Recurrent gastrointestinal bleeding caused by cytomegalovirus duodenitis.

A 78-year-old male hospitalized due to acute pneumonia presented with hematemesis, melena and hypotension. Past medical history was relevant for prostate cancer with bone and lung metastasis under systemic chemotherapy. Upper gastrointestinal endoscopy revealed a 50mm serpiginous ulcer in the second portion of the duodenum with a visible vessel (Forrest IIa). Hemostatic therapy with adrenaline, polidocanol and one clip placement was performed. Biopsies of the ulcer were also obtained. During hospitalization the patient developed recurrent gastrointestinal bleeding requiring several red blood cell transfusions and endoscopic reintervention. Further histopathologic evaluation revealed chronic duodenitis caused by cytomegalovirus (CMV) infection. Considering the poor performance status and successful hemostasis with ulcer healing, antiviral treatment was not initiated. The patient died a few weeks later due to neoplastic disease progression.

An extreme megaesophagus causing lung collapse.

An 83-year-old male with long-term dysphagia and weight loss was admitted due to an acute ST-elevation myocardial infarction. During hospitalization he developed hematemesis requiring several red blood cell transfusions. An upper endoscopy was attempted being interrupted due to esophageal high-volume stasis. Despite remaining fasting for several days and naso-esophageal tube drainage, three additional upper endoscopies still revealed non-removable solid food stasis in a markedly dilated esophagus and bleeding from severe underlying esophagitis. A thoracic CT confirmed an aberrant and massive esophageal dilation with 110x100mm and large food impaction leading to almost complete right lung atelectasis and respiratory failure. A narrow esophagogastric junction and no apparent associated obstructive lesions were also observed on CT scan. Based on clinical symptoms and radiologic findings a presumptive diagnosis of achalasia was considered although it could not be confirmed through esophageal manometry. Parenteral nutrition was started. Nevertheless, the patient died a few days later from aspiration pneumonia.

EUS-guided hepaticogastrostomy in multimetastatic liver disease - an effective approach for biliary drainage that may complement ERCP.

A 36-year-old male was diagnosed with a metastasized colon adenocarcinoma causing obstructive jaundice. Magnetic resonance cholangiography showed a dominant lesion causing hilar stenosis. The patient was submitted to endoscopic retrograde cholangiopancreatography (ERCP), nevertheless it was just possible to place a single uncovered self-expandable metallic stent (SEMS) in the right lobe. Although cholestasis significantly improved, safe levels for oncologic therapy were not reached. EUS-guided hepaticogastrostomy was proposed to complement ERCP biliary drainage. Using a forward-viewing echoendoscope and a transgastric approach, EUS-guided puncture of a dilated left intrahepatic duct at segment III was accomplished with a 19G needle (EchoTip ProCore®) that allowed passage of a 0.035 guidewire. A 6F cystotome and biliary dilators (5Fr+8.5Fr) were used for needle tract dilation. A partially-covered SEMS (GIOBOR™ 8x100mm) could be deployed under endoscopic and fluoroscopic control, being placed 3cm inside the gastric lumen. No associated complications were observed after the procedure.

Metastatic melanoma: an uncommon cause of upper gastrointestinal bleeding.

Melanoma gastrointestinal metastases are rare and represent a late stage of malignant disease with the jejunum and ileum being the most common locations followed by stomach, colon and duodenum. We present a case of a patient with past history of cutaneous melanoma treated twelve years before, in remission. The patient developed upper gastrointestinal bleeding due to metastatic melanoma in the duodenum.

Duodenal angiolipoma: a rare tumor causing recurrent upper gastrointestinal bleeding.

Duodenal angiolipoma is a rare adipocytic tumor, with non-specific symptoms precluding an early diagnosis. We present a case of a 67-year-old female admitted due to upper gastrointestinal bleeding. The upper endoscopy and endoscopic ultrasound evaluation showed a subepithelial lesion in the third portion of the duodenum. Endoscopic excision was performed using a standard polypectomy technique after endoloop placement. Histopathology was compatible with duodenal angiolipoma. The authors highlight duodenal angiolipoma as a rare adipocytic tumor potentially causing gastrointestinal bleeding, which can be safely treated with endoscopic excision.

NOBLADS-External Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding.

BACKGROUND: Acute lower gastrointestinal bleeding is a common cause of hospital admission. NOBLADS is a lower gastrointestinal bleeding clinical risk score. OBJECTIVE: This study aimed to externally validate NOBLADS in predicting severe acute lower gastrointestinal bleeding and clinical outcome. DESIGN: Observational retrospective study. SETTING: This study was performed in a single large tertiary hospital. PATIENTS: Patients who were admitted with acute lower gastrointestinal bleeding during a 15-month period and underwent endoscopic evaluation were included. Patients with chronic lower gastrointestinal bleeding or acute lower gastrointestinal bleeding who were admitted for other conditions were excluded. MAIN OUTCOME MEASURES: Primary outcome was acute severe lower gastrointestinal bleeding (classified as severe if requires transfusion of >2 units of packed red blood cells and/or produces a >20% hematocrit fall). Secondary outcomes: red blood cells requirement, therapeutic intervention and hospital stay duration. NOBLADS score was applied to all patients. Its accuracy to predict acute severe bleeding and secondary outcomes were studied using receiver operating characteristic analysis. RESULTS: A total of 173 patients (50.3% males, age 69 ± 17 years) were included. The most common lower gastrointestinal bleeding etiologies were diverticular bleeding (18.5%) and ischemic colitis (15.6%). Fifty patients (28.9%) presented criteria for severe bleeding and 33 patients required instrumental intervention: endoscopic (n = 28), surgical (n = 4), and radiologic (n = 1) therapy. NOBLADS score was significantly different according with acute lower gastrointestinal bleeding causes (p < 0.001) and accurately predicted severe bleeding (area under the receiver operating characteristic curve 0.923 ± 0.018 (p < 0.001)). NOBLADS ≥2 detected acute severe lower gastrointestinal bleeding with 100% sensitivity/62.4% specificity, identifying the need for higher red blood cells requirement (3.6 vs 0.08, p < 0.001), therapeutic intervention (38% vs 13%, p < 0.001), and longer hospital stay (12.8 vs 3 days, p < 0.001). LIMITATIONS: Unicenter retrospective study; number of unprepared sigmoidoscopies/left side colonoscopies; comparison between NOBLADS and other scoring systems was not performed. CONCLUSION: NOBLADS is a practical, highly accurate tool and predicts the need of in-hospital management, early colonoscopy, red blood cells transfusion, and longer hospital stay in patients admitted with acute lower gastrointestinal bleeding. See Video Abstract at http://links.lww.com/DCR/B748.NOBLADS: VALIDACIÓN EXTERNA DE UN SISTEMA DE PUNTUACIÓN DE RIESGO PARA HEMORRAGIA DIGESTIVA BAJA AGUDA GRAVE. ANTECEDENTES: La hemorragia digestiva baja aguda es causa común de admisión hospitalaria. NOBLADS es una puntuación de riesgo clínico de hemorragia gastrointestinal baja. OBJETIVO: Este estudio tuvo como objetivo validar externamente NOBLADS en la predicción de hemorragia digestiva baja aguda grave y sus resultados clínicos. DISEO: Estudio observacional retrospectivo. AJUSTE: Realizado en un gran hospital terciario. PACIENTES: Se incluyeron todas aquellas personas ingresados con hemorragia digestiva baja aguda durante un período de 15 meses y que fueron sometidos a evaluación endoscópica. Se excluyó la hemorragia digestiva baja crónica o la hemorragia digestiva baja aguda en pacientes ingresados por otras afecciones. PRINCIPALES MEDIDAS DE RESULTADO: El resultado pricipal fue la hemorragia digestiva baja grave aguda (clasificada como grave si requiere >2 transfusiones de glóbulos rojos y / o produce una caída del hematocrit >20%). Las medidas de resultados secundarias fueron: requerimiento de glóbulos rojos, intervención terapéutica y duración de la estancia hospitalaria. Se aplicó la puntuación NOBLADS a todos los pacientes. Se estudió su precisión para predecir la hemorragia aguda grave y los resultados secundarios mediante análisis ROC. RESULTADOS: Se incluyeron 173 pacientes (50,3% varones, edad 69 ± 17 años). La etiología de hemorragia digestiva baja más frecuentes fueron: la hemorragia de orígen diverticular (18,5%) y la colitis isquémica (15,6%). 50 pacientes (28,9%) presentaron criterios de sangrado severo y 33 pacientes requirieron intervención instrumental: terapia endoscópica (n = 28), quirúrgica (n = 4), radiológica (n = 1). La puntuación NOBLADS fue significativamente diferente según las causas de hemorragia digestiva baja aguda (p <0,001), siendo precisa para predecir hemorragia grave (AUC 0,923 ± 0,018 (p <0,001). NOBLADS ≥2 detectó hemorragia digestiva baja aguda grave con 100% de sensibilidad / 62,4 % de especificidad, identificando la necesidad de mayor requerimiento de glóbulos rojos (3.6 vs 0.08, p <0.001), intervención terapéutica (38% vs 13%, p <0.001) y estadía hospitalaria más prolongada (12.8 vs 3 días, p <0.001). LIMITACIONES: Estudio retrospectivo Unicentrico; número de sigmoidoscopias / colonoscopias del lado izquierdo no preparadas; no se realizó comparación entre NOBLADS y otros sistemas de puntuación. CONCLUSIN: NOBLADS es una herramienta práctica y altamente precisa que predice la necesidad de manejo hospitalario, colonoscopia precoz, transfusión de glóbulos rojos y estadía hospitalaria más prolongada en pacientes ingresados con hemorragia digestiva baja aguda. Consulte Video Resumen en http://links.lww.com/DCR/B748. (Traducción-Dr. Xavier Delgadillo).

Vitamin D in dysphagic patients who have undergone endoscopic gastrostomy for long-term enteral feeding.

OBJECTIVE: Vitamin D plays a major role in biological processes. Its deficiency is associated with increased morbidity and mortality. Patients who have undergone endoscopic gastrostomy (PEG) present with protein-energy malnutrition, and may be at risk for Vitamin D deficiency, due to their age, less sunlight exposure and lower dietary intake. We aimed to determine the prevalence of hypovitaminosis D in PEG-patients, its change under PEG-feeding, and its relationship with serum proteins and risk factors for Vitamin D deficiency. METHODS: This was a prospective observational study, over 4 weeks, after gastrostomy. Data were collected at the initial PEG procedure (T0), and after 4 weeks (T1). Initial evaluation included age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and Vitamin D. At T1 we assessed Vit. D, albumin, and transferrin. Vitamin D was performed with Electrochemiluminescence through Elecsys 2010 assay. Patients were fed with blended homemade meals. RESULTS: 200 patients (118 males), 22-92 years of age, were studied. There were initial low values for Vit. D (181), albumin (96), transferrin (121), and BMI (124). A correlation was found between Vit. D and serum albumin (r=0.49, p=0.005) but not with transferrin (r=0.26, p=0.195). At T1 the subgroup who had Vit. D levels assessed (n=48) was part of the initial study group maintained low levels of Vitamin D despite nutritional intervention. CONCLUSION: We recommend systematic Vitamin D supplementation of PEG fed patients using homemade meals or at least screening for hypovitaminosis D as a routine part of their care.

Mantle cell lymphoma of the cecum.

The authors have read with great interest the recently published article "Colon lymphomas: an analysis of our experience over the last 23 years" by Martín Domínguez V et al., a single center retrospective review of 29 patients diagnosed with colon lymphoma. The present report describes a case of mantle cell lymphoma (MCL) of the cecum that aims to improve the knowledge regarding this unusual clinical and endoscopic entity.

Nutritional deficiency during colonoscopy preparation: the forgotten iatrogeny.

BACKGROUND AND AIMS: bowel preparation for colonoscopy induces a semi-fasting state, with a potential negative impact on fragile patients. The present study aims to quantify nutritional deficiency during colonoscopy preparation. METHODS: this was an observational and cross-sectional study. A convenience sample was obtained that included adults that underwent colonoscopy after bowel preparation with Klean-Prep® according to the center protocol. Anthropometric evaluation was performed and nutritional deficiency was calculated via the quantification of energy and protein intake during the 48 hours prior to the examination which was compared with the individuals' needs. The association between nutritional deficiency with the quality of bowel preparation, age and status (hospitalized/ambulatory) was evaluated. RESULTS: the study included 131 patients aged 21-91 years (mean 63.6 ± 13.2 years); 73 cases were male. Malnutrition reached 67.2% using specific anthropometric tools. A median preparation quality of six points was found when the Boston Bowel Preparation Scale was considered. The mean intake 48 hours prior to the procedure was 1,795 kcal and 100 g of protein. A daily energy intake of less than 50% of the individual needs was observed in 88 patients and less than 25% in 29 cases. The mean energy and protein deficiency were 59% (p < 0.01) and 45% (p < 0.01), and there was no correlation with preparation quality (p > 0.05). Nutritional defiency is similar in hospitalized and ambulatory patients (p > 0.05), but higher in older individuals (p = 0.04). CONCLUSIONS: nutritional deficiency during colonoscopy preparation was significant, more so in older patients, and there was no correlation with the quality of bowel preparation. We conclude that bowel preparation regimens should be reformulated with an improved nutritional intake and the inclusion of nutritional supplements without residues.

Giant esophageal diverticulum as a new clinical indication for endoscopic gastrostomy.

Persistent mechanical or functional dysphagia is the most common clinical indication for endoscopic gastrostomy (PEG), however less common conditions may justify prolonged enteral feeding to avoid malnutrition and prevent aspiration. The authors report the case of a 76 year old man referred to the artificial feeding outpatient clinic presenting dysphagia, malnutrition and several episodes of aspiration pneumonia. Upper endoscopy showed a giant esophageal diverticulum, ineffective peristalsis and transient lumen narrowing. X-ray and CT scan confirmed a 9cm long diverticulum. Due to a high surgical risk and unsuitability of endoscopic therapy, the patient underwent PEG, which solved aspiration and improved nutritional status. Dysphagia and aspiration due to giant esophageal diverticula emerges as a new clinical indication for PEG in malnourished patients with respiratory aspiration, not previously reported in the literature.

Paraesophageal hernia and gastric volvulus: an uncommon etiology of vomiting and upper gastrointestinal bleeding.

The authors report the case of a 75 year-old woman admitted to the emergency room with abdominal pain and coffee ground vomiting. Marked epigastric distension with tenderness and signs of severe dehydration were present. Upper GI endoscopy showed a black esophagus covered by a large amount of dark fluid, diffuse hyperaemia and superficial erosions. Marked distortion of gastric anatomy caused by stomach rotation and a large paraesophageal hernia was observed and the pylorus was not identified. Chest X-ray and CT scan confirmed the presence of an organoaxial gastric volvulus with antero superior rotation and incarceration of the gastric antrum, which was located above the diaphragm. Immediate surgery repaired the diaphragmatic hernia, obtained volvulus reduction and a Nissen fundoplication was performed to prevent recurrence. The patient was discharged without further complications. Acute gastric volvulus is a rare entity that may manifest with vomiting due to gastric outlet obstruction and gastrointestinal bleeding associated with mucosal ischemia and sloughing. Emergency surgery wass required to resolve symptoms and prevent complications.

CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on chronic liver failure admitted to the ward.

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is a frequent syndrome associated with high mortality. The aims of the present study are: a) comparing the Chronic Liver Failure Consortium (CLIF-C) ACLF Model for End-Stage Liver Disease (MELD), MELD Sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores for prediction of short/medium term mortality; b) identifying ACLF prevalence in patients admitted to the ward; and c) comparing mortality between non-ACLF/ACLF. METHODS: Retrospective cohort study of 177 patients admitted to the Gastroenterology ward for acute decompensation of cirrhosis. RESULTS: We included 132 males. Alcohol was the cirrhosis cause/co-factor in 79.7% of cases. Infection was present in 40.7%. At admission, 19.8% of patients presented ACLF and 7.9% developed it during hospitalization (overall prevalence was 27.7%). ACLF grade 1 was diagnosed in 55.1% of the ACLF patients; grade 2, in 42.8%, and grade 3, in 2.0%. Infection (p < 0.001) and hepatic encephalopathy (p = 0.004) were more prevalent and C-reactive protein and leukocyte counts were higher in ACLF patients. ACLF 28 and 90-day mortality was 45.8% and 60.4%, respectively. The CLIF-C ACLF score was significantly superior to CTP, MELD, MELD-Na in predicting 28-day (AUROC 0.799 ± 0.078, 95% CI 0.637-0.891) and 90-day mortality (AUROC 0.828 ± 0.063, 95% CI 0.705-0.952). CONCLUSION: ACLF is highly prevalent in the ward. The new CLIF scores identify high mortality cirrhotic patients admitted to the ward and are better than their predecessors to predict ACLF patients' short/medium term mortality.

Percutaneous endoscopic gastrostomy for nutritional support in dementia patients.

BACKGROUND: A link between aging, dementia and malnutrition is established and leads to poor prognosis. Endoscopic gastrostomy (PEG) is used without clear benefit on survival, nutritional status or quality of life. AIMS: This work aims to assess the effectiveness of PEG-feeding for nutritional support in patients with dementia. METHODS: We conducted an observational, longitudinal and retrospective study using records from patients with moderate-severe dementia that underwent PEG. Age, gender, dementia subtype and mortality were considered. Body mass index (BMI), serum albumin, transferrin and total cholesterol were recorded at the time of the PEG procedure (T0) and repeated after 3 months (T3). The evolution of those parameters was analysed and compared to survival. RESULTS: We obtained data from 46 patients (16 men/30 women) between 50 and 94 years (M = 79 years). Most had Alzheimer's. Mean survival was 21 months. Mortality rate at 3 months was 15 %. At T0, 30 patients were undernourished according to BMI and 29, 31 and 16 patients displayed low albumin, transferrin and total cholesterol, respectively. Albumin (p < 0.01) and transferrin levels (p < 0.05) were significantly increased from T0 to T3. High albumin (r = 0.2), transferrin (r = 0.3) and cholesterol (r = 0.1) at T0 were positively correlated with longer survival. CONCLUSIONS: Low albumin, transferrin and cholesterol were predictors of a poor survival. PEG improves low albumin and transferrin, serum markers of malnutrition and poor outcome. PEG should be considered on an individual basis in patients with moderate-severe dementia when risk of malnutrition and aspiration is present.

Long-evolution ascites in a patient with constrictive pericarditis.

Constrictive pericarditis (CP) is an uncommon disease resulting from chronic pericardial inflammation, fibrosis and calcification. Once there are atypical forms of presentation, with subtle or nonexistent cardiorespiratory symptoms, diagnosis may be challenging and difficult. Recurrent ascites in patients with congestive hepatopathy due to constrictive pericarditis is common and, in most cases, reversible after pericardiectomy. Nevertheless, development of persistent liver dysfunction may be a long-term complication. The present work describes a 23 years old man with growth delay, dyspnoea and long evolution ascites, whose exhaustive etiological investigation led to diagnosis. Afterwards the patient underwent elective surgery with symptom and general condition improvement. Ascites differential diagnosis and its association with constrictive pericarditis are briefly reviewed in this article.