A rare case of gastro-intestinal stromal tumor presented with hematemesis and severe anemia from a low and middle-income country

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with varied clinical presentations. This case report highlights the significance of recognizing atypical GIST presentations, such as hematemesis, especially in resource-limited settings.

CASE PRESENTATION

A 52-year-old male from an economically disadvantaged background presented with hematemesis and severe anemia. Initial investigations suggested iron deficiency anemia, but further evaluation revealed a gastric mass, raising suspicion of GIST. Despite limited resources, a distal radical gastrectomy confirmed the GIST diagnosis, and the patient underwent surgical resection followed by imatinib therapy.

CLINICAL DISCUSSION

This case underscores the diagnostic challenges posed by GISTs and the importance of imaging studies, given their often nonspecific symptoms. Limited resources and economic constraints in low-income settings can hinder comprehensive diagnosis and treatment. Access to specialized oncological services is crucial for accurate management.

CONCLUSION

Early recognition and management of GIST, even in atypical presentations like hematemesis, can significantly impact patient outcomes. This case report highlights the need for improved healthcare infrastructure in low-resource settings and calls for initiatives to ensure equitable access to diagnostic tests and appropriate treatment for rare diseases like GIST.

Duodenocaval Fistula: Unmasking the Rare Culprit of Gastrointestinal Hemorrhage

Duodenocaval fistula is an extremely rare and life-threatening cause of gastrointestinal hemorrhage and septicemia. Diagnosing this condition is challenging due to its nonspecific symptoms, leading to significant delays in diagnosis and contributing to its remarkably high mortality rate. We present a unique case of duodenocaval fistula associated with prior radiation, peptic ulcer disease, and antiangiogenic cancer therapy, nearly resulting in the death of a young patient.

Gastrointestinal bleeding in children: diagnostic approach

Different conditions may underlie gastrointestinal bleeding (GIB) in children. The estimated prevalence of GIB in children is 6.4%, with spontaneous resolution in approximately 80% of cases. Nonetheless, the initial approach plays a pivotal role in determining the prognosis. The priority is the stabilization of hemodynamic status, followed by a systematic diagnostic approach. GIB can originate from either upper or lower gastrointestinal tract, leading to a broad differential diagnosis in infants and children. This includes benign and self-limiting disorders, alongside serious conditions necessitating immediate treatment. We performed a nonsystematic review of the literature, in order to describe the variety of conditions responsible for GIB in pediatric patients and to outline diagnostic pathways according to patients' age, suspected site of bleeding and type of bleeding which can help pediatricians in clinical practice. Diagnostic modalities may include esophagogastroduodenoscopy and colonoscopy, abdominal ultrasonography or computed tomography and, when necessary, magnetic resonance imaging. In this review, we critically assess these procedures, emphasizing their respective advantages and limitations concerning specific clinical scenarios.

Vallecular Varix: An Uncommon Cause for a Common Clinical Scenario

Vallecular varix can be a rare, potentially life-threatening source for Upper Gastrointestinal Bleeding. It is often a diagnostic dilemma and can present as persistent Hematemesis, Haemoptysis, or Malena. We describe a case of Vallecular varix, highlighting the presentation, diagnosis, management, along with the post-operative follow-up.

UPPER GASTROINTESTINAL TRACT ENDOSCOPY: A RETROSPECTIVE ANALYSIS OF INDICATIONS AND FINDINGS AT ATBUTH BAUCHI

Introduction

Upper gastrointestinal (UGI) endoscopy is considered a safe procedure performed for diagnosis, monitoring the course of disease, early detection of complications, treatment, and responses to therapeutic intervention. The indications have increased over the years. This study aimed to analyse the indications, findings, and safety of UGI endoscopy in our environment.

Methodology

A retrospective study of consecutive patients who had UGI endoscopy at ATBUTH over the period of two years (2014 -2016). Data extracted from the records of the patients including biodata, clinical presentation, indications, findings, and complications of the procedure was analyzed using SSPS version 26. The procedure was explained to each patient. After a spray of 10% xylocaine spray to the patient's pharynx, the procedure was carried out with an Olympus CV-170 machine using standard protocols and monitoring of vital signs throughout.

Results

Two hundred and fifty-two patients were included, 148 (58.7%) males, 104 (41.3%) females, age range of 17-85 years (mean age ± SD = 44.1 ± 15.2). The commonest indications were dyspepsia 160 (63.5%). Hematemesis 32 (12.7%), suspicion for gastric 9(3.6%), and oesophageal tumours 6(2.4%) were also indications. The most common finding was gastritis 67 (26.6%). There was increased detection of gastric 11(4.4%) and oesophageal tumours 8(3.2%) more than clinical acumen and in elderly patients with troublesome symptoms. None of the patients developed complications from the procedure.

Conclusions

UGI endoscopy is a safe procedure, and detects gastric and oesophageal tumours more accurately than clinical acumen and is recommended in all patients with troublesome upper GI symptoms.

Prospective observational study on clinical and epidemiological profile of adult patients presenting to the emergency department with suspected upper gastrointestinal bleed

BACKGROUND AND OBJECTIVE

Bleeding from the upper gastrointestinal (GI) tract is one of the common medical emergencies. In this study, we assessed patients' socio-demographic and clinical characteristics and the association of clinical characteristics with treatment outcomes among patients with suspected upper gastrointestinal bleed (UGIB) presenting to the emergency department (ED). At present, there is a scarcity of data on UGIB in Northern part of India.

MATERIAL AND METHOD

The study was a single-center, prospective observational study conducted at an urban tertiary care center. Consecutive patients with suspected UGIB were enrolled in the study from August 2020 to February 2022. A detailed history was obtained, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction, and drug history. Pre-endoscopic Rockall and Glasgow-Blatchford Score were calculated for each patient. The patients were subsequently followed up till discharge from the hospital. The final outcomes with regard to mortality, need for blood transfusion, length of emergency department stay, and discharge were noted.

RESULT

141 patients were included in the study. The mean age of the patients with suspected UGIB was 48 ± 14 years. 115 (81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%). The most frequent presenting complaint in this study was hematemesis (96; 68.1%), followed by melena (76;53.9%). The mean (Standard Deviation, SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15 in patients with UGIB.

CONCLUSION

In our study, hematemesis was the most prevalent symptom of suspected UGIB, followed by melena. Portal hypertension was the most common cause of UGIB. Most frequent comorbidities in patients suspected of UGIB were alcohol intake, Nonsteriodal Antiinflammatory Drugs (NSAIDs) abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes. Early endoscopy can be of great utility to reduce morbidity and mortality.

Changing trend in the spectrum of upper gastrointestinal bleeding in children-A multicentre experience

In children, upper gastrointestinal bleeding (UGIB) is an uncommon, but potentially serious, condition with diverse etiologies. A prospective study had been undertaken to find out any changing trend in the etiology and outcome of pediatric UGIB in Eastern India. This retrospective analysis of case records of children, presenting in outpatient or emergency with hematemesis and/or melena from 2 tertiary GI centers of Kolkata, was undertaken to find out the etiologies of bleed and the outcome of management. A total of 180 children were evaluated including 30 (16.7%) infants. The predominant cause of GGIB was gastroduodenal ulcer and erosions (60%) followed by variceal bleeding (19.4%). Vascular lesions were detected in 4 (2%). Hyperplastic antral polyp was an unusual etiology in 3 (1.7%) infants. Various endotherapies were needed in 28% of cases. No mortality was noted. Melena, hemoglobin below 8 gm%, the need for volume replacement, and packed red blood cells transfusion on admission were associated with significant endoscopic lesions, which needed endotherapies. This study, comprising the largest cohort among Indian published series, found an etiology of pediatric upper GI bleed, different from the one, previously depicted. This may be a reflection either of regional variations or a changing trend over time.

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

BACKGROUND

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.

CASE PRESENTATION

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.

CONCLUSIONS

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.

Clinical and Endoscopic Outcomes in Coronavirus Disease-2019 Patients With Gastrointestinal Bleeding

Background and Aims

Over 404 million people worldwide have been infected with coronavirus disease-2019 (COVID-19), 145 million in the United States (77 million) and Europe (151 million) alone (as of February 10, 2022). This paper aims to analyze data from studies reporting gastrointestinal bleeding (GIB) and/or endoscopic findings in COVID-19 patients in Western countries.

Methods

We conducted a systematic review of articles on confirmed COVID-19 cases with GIB in Western countries published in PubMed and Google Scholar databases from June 20, 2020, to July 10, 2021.

Results

A total of 12 studies reporting GIB and/or endoscopic findings in 808 COVID-19 patients in Western countries were collected and analyzed. Outcomes and comorbidities were compared with 18,179 non-GIB COVID-19 patients from Italy and the United States. As per our study findings, the overall incidence of GIB in COVID-19 patients was found to be 0.06%. When compared to the non-GIB cohort, the death rate was significantly high in COVID-19 patients with GIB (16.4% vs 25.4%, P < .001, respectively). Endoscopic treatment was rarely necessary, and blood transfusion was the most common GIB treatment. The most common presentation in GIB patients is melena (n = 117, 47.5%). Peptic, esophageal, and rectal ulcers were the most common endoscopic findings in upper (48.4%) and lower (36.4%) endoscopies. The GIB cohort had worse outcomes and higher incidence of hypertension (61.1%), liver disease (11.2%), and cancer (13.6%) than the non-GIB cohort. Death was strongly associated with hypertension (P < .001, r = 0.814), hematochezia (P < .001, r = 0.646), and esophagogastroduodenoscopy (P < .001, r = 0.591) in COVID-19 patients with GIB.

Conclusions

Overall, the incidence of GIB in COVID-19 patients is similar to that estimated in the overall population, with melena being the most common presentation. The common endoscopic findings in GIB COVID-19 patients were ulcers, esophagitis, gastritis, and colitis. Patients with GIB were more prone to death than non-GIB COVID-19 patients.

A novel scoring system to predict therapeutic intervention for non-variceal upper gastrointestinal bleeding

Various scoring systems have been developed to predict the need for endoscopic treatment in patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, they have rarely been applied in clinical practice because the processes are complicated. The aim of this study was to establish a simple scoring system that predicts the need for endoscopic intervention in patients with NVUGIB. We retrospectively enrolled 509 consecutive patients with suspected NVUGIB who underwent emergency endoscopy. In the development cohort (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from 349 patients' data by multivariate logistic regression analysis. This led to the development of a novel scoring system named the Nagoya University score (N score). In the validation cohort (from January 2019 to September 2020), we evaluated the diagnostic value of the N score, the Hirosaki score, and the Glasgow-Blatchford scores (GBS) by receiver operating characteristic (ROC) curves using another 160 patients' data. Multivariate logistic regression analysis revealed syncope, hematemesis, blood urea nitrogen (BUN), and BUN/Cr as significant predictive factors for endoscopic intervention. In the validation study, the N score was superior to the GBS and equal to the Hirosaki score in predicting the endoscopic intervention (AUC, N score 0.776 [95% CI 0.702-0.851] vs. GBS 0.615 [0.523-0.708], Hirosaki 0.719 [0.636-0.803]). The N score revealed a sensitivity of 84.5% and a specificity of 61.8%. Our N score, which is consisted of only four factors, would select patients who require endoscopic intervention with high probability.

The Current Portrayal of Non-Variceal Upper Gastrointestinal Bleeding in a Portuguese Tertiary Center

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important healthcare problem whose epidemiology and outcomes have been changing throughout the years. The main goal of this study was to characterize the current demographics, etiologies, and risk factors of NVUGIB.

Methods

Analysis of clinical, endoscopic, and outcome data from patients who were admitted for NVUGIB between January 2016 and January 2019 in an emergency department of a tertiary hospital center.

Results

A total of 522 patients were included, with a median age of 71 years, mainly men, with multiple comorbidities. Most patients were directly admitted, while the others were transferred from other hospitals. Peptic ulcer disease was the most common cause of NVUGIB and it was followed by tumor bleeding. Esophagogastroduodenoscopy was performed within <12 h after hospital admission in 51.9%. In-hospital rebleeding occurred in 6.9% and overall mortality was 4.2%. Transferred patients had superior Glasgow-Blatchford score (GBS), required more blood transfusion, endoscopic and surgical interventions, and presented higher rebleeding rate, with similar mortality. Complete Rockall score (CRS) and GBS were predictors of endoscopic therapy. Surgery need was only related to CRS. Patients who rebled had superior pre-endoscopic Rockall score (RS), CRS, and GBS. Mortality was increased in patients with higher RS and CRS.

Discussion/Conclusion

Ageing and increasing comorbidities have not been related to worse outcomes in NVUGIB. These findings seem to be the consequence of the correct use of both diagnostic and therapeutic tools in an organized and widely accessible healthcare system.

A case report]

INTRODUCTION

Heiner syndrome is a very rare but reversible lung disease caused by non-IgE-mediated hypersensitivity to cow's milk proteins resulting in an atypical pulmonary disease in babies and infants. Very few cases have been reported. Due to its heterogeneous manifestations, the diagnosis can be delayed since it can occur with chronic or recurrent infections of the upper or lower respiratory tract, fever, growth failure, or gastrointestinal symptoms. Pulmonary infiltrates can be mistaken for pneumonia, but Heiner's syndrome is refractory to antibiotic treatment.

CASE REPORT

We describe the case of a 1-month-old newborn baby whose main symptom was hematemesis, which is a rare symptom. The diagnosis was confirmed with the complete disappearance of the symptoms when milk and dairy products were strictly avoided.

CONCLUSIONS

The prognosis is favorable if a milk-free diet is begun early. Most children will tolerate cow´s milk within a few years.

Acute Esophageal Necrosis Secondary to a Paraesophageal Hernia

Acute esophageal necrosis (AEN) or “black esophagus” is a rare clinical entity caused by necrosis of distal esophageal mucosa stemming from esophageal ischemia. Possible etiologies are broad but most commonly include possible triggers of low-flow vascular states in the esophagus, including infections, broad-spectrum antibiotic use, and gastric volvulus, among others. Patients most commonly present clinically with acute onset hematemesis and melena. Here, we describe a patient who initially presented with multiple nonspecific gastrointestinal symptoms, including abdominal pain and nausea, that progressed over a 10-day period, culminating in multiple episodes of hematemesis prior to presentation. Endoscopic evaluation confirmed the diagnosis of AEN and unveiled a possible paraesophageal hernia (PEH) as the causative factor. A subsequent videofluoroscopic barium swallow was utilized to better characterize the upper gastrointestinal anatomy and confirmed the PEH as a likely etiology. Esophagogastroduodenoscopy (EGD) can often identify PEH independently, but in patients with AEN secondary to a possible, but unclear, PEH on EGD, a videofluoroscopic barium swallow is an appropriate and useful next step in confirming the diagnosis. While treatment of AEN traditionally involves fluid resuscitation, intravenous protein pump inhibitors, and total parenteral nutrition, surgical intervention is often indicated in patients who have a contributing and symptomatic PEH.

Factitious Gastrointestinal Bleeding: A Case Series and Review

Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.

Herpes Simplex Virus Esophagitis in the Setting of Acute Use of Corticosteroids for COPD Exacerbation in an Immunocompetent Middle-Aged Woman

Herpes simplex (HSV) esophagitis is usually identified in patients with significant immunosuppressive conditions such as AIDS. Short course of immunosuppressive therapy is an uncommon risk factor for this condition. We present a case of acute gastrointestinal bleeding secondary to HSV type 1-induced esophageal ulcers. A 63-year-old woman developed acute hypoxic hypercapnic respiratory failure. Past medical history was significant for COPD for which the patient was taking short-acting bronchodilator inhalers. The patient was intubated and started on mechanical ventilation. Intravenous Solu-Medrol 40 mg Q6 was started. Hospital course was complicated by sepsis of unknown source. Empiric broad-spectrum antibiotic therapy was started. On the 11th hospital day, the patient experienced multiple episodes of coffee ground emesis. There was abdominal tenderness on physical examination. Significant laboratory results were lipase 1,911 U/L and lymphopenia (ALC = 300/mm3). Endoscopy revealed severe erosive esophagitis and multiple punched-out ulcerations of the esophagus. Empiric treatment with valacyclovir 500 mg OD was started. The patient required PEG tube insertion for dysphagia. Complete resolution of esophagitis was noted then. Immunohistochemical staining for HSV was strongly positive in the cells with inclusions. Short course of intravenous corticosteroids is an uncommon cause of HSV-1 esophagitis. Corticosteroid-induced lymphopenia impedes underlying cellular immunity, which might explain the reactivation of latent herpes and esophageal ulcer formation. Given the rarity of the disease, evidence of treatment is available from case reports only. We found complete resolution of esophageal ulcers after the patient received valacyclovir therapy for 10 days.

Aortoesophageal fistula treated with emergent thoracic stent grafting

Aortoesophageal fistula (AEF) is a rare pathology with a poor prognosis. Historically, open repair approaches were undertaken. With the advent of endovascular techniques, alternative methods such as thoracic endovascular aortic repair (TEVAR) have emerged. This case describes a patient who presented with severe hematemesis and, upon imaging, an AEF was discovered. Urgent TEVAR was indicated with a graft oversized to the native aorta by 10% to 15%, along with coil embolization of the intercostal artery. We report here on the successful management of AEF via TEVAR.

Taeniasis: An unexpected variceal hemorrhage trigger

Here we report a fatal and uncommon case of esophageal variceal bleeding secondary to the presence of a Tapeworm in the upper digestive tract in a patient coming back from North Africa.

Patients with severe schistosomiasis mansoni in Ituri Province, Democratic Republic of the Congo

BACKGROUND

Severe hepatosplenic complications arise in patients with chronic Schistosoma mansoni infection after heavy exposure to disease agents in endemic areas. These complications are rarely reported and, hence, underestimated.

CASE PRESENTATION

We report on eight patients with severe morbidity associated with S. mansoni infection in Ituri Province, northeastern Democratic Republic of Congo (DRC). The patients were identified during a community-based survey in 2017; one patient was seen at the district hospital. After taking the patients' history, a clinical examination and an abdominal ultrasonographical examination were performed. S. mansoni infection was diagnosed in fecal (Kato-Katz technique) and urine (point-of-case circulating cathodic antigen test) samples. These eight patients with severe intestinal and hepatosplenic complications were identified from four villages with high S. mansoni infection prevalence and related morbidity. The patients' ages ranged from 19 to 57 years; four patients were women. Three patients reported hematemesis. Two patients were severely anemic. All patients reported non-specific abdominal symptoms, such as diarrhea (six patients), abdominal pain (seven patients), and blood in the stool (five patients), as well as weight loss (two patients). Abdominal ultrasonography revealed ascites in four patients. All patients had portal hypertension with hepatomegaly (seven patients) or splenomegaly (five patients). Of the six patients with a discernable liver parenchyma pattern, five displayed pattern F and three patient displayed pattern E. Liver parenchyma was not visible for two patients with severe ascites. An S. mansoni infection was confirmed in six patients, with infection intensity ranging from light to heavy. All S. mansoni positive patients were treated with praziquantel (40 mg/kg body weight) and referred to the district hospital for follow-up. One patient with severe ascites died two weeks after we saw her. Due to security and accessibility reasons, the villages could not be visited again and the patients were lost to follow-up.

CONCLUSIONS

Our observations of patients with severe schistosomiasis document the severe degree of endemicity of S. mansoni in the province and suggest an urgent need for adequate schistosomiasis control measures that target vulnerable population groups and address severe complications.

Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.

Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report

BACKGROUND

Cholecystoduodenal fistula is a rare complication of cholelithiasis. Symptoms are usually non-specific and often indistinguishable from those of etiologic diseases, but it rarely presents as severe gastrointestinal bleeding. Bleeding associated with cholecystoduodenal fistula usually requires surgery because significant bleeding from the cystic artery is unlikely to be resolved by conservative management or endoscopic hemostasis.

CASE SUMMARY

We report a case of cholecystoduodenal fistula that presented with hematemesis which was diagnosed by endoscopy and computed tomography. Endoscopic hemostasis could not be achieved, but surgical treatment was successful. Additionally, we have presented a literature review.

CONCLUSION

Cholecystoduodenal fistula should be considered as differential diagnosis when a patient with history of gallstone disease presents with gastrointestinal bleeding.

Endoscopic Ultrasound-Guided Ethanol Injection Associated with Trans-arterial Embolization of a Giant Intra-abdominal Cavernous Hemangioma: Case Report and New Therapeutic Option

BACKGROUND

Cavernous hemangiomas are congenital hamartomatous lesions that originate from mesodermal tissue composed of dilated blood vessels. Abdominal pain and palpable mass are the most common presenting symptoms. The different types of treatment for symptomatic patients remain controversial. However, surgical resection is always the most preferred method when possible. To date, there are no reports of endoscopic ultrasound-guided (EUS-guided) absolute ethanol injection as a treatment for such disease when surgery is not an option.

CASE PRESENTATION

A 19-year-old girl with giant cavernous intra-abdominal hemangioma extending to the hepatic hilum, also affecting the gastric wall and occupying the entire supra-mesocolic cavity, initially presents with upper gastrointestinal bleeding and loss of 20 kg in 1 year (BMI = 18 kg/m²). Percutaneous angiography identified a mass with arterial blood supply by the left gastric artery that was embolized. After re-bleeding, an alternative treatment with EUS-guided injection of alcohol was proposed once resection was not feasible without major risks to a young patient. This procedure was repeated 15 and 45 days after the initial treatment, with the ethanol injection of 25 cc and 15 cc, respectively. On the second and third procedure dates, there was evident regression of the hemangioma. On the third procedure, it was possible to identify all anatomic structures that were not clear on the first EUS. After 45 days of last injection, abdominal CT and EUS showed notorious regression of the lesion. Eight months later, abdominal CT showed only a remnant lesion in the hepatogastric ligament with 129 cm³ on volumetry (87% lower in comparison to the initial image), and the patient remains asymptomatic with BMI of 26. In the most recent follow-up CT, 4 years and 2 months after first treatment, the patient presents with a slight increase in the hemangioma-now with 183 cm³ on volumetry.

CONCLUSION

Transgastric EUS-guided ethanol injection in the treatment of giant intra-abdominal cavernous hemangioma can provide good outcomes without major complications and can be repeated if necessary.

Gastrointestinal bleeding due to gastrointestinal lipoma: A case report

BACKGROUND

Lipomas are common harmless tumors that are created in the colon in the gastrointestinal tract. The aim of this study was to report a case study on gastrointestinal lipoma with GIB.

CASE PRESENTATION

A 38-year-old man was admitted to the hospital because of gastrointestinal bleeding for two months in December 2017. He had abdominal pain, dyspeptic disorders, vomiting, melena, and intermittent hematemesis without significant weight loss. Upper gastrointestinal endoscopy indicated a large subepithelial lesion in the antrum of the stomach with near-normal mucosa. Endoscopic ultrasound (EUS) showed a large well-defined heterogeneous mass-like lesion in the antrum of the stomach. A subtotal gastrectomy was done in the patient. The histology results of the separated samples presented a gastric lipoma.

CONCLUSION

Gastric lipoma is often yellowish. It might ulcerate and bleed, but it does so, only rarely. It most frequently occurs as a solitary and smooth mass in the gastric antrum.

Boerhaave syndrome due to excessive alcohol consumption: two case reports

BACKGROUND

Spontaneous esophageal rupture, or Boerhaave syndrome, is a fatal disorder caused by an elevated esophageal pressure owing to forceful vomiting. Patients with Boerhaave syndrome often present with chest pain, dyspnea, and shock. We report on two patients of Boerhaave syndrome with different severities that was triggered by excessive alcohol consumption and was diagnosed immediately in the emergency room.

CASE PRESENTATION

The patient in case 1 complained of severe chest pain and nausea and vomited on arrival at the hospital. He was subsequently diagnosed with Boerhaave syndrome coupled with mediastinitis using computed tomography (CT) and esophagogram. An emergency operation was successfully performed, in which a 3-cm tear was found on the left posterior wall of the distal esophagus. The patient subsequently had anastomotic leakage but was discharged 41 days later. The patient in case 2 complained of severe chest pain, nausea, vomiting, and hematemesis on arrival. He was suggested of having Boerhaave syndrome without mediastinitis on CT. The symptoms gradually disappeared after conservative treatment. Upper gastrointestinal endoscopy performed on the ninth day revealed a scar on the left wall of the distal esophagus. The patient was discharged 11 days later. In addition to the varying severity between the cases, the patient in case 2 was initially considered to have Mallory-Weiss syndrome.

CONCLUSION

Owing to similar histories and symptoms, Boerhaave syndrome and Mallory-Weiss syndrome must be accurately distinguished by emergency clinicians. CT can be a useful modality to detect any severity of Boerhaave syndrome and also offers the possibility to distinguish Boerhaave syndrome from Mallory-Weiss syndrome.

Heart of glass: fatal hematemesis caused by bronchiole-cardiac fistula

A 58-year old woman presented for autopsy after having been found unresponsive in a public bathroom surrounded by a pool of blood. During attempts at resuscitation, blood was noted in her airway. She had a past medical history that included surgical repair of Tetralogy of Fallot as a child. At autopsy, a shard of glass was identified projecting from the surface of the left lung, having formed densely fibrotic adhesions at the pleural surface. The glass also penetrated through a bronchiole lumen and into a previously surgically repaired bulging right ventricular outflow tract, forming a bronchiole-cardiac fistula, allowing for the massive hemoptysis that led to her death. After further inquiry, it was discovered that the decedent also had a history of seizure disorder and had fallen through a glass door during a seizure many years ago, requiring several shards of glass to be removed from her chest wall.

The global impact of COVID-19 on gastrointestinal endoscopy units: An international survey of endoscopists

BACKGROUND & STUDY AIMS

Corona virus disease-19 (COVID-19) pandemic has markedly impacted routine medical services including gastrointestinal (GI) endoscopy. We aim to report the real-life performance in high volume GI endoscopy units during the pandemic.

PATIENTS AND METHODS

A web-based survey covering all aspects of daily performance in GI endoscopy units was sent to endoscopy units worldwide. Responses were collected and data were analyzed to reveal the effect of COVID-19 pandemic on endoscopy practice.

RESULTS

Participants from 48 countries (n = 163) responded to the survey with response rate of 67.35%. The majority (85%) decreased procedure volume by over 50%, and four endoscopy units (2.45%) completely stopped. The top three indications for procedures included upper GI bleeding (89.6%), lower GI bleeding (65.6%) and cholangitis (62.6%). The majority (93.9%) triaged patients for COVID-19 prior to procedure. N95 masks were used in (57.1%), isolation gowns in (74.2%) and head covers in (78.5%). Most centers (65%) did not extend use of N95 masks, however 50.9% of centers reused N95 masks. Almost all (91.4%) centers used standard endoscopic decontamination and most (69%) had no negative pressure rooms. Forty-two centers (25.8%) reported positive cases of SARS-CoV-2 infection among patients and 50 (30.7%) centers reported positive cases of SARS-CoV-2 infection among their healthcare workers.

CONCLUSIONS

Most GI endoscopy centers had a significant reduction in their volume and most procedures performed were urgent. Most centers used the recommended personal protective equipment (PPE) by GI societies however there is still a possibility of transmission of SARS-CoV-2 infection in GI endoscopy units.

Hemorrhagic tonsillitis in an infant: A case report

This case report describes a case of severe hemorrhagic tonsillitis in a nine month-old child who suffered significant amount of blood loss and was emergently taken to operating room for control of hemorrhage. The child was brought to emergency room by mom after noticing blood around child's mouth and nose and a subsequent episode of hematemesis having awoken from sleep. Initial impression was bleeding secondary to epistaxis however a thorough bedside otolaryngology exam including flexible rhinolaryngoscopy ruled this out. Rapid pooling of blood in oropharynx, continued hemorrhage with significant blood loss and recent history of hematemesis prompted emergent intervention in operating room for endoscopy for control of hemorrhage including esophagogastroduodenoscopy (EGD). Bleeding was identified from a blood vessel at left lower tonsil pole. Although there is a description in literature of such cases, these are uncommon in the pediatric population and none has been described in a patient this young requiring emergent operative intervention. This case report discusses the diagnostic and decision making dilemma in an infant in setting of ongoing active hemorrhage and the role of multidisciplinary team management.

Gastric AA amyloidosis secondary to chronic infection presenting with hematemesis: a case report

AA amyloidosis, previously known as secondary amyloidosis, has been associated with multiple chronic inflammatory conditions, including various autoimmune diseases and rarely chronic infection. Hereby, we present a case of AA amyloidosis secondary to chronic infection which initially presented with nausea and hematemesis. Endoscopic biopsies revealed diffuse AA amyloid deposition in the stomach, but not the esophagus. AA Amyloidosis presumably compromised gastric motility, promoted reflux related esophageal ulcers and erosions, and caused his cardiac and renal insufficiency. Therefore, endoscopic biopsies could be practical investigation to identify AA amyloidosis in the setting of chronic inflammatory diseases, especially with multi-organ involvement.

Strongyloides stercoralis Gastric Ulcer: A Rare Cause of Upper Gastrointestinal Bleeding

Strongyloidiasis is an infection caused by Strongyloides stercoralis. Gastrointestinal manifestations typically include duodenitis, chronic enterocolitis, and malabsorption, while gastric involvement is very rare. In this case report, the -authors present a case of upper gastrointestinal bleeding caused by a gastric ulcer with a challenging etiological diagnosis. In Portugal, there have been reports in the past century of autochthonous cases of S. stercoralis infection suggesting endemic zones, but with the current sanitation infrastructure strongyloidiasis is thought to be rare. A 56-year-old Caucasian male smoker with a history of significant weight loss presented to the emergency department with hema-temesis and abdominal pain. Upper endoscopy revealed a giant gastric ulcer with a macroscopic appearance suggestive of malignancy. Further investigation with CT scan highlighted gastric wall thickness and a spiculated lung lesion in the upper right lobe without lymph node involvement or metastatic disease. Bronchoscopy with bronchial brushing was performed. Histological examination identified squamous cell carcinoma of the lung and the patient was referred to Oncological Pneumology. Gastric ulcer biopsies ruled out malignancy and identified fragments of nematodes with inflammatory infiltrates and fibrinogranulocytic exudate, suggestive of S. stercoralis. Accordingly, the diagnosis of strongyloidiasis was made and further confirmed with molecular methods and serology. The giant gastric ulcer was affirmed to be caused by S. stercoralis infection and the patient was treated with ivermectin with improvement of epigastric pain. On reevaluation 6 weeks later the patient was asymptomatic, had gained weight, parasitological stool examinations were negative, and upper endoscopy showed complete ulcer healing. Further tests were done targeting risk factors for strongyloidiasis, and in addition to the presence of malignancy, other underlying causes for immunosuppression were ruled out. In this case report strongyloidiasis was manifested by gastric involvement with upper gastrointestinal bleeding in a patient who was subsequently diagnosed with squamous cell carcinoma of the lung.

An unusual presentation of portal vein thrombosis in a 2-year-old girl

Portal vein thrombosis (PVT) is the most common cause of extrahepatic portal vein obstruction in children. Upper gastrointestinal (GI) bleeding and splenomegaly are the most common presenting features. PVT diagnosis is usually delayed in the absence of upper GI bleeding and many children undergo a hematologic work-up due to splenomegaly and signs of hypersplenism. Here, we present a case of a 2-year-old girl who had pancytopenia and splenomegaly. The hematologic work-up including a bone marrow aspirate was unrevealing and she was thought to have viral-induced bone marrow suppression and severe iron deficiency anemia. She presented 2 months later with hematemesis and abdominal CT angiography confirmed the diagnosis of PVT with portal cavernoma. Conclusion: PVT should be suspected in any child who presents with afebrile splenomegaly and signs of hypersplenism even in the absence of upper GI bleeding.

Caput medusae sign; a unique finding during abdominal examination in patients with portal hypertension; case report

Portal hypertension is an increase in the portal venous pressure resulting in the formation of dilated veins at the site of porto-systemic venous anastomosis causing shifting of the blood flow from the portal venous system to the systemic circulation.

A 53-year-old male presented to the emergency department complaining from hematemesis. He was admitted to the emergency department. Abdominal examination showed hugely dilated veins in the abdominal wall with palpable spleen and liver. The hemoglobin level was low and liver enzymes were mildly elevated. The patient received two units of blood and four units of fresh frozen plasma, intravenous propranolol and intravenous vasopressin. Endoscopy showed variceal bleeding which was mild, multiple bandings were performed for the bleeding vessels. The past medical history was negative apart from idiopathic portal vein thrombosis. He was on regular anticoagulants and beta blockers. The patient was prepared to undergo surgical shunting procedure.

Acute variceal bleeding is a medical emergency, and patients need aggressive form of treatment. Most drugs like beta-blockers, derivatives of vasopressin and somatostatins work by inducing splanchnic vasoconstriction and decrease the portal venous pressure. Endoscopic band ligation may be required but this has no effect on the portal venous pressure, other alternatives include trans-jugular intrahepatic portosystemic shunts or surgery.

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Caput medusae sign is a clinical sign indicating portal hypertension.

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It results from shifting of blood flow from the portal venous system to the systemic circulation.

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This results in the formation of dilated veins at the site of porto-systemic venous anastomosis.

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Portal hypertension results in splenomegaly, ascites, esophageal and gastric varices.

Impact of the stress ulcer prophylactic protocol on reducing the unnecessary administration of stress ulcer medications and gastrointestinal bleeding: a single-center, retrospective pre-post study

Background

Clinically significant gastrointestinal bleeding from stress ulcers increases patient mortality in intensive care, and histamine type 2 receptor blockers and proton pump inhibitors as stress ulcer prophylaxes were reported to decrease the incidence of that.

Although medical checklists are widely used to maintain high compliance with medications and interventions to improve patient outcome in the intensive care field, the efficacy of medical checklists regarding the incidence of gastrointestinal bleeding and the reduction of unnecessary administration of stress ulcer prophylaxis medications has not been sufficiently explored to date.

This study aimed to investigate the incidence of gastrointestinal bleeding and the rate of administering stress ulcer prophylaxis medication before and after setting administration criteria for stress ulcer prophylaxis and introducing a medical checklist for critically ill adults.

Methods

This was a retrospective pre-post study at a single-center, tertiary adult and pediatric mixed ICU. Adult patients (≥ 18 years) who were admitted to the ICU for reasons other than gastrectomy, esophagectomy, pancreatoduodenectomy, and gastrointestinal bleeding were analyzed. A medical checklist and stress ulcer prophylaxis criteria were introduced on December 22, 2014, and the patients were classified into the preintervention group (from September to December 21, 2014) and the postintervention group (from December 22, 2014, to April 2015). The primary outcome was the incidence of upper gastrointestinal bleeding, and the secondary outcome was the proportion administered stress ulcer prophylaxis medications.

Results

One hundred adult patients were analyzed. The incidence of upper gastrointestinal bleeding in the pre- and postintervention groups was both 4.0% [95% confidence interval, 0.5–13.7%]. The proportion administered stress ulcer prophylaxis medications decreased from 100 to 38% between the pre- and post-intervention groups.

Conclusions

After the checklist and the criteria were introduced, the administration of stress ulcer prophylaxis medications decreased without an increase in upper gastrointestinal bleeding in critically ill adults. Prospective studies are necessary to evaluate the causal relationship between the introduction of them and gastrointestinal adverse events in critically ill adults.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated.

AIM

To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB.

METHODS

This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups.

RESULTS

A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.

CONCLUSION

In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Epithelioid hemangioendothelioma of the pancreas presented as massive hematemesis

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Hemangioendothelioma is vascular tumors characterized by the presence of an “epithelioid” or “histiocytoid” endothelial cell.

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The majority of the tumors affects the liver.

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The natural history of the disease is still poorly understood and there is no uniform treatment form for such tumors.

Introduction

Hemangioendotheliomas are vascular tumors characterized by the presence of an “epithelioid” or “histiocytoid” endothelial cell. They consist of blood filled spaces mixed with cellular areas that mostly occur in the liver, but other organs can be affected. These lesions cause a wide spectrum of clinical presentations depending on the organ involved. Complete surgical excision is the primary form of treatment; they tend to recur after surgery in some cases.

Presentation of case

A-45-year old lady presented with 2 attacks of massive hematemesis. Upper GIT endoscopy was done which showed a vascular tumor arising from the duodenal ampulla, biopsy was not taken because of the risk of bleeding.

Laparotomy and duodenotomy were performed, there was a soft irregular 3 cm mass with areas of hemorrhage arising from the duodenum, complete excision was done and frozen section examination showed a benign lesion.

Two months later the patient presented with melena and anemia. CT-scan of the abdomen showed a mass at the head of pancreas. Second surgery was done and during surgery a firm mass was found in the region of the head of pancreas, pancreaticoduodenectomy was done and the sample was sent for histopathological examination which showed an epithelioid hemangioendothelioma of the head of the pancreas.

Discussion & conclusion

The treatment strategy should be tailored to the individual patient, the clinical presentation, and the rate of progression of the tumor. The natural history of the disease is still poorly understood and there is no uniform treatment form for such tumors.

Development, Validation, and Comparative Assessment of an International Scoring System to Determine Risk of Upper Gastrointestinal Bleeding

BACKGROUND & AIMS

The Glasgow-Blatchford score (GBS) and pre-endoscopy Rockall score (pRS) are used in determining prognoses of patients with acute upper gastrointestinal bleeding, but neither predicts outcomes of patients with a high level of accuracy. A scoring system is needed to identify patients at risk of adverse outcomes and patients at low risk of harm.

METHODS

We pooled data from 5 data sets in Canada, the United Kingdom, and Australia on 12,711 patients with acute upper gastrointestinal bleeding. The GBS and pRS were calculated for each patient. We performed multivariable logistic regression modeling of data from 10,639 cases to develop the new scoring system Canada - United Kingdom - Adelaide (CANUKA). We performed area under the receiver operating characteristic analyses to test the ability of CANUKA to identify patients who died or had rebleeding within 30 days, surgical or radiologic intervention to control bleeding, need for therapeutic endoscopy, and transfusion-a poor outcome was defined as 1 or more of these outcomes. Patients at low risk of a poor outcome (safe for management as an outpatient) were identified based on lack of transfusion, rebleeding, therapeutic endoscopy, interventional radiology or surgery, or death. We validated in 2072 patients from a separate cohort compiled from 2 datasets.

RESULTS

In the development data set there was no difference between GBS and pRS in identifying patients who died without 30 days of bleeding (area under the receiver operating characteristic curve [AUROC], 0.67; 95% CI, 0.62-0.72 for GBS; AUROC, 0.70; 95% CI, 0.66-0.74 for pRS; P = .21). The GBS was superior to the pRS in identifying patients with rebleeding, hemostatic interventions, and transfusions. In the validation data set, CANUKA had higher accuracy than the GBS in identifying patients who died within 30 days of bleeding (AUROC, 0.77 vs 0.74; P = .047), but there was no significant difference in the accuracy of these scoring systems in identifying patients who required hemostatic intervention. The GBS more accurately identified patients who required therapeutic endoscopy (AUROC, 0.78; 95% CI, 0.76-0.81 for GBS; AUROC, 0.77; 95% CI, 0.74-0.79 for CANUKA; P = .47). For patients classified as low-risk patients by CANUKA (score ≤1), 96.3% were safely discharged, whereas 16 patients with a GBS ≤1 had an adverse outcome (a 95.3% probability of safe discharge).

CONCLUSIONS

In an international validation analysis of the GBS and pRS for patients with acute upper gastrointestinal bleeding, we found the GBS to more accurately identify those who later required hemostatic interventions and transfusions; the scoring systems identified 30-day mortality or rebleeding with equal levels of accuracy. We developed a scoring system (CANUKA) that had similar performance to the GBS in predicting patient outcomes and it more accurately identifies patients at low risk for adverse outcomes.

A different clinical presentation of Heiner syndrome: The case of diffuse alveolar hemorrhage causing massive hemoptysis and hematemesis

Heiner syndrome is a non-IgE-mediated hypersensitivity to cow's milk, which often causes pulmonary disease in infants and young children. Patients often have symptoms of chronic or recurrent upper or lower respiratory tract infection. It has been reported that the Heiner's syndrome can cause recurrent pulmonary hemorrhage, and it is difficult to differentiate from the entity of idiopathic pulmonary hemosiderosis, another disease with recurrent pulmonary hemorrhage of unknown etiology usually occurring in the older children. Acute respiration is a rare problem in Heiner syndrome, which usually has symptoms and signs of chronic respiratory disease. In this case report, we present a 6-month-old patient who was admitted to our hospital with massive hemoptysis, hematemesis, and deep anemia.

An Alternative Approach to Life-Threatening Gastrointestinal Bleeding After Corrosive Ingestion

Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of acute corrosive injury has not been described. Here, we present our experience of a case of acute corrosive injury presenting with massive upper gastrointestinal bleeding in the delayed phase which was successfully managed by angioembolization. We discuss the case in light of the literature available and describe markers which may serve to identify potential candidates for angioembolization.

Management of gastrosplenic fistula in the emergency setting - A case report and review of the literature

INTRODUCTION

A gastrosplenic fistula (GSF) is a very rare complication that arises mainly from a splenic or gastric large cell lymphoma. The proximity of the gastric fundus to the enlarged fragile spleen may facilitate the fistulisation. This complication can lead to massive bleeding, which, though uncommon, may be lethal. We present a patient with massive upper gastrointestinal bleeding secondary to a GSF.

CASE PRESENTATION

We present a 48-year-old man with a refractory diffuse large B-cell lymphoma who was admitted to our hospital due to hematemesis. On arrival, he was in hemorrhagic shock, and was taken directly to the intensive care unit. The source of bleeding could not be identified on gastroscopy, the patient remained hemodynamically unstable and a laparotomy was performed.A fistula between a branch of the splenic artery and the stomach was identified. The stomach appeared to be involved in the malignant process. After subtotal gastrectomy and splenectomy, the bleeding was controlled. After stabilization, the patient was admitted to the intensive care unit, and 24 hours later was discharged in stable condition.

DISCUSSION

We describe a fistula between a branch of the splenic artery and the stomach, which was accompanied by massive bleeding. An emergency laparotomy saved the patient's life.

CONCLUSION

The purpose of this report is to alert physicians that surgical intervention can be lifesaving in this rare malignant condition. A literature review focusing on the presenting symptoms and the epidemiology of GSF is presented.

Endoscopic Suturing for Massively Bleeding Marginal Ulcer 10 days Post Roux-en-Y Gastric Bypass. Obes Surg. 2017;27:1394-1396. [PMID: 28247322 DOI: 10.1007/s11695-017-2621-x]

BACKGROUND

Marginal ulceration post Roux-en-Y gastric bypass (RYGB) with associated bleeding, although infrequently encountered, can be challenging to treat. Flexible endoscopic therapy is preferred over surgery due to its minimally invasive nature. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis, or clips. Here, we describe our treatment with endoscopic suturing for a massively bleeding marginal ulcer after RYGB.

METHODS

A 56-year-old female 10 days post RYGB underwent her fourth endoscopy for investigation and management of hematemesis and was found to have a large bleeding anastomotic ulcer. A Rothnet was utilized to remove large blood clots which obstructed endoscopic visualization. Two marginal ulcers were noted, and these were successfully oversewn with endoscopic suturing. The multimedia video (7 min) demonstrates the management of massively bleeding marginal ulcer after RYGB by endoscopic suturing.

RESULTS

Patient had no further bleeding and tolerated diet the subsequent day. She was discharged home with no further episodes of hematemesis, and follow-up at 6 weeks showed well-healed ulcer on endoscopy.

CONCLUSION

Endoscopic suturing of a bleeding marginal ulcer appears technically feasible and safe. It should be considered in the treatment algorithm prior to emergency surgery.

Risk factors for hematemesis in Hoima and Buliisa Districts, Western Uganda, September-October 2015

Introduction

On 17 September 2015, Buliisa District Health Office reported multiple deaths due to haemorrhage to the Uganda Ministry of Health. We conducted an investigation to verify the existence of an outbreak and to identify the disease nature, mode of transmission and risk factors.

Methods

We defined a suspected case as onset of hematemesis between 1 June 2015 and 15 October 2015 in a resident of Hoima, Buliisa or neighbouring districts. We identified cases by reviewing medical records and actively searching in the community. We interviewed case-patients and health-care workers and performed descriptive epidemiology to generate hypotheses on possible exposures. In a case-control study we compared exposures between 21 cases and 81 controls, matched by age (± 10 years), sex and village of residence. We collected 22 biological specimens from 19 case-patients to test for Viral Haemorrhagic Fevers (VHF). We analysed the data using the Mantel-Haenszel method to account for the matched study design.

Results

We identified 56 cases with onset from June to October (attack rate 15/100,000 in Buliisa District and 5.2/100,000 in Hoima District). The age-specific attack rate was highest in persons aged 31-60 years (15/100,000 in Hoima and 47/100,000 in Buliisa); no persons below 15 years of age had the illness. In the case-control study, 42% (5/12) of cases vs. 0.0% (0/77) of controls had liver disease (OR_M-H = ∞; 95%CI = 3.7-∞); 71% (10/14) of cases vs. 35% (28/81) of controls had ulcer disease (OR_M-H = 13; 95% CI = 1.6-98); 27% (3/11) of cases vs. 14% (11/81) of controls used indomethacin prior to disease onset (OR_M-H = 6.0; 95% CI = 1.0-36). None of the blood samples were positive for any of the VHFs.

Conclusion

This reported cluster of hematemesis illness was due to predisposing conditions and use of Non-Steroidal Anti-inflammatory Drugs (NSAID). Health education should be conducted on the danger of NSAIDs misuse, especially in persons with pre-disposing conditions.

Complicated Gastric Duplication Cyst in an Adult Patient: Uncommon presentation of an uncommon disease

Gastric duplication cyst is a very rare congenital anomaly accounting up to 4% of all gastrointestinal tract duplications. It is a quite rare anomaly in adults, the majority of the cases are diagnosed in the neonatal period. Gastric duplication cysts are usually asymptomatic or they do present with non-specific symptoms. They are usually discovered incidentally during endoscopy or laparotomy or very rarely after getting complicated. We describe herein, along with literature review, a case of an adult patient who presented with abdominal pain and bloody vomiting and turned out to have a gastric duplication cyst complicated by internal bleeding.

Management of upper gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis: a prospective, multicenter, observational study

Background

Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective.

We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes.

Method

This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included.

Results

In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs.

Conclusion

Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0425-6) contains supplementary material, which is available to authorized users.