Esophageal tuberculosis presenting with hematemesis

Esophageal tuberculosis is rare, constituting about 0.3% of gastrointestinal tuberculosis. It presents commonly with dysphagia, cough, chest pain in addition to fever and weight loss. Complications may include hemorrhage from the lesion, development of arterioesophageal fistula, esophagocutaneous fistula or tracheoesophageal fistula. There are very few reports of esophageal tuberculosis presenting with hematemesis due to ulceration. We report a patient with hematemesis that was due to the erosion of tuberculous subcarinal lymph nodes into the esophagus. A 15-year-old boy presented with hemetemesis as his only complaint. Esophagogastroduodenoscopy(EGD) revealed an eccentric ulcerative lesion involving 50% of circumference of the esophagus. Biopsy showed caseating epitheloid granulomas with lymphocytic infiltrates suggestive of tuberculosis. Computerised tomography of the thorax revealed thickening of the mid-esophagus with enlarged mediastinal lymph nodes in the subcarinal region compressing the esophagus along with moderate right sided pleural effusion. Patient was treated with anti-tuberculosis therapy(Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 6 mo. Repeat EGD showed scarring and mucosal tags with complete resolution of the esophageal ulcer.

Hematemesis as the initial complication of pancreatic adenocarcinoma directly invading the duodenum: A case report

Pancreatic carcinoma is a debilitating disease and carries a poor prognosis. It is a rare cause of upper gastrointestinal bleeding, even though pancreas, stomach, duodenum and jejunum are adjacent organs. The incidence of pancreatic adenocarcinoma directly invading the gastrointestinal tract leading to gastrointestinal hemorrhage is very low, and most of them present with melena and hematochezia. Here, we describe one unique case manifesting characteristically severe and unremitting hematemesis as an initial presentation of pancreatic adenocarcinoma. This tumor directly invaded the duodenal mucosa as a bleeding protruding tumor mass. Our MEDLINE search has confirmed that this is the first reported case with an initial manifestation of hematemesis from pancreatic adenocarcinoma in Asians.Pancreatic adenocarcinoma directly invading duodenum complicated by hemorrhage can be a rare cause of hematemesis, and clinicians should be reminded of it while they are making differential diagnosis.

Dieulafoy Gastric Lesion: An Unusual Cause of Pediatric Hematemesis

Dieulafoy lesion is a vascular anomaly predominantly found in the stomach, which represents a rare cause of gastrointestinal bleeding and life-threatening haemorrhages in pediatric age with few cases reported in the literature. We experienced a 7-year-old previously healthy boy with hematemesis endoscopically diagnosed and successfully treated for a Dieulafoy lesion in the stomach. This case report illustrates the initial diagnostic workup and the possible differential diagnosis in presence of an acute episode of hematemesis in children. It focuses on an uncommon cause of gastrointestinal bleeding that is probably underestimated because of missing diagnosis. Any unusual and acute case of upper gastrointestinal bleeding should raise the suspicion of Dieulafoy lesion also in children, especially in those who have a past medical history negative for peptic disease and varices due to portal hypertension: a promptly endoscopy can provide visual diagnostic criteria and ensure an adequate hemostasis that is generally the definitive treatment of the lesion.

An unusual cause of hematemesis:Goiter

Downhill varices are located in the upper part of the esophagus and are usually related to superior vena cava obstruction. Bleeding from these varices is extremely rare. We describe a 77-year-old patient with hematemesis due to downhill varices as a result of recurrent goiter. A right lobe thyroidectomy was carried out with disappearance of the varices.

An Infant with Dieulafoy’s Lesion: A Case Report from the Philippines

This is a case of a 5-month-old infant who experienced repeated episodes of hematemesis and no known underlying health conditions. It was subsequently diagnosed as Dieulafoy’s lesion localized in the lesser curvature of the stomach. Endoscopic diagnosis and treatment were done by angiographic embolization. Dieulafoy’s lesion is considered rare even for adult cases, much more for pediatric patients and usually underdiagnosed. Hence, patients presenting with gastrointestinal bleeding should be managed in a multidisciplinary approach. Spreading awareness about this lesion by including it in the considerations, may help improve early detection and treatment.

Italian survey on non-steroidal anti-inflammatory drugsand gastrointestinal bleeding in children

AIM: To investigate gastrointestinal complications associated with non-steroidal anti-inflammatory drug(NSAIDs) use in children.METHODS: A retrospective, multicenter study was conducted between January 2005 and January 2013, with the participation of 8 Italian pediatric gastroenterology centers. We collected all the cases of patients who refer to emergency room for suspected gastrointestinal bleeding following NSAIDs consumption, and underwent endoscopic evaluation. Previous medical history, associated risk factors, symptoms and signs at presentation, diagnostic procedures, severity of bleeding and management of gastrointestinal bleeding were collected. In addition, data regarding type of drug used, indication, dose, duration of treatment and prescriber(physician or selfmedication) were examined. RESULTS: Fifty-one patients, including 34 males, were enrolled(median age: 7.8 years). Ibuprofen was the most used NSAID [35/51 patients(68.6%)]. Pain was the most frequent indication for NSAIDs use [29/51 patients(56.9%)]. Seven patients had positive family history of Helicobacter pylori(H. pylori) infection or peptic ulcer, and 12 had associated comorbidities. Twenty-four(47%) out of 51 patients used medication inappropriately. Hematemesis was the most frequent symptom(33.3%). Upper gastrointestinal endoscopy revealed gastric lesions in 32/51(62%) patients, duodenal lesions in 17(33%) and esophageal lesions in 8(15%). In 10/51(19.6%) patients, a diagnosis of H. pylori gastritis was made. Forty-eight(94%) patients underwent medical therapy, with spontaneous bleeding resolution, while in 3/51(6%) patients, an endoscopic hemostasis was needed.CONCLUSION: The data collected in this study confirms that adverse events with the involvement of the gastrointestinal tract secondary to NSAID use are also common in

Ruptured high flow gastric varices with an intratumoral arterioportal shunt treated with balloon-occluded retrograde transvenous obliteration during temporary balloon occlusion of a hepatic artery

A patient presented with hematemesis due to gastric variceal bleeding with an intratumoral arterioportal shunt. Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein. Angiography and angio-CT revealed a marked intratumoral arterioportal shunt accompanied with reflux into the main portal vein and gastric varices. Balloon-occluded retrograde venography from the gastro-renal shunt showed no visualization of gastric varices due to rapid blood flow through the intratumoral arterioportal shunt. The hepatic artery was temporarily occluded with a balloon catheter to reduce the blood flow through the arterioportal shunt, and then concurrent balloon-occluded retrograde transvenous obliteration （BRTO） was achieved. Vital signs stabilized immediately thereafter, and contrast-enhanced CT revealed thrombosed gastric varices. Worsening of hepatic function was not recognized. BRTO combined with temporary occlusion of the hepatic artery is a feasible interventional procedure for ruptured high flow gastric varices with an intratumoral arterioportal shunt.

Isolated gastric variceal bleeding caused by splenic lymphoma-associated splenic vein occlusion

Isolated gastric varices(IGV) can occur in patients with left-sided portal hypertension resulting from splenic vein occlusion caused by thrombosis or stenosis. In left-sided portal hypertension,blood flows retrogradely through the short and posterior gastric veins and the gastroepiploic veins,leading to the formation of an IGV. The most common causes of splenic vein occlusion are pancreatic diseases,such as pancreatic cancer,pancreatitis,or a pseudocyst. However,various other cancers,such as colon,gastric,or renal cancers,have also been known to cause splenic vein occlusion. Our patient presented with a rare case of IGV bleeding induced by splenic lymphoma-associated splenic vein occlusion. Splenectomy,splenic artery embolization,and stenting of the splenic vein are the current treatment choices. Chemotherapy,however,is an alternative effective treatment for splenic vein occlusion caused by chemotherapy-sensitive tumors. Our patient responded well to chemotherapy with a cyclophosphamide,hydroxydaunorubicin,oncovin,and prednisolone regimen,and the splenic vein occlusion resolved after the lymphoma regressed.

Vascular emergencies in cholelithiasis and cholecystectomy: our experience with two cases and literature review

BACKGROUND:Complications from gallstones and laparoscopic cholecystectomy can be serious and fatal if there is a delay in recognition and treatment. We aim to present two unusual, life threatening vascular complications as a result of gallstones and laparoscopic cholecystectomy. Their management is highlighted with a brief review of literature. METHODS:Data for the article were gathered from clinical case note review. Radiology database was used for images. A brief literature review was undertaken using Pubmed search. The keyword used included hemobilia, pseudoaneurysm, arterio-biliary fistula and laparoscopic cholecystectomy. RESULTS:The article highlights two individual case reports. The first case constitutes an 81-year woman who had cystic arterial erosion causing hematemesis, while the second patient was a 57-year man who presented with hemobilia from a pseudoaneurysm of right hepatic artery (RHA) following laparoscopic cholecystectomy. Cystic arterial erosion was treated with subtotal cholecystectomy with duodenal defect closure while the pseudoaneurysm underwent radiological intervention. CONCLUSIONS:Cystic artery erosion and pseudoaneurysm causing arteriobiliary fistula are rare vascular complications related to the biliary tree. A high index of suspicion and timely intervention is important. Trauma to arteries should be avoided during laparoscopic cholecystectomy.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND Acute upper gastrointestinal bleeding(AUGIB)is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%.Despite recent newer innovations and advancements in endoscopic techniques and available medications,the mortality rate associated with AUGIB remained persistently elevated.AIM To explore mortality,characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital,and patients who initially present with AUGIB.METHODS This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically.Patients were divided in two groups:Group 1 comprised patients who developed AUGIB during their hospital stay;group 2 consisted of patients who initially presented with AUGIB as their main complaint.Patient characteristics,time to endoscopy,endoscopy findings and interventions,and clinical outcomes were collected and compared between groups.RESULTS A total of 336 patients were included.Group 1 consisted of 139 patients and group 2 of 196 patients.Mortality was significantly higher in the 1st group compared to the 2nd(20%vs 3.1%,P≤0.05).Increased length of stay(LOS)was noted in the 1st group(13 vs 6,P≤0.05).LOS post-endoscopy,vasopressor use,number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1.Inpatients were more likely to be on corticosteroids,antiplatelets and anticoagulants.Conversely,the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.CONCLUSION In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy.Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Gastric ischemia after epinephrine injection in a patient with liver cirrhosis

Endoscopic epinephrine injection is relatively easy,quick and inexpensive.Furthermore,it has a low rate of com-plications,and it is widely used for the management of nonvariceal upper gastrointestinal bleeding.There have been several case reports of gastric ischemia after en-doscopic injection therapy.Inadvertent intra-arterial in-jection may result in either spasm or thrombosis,leading to subsequent tissue ischemia or necrosis,although the stomach has a rich vascular supply and the vascular reserve of the intramural anastomosis.In addition to endoscopic injection therapy,smoking,hypertension and atherosclerosis are risk factors of gastric ischemia. We report a case of gastric ischemia after submucosal epinephrine injection in a 51-year-old woman with hy-pertension and liver cirrhosis.

Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report

BACKGROUND Cholecystoduodenal fistula is a rare complication of cholelithiasis.Symptoms are usually non-specific and often indistinguishable from those of etiologic diseases,but it rarely presents as severe gastrointestinal bleeding.Bleeding associated with cholecystoduodenal fistula usually requires surgery because significant bleeding from the cystic artery is unlikely to be resolved by conservative management or endoscopic hemostasis.CASE SUMMARY We report a case of cholecystoduodenal fistula that presented with hematemesis which was diagnosed by endoscopy and computed tomography.Endoscopic hemostasis could not be achieved,but surgical treatment was successful.Additionally,we have presented a literature review.CONCLUSION Cholecystoduodenal fistula should be considered as differential diagnosis when a patient with history of gallstone disease presents with gastrointestinal bleeding.

Etiologies of Splenic Venous Hypertension:A Review

Splenic venous hypertension or left-sided portal hypertension is a rare condition caused by an obstruction of the splenic vein.Usually,it presents with upper gastrointestinal bleeding in the absence of liver disease.Etiologies can be classified based on the mechanism of development of splenic vein hypertension:compression,stenosis,inflammation,thrombosis,and surgically decreased splenic venous flow.Diagnosis is established by various imaging modalities and should be suspected in patients with gastric varices in the absence of esophageal varices,splenomegaly,or cirrhosis.The management and prognosis vary depending on the underlying etiology but generally involve reducing splenic venous pressure.The aim of this review was to summarize the etiologies of splenic venous hypertension according to the mechanism of development.

Pancreatic head cancer with gastrointestinal bleeding as the initial manifestation:a case report and literature review

Gastrointestinal bleeding(GIB)as the initial symptom is rare in patients with pancreatic cancer,which is prone to misdiagnosis and should be paid attention to by clinicians.Here,we present a patient with pancreatic head cancer whose first symptom was only severe upper gastrointestinal bleeding,which initially led to misdiagnosis.However,subsequent imaging revealed a mass in the pancreatic head which was considered a malignant tumor.After surgical resection,the pathology confirmed that the mass in the pancreatic head was pancreatic ductal adenocarcinoma,and the duodenal bulb’s full thickness was infiltrated.A literature review found that pancreatic cancer can present gastrointestinal bleeding by invading the digestive tract and blood vessels,left-sided portal hypertension(LSPH),digestive tract metastasis,and canceration of ectopic pancreatic tissue in the digestive tract.For these cases,clinicians should utilize multidisciplinary diagnosis and treatment based on digestive endoscopy,imaging,interventional therapy,and surgery to control bleeding,identify etiology,and remove tumors.

颈部感染性假性动脉瘤

作者三十年间共收治了6例颈部感染性假性动脉瘤.本文就该症的病理临床表现进行了总结.提出了治疗意见.

To restrict indication for stenting of the inferior vena cava and liver transplantation in patients with Budd-Chiari syndrome

The Budd-Chiari syndrome(BCS)used to be a very rare disorder and lacked a means of relieving.However,various shuntings and radical procedures have emerged in the last three decades with quite encouraging outcomes.Recent minimally invasive therapies,such as stenting of the inferior vena cava(IVC),are simple and easy to handle.However,it has been realized that the IVC stent may compromise the hepatic veins and cause catastrophic consequences,thus the indication for IVC stenting should be reevaluated and especially not to be overused.Instead,it should be applied by percutaneous transangiography(PTA)only,which may be repeated when necessary.The BCS in China predominantly belongs to the IVC type rather than the intrahepatic type in Western;the outcome from its conventional therapy,at least for the moment,is better than that of liver transplantation.It is thus suggested that,before liver transplantation is decided,the conventional means for managing BCS be considered.The final suggestion is to restrict the indication both for stenting of the IVC and liver transplantation.In this paper,ten examples are given with figures.

Patients with severe schistosomiasis mansoni in Ituri Province, Democratic Republic of the Congo

Background:Severe hepatosplenic complications arise in patients with chronic Schistosoma mansoni infection after heavy exposure to disease agents in endemic areas.These complications are rarely reported and,hence,underestimated.Case presentation:We report on eight patients with severe morbidity associated with S.mansoni infection in Ituri Province,northeastern Democratic Republic of Congo(DRC).The patients were identified during a community-based survey in 2017;one patient was seen at the district hospital.After taking the patients'history,a clinical examination and an abdominal ultrasonographical examination were performed.S.mansoni infection was diagnosed in fecal(Kato-Katz technique)and urine(point-of-case circulating cathodic antigen test)samples.These eight patients with severe intestinal and hepatosplenic complications were identified from four villages with high 5.mansoni infection prevalence and related morbidity.The patients'ages ranged from 19 to 57 years;four patients were women.Three patients reported hematemesis.Two patients were severely anemic.All patients reported non-specific abdominal symptoms,such as diarrhea(six patients),abdominal pain(seven patients),and blood in the stool(five patients),as well as weight loss(two patients).Abdominal ultrasonography revealed ascites in four patients.All patients had portal hypertension with hepatomegaly(seven patients)or splenomegaly(five patients).Of the six patients with a discernable liver parenchyma pattern,five displayed pattern F and three patient displayed pattern E.Liver parenchyma was not visible for two patients with severe ascites.An 5.mansoni infection was confirmed in six patients,with infection intensity ranging from light to heavy.All S.mansoni positive patients were treated with praziquantel(40 mg/kg body weight)and referred to the district hospital for follow-up.One patient with severe ascites died two weeks after we saw her.Due to security and accessibility reasons,the villages could not be visited again and the patients were lost to follow-up.Conclusions:Our observations of patients with severe schistosomiasis document the severe degree of endemicity of S.mansoni in the province and suggest an urgent need for adequate schistosomiasis control measures that target vulnerable population groups and address severe complications.