Sustained Hemostasis With the Padlock™ Over-the-scope Clip for Gastric Fundus Dieulafoy's Lesion in the Setting of Anticoagulation Following Hemorrhagic Shock From Two Dieulafoy's Lesions.

Dieulafoy's lesions (DLs) are a rare and difficult-to-identify cause of acute gastrointestinal bleeding that can lead to hemorrhagic shock. We present a case of a 23-year-old previously healthy male presenting with melenic stools and hemorrhagic shock. Computed tomography of abdomen and pelvis with oral and intravenous contrast showed a possible source of hemorrhage as a hyperdense intraluminal material within the stomach. Initial urgent esophagogastroduodenoscopy showed a large, nonbleeding distal esophageal DL, which was treated successfully with 10 mL of 1:10,000 epinephrine and bipolar cauterization with 10 Fr Gold Probe™. Hemorrhage recurred 2 d later, prompting another esophagogastroduodenoscopy, which found another DL within the gastric fundus. Treatment with epinephrine, Gold Probe™, and through-the-scope Hemoclips was unsuccessful because of difficult visualization and positioning. A subsequent attempt was made using the over-the-scope clip (OTSC) Padlock™ Clip Defect Closure System with successful hemostasis and stabilization of the patient. His hospital course was complicated by left lower lobe segmental pulmonary embolism without right heart strain for which he was discharged on 3 months of anticoagulation with apixaban. On follow-up, there was no recurrence of gastrointestinal bleeding (GIB) despite 3 months of anticoagulation. He did not complete the Basic Underwater Demolition/SEAL (BUD/S) Training. This case report demonstrates the evaluation and management of a patient with hemorrhagic shock from two DLs and sustained hemostasis with the Padlock™ OTSC in the setting of apixaban anticoagulation.

Clarification of Eosinophilic Esophagitis Treatment in the DoD Retention Standards.

The DoD Instruction 6130.03, Volume 2, outlines the retention standards for the U.S. Military, providing guidance on medical conditions and treatments that are disqualifying for all branches of the military. This document states that patients with conditions requiring immunomodulating or immunosuppressant medications do not meet retention standards. Eosinophilic esophagitis is a common, chronic inflammatory disease of the esophagus that typically presents with dysphagia. Although proton pump inhibitors are effective at treating this disease in some cases, swallowed topical steroids are the most frequently used therapy within the DoD. These medications act locally in the esophagus and do not cause systemic side effects typical of oral steroid therapy, including immunosuppression. They are effective at inducing and maintaining disease remission and are generally well tolerated, with minimal side effects. We propose a brief amendment to this document to clarify the language used and avoid inappropriate Medical Evaluation Board referrals.

Tattoo Trouble: A Case of Drug-induced Thrombocytopenic Purpura.

Trimethoprim-sulfamethoxazole, otherwise known as Bactrim or Septra, is a commonly prescribed antibiotic for soft tissue infections. Drug-induced thrombocytopenia is a rare but serious adverse reaction to sulfonamide antibiotics like Bactrim/Septra. A 34-year-old active duty marine male with no significant past medical history presented with a chief complaint of a rash on his lower extremities. The patient stated that 2 weeks earlier, he was prescribed Bactrim for cellulitis at the site of a new tattoo. The intern noted a petechial rash that was pathognomonic for thrombocytopenia. Laboratory testing confirmed the patient's thrombocytopenia with platelets of 2,000/µL on initial complete blood count, without pancytopenia or other coagulopathies. The blood smear indicated a profound lack of platelets but otherwise normal cell counts and morphology. In the emergency department, the patient was typed and crossed, platelets were ordered, and hematology-oncology was consulted. Once admitted to the internal medicine ward, he was administered glucocorticoids as well as platelet transfusions. He was monitored for 3 days and discharged with a diagnosis of resolved drug-induced thrombocytopenia. This case illustrates the importance of conducting a thorough review of systems and physical examination in stable and otherwise healthy patients. In this case, the seemingly benign rash was one of the only clinical signs of severe thrombocytopenia, with a high risk of spontaneous bleeding in clinically significant organ systems. It is important to recognize immune thrombocytopenic purpura as a potential complication of Bactrim/Septra, as this antibiotic is widely used by military providers in operational settings.