Surgical treatments of recurrent small intestine metastatic melanoma manifesting with gastrointestinal hemorrhage and intussusception:A case report

BACKGROUND Melanoma is the most aggressive form of skin cancer,with a tendency to metastasize to any organ.Malignant melanoma is the most frequent cause of skin cancer-related deaths worldwide.Small intestine cancers especially small intestine metastases are relatively rare.Small intestine metastases are seldom described and likely underdiagnosed.Intussusception is most common in pediatric age,and in adults are almost 5%of all cases.CASE SUMMARY A 75-year-old man with a history of acral malignant melanoma was admitted to the Gastroenterology Department of our hospital,complaining of intermittent melena for 1 mo.Magnetic resonance enterography showed partial thickening of the jejunal wall and formation of a soft tissue mass,indicating a neoplastic lesion with jejunojejunal intussusception.The patient underwent partial small bowel resection.Pathological findings and immunohistochemical staining indicated small intestine metastatic melanoma.The patient refused further anti-tumor treatment after the surgery.Ten months after the first surgery,the patient presented with melena again.Computed tomography enterography showed the anastomotic stoma was normal without thickening of the intestinal wall,and routine conservative treatment was given.Three months later,the patient developed melena again.The patient underwent a second surgery,and multiple metastatic melanoma lesions were found.The patient refused adjuvant anti-tumor treatment and was alive at the latest follow-up.CONCLUSION Small intestine metastatic melanoma should be suspected in any patient with a history of malignant melanoma and gastrointestinal symptoms.

Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Hemorrhage:A Retrospective Analysis

Objective:The role of urgent endoscopy in nonvariceal upper gastrointestinal hemorrhage(NVUGIH)remains controversial.We designed a retrospective study to compare the outcomes between urgent endoscopy(within 12 h)and non-urgent endoscopy for patients with NVUGIH.Methods:A total of 540 hospitalized patients with NVUGIH were included in our study.Patients who received endoscopy within 12 h or after 12 h were divided into two groups,the urgent and non-urgent endoscopy groups,respectively.The clinical outcomes including rebleeding,mortality,endoscopic re-intervention,need for emergency surgery and interventional radiotherapy were compared between the groups.Patients with Glasgow-Blatchford scores(GBS)<12 and>12 were defined as the lower-and high-risk groups,respectively,and the predictors of rebleeding and mortality in both groups were analyzed individually.Results:Patients with NVUGIH in the urgent endoscopy group had a higher rate of rebleeding(27.6%vs.16.9%,P=0.003)and blood transfusion(73.2%vs.55.5%,P<0.001)than those in the non-urgent endoscopy group,while the mortality and the length of hospitalization were not significantly different between the groups(P>0.05).For lower-risk patients,urgent endoscopy was independently associated with a higher likelihood of rebleeding(adjusted OR:1.73,95%CI:1.03-2.88),while it was not associated with in-hospital mortality.However,the urgent need for endoscopy was not associated with rebleeding and in-hospital mortality in high-risk patients.Conclusion:Endoscopy within 12 h did not provide any advantage in the outcomes of patients with NVUGIH,and may even lead to an increased rebleeding rate in lower-risk patients.

Upper gastrointestinal hemorrhage caused by superwarfarin poisoning

Superwarfarins are a class of rodenticides. Gastrointestinal hemorrhage is a fatal complication of superwarfarin poisoning, requiring immediate treatment. Here, we report a 55-year-old woman with tardive upper gastrointestinal hemorrhage caused by superwarfarin poisoning after endoscopic cold mucosal biopsy.

Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions

BACKGROUND Gastrointestinal hemorrhage(GIH)is a common complication with gastrointestinal cancers(GIC).There is no comprehensive research that examines GIH in different types of GIC.AIM To study the prevalence,predictors,and interventions of GIH based on the anatomical location of GIC.METHODS This is a retrospective analysis of the 2016-2018 National Inpatient Sample database,the largest inpatient care database in the United States.All adult inpatients(≥18-year-old)were included.ICD-10-CM codes were used to identify patients with GIH and GIC.Prevalence of GIH was obtained based on the anatomical location of GIC.Predictors of GIH in the GIC population were studied using multivariate analysis.Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality.RESULTS Out of a total of 18173885 inpatients,321622(1.77%)cases had a diagnosis of GIC.Within GIC patients,30507(9.5%)inpatients had GIH,which was significantly(P<0.001)more than the prevalence of GIH in patients without GIC(3.4%).The highest to lowest GIH rates are listed in the following order:Stomach cancer(15.7%),liver cancer(13.0%),small bowel cancer(12.7%),esophageal cancer(9.1%),colorectal cancer(9.1%),pancreatic cancer(7.2%),bile duct cancer(6.0%),and gallbladder cancer(5.1%).Within gastric cancer,the GIH rate ranged from 14.8%in cardia cancer to 25.5%in fundus cancer.Within small bowel cancers,duodenal cancers had a higher GIH rate(15.6%)than jejunal(11.1%)and ileal cancers(5.7%).Within esophageal cancers,lower third cancers had higher GIH(10.7%)than the middle third(8.0%)or upper third cancers(6.2%).When studying the predictors of GIH in GIC,socioeconomic factors such as minority race and less favorable insurances(Medicaid and self-pay)were associated with significantly higher GIH on multivariate analysis(P<0.01).Chemotherapy and immunotherapy were also identified to have a lower risk for GIH[odds ratios(OR)=0.74(0.72-0.77),P<0.001].Out of 30507 GIC inpatients who also had GIH,16267(53.3%)underwent an endoscopic procedure,i.e.,upper endoscopy or colonoscopy.Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy[5.5%vs 14.9%,OR=0.42(0.38-0.46),P<0.001].CONCLUSION The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location.Endoscopy,which appears to be associated with a substantial reduction in inpatient mortality,should be offered to GIC patients with GIH.Nevertheless,the decision on intervention in the GIC population should be tailored to individual patient's goals of care,the benefit on overall care,and long-term survival.

Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum.Small bowel tuberculosis,characterized by predominant involvement of the small intestine,is an extremely rare condition with highly atypical clinical presentations,making diagnosis even more challenging.CASE SUMMARY We report three cases of small intestinal tuberculosis,two of the patients pre-sented primarily with abdominal pain,and one presented with gastrointestinal bleeding.All patients underwent blood tests and imaging examinations.Small bowel endoscopy(SBE)revealed that the main lesions in these patients were in-testinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers.One patient ultimately underwent surgical treatment.Following a complex diagnostic process and comprehensive analysis,all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment,leading to an improvement in their condition.CONCLUSION Patients with SBTs present with nonspecific symptoms such as abdominal pain,weight loss,and occasional gastrointestinal bleeding.Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagno-sis and complications.

Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis:A case report and literature review

BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis.It can lead to increased blood flow through mesenteric collaterals.This segmental hypertension may result in the development of colonic varices(CV)with a high risk of severe gastrointestinal bleeding.While clear guidelines for treatment are lacking,splenectomy or splenic artery embolization are often used to treat bleeding.Splenic vein stenting has been shown to be a safe option.CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding.She was anemic with a hemoglobin of 8.0 g/dL.As a source of bleeding,CV were identified.Computed tomography scans revealed thrombotic occlusion of the splenic vein,presumably as a result of a severe acute pancreatitis 8 years prior.In a selective angiography,a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed.The hepatic venous pressure gradient was within normal range.In an interdisciplinary board,transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting,as well as coiling of the aberrant veins was discussed and successfully performed.Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV.However,a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Upper gastrointestinal bleeding as an unusual manifestation of localized Ménétrier’s disease with an underlying lipoma:A case report

BACKGROUND Ménétrier’s disease is a rare condition characterized by enlarged gastric folds,usually located in the whole body and fundus of the stomach.This report presents an unusual case of localized Ménétrier’s disease elevated by a submucosal lipoma and thus looking like a polypoid mass and causing an episode of upper gastrointestinal bleeding.The mass was successfully removed with endoscopic submucosal dissection.CASE SUMMARY Esophagogastroduodenoscopy was performed on a 76-year-old male patient after an episode of upper gastrointestinal bleeding,manifesting as fatigue and melena.A large polypoid mass(4 cm×1 cm)with enlarged mucosal folds was found in the body of the stomach,between the lesser curvature and posterior wall.A small ulcer at the distal end of the mass was identified as the source of the bleeding.Biopsy was negative for neoplasia.Computed tomography showed a submucosal lesion beneath the affected mucosa,most likely a lipoma.The mass was removed en bloc with tunneling endoscopic submucosal dissection.Final pathology determined that the mass included Ménétrier’s disease and a submucosal lipoma.The patient was scheduled for follow-up esophagogastroduodenoscopy.CONCLUSION Localized Ménétrier’s disease can coexist with a submucosal lipoma creating a polypoid mass with risk of bleeding.

Massive bleeding in small intestinal mucosa-associated lymphoid tissue lymphoma associated with COVID-19 infection:a case report

The increased risk of mucosa-associated lymphoid tissue(MALT)lymphoma is closely associated with chronic antigenic stimulation,with infection being the most common cause of recurrence.Lesions are usually associated with the gastrointestinal tract,and the involvement of small intestinal is rare.Recent studies have established a close relationship between novel coronavirus 2019(COVID-19)and the occurrence and progression of various diseases.This article presents a rare case of a small intestinal MALT lymphoma.The patient was initially admitted with COVID-19 pneumonia and subsequently developed gastrointestinal bleeding during hospitalization.Medical and endoscopic treatments were ineffective,and an emergency exploratory laparotomy was performed.The affected segment of the small intestine was excised,and a pathological biopsy confirmed the diagnosis of MALT lymphoma.This case underscores the significance of raising clinical awareness of this condition among health care professionals.

Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding:A meta-analysis

AIM: To analyze the accuracy of computed tomography (CT) angiography in the diagnosis of acute gastrointestinal (GI) bleeding. METHODS: The MEDLINE, EMBASE, Cancerlit, Cochrane Library database, Sciencedirect, Springerlink and Scopus, from January 1995 to December 2009, were searched for studies evaluating the accuracy of CT angiography in diagnosing acute GI bleeding. Studies were included if the ycompared CT angiography to a reference standard of upper GI endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute GI bleeding. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic. RESULTS: A total of 9 studies with 198 patients were included in this meta-analysis. Data were used to form 2 × 2 tables. CT angiography showed pooled sensi-tivity of 89% (95% CI: 82%-94%) and specificity of 85% (95% CI: 74%-92%), without showing significant heterogeneity (χ2 = 12.5, P = 0.13) and (χ2 = 22.95, P = 0.003), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.9297. CONCLUSION: CT angiography is an accurate, costeffective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management.

Prognosis of hepatic cirrhosis patients with esophageal or gastric variceal hemorrhage: multivariate analysis

Objective: To study the effect of bacterial infection, use of antibiotics, active bleeding at endoscopy, and the severity of liver disease as prognostic factors in hepatic cirrhotic patients during the first 5 days after the episode of esophageal or gastric variceal hemor- rhage. Methods: Seventy-six hepatic cirrhosis patients with esophageal or gastric variceal bleeding were enrolled. Bleeding was managed in a standardized protocol u- sing octreotide and vasopressin in sclerotherapy or band ligation for active bleeding at endoscopy. The screening protocol for bacterial infection consisted of chest radiograph; blood, urine and ascitic fluid cul- tures; the severity of liver disease shown by Child- Pugh score. Results: Active bleeding was observed at endoscopy in 40 patients (53%). Failure to control bleeding Within 5 days occurred in 36 patients (45%). Empir- ical antibiotic treatment was used in 53 patients (67%), whereas bacterial infections were documen- ted in 43 patients (57%). Multivariate analysis showed that proven bacterial infection (P<0.01) or antibiotic use (P<0.05) as well as active bleeding at endoscopy (P<0.01) and Child-Pugh score (P< 0.01) were independent prognostic factors of failure to control bleeding. Conclusion: Bacterial infection is associated with fai- lure to control esophageal or gastric variceal bleeding in hepatic cirrhotic patients.

Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding:A systematic review

BACKGROUND Anemia is considered a public health issue and is often caused by iron deficiency.Iron-deficiency anemia(IDA)often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women,and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%.However,few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.AIM To review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.METHODS Five gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites.MEDLINE(via PubMed)searches combined medical subject headings(MeSH)terms and the keywords“gastrointestinal bleeding”with“iron-deficiency anemia”and“diagnosis”or“treatment”or“management”or“prognosis”or“prevalence”or“safety”or“iron”or“transfusion”or“quality of life”,or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding;retrieved studies were published in English between January 2003 and April 2019.Worldwide professional association websites were searched for clinical practice guidelines.Reference lists from guidelines were reviewed to identify additional relevant articles.The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.RESULTS From 494 Literature citations found during the initial literature search,17 original articles,one meta-analysis,and 13 clinical practice guidelines were analyzed.Based on the published evidence and clinical experience,the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding:(1)Evaluation of hemoglobin and iron status;(2)Laboratory testing;(3)Target treatment population identification;(4)Indications for erythrocyte transfusion;(5)Treatment targets for erythrocyte transfusion;(6)Indications for intravenous iron;(7)Dosages;(8)Monitoring;(9)Indications for intravenous ferric carboxymaltose treatment;and(10)Treatment targets and monitoring of patients.The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding,which should be implemented during the hospital stay and follow-up visits after patient discharge.CONCLUSION These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding,which ultimately may improve health outcomes in these patients.

Hemosuccus pancreaticus:a rare cause of gastrointestinal bleeding

BACKGROUND: Hemosuccus pancreaticus (HP) is defined as upper gastrointestinal (GI) hemorrhage from the papilla of Vater via the pancreatic duct and is a rare cause of digestive bleeding. DATA SOURCE: A PubMed search of relevant articles published from January 1967 to September 2011 was performed to identify current information about HP in terms of its etiology, pathophysiology, clinical presentation, diagnosis and management. RESULTS: A variety of etiological factors, most commonly chronic pancreatitis but also tumors and vascular diseases, can lead to this condition. Appropriate endoscopic or radiologic procedures should be chosen to establish a precise diagnosis for patients, especially those with a known history of pancreatic disorders, who present with abdominal pain, GI hemorrhage and hyperamylasemia. There are two main therapeutic options for this condition: angiographic embolotherapy and surgery. Both treatments can stop bleeding, but angiographic embolotherapy is the treatment of choice for stable patients. Recently, new and less invasive treatments have emerged to treat this condition. CONCLUSIONS: Because of its rarity and broad spectrum of causes, HP is difficult to diagnose accurately. However, appropriate endoscopic and radiologic procedures are extremely helpful for establishing a correct diagnosis. Both angiographic embolotherapy and surgery are reliable treatment options for this condition, and transcatheter intervention is the treatment of choice for clinically stable patients. Additional innovative treatments have emerged, but their effectiveness and safety must be confirmed. (Hepatobiliary Pancreat Dis Int 2012;11:479-488)

Concurrent amoebic and histoplasma colitis:A rare cause of massive lower gastrointestinal bleeding

Infective colitis can be a cause of massive lower gastrointestinal bleeding requiring acute surgical intervention. Causative organisms include entamoeba and histoplasma species. However, concurrent colonic infection with both these organisms is very rare, and the in vivo consequences are not known. A 58-year-old male presented initially to the physicians with pyrexia of unknown origin and bloody diarrhea. Amoebic colitis was diagnosed based on biopsies, and he was treated with metronidazole. Five days later, the patient developed massive lower gastrointestinal bleeding with hemorrhagic shock. Emergency total colectomy with end-ileostomy was performed. However, he deteriorated and died on the second postoperative day. Histopathological examination revealed multiple deep ulcers at the hepatic flexure where fungal bodies of mycelial and yeast forms were noted. Isolated lymph nodes showed abscess formation with fungal bodies. Infective fungal colitis with Histoplasma capsilatum was diagnosed. In vitro, amoebic parasites can increase virulence and pathogenicity of histoplasma which may account for the fulminant presentation in this patient. Although rare, this unusual dual infection should be considered in the differential diagnosis of infective colitis, as appropriate antimicrobial treatment may prevent progression to massive lower gastrointestinal bleeding, obviating the need for urgent surgical intervention.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease

BACKGROUND Acute severe lower gastrointestinal bleeding(LGIB)is an uncommon but challenging complication of Crohn’s disease(CD).AIM To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODS A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center,a tertiary university hospital in Korea.Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB.A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.RESULTS Multivariable Cox regression analysis revealed that early use of thiopurines[hazard ratio(HR):0.23,95%confidence interval(CI):0.12-0.48;P<0.001]and female sex(HR:0.51,95%CI:0.27-0.94;P=0.031)were significantly associated with a lower risk of acute severe LGIB.The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups(P=0.139 and P=0.769,respectively).The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group(22.1/100 vs 13.2/100 patient-years;P=0.012).However,if hospitalizations due to bleeding episodes were excluded from the analysis,the hospitalization rate was not significantly different between the bleeding group and the matched nonbleeding group(14.5/100 vs 13.2/100 patient-years;P=0.631).CONCLUSION Early use of thiopurines may reduce the risk of acute severe LGIB.History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Risk factors for major gastrointestinal bleeding in the general population in Finland

BACKGROUND Data on non-drug related risk-factors for gastrointestinal bleeding(GIB)in the general population are limited,especially for life-style factors,clinical measurements and laboratory parameters.AIM To identify and investigate non-drug risk factors for major GIB in the general population of Finland.METHODS We performed a retrospective cohort study using data from the FINRISK health examination surveys,which have been conducted every 5 years across Finland from 1987 to 2007.Participants were adults aged 25 years to 74 years,excluding those with a previous hospitalization for GIB.Follow-up from enrollment was performed through linkage to national electronic health registers and ended at an event of GIB that led to hospitalization/death,death due to any other cause,or after 10 years.Covariates included demographics,socioeconomic and lifestyle factors,clinical measurements,laboratory parameters and comorbidities.Variable selection was undertaken using Least Absolute Shrinkage and Selection Operator(LASSO)and factors associated with GIB were identified using Cox regression.RESULTS Among 33,508 participants,403(1.2%)experienced GIB[256 men(63.5%);mean age,56.0 years(standard deviation(SD)±12.1)]and 33105 who did not experience GIB[15768 men(47.6%);mean age,46.8(SD±13)years],within 10 years of follow-up.Factors associated with a significantly increased risk of GIB were baseline age[per 10-year increase;hazard ratio(HR)1.62,95%confidence interval(CI):1.42-1.86],unemployment(HR:1.70,95%CI:1.11-2.59),body mass index(BMI)(HR:1.15,95%CI:1.01-1.32),gamma-glutamyl transferase(GGT)(HR:1.05,95%CI:1.02-1.09),precursors of GIB(HR:1.90,95%CI:1.37-2.63),cancer(HR:1.47,95%CI:1.10-1.97),psychiatric disorders(HR:1.32,95%CI:1.01-1.71),heart failure(HR:1.46,95%CI:1.04-2.05),and liver disorders(HR:3.20,95%CI:2.06-4.97).Factors associated with a significantly decreased risk of GIB were systolic blood pressure(SBP)(HR:0.78,95%CI:0.64-0.96),6-10 cups of coffee a day(HR:0.67,95%CI:0.46-0.99),or>10 cups(HR:0.43,95%CI:0.23-0.81).CONCLUSION Our study confirms established risk-factors for GIB and identifies potential risk-factors not previously reported such as unemployment,BMI,GGT,SBP and coffee consumption.

Duodenal giant stromal tumor combined with ectopic varicose hemorrhage:A case report

BACKGROUND Gastrointestinal stromal tumors(GISTs)are mesenchymal tissue tumors originating from Cajal cells,presenting diverse clinical manifestations due to the different sizes,locations,and growth patterns of the lesions.Duodenum is an uncommon site of GISTs,more with gastrointestinal obstruction and bleeding as the first symptoms.Ectopic duodenal varix,as a rare varix occurring outside the gastroesophageal region,is the main type of heterotopic varices and an unusual cause of gas-trointestinal hemorrhage.The etiology is mainly seen in liver cirrhosis,portal hypertension,vasculitis,portal vein embolism and obstruction caused by various factors.Reports of duodenal stromal tumor combined with ectopic variceal hemorrhage are rarely seen;however,when it occurs,the situation can sometimes be urgent and life-threatening,especially when traditional endoscopy and imaging fail to detect the lesion timely.CASE SUMMARY We report a 52-year-old female patient who had no obvious inducement to develop black stool.Gastroscopy in a local hospital revealed that the duodenal horizontal ectopic varices were ruptured and bleeding.After metal clamping hemostasis,she still had gastrointestinal bleeding and was transferred to our hospital.Gastroscopy showed that active bleeding was still seen in the horizontal part of duodenum,and suspicious submucosal eminence was seen in the bleeding part.Abdominal computed tomography showed a huge stromal tumor of duodenum,specimens were pathologically confirmed after surgery.After a 3-mo follow-up,no gastrointestinal hemorrhage and complications occurred.CONCLUSION Ectopic variceal hemorrhage is rare but sometimes fatal.It may be combined with stromal tumor,which can be diagnosed by multiple methods.Endoscopic and surgical treatment are effective.

Gastric Gist as Cause of High Digestive Hemorrhage

Introduction: Gastrointestinal stromal tumor (GIST) occurrence is uncommon and usually manifested by nonspecific signs and symptoms, which hinders its reasoning as a diagnostic hypothesis. The objective is to report a case of female GIST with curative treatment through video-laparoscopy with partial gastrectomy. Case report: A 61-year-old female patient attended the Luiz Gioseffi Jannuzzi School Hospital (HELGJ) emergency room, with a sudden onset of upper gastrointestinal bleeding with hemodynamic instability. After stabilization, she was admitted for diagnostic investigation, showing sub-epithelial lesion of antrum in upper digestive endoscopy (UDE) and solid-cystic mass in the gastric antrum to computed tomography (CT). The conduct was the video laparoscopy surgical approach with partial gastrectomy. The histopathological and immunohistochemical aspects of the surgical specimen showed a gastrointestinal stromal tumor (GIST) in a gastric antrum of low grade of malignancy, positive e-Kit and mycotic index (50 cga) Discussion: Compared to the scarce reports in literature, the case described presented typical epidemiology, but the clinical picture was not the most incident. Conclusions: Given the rarity of this pathology cases, it is essential to report these in order to elucidate the specificities and also to discuss diagnostic and therapeutic methods.

Serum prealbumin as an effective prognostic indicator for determining clinical status and prognosis in patients with hemorrhagic stroke

Serum prealbumin is a recognized marker of malnutrition,but its prognostic role in patients with hemorrhagic stroke remains unclear.In this study,we retrospectively reviewed the records of 105 patients with hemorrhagic stroke admitted to Renmin Hospital of Wuhan University,China,from January to December 2015.We collected demographic and radiological data,and recorded serum prealbumin levels at admission and on days 1,3,6,9,and 14-21.The existence of infections and gastrointestinal hemorrhage,and clinical condition at discharge were also recorded.Serum prealbumin levels during hospitalization were significantly lower in patients with infections compared with those without infections,and also significantly lower in patients with gastrointestinal hemorrhage compared with those without.Serum prealbumin levels at discharge were significantly higher in patients with good recovery than in those with poor recovery.We conclude that regular serum prealbumin measurements in patients with hemorrhagic stroke may be a useful indicator for determining clinical status and prognosis,which may therefore help to guide clinical decision-making.

Black esophagus: Acute esophageal necrosis syndrome

Acute esophageal necrosis (AEN), commonly referred to as "black esophagus", is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory f indings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic "black esophagus" abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classif ication of the disease spectrumis best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.