Congenital Gastric Teratoma Presenting with Gastrointestinal Bleeding: Case Report and Review of Literature.

BACKGROUND: Gastric teratoma is an extremely rare tumor, representing <1% of all pediatric teratomas, and commonly manifests as a palpable abdominal mass. Upper gastrointestinal tract bleeding in newborns and infants is rare and is mostly caused by a benign lesion. CASE REPORT: We present a 3-month-old boy who presented with recurrent attacks of hematemesis, vomiting, and melena which on work up revealed a gastric teratoma. DISCUSSION/CONCLUSION: Owing to the unique characteristics and the extreme rarity of this entity, accurate preoperative diagnosis has remained elusive.

Risk factors and outcomes of upper gastrointestinal bleeding in hospitalized patients in a tertiary care hospital.

Objective: To determine different aetiologies and outcomes of upper gastrointestinal bleeding in hospitalised patients. METHODS: The retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from December 2019 to April 2021 related to adult patients of either gender with nongastrointestinal illnesses who developed bleeding at least 24 hours after admission. Data was reviewed for clinical characteristics, cause of bleeding and clinical outcome. Data was analysed using SPSS 23. RESULTS: Among 47,337 hospitalised patients, upper gastrointestinal bleeding was identified in 147(0.3%); 98 (66.7%) males and 49 (33.3%) females. The overall mean age was 62.73±14.81 years (range 20-95 years). Of the total, 125(85%) presented with overt bleeding and 22(15%) with a drop in haemoglobin level. There were 34(23%) patients on aspirin, 36(24%) on dual anti-platelets, 41(28%) on therapeutic anticoagulation, and 81(55%) on prophylactic anticoagulation. There were 7(5%) patients having a history of non-steroidal anti-inflammatory drugs (NSAIDs), and 12(8%) were on steroids. In terms of associated medical conditions, pneumonia, stroke, and acute coronary syndrome were commonly seen with frequency of 29.9%, 8.1% and 7.4% respectively. Overall, 36(24.4%) patients underwent endoscopy, 8(5.4%) had therapeutic measures to control bleeding, 14(9.5%) had bleeding for >48 hours, 89(60.5%) were stepped up to special care. Mortality was seen in 36(24.5%) cases. CONCLUSIONS: Hospital acquired gastrointestinal bleeding was found to be uncommon, and there were several risk factors for such bleeding events.

Pure testicular choriocarcinoma with gastrointestinal metastasis and paraneoplastic symptoms: a case report.

BACKGROUND: Pure testicular choriocarcinoma is a rare type of non-seminomatous germ cell tumor extremely poor prognostic with the tendency to bleed at the metastatic site. At the time of the diagnosis, 70% of patients have metastatic lesions. Depending on the site of the metastasis, symptoms vary. Gastrointestinal involvement is seen in less than 5% of cases, mostly in the duodenum. CASE PRESENTATION: We present a 47 years old male with testicular choriocarcinoma involving the jejunum, lung, liver, and kidney presenting with acute abdominal pain, melena, and dyspnea with some paraneoplastic symptoms. The patient had increased, severe and constant pain in the right lower quadrant for the previous four days. Additionally, he was complaining of nausea, vomiting, anorexia, and a history of melena for the last 10 days. Dyspnea on exertion, hemoptysis, and dry cough were the symptoms he was suffering from, for almost one year. The patient's general appearance was pale, ill, and thin with 10 kg of weight loss during the last some months. The computed tomography (CT) scan reported multiple metastatic lesions in both liver lobes and the left kidney. Pathologic study of the samples of small bowel lesions showed metastatic choriocarcinoma. Following the patient had been referred to an oncologist to start the chemotherapy regime. Finally, the patient has expired after 40 days of his first admission. CONCLUSIONS: Testicular choriocarcinoma is a rare but fatal malignancy among young men. Gastrointestinal metastases are infrequent involvement represented by melena and acute abdominal pain, obstruction, and mass. Physicians should consider it as a differential diagnosis for acute abdomen and gastrointestinal bleeding causation.

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.

Long Tubular Duplication of the Small Intestine - Lessons Learnt from a Common Presentation of a Rare Disease.

Long tubular duplication of the small intestine is one of the most difficult surgical challenges. The presence of heterotopic gastric mucosa necessitates resection of the duplicated bowel, but shared vascularity with the normal adjoining bowel makes the task daunting. We present a case of long tubular small intestinal duplication with certain special surgical and perioperative challenges which were successfully managed.

Long-Term Outcomes in Patients with Post-Bulbar Ulcer Bleeding Compared to Bulbar Ulcer Bleeding in the Duodenum.

BACKGROUND: Duodenal ulcers are classified into bulbar and post-bulbar ulcers. The aim of this study is to compare the long-term outcomes of patients with post-bulbar ulcer bleeding and those with bulbar ulcer bleeding. METHODS: A total of 272 patients with hemorrhagic duodenal ulcers requiring hospitalization were included. Their medical records were retrospectively reviewed. RESULTS: All patients were categorized as bulbar or post-bulbar bleeding ulcer groups. The post-bulbar ulcer group had more patients of advanced age, concurrent malignancy, diabetes mellitus, hypertension, cirrhosis, and chronic kidney disease undergoing hemodialysis. We performed long-term follow-up for an average of 2.6 years. The mortality rate during the follow-up period in the post-bulbar ulcer group was significantly higher than that in the bulbar ulcer group (p < 0.001). The PNED score was a better predictor of 30-day mortality compared to the complete Rockall score and the Glasgow-Blatchford Score. Predictors of mortality were evaluated using a Cox proportional hazards regression model. In multivariate analysis, post-bulbar ulcer, concurrent malignancy, cirrhosis, antiplatelet/anticoagulant use, and transfusion were significant predictors of mortality. CONCLUSIONS: Patients with post-bulbar ulcers have a poorer prognosis than those with bulbar ulcers. After the diagnosis of hemorrhagic post-bulbar duodenal ulcer, close follow-up is necessary.

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.

Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience.

INTRODUCTION: Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. MATERIAL AND METHODS: Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. RESULTS: The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. CONCLUSION: HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

The 'nick' or 'clip'? A giant hepatic artery pseudoaneurysm complicating laparoscopic cholecystectomy.

Right hepatic artery pseudoneurysm (HAPA) is a rare but potentially lethal complication following laparoscopic cholecystectomy. Its incidence is as low as 0.6%-0.8% and usually presents within the first month following the surgery due to iatrogenic injury to the concerned artery. A high index of suspicion is essential since it may often be missed leading to a catastrophic outcome. Often a contrast-enhanced computer-aided tomography of the abdomen done as evaluation of postcholecystectomy state suggests a pseudoanerysm. We report a single case of a 27-year-old female who presented to us and deteriorated rapidly due to a ruptured right HAPA, with an acute abdomen and melena, who was surgically managed by exploration and excision of the pseudoaneurysmal sac due to unavailability of transarterial embolization. During surgery, the cystic artery metal clip was seen eroding in hepatic artery producing pseudoanerysm.

Gastrointestinal bleeding in hospitalized COVID-19 patients: a propensity score matched cohort study.

BACKGROUND AND AIMS: Gastrointestinal (GI) bleeding has been observed amongst patients hospitalized with COVID-19. Recently, anticoagulation has shown to decrease mortality, but it is unclear whether this contributes to increased GI bleeding. The aims of this study are: (i) to examine whether there are risk factors for GI bleeding in COVID-19 patients and (ii) to study whether there is a mortality difference between hospitalized patients with COVID-19 with and without GI bleeding. METHODS: This is a propensity score matched case-control study from a large health system in the New York metropolitan area between March 1st and April 27th. COVID-19 patients with GI bleeding were matched 1:1 to COVID-19 patients without bleeding using a propensity score that took into account comorbidities, demographics, GI bleeding risk factors and length of stay. RESULTS: Of 11, 158 hospitalized with COVID-19, 314 patients were identified with GI bleeding. The point prevalence of GI bleeding was 3%. There were no identifiable risk factors for GI bleeding. Use of anticoagulation medication or antiplatelet agents was not associated with increased risk of GI bleeding in COVID-19 patients. For patients who developed a GI bleed during the hospitalization, there was an increased mortality risk in the GI bleeding group (OR 1.58, P = 0.02). CONCLUSION: Use of anticoagulation or antiplatelet agents was not risk factors for GI bleeding in a large cohort of hospitalized COVID-19 patients. Those with GI bleeding during the hospitalization had increased mortality.

Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients.

BACKGROUND: Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions. METHODS: This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12 months. Rebleeding was defined as a drop of hemoglobin ≥ 2 g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding. RESULTS: From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9 months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding. CONCLUSION: Heart failure, smoking status, and angioectasias with a size superior to 5 mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.

Presence of Melena in Obscure Gastrointestinal Bleeding Predicts Bleeding in the Proximal Small Intestine.

BACKGROUND AND AIMS: Melena is a symptom of upper gastrointestinal bleeding and usually indicates bleeding proximal to the ligament of Treitz. However, whether melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding (OGIB) is unknown and the objective of this study. METHODS: A retrospective cohort study of consecutive patients undergoing capsule endoscopy for OGIB between July 2009 and May 2016 was conducted. Subjects were categorized based on the presence of melena, and the primary outcome was identification of a bleeding source within the proximal 2/3 of the small intestine. Multi-variable regression was performed to control for confounders. RESULTS: During the study, 288 patients met the eligibility criteria. Subjects with melena accounted for 37.1% of the cohort and were more likely to be older (mean age 66.9 vs. 63.9, p = 0.0457), take warfarin (15.1 vs. 9.4%, p = 0.0122), and have a lower 12-month hemoglobin nadir (7.3 vs. 8.3 g/dL, p = 0.0002). On crude analysis, 56.1% of patients with melena had a bleeding source within the proximal small intestine compared to 34.8% for those without (RR 1.61, 95% CI 1.24-2.09, p = 0.0004). On multi-variable analysis, the presence of melena doubled the odds of finding a bleeding site within the proximal small intestine (OR 1.97, 95% CI 1.17-3.33, p = 0.010). CONCLUSIONS: The presence of melena doubles the odds of finding a bleeding site within the proximal small intestine among patients with OGIB, and deep enteroscopy, if performed before a capsule study, should begin with an antegrade approach in these patients.

Exploratory laparoscopy combined with pathological examination in the diagnosis of obscure gastrointestinal bleeding in a child: a case report.

BACKGROUND: The diagnosis of obscure gastrointestinal bleeding (OGIB) which is defined as bleeding of unknown origin of the small bowel by routine evaluation in childhood is a challenge. CASE PRESENTATION: Here we report a one-year-old Chinese girl who was suspected with idiopathic pulmonary haemosiderosis (IPH) and referred to our department for further diagnosis. Finally she was diagnosed with vascular malformations (VM) by exploratory laparoscopy combined with pathological examination. CONCLUSIONS: Children OGIB could be easily misdiagnosed in the beginning, and OGIB children with active ongoing bleeding may benefit from proceeding directly to exploratory laparoscopy, followed by pathological confirmation of the diagnosis.

Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes.

BACKGROUND: Gastrointestinal (GI) tumor bleeding can vary from occult bleeding to massive hemorrhage and can be the presenting sign of malignancy. AIMS: Our primary aims were to: (1) characterize the natural history, treatment, and outcomes in patients with GI tumor bleeding and (2) compare and contrast bleeding in upper GI (UGI)/small bowel (SB) and lower GI malignancies. METHODS: Patients with endoscopically confirmed tumor bleeding were identified through search of consecutive electronic medical records: Bleeding was determined by the presence of melena, hematochezia, hematemesis, or fecal occult blood. Comprehensive clinical and management data were abstracted. RESULTS: A total of 354 patients with GI tumors were identified: 71 had tumor bleeding (42 UGI/SB and 29 colonic). GI bleeding was the initial presenting symptom of malignancy in 55/71 (77%) of patients; 26/71 patients had widely metastatic disease at presentation. Further, 15 of 26 patients with metastatic disease presented with GI bleeding. Visible bleeding was present in 14/42 (33%) and 4/29 (14%) of UGI/SB and colonic tumors, respectively. Endoscopic hemostasis was attempted in 10 patients, and although initial control was successful in all, bleeding recurred in all of these patients. The most common endoscopic lesion was clean-based tumor ulceration. Overall mortality at 1 year was 57% for esophageal/gastric, 14% for SB, and 33% for colonic tumors. CONCLUSIONS: When patients with GI malignancy present with GI bleeding, it is often the index symptom. Initial endoscopic hemostasis is often successful, but rebleeding is typical. Esophageal and gastric tumors carry the poorest prognosis, with a high 1-year mortality rate.

Hookworm infestation as a cause of melena and severe anaemia in farmer.

Hookworm infections remain a major cause of morbidity in the developing world. Prevalence is highest in agricultural areas, where use of waste water for irrigation and poor hygiene increases infection rates among farmers. Infections present with gastrointestinal symptoms and chronic anaemia, and there are usually no signs of overt blood loss. The following report describes a case of melena in a middle-aged farmer, where the diagnosis of hookworm infestation was delayed due to the unusual presentation. The patient underwent multiple blood transfusions before referral to the Aga Khan University Hospital (AKUH), Karachi and was managed conservatively with mebendazole at our hospital after exclusion of other possible causes of gastrointestinal bleeding. This case highlights the importance of considering hookworm infestations as a cause of melena in the older age group, where other critical differentials such as peptic ulcer disease and occult malignancy may result in delay in initiation of treatment and a significant financial burden on the patient.

COLONIC DIVERTICULOSIS AND DIVERTICULAR HEMORRHAGE IN A GERIATRIC FEMALE ORANGUTAN ( PONGO ABELII).

A 57-yr-old female Sumatran orangutan ( Pongo abelii) presented with signs of intermittent lethargy and inappetence, then subsequently developed profuse hemorrhagic diarrhea. Colonoscopy under anesthesia revealed diverticulosis of the descending colon, with multiple large diverticula containing fecoliths. There was no evidence of diverticulitis, but a regenerative anemia had developed following an acute diverticular bleed. The orangutan recovered with conservative therapy. Colonic diverticulosis has been reported in nonhuman primates and appears to have a similar clinical presentation to the condition as it occurs in humans. This is the first published report of colonic diverticulosis in a great ape.

The Incidence and Treatment Outcomes of Macrorhabdus ornithogaster Infection in Budgerigars ( Melopsittacus undulatus) in a Veterinary Clinic.

Macrorhabdus ornithogaster, avian gastric yeast, is a common cause of gastrointestinal disease in budgerigars ( Melopsittacus undulatus). To better understand the clinical disease in budgerigars presented in a practice population, we reviewed the occurrence, clinical signs, and treatment success of M ornithogaster disease in budgerigars during a 2.5-year period at the Clinic for Birds and Reptiles, University of Leipzig (Leipzig, Germany). The yeast was diagnosed by microscopic examination of fresh fecal samples. Male budgerigars of all ages were most affected. Most clinical signs in birds with confirmed positive results were nonspecific, except for the occurrence of undigested seeds in the feces. Although radiographic appearance of a dilated proventriculus is indicative of a M ornithogaster infection, it is difficult to recognize because of the small size of the budgerigars. Birds with positive results were treated with amphotericin B (100 mg/kg PO q12h) for 4 weeks. Treatment was stressful for the birds because of the handling required and the long treatment duration, and therapeutic results were unsatisfactory. Therefore, the indications for treatment with amphotericin B should be carefully considered in birds with positive M ornithogaster results. An increased occurrence of the infection in association with other pathogens was detected.

JP-HHT phenotype in Danish patients with SMAD4 mutations.

Patients with germline mutations in SMAD4 can present symptoms of both juvenile polyposis syndrome (JPS) and hereditary hemorrhagic telangiectasia (HHT): the JP-HHT syndrome. The complete phenotypic picture of this syndrome is only just emerging. We describe the clinical characteristics of 14 patients with SMAD4-mutations. The study was a retrospective, register-based study. SMAD4 mutations carriers were identified through the Danish HHT-registry, the genetic laboratories - and the genetic departments in Denmark. The medical files from relevant departments were reviewed and symptoms of HHT, JPS, aortopathy and family history were noted. We detected 14 patients with SMAD4 mutations. All patients had polyps removed and 11 of 14 fulfilled the diagnostic criteria for JPS. Eight patients were screened for HHT-symptoms and seven of these fulfilled the Curaçao criteria. One patient had aortic root dilation. Our findings support that SMAD4 mutations carriers have symptoms of both HHT and JPS and that the frequency of PAVM and gastric involvement with polyps is higher than in patients with HHT or JPS not caused by a SMAD4 mutation. Out of eight patients screened for aortopathy, one had aortic root dilatation, highlighting the need for additional screening for aortopathy.