA and sensor contact pressure also affected OOI. Skin surface and room temperatures showed no impact on OOI. Lateral measurements showed 39.6% more inversion at maximum compared to minimum contact pressure. Mechanical capillary bed variations and arterial reflections during venous engorgement are considered viable explanations for our observations. These findings motivate an expanded study of the occurrence of PPG signal inversion.

Mechanical Thrombectomy in Cerebral Venous Thrombosis Caused by Spontaneous Intracranial Hypotension: A Case Report with Novel Pathological Findings of Fibrin/Platelet-predominant Thrombus

This case report presents pathological findings in a rare case of cerebral venous thrombosis (CVT) caused by spontaneous intracranial hypotension (SIH) that was treated successfully with mechanical thrombectomy. The etiologies and prognosis of CVT vary, and CVT resulting from SIH is particularly uncommon and challenging to diagnose and manage. In this case, magnetic resonance imaging revealed signs consistent with both SIH and CVT, which contributed to the patient’s worsening weakness. The patient was treated with a combination of endovascular thrombectomy and epidural blood patch, followed by anticoagulation therapy, and recovered without any complications. A pathological analysis of the retrieved thrombus using hematoxylin and eosin staining showed a high proportion of fibrin and platelets, which could shed light on the mechanism of CVT induced by SIH under conditions of low blood flow due to venous engorgement.

Tight Application of a Surgical Tourniquet Prior to Inflation Increases Venous Pressure In the Upper Limb; Potentially Resulting in Increased Blood Loss and Poorer Visibility

Tourniquets are commonly used in extremity surgery to help provide a bloodless operative field to improve visibility and reduce length of procedures. With the development of WALANT (wide awake, local anaesthetic, no tourniquet) techniques, many surgeons undertake surgery without tourniquet inflation. The correct technique of pneumatic tourniquet application is poorly understood by healthcare staff. The application of a tight tourniquet when applied for optional use or use for only a portion of a procedure, rather than for inflation throughout can cause venous engorgement of an extremity leading to increased blood loss and reduced operative field visualisation thereby discouraging surgeons from persevering with WALANT strategies. To determine the effect of tourniquet application tension on limb volume prior to skin incision. 30 volunteers had the volume of their non-dominant forearm measured post-inflation of a surgical tourniquet using two different application techniques. Tight application was defined as the tourniquet fastened using a dynamometer to a tension of 100N. Loose application was defined as the tourniquet fastened using a dynamometer to a tension of 50N. The tourniquet was then inflated to 200mmHg after both application techniques. Exsanguination was performed by elevation of the arm for 1min prior to tourniquet inflation. At 5min the forearm volume was measured using a volume displacement technique. 93% of participants (28/30) had a higher volume of water displaced when the tourniquet was applied tightly. The mean difference between the loose and tight applications was 30.06mls. The increase in volume in tightly applied tourniquets is believed to result from increased intravascular volume. This increase in blood volume can lead to increased intra-operative blood loss and poor intra-operative visualisation when operating without tourniquet inflation. Loose application of the tourniquet pre-inflation appears to prevent sequestration of venous blood in the limb, therefore decreasing operative blood loss and improving view for operating. Level 1; Symptom Prevalence Study.

Combined Central Retinal Artery and Vein Occlusion-like Manifestations with Aplastic Anemia: Unveiling Pathophysiological Insights

Purpose: To report the association of a combined central artery and vein occlusion (CCRAVO)-like pattern with aplastic anemia and discuss the pathophysiology associated with ophthalmologic examinations. Methods: We report a female patient with aplastic anemia who presented with retinal hemorrhage, blurred optic disc margins, retinal whitening, peripapillary subretinal fluid, and venous engorgement. The authors described the evolution of ophthalmologic lesions in correlation with improvements in systemic conditions. Results: We discuss and correlate the ophthalmological findings of this patient (optic disc edema, vascular engorgement, subretinal fluid, among others) with the pathophysiology of Aplastic Anemia based on current literature. Conclusion: These findings provide a better understanding of the pathophysiology of this rare disease. In certain cases, ophthalmologic symptoms can be the first presentation, underscoring the importance of reporting ocular findings for the recognition of this disease, which entails significant systemic involvement.

Significance of upper cervical epidural venous engorgement on head computed tomography in the initial diagnosis of spontaneous intracranial hypotension: patient series.

Spontaneous intracranial hypotension (SIH) is a rare condition characterized by positional headache, for which contrast-enhanced magnetic resonance imaging (MRI) is the preferred diagnostic method. Although MRI reveals characteristic findings, head computed tomography (CT) is usually the first diagnostic step, but identifying features of SIH on CT is often difficult. This study was specifically designed to evaluate the utility of head CT in detecting upper cervical epidural venous engorgement as a sign of SIH. Of 24 patients with SIH diagnosed between March 2011 and May 2023, 10 did not undergo upper cervical CT. In the remaining 14 patients, engorgement of the upper cervical epidural venous plexus was observed. CT detection rates were consistent with MRI for spinal fluid accumulation or dural thickening. After treatment, in 92.9% of patients, the thickness of the epidural venous plexus decreased statistically significantly from 4.8 ± 1.3 mm to 3.6 ± 1.2 mm. This study suggests that upper cervical spine CT focused on epidural venous engorgement may be helpful in the initial diagnosis of SIH and may complement conventional MRI evaluation. Extending CT imaging to the upper cervical spine will improve the diagnostic accuracy of patients with positional headaches suspected to be SIH.

An Adolescent Case of Unilateral Papillophlebitis Treated with Intravitreal Bevacizumab

Purpose: To report a case of papillophlebitis treated with an intravitreal bevacizumab injection in an adolescent patient.Case summary: A 15-year-old female with no medical history presented with a 3-day history of blurred vision and a floating sensation. The initial visual acuity (VA) was 0.0 logarithm of minimal angle of resolution (logMAR) in the left eye. A fundus examination revealed a blurry disc margin, peripapillary hemorrhage, and venous engorgement. Optical coherence tomography indicated subretinal fluid (SRF) accumulation. Both color vision and pupillary reactions were normal in bilateral eyes. Blood tests revealed no significant abnormalities. Brain magnetic resonance imaging (MRI) showed mild focal papillitis, but the patient did not report eye movement pain or discomfort. The diagnosis was papillophlebitis; however, high-dose steroid treatment was not initiated due to the absence of a significant decrease in VA. A single injection of intravitreal bevacizumab was administered to address the SRF. At the 9-month follow-up, VA remained at 0.0 logMAR, and the retina demonstrated anatomical stabilization after complete absorption of the SRF without recurrence.Conclusions: Papillophlebitis can manifest during adolescence. Treatment of a 15-year-old patient with intravitreal bevacizumab obviated the need for high-dose steroid therapy and produced favorable outcomes, including preservation of VA and anatomical stabilization of the retina.

Spinal stenosis secondary to engorged Batson’s plexus in pregnancy

Introduction: Lumbar venous plexus engorgement is a rare condition. It can be caused by compression or thrombosis of abdominal venous structures. Proper diagnosis requires attention to radiologic details in order to rule out other disc pathologies. Treatment of pregnancy-induced venous plexus engorgement includes positional maneuvers to prevent obstruction of venous return. Complete resolution of symptoms is achieved through delivery. Case Report: We present the case of a patient with recurrent lower extremity weakness and pain secondary to spinal stenosis caused by epidural venous plexus engorgement in multiple separate pregnancies. Conclusion: This case highlights a unique recurrent presentation with earlier onset and increasingly more severe symptoms with each subsequent pregnancy.

Papillophlebitis: A case series of a controversial diagnosis

Aims/Purpose: Papillophlebitis refers to an isolated optic disc oedema with venous engorgement in asymptomatic patients as defined by Walsh and Hoyt in 1969. We report a case series of 3 patients who developed papillophlebitis related to SARS‐CoV‐2 vaccination, type 2 diabetes or idiopathic. A literature review was also performed.Methods: Observational case report of 3 patients and a review of the literature covering papillophlebitis cases was performed using Pubmed, Embase and Web of Science. Cases presenting with visual loss, RAPD, visual field defect or retinal vascular occlusion were excluded.Results: We report the case of 3 patients who did not have any visual complain and presented a unilateral optic disc oedema found by chance. The 1st patient was 33 year‐old and her past medical history was significant for SARS‐Cov‐2 vaccination. The 2nd patient was 6 year‐old and in general good health. The 3rd patient was known for a type 2 diabetes with no complications. For all patients, the visual acuity was 1.0, the intraocular pressure was normal, the anterior segment was quiet and the fundus showed a unilateral optic disc oedema without any haemorrhage. The RNFL OCT confirmed the presence of an optic disc oedema. The visual field was normal. An extensive blood test was negative for auto‐immune, inflammatory and vascular disease. In our patients, the optic disc oedema decreased spontaneously after a couple of months without any treatment and they retain 1.0 vision. A diagnosis of papillophlebitis was made. In the literature, the term papillophlebitis is not well‐defined and controversial. No treatment is required, and the condition resolved spontaneously over time. The visual prognosis is excellent as patients keep a 1.0 vision with a normal visual function. No recurrence has been reported.Conclusions: Papillophlebitis is diagnosed after ruling out any inflammatory, infectious or auto‐immune disease in asymptomatic patients who present a spontaneous recovery without any treatment as reported in our cases.

Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System.

The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection. A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts. One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak. This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.

Comparison of Color Fundus Photography and Multicolor Fundus Imaging for Detection of Lesions in Diabetic Retinopathy and Retinal Vein Occlusion.

To evaluate the agreement between conventional fundus photography (CFP) and multicolor fundus imaging (MFI) for the detection of lesions of diabetic retinopathy (DR) and retinal vein occlusion (RVO). Cross-sectional analysis of eyes with DR or RVO who underwent CFP and MFI. All images were independently analyzed by two observers (O1 and O2), and the evaluated lesions were classified as "present" or "absent". Then, a paired comparison between both exams of the same eye was performed, to assess which made it easier to detect the lesions. Considering DR, the agreement was substantial for cotton wool spots and photocoagulation scars for both observers (O1: κ=0.75 and κ=0.67; O2: κ=0.71 and κ=0.64, respectively) and for hard exudates for O1 (κ=0.80). These lesions were detected more frequently on MFI. Regarding RVO, the agreement was considered substantial for venous sheathing by O1 (κ=0.64) and moderate for optociliary shunts by O2 (κ=0.60). Optociliary shunts were detected more frequently in CPF by both observers and venous sheathing on MFI by O1. For microaneurysms, retinal hemorrhages, retinal neovascularization, and proliferative membranes, in DR, and retinal hemorrhages, venous engorgement, and retinal neovascularization in RVO, the agreement was almost perfect (κ>0.82). In the paired analysis, both observers considered that, in DR, microaneurysms and retinal hemorrhages were easier to detect on CFP and that retinal neovascularization, cotton wool spots, and photocoagulation scars were easier to identify on MFI. Regarding RVO, optocilliary shunts were easier to identify on CFP and venous engorgement on MFI. The agreement of MFI and CFP was substantial to almost perfect for most lesions. MFI seems better to detect cotton wool spots and photocoagulations scars in DR and venous sheathing in RVO. Optocilliary shunts seem easier to detect on CFP.

Clinicoradiologic Criteria for the Diagnosis of Stroke-like Episodes in MELAS.

Stroke-like episodes (SLEs) in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome are often misdiagnosed as acute ischemic stroke (AIS). We aimed to determine unique clinical and neuroimaging features for SLEs and formulate diagnostic criteria. We retrospectively identified patients with MELAS admitted for SLEs between January 2012 and December 2021. Clinical features and imaging findings were compared with a cohort of patients who presented with AIS and similar lesion topography. A set of criteria was formulated and then tested by a blinded rater to evaluate diagnostic performance. Eleven MELAS patients with 17 SLE and 21 AISs were included. Patients with SLEs were younger (median 45 [37-60] vs 77 [68-82] years, p < 0.01) and had a lower body mass index (18 ± 2.6 vs 29 ± 4, p < 0.01), more commonly reported hearing loss (91% vs 5%, p < 0.01), and more commonly presented with headache and/or seizures (41% vs 0%, p < 0.01). The earliest neuroimaging test performed at presentation was uniformly a noncontrast CT. Two main patterns of lesion topography with a stereotypical spatiotemporal evolution were identified-an anterior pattern (7/21, 41%) starting at the temporal operculum and spreading to the peripheral frontal cortex and a posterior pattern (10/21, 59%) starting at the cuneus/precuneus and spreading to the lateral occipital and parietal cortex. Other distinguishing features for SLEs vs AIS were cerebellar atrophy (91% vs 19%, p < 0.01), previous cortical lesions with typical SLE distribution (46% vs 9%, p = 0.03), acute lesion tissue hyperemia and venous engorgement on CT angiography (CTA) (45% vs 0%, p < 0.01), and no large vessel occlusion on CTA (0% vs 100%, p < 0.01). Based on these clinicoradiologic features, a set of diagnostic criteria were constructed for possible SLE (sensitivity 100%, specificity 81%, AUC 0.905) and probable SLE (sensitivity 88%, specificity 95%, AUC 0.917). Clinicoradiologic criteria based on simple anamnesis and a CT scan at presentation can accurately diagnose SLE and lead to early administration of appropriate therapy. This study provides Class III evidence that an algorithm using clinical and imaging features can differentiate stroke-like episodes due to MELAS from acute ischemic strokes.

P400 WHEN COMMON VIRAL SYMPTOMS HIDE A PERFECT STORM: A CASE REPORT

Abstract A 38 years old woman without any cardiovascular risk was admitted to the Emergency Room of our Hospital symptomatic for chest pain and dyspnoea. She referred a recent holiday in Tunisia; she was excellent health until a week before when she developed flue–like symptoms, such as fever, fatigue, abdominal pain, diarrhea and myalgia, like all the family members; the night before the access to the ER, she suffered from weakness of breath. Physical examination revealed venous engorgement and sinus tachycardia with a rate of 102 bpm, blood pressure was about 85/50 mmHg, oxygen saturation in 3L nasal cannula was 92%. The EKG showed a sinus tachycardia without any ST elevation or depression and generalized low voltage. A transthoracic echocardiography revealed circumferential pericardial effusion (3,5 cm) and both right atrium and right ventricle collapse in the setting of cardiac tamponade; EF was 35% (GLS=6%). Our first clinical suspicion was viral pericarditis with pericardial effusion (early cardiac tamponade), in consideration of the anamnestic data, the holiday in Tunisia and the general symptoms. However, an urgent pericardiocentesis was performed and one liter of sero–sanguineous pericardial fluid (exudate) was drained; therefore, there was an immediate haemodynamic improvement. A pigtail was placed using the Seldinger technique. While the first sample of cytology on sero–sanguineus pericardial fluid was negative, the second sample resulted positive for malignancy. Chest CT showed bilateral pleural effusion and a mass which was compatible with a lung cancer. Lung nodule biopsy revealed a lung adenocarcinoma. Immunohistochemistry (IHC) and molecular testing for epidermal growth factor receptor (EGFR) were positive. The patient was affected by metastatic non small cell lung cancer with EGFR mutation, which was responsive to Osimertinib. Three days later, another echo was performed showing almost complete resolution of pericardial effusion and normal LV function (EF= 55%). The patient was transferred to the Oncology Department and then discharged from the Hospital. Before starting Osimertinib, she was suggested to undergo a baseline cardiovascular stratification, EKG and transthoracic echocardiogram, three–monthly echocardiography surveillance with monitoring of GLS (which guides the management of potentially cardiotoxic drugs); close monitoring of magnesium levels is also recommended to minimize the risk of QTc prolongation.

Glial, Neuronal, Vascular, Retinal Pigment Epithelium, and Inflammatory Cell Damage in a New Western Diet–Induced Primate Model of Diabetic Retinopathy

This study investigated retinal changes in a Western diet (WD)-induced nonhuman primate model of type 2 diabetes. Rhesus nonhuman primates, aged 15 to 17 years, were fed a high-fat diet (n=7) for >5 years with the aim of reflecting the traditional WD. Age-matched controls (n=6) were fed a standard laboratory primate diet. Retinal fundus, optical coherence tomography, autofluorescence imaging, and fluorescein angiography were undertaken before euthanasia. To assess diabetic retinopathy (DR), eyes were examined using trypsin digests, lipofuscin autofluorescence, and multimarker immunofluorescence on cross-sections and whole mounts. Retinal imaging showed venous engorgement and tortuosity, aneurysms, macular exudates, dot and blot hemorrhages, and a marked increase in fundus autofluorescence. Post-mortem changes included the following: decreased CD31 blood vessel density (P<0.05); increased acellular capillaries (P<0.05); increased density of ionized calcium-binding adaptor molecule expressing amoeboid microglia/macrophage; loss of regular distribution in stratum and spacing typical of ramified microglia; and increased immunoreactivity of aquaporin 4 and glial fibrillary acidic protein (P<0.05). Rhodopsin immunoreactivity (P<0.05) in rods and neuronal nuclei antibody-positive neuronal density of 50% (P<0.05), however, were decreased. This is the first report of a primate model of DR solely induced by a WD and that replicates key features of human DR.

A Classification Proposal for Spinal Vascular Lesions.

A Classification Proposal for Spinal Vascular Lesions.

Does deep cerebral venous engorgement contribute to non-hydrocephalic pineal cysts becoming symptomatic? Some missing links.

This scientific commentary refers to 'Physiological alterations of pineal recess crowding in symptomatic non-hydrocephalic pineal cysts' by Eide et al. (https://doi.org/10.1093/braincomms/fcad078).

Imaging the Cerebral Veins in Pediatric Patients: Beyond Dural Venous Sinus Thrombosis.

The range of intracranial venous anomalies in children differs from that in adults. As a commonly encountered highly morbid disease, sinovenous thrombosis has been discussed extensively in the literature, and the associated imaging considerations are similar in pediatric and adult patients. The authors shift the focus to less frequently discussed cerebral venous diseases in pediatric patients. First, the practical embryology pertinent to malformations, syndromes, and variants such as vein of Galen aneurysmal malformation, Sturge-Weber syndrome, and developmental venous anomalies are discussed. Second, anatomic considerations that are applicable to neuroimaging in pediatric patients with cerebral venous anomalies are reviewed. In the discussion of anatomy, special attention is given to the medullary venous system that serves the cerebral white matter, superficial cortical veins (tributaries of the dural venous sinuses), and bridging veins, which carry blood from the superficial cortical veins through the potential subdural space into the dural venous sinuses. Third, the selection of imaging modalities (US, CT and CT venography, and MRI) is addressed, and various MR venographic pulse sequences (time-of-flight, phase-contrast, and contrast-enhanced sequences) are compared. Finally, a broad variety of congenital and acquired superficial and deep venous diseases in children are reviewed, with emphasis on less frequently discussed entities involving the medullary (eg, deep medullary venous engorgement and thrombosis, periventricular hemorrhagic venous infarction due to germinal matrix hemorrhage), cortical (eg, cortical venous thrombosis), and bridging (eg, acute and chronic manifestations of injury in abusive head trauma) veins, as well as the deep veins and dural venous sinuses (eg, varix). © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Pathogenesis of Terson syndrome.

The aim of this experimental study was to investigate the pathogenesis of Terson syndrome (TS), which currently is controversial. The central retinal artery (in 39 orbits), posterior ciliary arteries (in 8 orbits), and central retinal vein (CRV in 21 orbits) were occluded in rhesus monkeys by exposing them to lateral orbitotomy. Fundus examination and fluorescein fundus angiography were performed before and immediately after cutting the vessels and serially thereafter during the follow-up period. The rationale of the experimental study design is discussed. In eyes with central retinal artery occlusion, retinal hemorrhages were seen soon after the procedure in 7 eyes, and on follow-up in a total of 15 eyes. In posterior ciliary artery occlusion, retinal hemorrhages were seen soon after the procedure in one eye, and on follow-up in a total of three eyes. In eyes with CRV, all eyes had extensive scattered retinal hemorrhages. The findings of this experimental study, and my basic, experimental, and comprehensive clinical studies on CRVO, suggest the following concept of the pathogenesis of TS: Compression of the CRV plays a crucial role in the development of TS. The CRV is compressed, as it lies in the subarachnoid space of the optic nerve sheath, by raised cerebrospinal fluid pressure and/or accumulated blood. venous stasis and raised venous pressure in the retinal veins, leading to venous engorgement, rupture of the retinal capillaries. retinal hemorrhages. The clinical importance of compression of the CRV and not occlusion of CRV in TS is that optic nerve sheath decompression by opening it and releasing the blood and raised cerebrospinal fluid (CSF) pressure, would result in immediate decompressing of the CRV in the subarachnoid space and restoration of normal circulation and prevent visual loss.

S1949 An Unusual Case of Chronic Pancreatitis Presenting With Recurrent Obscure Gastrointestinal Bleeding

Introduction: Chronic pancreatitis (CP) is a sequela of repeated pancreatic injury resulting in loss of exocrine and endocrine function of the pancreas. In most cases, CP presents with chronic abdominal pain and patients usually have either clinical and radiological features of CP, with gastrointestinal bleeding (GIB) as a very rare occurrence. Herein is a presentation of recurrent obscure GIB caused by chronic pancreatitis. Case Description/Methods: A 48-year-old male with a prior history of PUD and recurrent GIB episodes for several years presents with dark red bleeding per rectum for two days. Of note, the patient had undergone several endoscopies and the most recent endoscopies done six months prior were all unremarkable. He denied hematemesis, NSAIDs, or anticoagulant use. Denied liver or pancreatic disease but endorsed a prior history of moderate alcohol intake. Physical examination was unremarkable except for tachycardia and epigastric tenderness. He was mildly anemic with leukocytosis. The abdominal and pelvic CT scan was unremarkable. EGD revealed a small gastric oozing site (Figure) suspected to be an AVM or dieulafoy's lesion and clipped. He continued to have a frank bloody stool and developed hemorrhagic shock requiring multiple transfusions and vasopressors. Findings on two additional EGDs were unremarkable. He had mesenteric angiography performed with ligation of the gastroduodenal artery empirically. Despite the intervention, he continued to bleed. Abdominal CTA (Figure) noted active extravasation in the 2nd segment of the duodenum. Explorative laparotomy revealed an edematous head and uncinate portion of the pancreas with venous engorgement. There was erosion into the duodenum with acute hemorrhage (Figure). A duodenotomy and Roux-en-y (duodenojejunostomy and jejunojejunostomy) were performed. On account of the above findings, a tissue biopsy was not obtained. Following surgery, he remained hemodynamically stable and got discharged. Discussion: Massive obscure GIB due to complications of pancreatitis rarely does occur. A few cases reported are due to complications resulting from hemosuccus pancreaticus, pseudoaneurysm from a vascular supply, or erosion into adjacent viscus in the setting of known pancreatitis. Our patient represents an unusual presentation in which his recurrent obscure massive GI bleeding was the initial presentation of CP. We present this case to broaden our knowledge that obscure GI bleeding can be a complication of CP and the only manifestation of the disease.Figure 1.: The image on the left shows an EGD with the gastric oozing site with clips, and the middle image shows CTA with extravasation in the second segment of the duodenum. The image on the right shows the posterior aspect of the head of the pancreas, the uncinate, and venous engorgement.

Spontaneous Thoracic Spinal Epidural Hematoma During Pregnancy

Spontaneous Thoracic Spinal Epidural Hematoma During Pregnancy