Incidental diagnosis of gastric antral vascular ectasia in a case of chronic kidney disease from Nepal: a case report.

INTRODUCTION: Gastric antral vascular ectasia is an uncommon clinical disease that affects elder people and is characterized by severe chronic upper gastrointestinal bleeding mainly affecting the gastric antrum. It is generally unusual among patients undergoing maintenance hemodialysis for chronic kidney disease. CASE PRESENTATION: Here, we aim to present an uncommon case of incidental diagnosis of the gastric antral vascular ectasia and erosive gastritis in a 71-year-old Hindu male patient belonging to the Gurung ethnicity of Nepal undergoing maintenance hemodialysis due to chronic kidney disease. The patient presented with a history of melena and fatigue. On investigation, a low hemoglobin level of 7.3 gm% was used for blood transfusion. The patient was on regular hemodialysis after admission at our institution. Upper gastrointestinal bleeding was suspected after analyzing patient's history and investigations. Therefore, an upper gastrointestinal endoscopy was performed that showed linear ectatic punctuate lesions radiating from the body of the stomach to the antrum, and hence, an incidental diagnosis of the gastric antral vascular ectasia was made. Initial fluid resuscitation, iron therapy, and a triple regimen were administered. Proper management with argon plasma coagulation therapy was scheduled at another institution due to lack of respective facilities in our institution. DISCUSSION: Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding, primarily affecting the gastric antrum and pylorus with rare cases affecting the duodenum, jejunum, and gastric fundus. It is generally associated with other chronic disease conditions. Several hypotheses have been proposed for the pathogenesis of gastric antral vascular ectasia, especially its association with chronic kidney disease, as in our case, which is considered to be rare. Management varies from medical to endoscopic interventions to even surgery. CONCLUSION: Prompt proper diagnosis and treatment for the gastric antral vascular ectasia should be sought, as it is frequently misdiagnosed or missed during upper gastrointestinal endoscopy. Our case report presents a case of gastric antral vascular ectasia in chronic kidney disease undergoing maintenance hemodialysis, which is quite uncommon, as literature has suggested the same point.

Contrast-enhanced computed tomography assisted diagnosis of bleeding caused by colonic angiodysplasia: A case report.

RATIONALE: Angiodysplasia (AD) in the gastrointestinal tract is a degenerative vascular condition characterized by vascular dilation, tortuosity, and arteriovenous connections within the mucosal and submucosal layers. AD is a significant cause of lower gastrointestinal bleeding in the elderly, often presenting as chronic, intermittent hemorrhage. The research challenge lies in the potential for multiple and minute AD lesions to be missed during endoscopy, which may lead to post-hemostatic rebleeding. PATIENT CONCERNS: An 82-year-old female with a history of coronary artery disease treated with aspirin, presenting with recurrent melena and anemia. The patient exhibited a suboptimal response to blood transfusions and octreotide therapy. DIAGNOSIS: After excluding tumorous bleeding in the initial contrast-enhanced computed tomography (CECT), we suspect vascular bleeding as the most probable etiology. INTERVENTIONS: The initial colonoscopy was unsuccessful due to the occurrence of ventricular tachycardia. Considering the patient's advanced age, cardiac dysfunction, and frailty, a repeat CECT were conducted during episodes of suspected active bleeding. Vascular dilatation within the colonic hepatic flexure wall was visualized during the venous phase, accompanied by contrast agent extravasation into the intestinal lumen. The subsequent urgent colonoscopy and pathological specimens from surgical resection supported the diagnosis of colonic AD. OUTCOMES: After the surgery, the patient did not experience melena thereafter. LESSONS: We highlight that CECT for diagnosing AD-related bleeding offers higher safety and convenience, potentially superior to digital subtraction angiography, particularly in critically ill elderly patients.

Clinical and Endoscopic Findings in Patients Presenting with Upper Gastrointestinal Bleeding at a Tertiary Care Hospital.

Background Upper gastrointestinal (UGI) bleeding is a severe medical condition that requires prompt evaluation and management. Understanding the clinical and endoscopic findings in patients presenting with upper gastrointestinal bleeding is essential for accurate diagnosis and effective treatment. Objective To investigate the age and sex composition, clinical presentations, and endoscopic findings of patients with upper gastrointestinal bleeding at a tertiary care hospital. Method A total of 561 patients with upper gastrointestinal bleeding were included in the study. Data on age, sex, and clinical presentation were collected for each patient. Endoscopic findings were recorded, and the relative frequency of various upper gastrointestinal lesions was analyzed. Result The age distribution of patients revealed that 40.82% were between 15 and 45 years, 32.98% were aged 46 to 65 years, and 26.20% were above 65 years. Among the patients, 73.08% were male and 26.92% were female. Hematemesis was observed in 248 cases, while melena was present in 136 cases, and both were present in 171 cases. Recent onset anemia with positive occult blood was reported in 6 patients. The most common endoscopic finding was varices (39.39%), followed by ulcers (15.51%). Mallory Weiss tear was noted in 5.53% of cases. Conclusion According to our findings, varices are the most common endoscopic finding in individuals with upper gastrointestinal bleeding rather than peptic ulcer disease. The considerable increase in varices emphasizes the critical importance of early identification and care in high-risk individuals, as well as contributing to a better understanding of upper gastrointestinal bleeding.

Gastrointestinal stromal tumor of the duodenum presenting with shock and massive upper and lower gastrointestinal bleeding: a case report and review of the literature.

BACKGROUND: Due to rarity of duodenal GISTs, clinicians have few information about its clinical features, diagnosis, management and prognosis. CASE REPORT: We report a case of promptly diagnosed duodenal GIST in a 61-year-old Egyptian man presented shocked with severe attack of hematemesis and melena. Upper gastroduodenal endoscopy was done and revealed a large ulcerating bleeding mass at first part of duodenum 4 hemo-clips were applied with good hemostasis. An exploratory laparotomy and distal gastrectomy, duodenectomy and gastrojejunostomy were performed. The morphology of the mass combined with immunohistochemistry was consistent with duodenal gastrointestinal stromal tumours (GISTs) of high risk type. The patient is on amatinib one tablet daily and he was well with no evidence of tumor recurrence. CONCLUSION: despite being rare, emergency presentation with sudden severe, life-threatening hemorrhagic shock duodenal GISTs might be a cause of potentially lethal massive combined upper and lower gastrointestinal bleeding which is the key feature of this rare and challenging tumor.

An Unexpected Lymphoma: A Rare Case of Primary Gastric Burkitt's Lymphoma.

Primary gastric Burkitt's lymphoma is an aggressive non-Hodgkin's lymphoma that has been rarely reported in the literature. The majority of primary gastric lymphomas are diffuse large B-cell lymphomas and mucosa-associated lymphoid tissue (MALT) lymphomas. Patients with primary gastric Burkitt's lymphoma can present with abdominal pain, hematemesis, melena, perforation, and obstruction. Diagnosis is made with a combination of clinical, radiological, and pathological findings. Treatment data are limited due to the limited cases reported. We present a case of a 47-year-old female who presented with diffuse abdominal pain, melena, and coffee-ground emesis that was diagnosed with primary gastric Burkitt's lymphoma following biopsies taken from a gastric ulcerated mass found on upper endoscopy.

[Two Cases of Portal Vein Stent Placement for Portal Vein Stenosis Due to Recurrence of Pancreatic Cancer].

We report 2 cases of portal vein stent placement for malignant portal stenosis due to recurrence of pancreatic cancer with symptoms of portal hypertension. Case 1: The patient was a 68-year-old female. Five years ago, a mass was found around the aorta on a computerized tomography(CT)scan taken after a residual pancreatectomy for pancreatic cancer. It was diagnosed as lymph node recurrence and S-1 therapy was started. As further tumor enlargement led to portal vein compression, venostasis around the ascending jejunum, anemia, and black stools, a portal vein stent was placed. The portal vein blood flow was improved, the collateral vessels disappeared, and the patient no longer experienced anemia or black stool. Case 2: A 75-year-old female patient underwent a subtotal gastric-sparing pancreaticoduodenectomy and combined resection of the portal vein for pancreas head cancer. On a postoperative CT scan taken 6 months later, a mass compressing the portal vein appeared, which was diagnosed as a local recurrence. As thrombocytopenia was observed, a portal vein stent was placed before starting chemotherapy. The portal vein blood flow and the platelet count improved. Portal vein stenting is an effective procedure for malignant portal stenosis, improving portal blood flow and clinical symptoms.

Overt gastrointestinal bleeding secondary to left inferior phrenic artery pseudoaneurysm postgastric bypass surgery.

Bleeding from a visceral artery pseudoaneurysm (VAPA) is a rare but significant complication of bariatric surgery. Patients may present with gastrointestinal (GI) haemorrhage in the forms of haematemesis, melaena, haematochezia or haemodynamic compromise. Although CT angiogram, endoscopy and laparoscopy form essential parts of diagnostic assessment, small pseudoaneurysms with intermittent bleeding may be overlooked. We report the case of a man in his 40s who presented to the emergency department with massive GI bleeding and subsequent haemodynamic instability, secondary to a pseudoaneurysm from a vascular injury during a recent bariatric procedure. This case highlights the diagnostic challenges of obscure, intermittent bleeding involving the bypassed stomach with unremarkable investigation findings, and aims to raise awareness among clinicians in considering the less common postgastric-bypass complications.

The Brunner adenoma of the duodenum with positive fecal occult blood and anemia: A case report.

RATIONALE: Brunner gland adenoma (BGA) is a rare benign duodenal tumor that is an adenomatoid lesion in nature rather than an actual tumor. Patients with different adenoma sizes have various clinical manifestations with nonspecific clinical symptoms. Here, We report a case of BGA with black stool and anemia as the primary manifestations. PATIENT CONCERNS: A young female patient was admitted to the hospital because of black stool and anemia. Endoscopic surgery was performed to a definitive diagnosis, and endoscopic tumor-like lesions were resected. DIAGNOSIS: The patient was diagnosed with duodenal Brunner adenoma and received related treatment. OUTCOMES: After treatment, the patient symptoms improved, and he was discharged. LESSONS: Brunner adenoma of the duodenum is a rare benign duodenum tumor. This report paper describes a case of BGA with black stool and anemia as the primary manifestations, followed by endoscopic resection and treatment. The literature on Brunner adenoma of the duodenum has been analyzed and discussed. Clinicians should pay attention to differentiating the disease based on atypical symptoms.

Hookworm infestation as a rare cause of melaena in tropics: A case report.

Melaena due to hookworm infestation is a rare clinical presentation. It usually presents with symptoms of iron-deficiency anaemia owing to slow blood loss. Here we present a case of 45-year male who presented with a one-year history of intermittent melena requiring multiple blood transfusions. Preliminary endoscopies at different centres were normal. The presence of hookworm in the duodenum was only detected on repeat upper endoscopy as the cause of blood loss, and treatment with albendazole was successful in curing the patient.

An unpredictable gastrointestinal bleed.

A 65-year-old male complained of persistent melena for 6 days, and displayed anemia symptoms without hematemesis, vomiting, and abdominal distention. He was diagnosed as ruptured aneurysm of aortic sinus Valsalva, and had received coronary artery occlusion 1 month ago. After the operation, he was continually prescribed clopidogrel 75 mg once daily. The laboratory examination showed blood hemoglobin concentration was 60 g/L without other conspicuous abnormality. Unfortunately, neither esophagogastroduodenoscopy (EGD) nor colonoscopy found no obvious bleeding lesions. And abdominal computed tomography angiography (CTA) and enhanced computed tomography (CT) showed no obvious abnormal findings. Moreover, capsule endoscopy revealed small intestinal with mucosal erosion (Figure 1A). After discontinued clopidogrel, blood transfusion, and support therapy, his symptoms was resolved with negative fecal occult blood, continued clopidogrel 75 mg once daily, and uneventfully discharged 1 week later.

[Successful portal vein stent placement for chronic portal vein stenosis 5 years after pancreatoduodenectomy:a case report].

A 73-year-old man underwent pancreatoduodenectomy 5 years previously, and portal vein stenosis was observed immediately after surgery. A collateral vein with varices around the hepaticojejunostomy gradually developed. The patient experienced repeated episodes of melena that required transfusion. Enteroscopy confirmed varices around the hepaticojejunostomy, caused by portal vein stenosis, which was the source of intestinal bleeding. Varices were treated by placing an expandable metallic stent in the stenotic portal vein through a percutaneous transhepatic route. Although the portal vein stenosis was severe, the guidewire was successfully maneuvered into the superior mesenteric vein and stent placement was successful. Subsequently, the collateral vein disappeared and no further melena was observed.

Impact of secondary infections on dengue presentation: A cross-sectional study in a tertiary care hospital in Uttar Pradesh, India.

BACKGROUND: Recently, a wide range variety of manifestations, including a self­limiting to severe illness, has been increasingly reported in dengue. Few studies attract attention to severe dengue, mainly observed in secondary infection. With this background, this study aims to provide a comprehensive overview to differentiate primary from secondary dengue using serology (IgG) and the possible association of severity of illness in secondary dengue. METHODS: Present retrospective cross-sectional study was conducted at a North Indian tertiary care center from September 2021 to January 2022. Clinical data of confirmed dengue patients from the medicine department were collected and assigned as primary and secondary dengue. RESULTS: Of the 220 dengue patients, 22 (10 %) had secondary dengue infection. Hemorrhagic manifestations were reported in 58/220 (26.4 %) cases while 7/22 (31.8 %) in secondary dengue. Prevalent hemorrhagic manifestations in secondary dengue include purpura (27.3 %), vaginal bleeding (4.5 %), melaena (9.1 %), and epistaxis (4.5 %). In addition, 42 (19.1 %) patients had pancytopenia, and 8 (36.6 %) cases were of secondary dengue. Hepatic dysfunction was noted in 164 (74.5 %) cases. Notably, all secondary dengue cases (22;100 %) had hepatic dysfunction and severe in 9 (40.9 %) cases. In addition, in secondary dengue patients, evidence of plasma leakages such as hypoproteinemia 7 (31.8 %) and ascites (35 %) were statistically more frequent. Overall, two deaths (0.9 %) were reported, and were one in each group. CONCLUSIONS: Many parameters, including hemorrhagic manifestation (melaena), hematological characteristic (pancytopenia), evidence of plasma leakage (hypoproteinemia and ascites), gastrointestinal (GB wall thickening and hepatic dysfunction) and reduction in mean hemoglobin and platelet count were found to be statistically significant in secondary dengue infection. Additionally, early classification of secondary dengue may help to anticipate its severity and allow for early strategic intervention/management to lower morbidity and mortality.

Plasma urea:creatinine ratio as a biomarker of gastrointestinal bleeding in dogs with anaemia.

BACKGROUND: Gastrointestinal bleeding is a cause of anaemia in dogs. A reliable, non-invasive biomarker to differentiate gastrointestinal bleeding from other causes of anaemia would be advantageous to direct clinical decisions in anaemic patients. Plasma urea:creatinine ratio is an accepted biomarker of upper gastrointestinal bleeding in human medicine. OBJECTIVES: The objective of this study was to evaluate plasma urea:creatinine ratio as a biomarker of gastrointestinal bleeding in a population of dogs with anaemia. METHODS: This was a prospective cross-sectional study of dogs with anaemia presenting to referral centres for the investigation of anaemia. Cases were categorised as having overt gastrointestinal bleeding (melena on presentation), occult gastrointestinal bleeding (historical and diagnostic findings consistent with gastrointestinal bleeding without melena at presentation) or anaemia of other cause (confident diagnosis other than gastrointestinal bleeding reached, normal diagnostic imaging of gastrointestinal tract). Urea:creatinine ratio at presentation was calculated by dividing urea (mg/dL) by creatinine (mg/dL). RESULTS: Ninety-five dogs were included. Plasma urea:creatinine ratio was not significantly different between dogs with overt or occult gastrointestinal bleeding or those with anaemia of other cause (median urea:creatinine ratio 25.8, 20.7 and 22.5, respectively). No significant difference in urea:creatinine ratio was found between dogs with upper and lower gastrointestinal bleeding (median urea:creatinine ratio 19.4 and 24.6, respectively). CONCLUSIONS: Plasma urea:creatinine ratio was not helpful in differentiating between dogs with anaemia resulting from gastrointestinal bleeding (overt or occult) and those with other causes of anaemia.

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.

[Neuroendocrine carcinoma of the gallbladder as a rare cause for melena and hematemesis in dogs]. / Neuroendokrines Karzinom der Gallenblase als seltene Ursache für Meläna und Hämatemesis beim Hund.

A 9-year-old male Malinois was presented for further workup of acute melena, hematemesis and chronic weight loss for a duration of one month. Clinically, the patient presented with a mildly reduced general condition. Blood tests revealed mild non-regenerative anemia as well as a mild elevation of alanine aminotransferase (ALT). Ultrasonography showed signs of an early mucocele. Treatment with gastroprotectants failed to lead to clinical improvement and the dog developed progressive anemia. Gastroduodenoscopy was unremarkable. Due to persistent clinical signs, exploratory laparotomy was performed. An ulcerated bleeding mass was detected at the gallbladder neck. Histopathological examination led to the diagnosis of a neuroendocrine carcinoma. There was no evidence of a mucocele on histopathology. Melena and hematemesis subsided postoperatively and 13 months after cholecystectomy, the dog remains without clinical signs. Neuroendocrine carcinomas of the gallbladder should be considered as a rare cause of melena and hematemesis in dogs.

Duodeno-duodenal intussusception presenting as upper gastrointestinal bleed.

Duodeno-duodenal intussusception (DDI) is the type of intestinal intussusception in which a segment of the duodenum invaginates into the next part of the duodenum. We present a case of a male patient in his 50s presenting with right upper abdominal pain with multiple episodes of vomiting and a history of melena for 1 month. Imaging studies showed the presence of DDI without apparent growth. The patient underwent upper gastrointestinal endoscopy, which showed a doubtful growth in the duodenum, and the biopsy, was suggestive of adenocarcinoma. The patient underwent Whipple's procedure, and postoperative histology was diagnostic of Brunner's gland adenoma. The patient improved well without any complications.