Interesting Case of Contained Perforated Peptic Ulcer With Pancreatic Communication Causing Hemorrhagic Shock

Peptic ulcer disease (PUD) is a common gastrointestinal diagnosis affecting the stomach and proximal duodenum. A contained perforation with pancreatic communication is an exceedingly rare subtype where gastroduodenal perforation is limited by the surrounding pancreas, preventing free leakage of gastric and pancreatic contents into the peritoneal cavity. A 48-year-old male with a history of perforated antral ulcer requiring surgical management and placement of a Graham patch presented with upper gastrointestinal bleeding. Initial esophagogastroduodenoscopy (EGD) showed a new clean-based antral ulcer; however, the patient continued to experience hematemesis post-procedure. A repeat EGD revealed the same antral ulcer now with suture material exposed near the prior site of the Graham patch, along with a soft tissue mass resembling the pancreas and no evidence of active bleeding. Following this EGD, the patient had profuse hematemesis with hemorrhagic shock and underwent emergent exploratory laparotomy confirming contained posterior perforation of the stomach with complete erosion of the stomach wall onto the head of the pancreas. This case highlights an atypical presentation for a perforated peptic ulcer (PPU) with pancreatic communication.

Comparison Between Pantoprazole Intermittent Dosing and Continuous Infusion in Suspected Upper Gastrointestinal Bleeding Prior to Endoscopy: Impact of a Pharmacist-Driven Protocol to Reduce Utilization of Pantoprazole Continuous Infusion

BACKGROUND

Current practice for patients with suspected or confirmed upper gastrointestinal bleeding (GIB) is to utilize a proton pump inhibitor (PPI) bolus followed by a continuous infusion for 72 hours. Literature has shown similar outcomes with intermittent bolus dosing compared to continuous infusion. Substitution would lead to reduced costs and utilization of resources.

METHODS

This was a retrospective case-control study conducted via chart review. Utilizing electronic healthcare record reports, patients in the control arm were screened for inclusion if they received a pantoprazole continuous infusion from December 1, 2020, to March 31, 2021. A total of 38 patients were included in the control arm. Patients in the experimental arm were screened for inclusion with pantoprazole intermittent therapy from January 1, 2022, to June 30, 2022. A total of 60 patients were included in the experimental arm. The primary outcome was a 30-day GIB recurrence. Secondary outcomes included 30-day hospital readmission, 30-day Clostridioides difficile (C. difficile), hospital length of stay (LOS), and number of pantoprazole vials utilized.

RESULTS

There was a 65% reduction in the 30-day GIB recurrence in the intermittent bolus arm compared to the continuous infusion arm. Thirty-day hospital readmission was 57% lower in the intermittent bolus arm compared to the continuous infusion arm. The LOS between the two arms was almost identical with the median being five days for the intermittent bolus arm and the median being four days for the continuous infusion arm. The 30-day C. difficile infection rate had 5% of patients acquiring C. difficile in the intermittent bolus arm and 2.5% in the continuous infusion arm. The intermittent bolus arm used 55% fewer pantoprazole vials than the continuous infusion arm.

CONCLUSION

In hospitalized patients, the utilization of pantoprazole intermittent bolus is not only comparably efficacious but potentially represents a safer and economically advantageous alternative compared to the current guideline recommendation of a 72-hour pantoprazole continuous infusion. Further studies could provide more robust data to support our findings and challenge the current recommendation for patients who meet the indication criteria.

Purastat as an Adjunct Treatment Option in Acute Esophageal Varices Bleeding: A Case Report

Esophageal varices are dilated submucosal esophageal veins that connect the portal and systemic circulations. Bleeding esophageal varices is a well-recognized complication of liver cirrhosis.It is known that in active variceal bleeding, treatment needs to be started promptly. Treatments comprise band ligation, sclerotherapy, removable stent placement, balloon tamponade, and transjugular intrahepatic portosystemic shunt (TIPS).We report a case in which hemodynamic stability can be maintained with the use of Purastat to control bleeding.

Arteriovenous Malformation of the Jejunum, Causing Massive Gastrointestinal Bleeding, Treated With Intraoperative Enteroscopy Guidance: A Case Report

Arteriovenous malformations of the small intestine are an important differential in cases of occult gastrointestinal bleeding. Localization of the source of gastrointestinal bleeding can be a difficult task, especially in resource-limited settings where balloon-assisted enteroscopy or video capsule endoscopy are unavailable. We herein report the use of intraoperative enteroscopy to help localize and resect a short bowel segment containing a bleeding arteriovenous malformation of the jejunum in a 50-year-old man who presented with hematochezia and pallor leading to hemorrhagic shock. Esophagogastroduodenoscopy and colonoscopy showed no abnormalities, but a contrast-enhanced computed tomography scan of the abdomen revealed a contrast blush in the proximal jejunum. Angiography with coil embolization failed to control his symptoms, and he underwent exploratory laparotomy with intraoperative enteroscopy to try and localize the bleeding, followed by resection of the diseased segment and anastomosis of the small bowel, which led to the successful resolution of the patient's issues.

Utilizing Endoscopy for the Diagnosis of Acute Upper Gastrointestinal Bleeding

Background Acute upper gastrointestinal bleeding (UGIB) is a medical emergency requiring immediate diagnosis. While endoscopy is a commonly employed procedure in the evaluation of UGIB, its timing, outcomes, and the range of identified causes vary widely across different medical settings and regions. Therefore, the purpose of this study was to use endoscopy to investigate the cause of UGIB. Methodology A cross-sectional study was conducted at the Department of Gastroenterology, Mayo Hospital, Lahore, over a period of one year, from July 1st, 2021 to June 28th, 2022. The study enrolled all patients who were 18 years of age or older and exhibited symptoms of UGIB, including hematemesis and/or melena, within 48 hours of onset. An upper gastrointestinal endoscopy procedure was conducted in order to identify the underlying cause of UGIB and to apply appropriate therapeutic interventions. In patients where the endoscopic examination revealed bleeding ulcers, a specimen for biopsy was excised to test for Helicobacter pylori. Similarly, in cases where a malignancy was suspected during the endoscopy, a biopsy was performed for confirmatory diagnosis. A pre-designed proforma was utilized to collect data including the demographic variables such as age, gender, ethnicity, family history; clinical variables such as clinical presentation, comorbidities, medical history, medication use, vital signs, biochemical evaluation, and imaging results; endoscopic findings such as endoscopic location and severity of bleeding, endoscopic diagnosis, and the use of endoscopic interventions. Information relevant to the treatment and outcomes was also observed. Under outcomes, the rates of re-bleeding, need for repeat endoscopy, length of hospital stay, and mortality were recorded. Results The study reports that the mean age of the participants was 54.72 years with a standard deviation of 12.5 years. The mean hemoglobin level at the presentation was 7.98 ± 2.88 mg/dl. Out of the 309 patients, 215 (69.58%) were male, 202 (65.37%) presented with hematemesis, 97 (31.39%) presented with melena, and 10 patients had a mixed presentation. A total of 154 (49.84%) patients had portal hypertension. Out of these, 128 (83.12%) had esophageal varices and 21 (13.64%) had gastric varices. Five patients suffered from portal hypertensive gastropathy. In 114 (36.89%) patients, the cause of bleeding was ulcerative disease and out of these, duodenal ulcers were found in 49 (42.98%) while gastric ulcers were found in 22 (19.30%) patients. In total malignant lesions were detected in 20 (6.47%) cases. Conclusion The research indicates that hematemesis was the predominant initial symptom observed in individuals experiencing UGIB. The predominant etiology of the hemorrhage was identified as esophageal and gastric varices through endoscopic assessment. The study highlights the importance of early endoscopic evaluation in patients with UGIB as it can help identify the cause and guide appropriate management. This emphasizes the need for healthcare providers to be vigilant in identifying and managing patients with UGIB promptly to improve outcomes. Further research is needed to explore effective strategies for early detection and management of UGIB.

The GIST of It: A Rare Presentation of Neurofibromatosis Type I

Neurofibromatosis-1 (NF-1) is an autosomal dominant condition characterized by cutaneous pigmentation and tumour formation along nerves in the brain, skin, and other organs. Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours involving the gastrointestinal tract (GI) associated with NF-1. We present a case of life-threatening GI bleeding from GIST in a patient with NF-1. In NF-1 patients presenting with GI bleeding, GISTs should be part of the differential. Clinicians must have a low threshold for urgent abdominal imaging if endoscopy does not detect the source of GI bleeding.

A Silent Killer: Left Main Coronary Artery Disease in Gastrointestinal Bleed

Left main coronary artery disease (LMCAD) is defined as more than 50% angiographic arterial narrowing and has been demonstrated in nearly 5% of all patients undergoing coronary angiography. It carries an extremely high risk for cardiovascular morbidity and mortality as it impacts more than two-thirds of the left ventricle. Prediction of LMCAD in the right clinical setting is important for the selection of the proper treatment strategies. Typical ECG characteristics are ST elevation (STE) in lead augmented vector right (aVR-STE) of more than 0.5 mV accompanied by ST depression (STD) notably in leads I, II, and V4-6 or STE in aVR ≥ V₁. Furthermore, the presence of aVR-STE is associated with worse outcomes and careful evaluation and close monitoring are warranted. However, not every aVR-STE is an acute occlusion of the left main coronary artery (LMCA), as acute occlusion is a catastrophic event. aVR-STE can also be associated with severe triple-vessel disease or diffuse subendocardial ischemia.

Late Manifestation of Massive Jejunal and Cecal Varices Post Liver and Small Bowel Transplantation in a Patient With Microvillus Inclusion Disease

We report the case of an 18-year-old male with a medical history of microvillous inclusion disease (MID) and notable surgical history of small bowel, liver, and pancreas transplant who presented with massive jejunal and cecal varices. Endoscopy findings demonstrated a large grape-like cluster, with subsequent CT angiography (CTA) showing other variceal lesions in the cecum. The patient was transferred to the original transplant center for recommended open surgical evaluation and combined interventional radiology (IR) embolization of varices. MID is a rare genetic disorder caused by mutations in the Myosin VB (MYO5B) gene leading to a lack of myosin Vb. Patients subsequently develop liver damage at birth, which necessitates a small bowel/liver transplant in childhood.

The Role of Haemostasis Course in Increasing Knowledge and Skills in Managing Upper Gastrointestinal Bleed of the Delegates: A British Society of Gastroenterology's Endoscopy Quality Improvement Programme, Yorkshire Project

Introduction

An acute upper gastrointestinal bleed (AUGIB) is a fatal and prevalent medical emergency if not appropriately treated in a timely fashion.

Aim

The aim of this project was to compare the knowledge and skills of the participants in managing upper gastrointestinal bleeding (UGIB) before and after a one-day UGIB haemostasis course.

Methods

A one-day haemostasis course in line with the British Society of Gastroenterology’s Endoscopy Quality Improvement Project Initiative was organised at the Sheffield Teaching Hospitals National Health Service (NHS) Trust. The course included lectures on UGIB and its management, which was followed by hands-on training on adrenaline injection, variceal banding, clip placement, thermal therapy, Hemospray® use, Sengstaken-Blakemore tube placement, and Danis stent placement via porcine or plastic models. Pre- and post-course feedback questionnaires consisting of self-assessed ratings related to knowledge, skills, and behaviour relevant to UGIB were offered to all delegates. Two-tailed Wilcoxon signed-rank test was used to compare the results.

Results

A total of 36 individuals attended the course. Delegates had an average endoscopy procedure count of 583. The cohort ranged from different fields of medicine, including gastroenterology consultants and junior doctors. Ten of the delegates were Joint Advisory Group-certified in upper gastrointestinal endoscopy. Feedback datasheets were returned by 22 delegates. Significant improvements were reported post-course (p < 0.001), especially in the hands-on and behavioural areas.

Conclusion

Overall, there was a significant improvement in the knowledge, procedural skills, and confidence of the delegates in the management of an AUGIB post-course. We recommend not only to include this course in gastrointestinal training but also to conduct a course such as this for consultants and junior doctors who wish to undergo gastrointestinal training in the future.

Gastric Epithelioid Angiosarcoma: An Unexpected Tumor in an Unexpected Location

Angiosarcomas are aggressive neoplasms that arise from endothelial cells and can develop in any part of the body. Gastrointestinal angiosarcomas are very uncommon and can have a variable clinical presentation. We report a case of an 84-year-old female who presented with acute blood loss anemia. She underwent a gastrointestinal workup with esophagogastroduodenoscopy (EGD), which revealed two polyps in the stomach. Histologic evaluation of the polyps was indicative of angiosarcoma, and the diagnosis was eventually confirmed by immunohistochemical analysis with positive CD31, ERG, and FLI1 stains. This case is reported to demonstrate the importance of considering angiosarcoma in the differential for patients presenting with gastrointestinal bleeding.

Concurrent Langerhans Cell Histiocytosis and Autoimmune Hepatitis: A Case and Review of the Literature

Autoimmune hepatitis (AIH) and Langerhans cell histiocytosis (LCH) are two independently rare disease processes that can have similar presentations. We present a unique, complex case that required a multidisciplinary approach to ultimately diagnose and treat the patient. A 20-year-old male with no significant history presented with worsening jaundice, diffuse, pruritic rash, and abdominal pain over one month. On admission, the patient's labs showed significantly elevated liver function tests (LFTs), eosinophilia, and anemia. The exam was notable for diffuse lymphadenopathy (LAD), hepatosplenomegaly, and a diffuse, non-blanching, morbilliform rash. Interdisciplinary workup was notable for positive anti-smooth muscle antibody (ASMA) and anti-neutrophilic antibody (ANA). A liver biopsy showed severe inflammation with interface activity, consistent with AIH. A lymph node (LN) biopsy showed findings consistent with LCH, including histiocyte clusters. He was started on high-dose steroids with LAD/LFT improvement; yet, his course was complicated by a gastrointestinal (GI) bleed requiring a hemicolectomy. The patient was transferred to a larger referral center where he continued to improve with steroids and was ultimately discharged. This case was notable for an LN biopsy showing histiocyte clusters with reniform nuclei, nuclear grooves, and eosinophils with immunohistochemical stains positive for S-100, CD1a, fascin, langerin, CD45, and CD68, consistent with LCH. The resected colon showed atypical histiocyte proliferation positive for fascin, CD4, and CD68. Other findings, including elevated LFTs, ASMA, and a liver biopsy showing inflammation with interface activity, eosinophils, plasma cells, and characteristic fibrosis, supported a diagnosis of AIH. In either case, steroids were indicated.