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PURPOSE The purpose of this study was to identify variables associated with extravasation on computed tomography angiography (CTA) in patients with hematochezia/melena and compare the outcome of patients with extravasation on CTA to those without extravasation. MATERIAL AND METHODS Ninety-four patients (51 men, 38 women; mean age, 69 ± 16 [SD] years) who underwent CTA within 30 days of hematochezia/melena were included. Variables associated with extravasation on CTA were searched using univariable and multivariable analyses. Outcomes of patients with visible extravasation on CTA were compared with those without visible extravasation. RESULTS One hundred and one CTA examinations were included. Extravasation was observed on 26/101 CTA examinations (26%). At multivariable analysis the need for vasopressor drugs (odds ratio [OR], 7.6; P = 0.040), high transfusion requirements (> 2 blood units) (OR, 7.1; P = 0.014), CTA performed on the day of a hemorrhagic event (OR, 46.2; P = 0.005) and repeat CTA (OR, 27.8; P = 0.011) were independently associated with extravasation on CTA. Extravasation on CTA was followed by a therapeutic procedure in 25/26 CTAs (96%; 26 patients) compared to 13/75 CTAs (17%; 68 patients) on which no extravasation was present (P < 0.001). No patients (0/26; 0%) with contrast extravasation on CTA died while 8 patients (8/61; 13%) without contrast extravasation died, although the difference was not significant (P = 0.099). CONCLUSION Extravasation on CTA in the setting of hematochezia or melena is especially seen in clinically unstable patients who receive more than two blood units. Presence of active extravasation on CTA leads to more frequent application of a therapeutic procedure; however, this does not significantly affect patient outcome.

Congenital extrahepatic portosystemic shunts are a rare cause of lower gastrointestinal bleeding in children. They result from the connection of a systemic vessel with the portomesenteric vasculature before the division of the main portal vein. Herein, we report a case of a congenital extrahepatic portosystemic shunts type II in a 4-year-old male diagnosed by Doppler ultrasonography during the investigation of abdominal pain and recurrent hematochezia, later confirmed by computed tomography. Conventional angiography with a balloon occlusion test revealed patent intrahepatic portal branches not depicted by previous imaging techniques. Successful shunt closure was achieved by endovascular approach with an Amplatzer Septal Occluder without complications.

Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.

World health care systems are affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its associated disease, coronavirus disease 2019 (COVID-19). This new human pathogen mostly affects the respiratory system, but various extrapulmonary pathologies have been reported in the literature. It seems that the gastrointestinal system is one of the target organs for SARS-CoV- 2. Diarrhea as a long-term bowel symptom is not rare, although its occurrence is not as high as that of fever and cough.

Superwarfarins are second generation anticoagulants that work as highly potent vitamin K antagonist, used in many chemical poisons as rodenticide. Superwarfarins currently constitute variety of examples like Brodifacoum, Difenacoum, Bromadiolone, and Flocoumafen. With the increase usage of these compounds a lot of poisoning cases has been reported worldwide, most of these poisoning cases occur either by accidental exposure or suicidal attempts. Poisoning routes are inhalational, trans-cutaneous and oral routes. Most of the cases present clinically with skin bleeding, hematuria, epistaxis, digestive tract bleeding, and rarely intracranial bleeding. We report a 49-year-old man with a Bromadiolone poisoning that led to massive intracranial hemorrhage and treated for several months with vitamin K1 agonist. His first clinical presentation was altered level of consciousness, right sided Hemiplegia, left sided hemiparesis, headache, and recurrent vomiting, with history of gross hematuria, hematochezia, and epistaxis, which had been persistent over the last 10 days prior to his presentation. On physical examination Glasgow Coma Scale (GCS) was 14/15 (confused), cranial nerves were intact except flatten right nasolabial fold and mild mouth drop, deep Tendon reflexes were brisk reflexes (+3) all over, power showed right sided hemiplegia (0/5), and left sided hemiparesis (4/5). Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), and the International Normalized Ratio (INR) was prolonged and high, respectively. In conclusion, Superwarfarin toxicity should be suspected in cases of unknown etiology of coagulopathy, with increased INR of more than six and increased coagulation profile time PT, and aPTT which is not responding to FFP treatment.

Diverticulosis is an anatomic change in the colon that is characterized by outpouching of the mucosa and submucosa through the muscularis. Its prevalence increases with age so most of the elderly patients have this condition. Although diverticulosis is common, diverticular disease, in which there are clinical sequelae, is rare. This collective term includes diverticulitis, diverticular hemorrhage and less well-defined entities such as segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Diverticulitis presents as acute lower abdominal pain, and initial management traditionally includes antibiotics, with surgery reserved for complicated disease, although newer evidence questions the optimal role and timing of both interventions.

The Fontan procedure used for palliation of single ventricle physiology is associated with multisystemic morbidity. With improving survival and increased use of surveillance imaging in this patient population, long-term complications associated with Fontan circuits are commonly encountered by radiologists. One interesting observation is the apparent increased risk of paragangliomas and pheochromocytomas in this group of patients and perhaps a pathogenetic role of chronic hypoxia. We report 2 cases of gastrointestinal neuroendocrine tumors (NET) in the setting of Fontan circuit. The first is a 20-year-old female with history of hypoplastic left heart and Fontan palliation who presented with hematochezia and was diagnosed with a jejunal grade 2 NET. The second case is of a 12-year-old boy with history Fontan palliation for single ventricle physiology, incidentally found to have a well-differentiated pancreatic NET during precardiac transplant workup. These cases should alert the radiologists to be aware of the apparent association between Fontan procedure and NET.

Purpose To determine if there is a role for routine pouchogram before ileostomy reversal after IPAA in pediatric patients. Methods The medical records of pediatric patients who underwent pouchogram between 2007 and 2017 prior to ileostomy reversal after IPAA at two affiliated hospitals were reviewed for concordance between exam under anesthesia (EUA) and pouchogram findings, management of abnormal pouchogram findings, and short and long-term outcomes after ileostomy reversal. Clinical notes were used to find patient-reported symptoms at the time of pouchogram. Results Sixty patients (57% female) underwent pouchogram before planned ileostomy reversal. The median time from IPAA formation to pouchogram was 60.5 days (IQR: 46–77) and median follow-up was 4 years (IQR: 1–6). Fifty-seven patients (95%) were asymptomatic prior to reversal. Of the 40 asymptomatic patients with a normal EUA, pouchogram detected one stricture (3%), but reversal proceeded as planned. In the 16 patients with strictures on EUA, pouchogram only detected six (40%). One of 50 (2%) asymptomatic patients with normal pouchogram had anastomotic dehiscence found on EUA. Despite normal pouchogram and EUA, four asymptomatic patients required subsequent diversion for pouch-related complications between 13 and 60 months after ileostomy reversal. Three patients had pelvic pain prior to pouchogram; associated symptoms included perineal pain (n = 1) hematochezia (n = 1), and tenesmus (n = 1). EUA and pouchogram were concordant in two patients (n = 1 anastomotic complication, n = 1 pouch septum) and ileostomy reversal was delayed. In the remaining symptomatic patient, pouchogram detected an anastomotic leak where EUA detected only a stricture, and this prompted a delay in reversal. Long term, none of these patients required diversion or excision of their pouch. Conclusion Routine pouchogram in asymptomatic pediatric patients does not change management and can be omitted, thereby sparing patients discomfort and unnecessary radiation exposure. Pouchogram may have diagnostic value in symptomatic patients. Level of Evidence III. Type of Study Study of Diagnostic Test.

Case Presentation A 57-year-old woman with a history of mantle cell lymphoma presented to the ED with complaints of vomiting, bleeding per rectum, and leg cramps, that started 6 h prior to her arrival. She had received chemotherapy a week prior. Her leg cramps were not associated with pain or swelling of the legs; she also denied any trauma to the legs. She did complain of mild lower abdominal pain at presentation. Review of systems was negative for fever, chills, diarrhea, chest pain, and dizziness. She denied using alcohol or nonsteroidal anti-inflammatory drugs. The patient was tachycardic with a systolic BP (SBP) of 85 mm Hg and was administered 1-L normal saline, with improvement in her SBP to 90 mm Hg. The hematocrit level was 24%, the WBC count was 0.3 × 109/L, and the platelet count was 6 × 109/L in the ED. On arrival in the ICU, she was noted to have an SBP of 70 mm Hg. Resuscitation with IV fluids was initiated, followed by transfusion of packed RBCs and platelets, based on the blood counts. Despite aggressive fluid resuscitation and improvement in her hemoglobin, the patient remained persistently hypotensive. The diagnosis of underlying septic shock because of neutropenia was considered; the patient was started on vasopressors and empirical broad-spectrum antibiotics, with improvement in her BP. After this, the patient was sent to radiology for a CT scan of the abdomen and pelvis with contrast to evaluate for mesenteric infarction, enteric or colonic bleeding, and the need for arterial embolization.

Background and Aims The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied. Methods Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed. Results Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy. Conclusions Most EHPVO children had colonic changes, and 16% had ileopathy. “Colitis-like” changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

Case Presentation A 55-year-old man presented to the ED with a 3-week history of worsening cough and shortness of breath. He had blood-tinged sputum, fever, night sweats, and a 2.7 kg weight loss within the same period. For the past few days, he had taken amoxicillin-clavulanate for presumed sinusitis. Despite this, his symptoms persisted, prompting him to seek further evaluation. His medical history was significant for ulcerative colitis and he had some bloody diarrhea for the past few weeks. Medications included aspirin, mesalamine, multivitamins, folic acid, and herbal supplements including gingko biloba, ginseng, and turmeric-ginger. He never smoked and drank alcohol occasionally. Family history was notable for stroke and myocardial infarction.

Highlights • Hereditary hemorrhagic telangiectasia (HHT) affects the vascular structure of numerous organs. • Clinical symptoms of HHT is epistaxis, GI bleeding, and iron deficiency anemia caused by mucocutaneous telangiectasias. • The treatment of HHT with gastrointestinal bleeding may need surgical treatment., Introduction Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease that affects the vasculature of numerous organs. HHT is characterized by the presence of multiple arteriovenous malformations that lack intervening capillaries and result in direct connections between arteries and veins. Presentation of case A 58-year-old South Korean female was admitted presenting with severe anemia, dizziness, and intermittent hematochezia. The patient had experienced chronic severe refractory gastrointestinal bleeding for years. She had an intermittent spontaneous epistaxis, telangiectasias in the oral cavity (tongue), and hepatic arteriovenous malformations and gastrointestinal telangiectasia. She underwent a segmental resection of a segment of the ileum and cecum (about 77 cm). After surgery, the patient experienced no more drops in hemoglobin count or symptoms of anemia and melena. She is living a normal life. Conclusion The present case report is a surgical case of undiagnosed HHT with chronic refractory gastrointestinal bleeding. Surgical treatment is rarely required for gastrointestinal bleeding unless nonsurgical methods such as endoscopy/colonoscopy and angiography have failed.

Highlights • Colonoscopy post perforating rectal injury may be employed to evaluate and treat bleeding. • DRE should be cautioned when suspecting hazardous material in the colorectal tract. • Mobilization of foreign bodies must be determined in a case by case basis., Introduction Retained rectal foreign bodies are commonly implicated in patients engaging in erotic behavior. The foreign bodies vary widely, however, penetrating rectal wounds are uncommon and often complicate the retrieval of the object. The rich vascular bed of the rectal mucosa provides additional bleeding complications. Presentation of case A 55-year-old male presented with active bleeding after intentional insertion of a glass bottle into the rectum which shattered. Partial retrieval via proctoscopy was followed by an exploratory laparotomy with a diverting colostomy, mucous fistula, and presacral drainage. Postoperative course was complicated by severe hematochezia. Colonoscopy was performed in the operating room found actively bleeding ulcers at sites of previously lacerated mucosa; one pulsating, protruding, vessel was visible. Clips were placed over the vessel with cessation of bleeding. Barium enema at three months follow revealed no leaks allowing for reversal of the colostomy. Discussion This case of operative retrieval of a rectal foreign body is unique because it displays deviation from commonly used algorithms are periodically needed to optimize patient recover. Conclusion The utilization of minimally-invasive colonoscopy prior to additional surgical intervention in post-operative rectal bleeding following a rectal foreign body retrieval may improvie patient recovery time, functionality, and long-term outcomes.

Highlights • Dieulafoy lesions are aberrant submucosal lesions that, in rare circumstances, can result in massive gastrointestinal bleeding. • These lesions are particularly rare in the jejunum, thus usual diagnostic and therapeutic modalities such as endoscopy may prove difficult. • Additional imaging such as angiography or radionuclide scanning can be beneficial in identifying the source of bleeding. • If advanced endoscopic instruments are unavailable at one’s facility, the surgeon must consider operative intervention for life-saving measures. • The operative findings and management discussed can guide clinicians unexposed to this disease process when surgical intervention is imminent., Introduction Dieulafoy lesions are enlarged atypical submucosal vessels that erode the superimposing epithelium in the absence of a primary ulcer. They occur predominantly in the gastric mucosa; however, cases have been seen throughout the gastrointestinal (GI) tract, and rarely, the jejunum. These lesions can cause massive GI hemorrhage leading to shock. Case Presentation We present a healthy 19-year-old male who arrived at our institution’s emergency department with multiple episodes of hematemesis and hematochezia that began earlier that morning. The patient was resuscitated and underwent a computerized tomographic (CT) angiography that did not identify any areas of active extravasation. The patient was then taken for an emergent upper and lower endoscopy that was inconclusive. He was subsequently sent for a tagged red blood cell scan, which demonstrated active bleeding in the proximal jejunum. Shortly thereafter, the patient began to decompensate requiring additional blood products and vasopressors. The decision was made for immediate operative intervention, which identified the bleeding Dieulafoy lesion (confirmed by histopathology) in the jejunum. Discussion Dieulafoy lesions are rare with an initial presentation of upper or lower GI bleeding, generally treated with endoscopic intervention. They are predominately found in the stomach or duodenum. When no clear source is identified by endoscopy, further diagnostic testing may be of value. Various imaging modalities exist; however, CT angiography or radionuclide scanning are particularly sensitive and can be beneficial in localizing the bleed when preparing for operative intervention. Conclusion With advances in endoscopic techniques, surgical intervention is rarely performed for a Dieulafoy lesion. If endoscopy is unsuccessful, additional imaging can be obtained to localize the source of bleeding. However, in emergent cases, when additional imaging cannot be obtained due to lack of time or resources, adequate resection of the lesion should be performed for complete resolution of the disease process. Based on the case presentation and pathologic findings, this case provides further insight into Dieulafoy lesions and the rare need for surgical management.

Case Presentation An 80-year-old man was admitted to our hospital with 24 hours of epigastric pain. The pain was described as sharp, episodic, nonradiating, and without an identifiable provoking factor. Associated symptoms included nausea and nonbloody vomiting. He denied dyspnea, angina, fevers, chills, dysphagia, diarrhea, melena, or hematochezia. He had taken less than 2 g of acetaminophen earlier in the day without symptomatic relief. He had a 30-pack-year smoking history but quit over 25 years ago. He did not drink alcohol or use illicit drugs. He had a medical history of end-stage renal disease, for which he had undergone hemodialysis; hypertension; metastatic prostate cancer, for which he had received androgen deprivation therapy; and abdominal aortic aneurysm. His surgical history included a remote endovascular repair of the abdominal aortic aneurysm. His medications included amlodipine, losartan, carvedilol, sevelamer, and leuprolide.

Cholelithiasis is a common gastrointestinal pathology that can lead to rare complications including cholecystoduodenal fistulas and GI hemorrhage. Diagnosing cholelithiasis and cholecystoduodenal fistulas in the emergency department (ED) using computed tomography (CT) imaging despite nonspecific and variable symptoms is critical in determining management strategies for medically complex patients. An 87-year-old medically complex female presented to the ED in hemorrhagic shock after several episodes of hematemesis, hematochezia, and other nonspecific gastrointestinal symptoms. A CT of the abdomen/pelvis was performed revealing cholecystitis with a large 6-cm stone; additionally, a biliary enteric fistula was noted with blood products in the gallbladder. This case highlights the importance of CT imaging in the setting of gastrointestinal bleeding with cholelithiasis and biliary enteric fistula diagnosis, and discusses potential management strategies of these diagnoses in medically complex patients.

Oseltamivir, an established oral anti-influenza medication, increases the risk of ischemic colitis. Baloxavir marboxil is a novel oral anti-influenza medication, and few studies have evaluated its potential side effects, including ischemic colitis. Moreover, as influenza A can also induce ischemic colitis, drug-induced colitis associated with anti-influenza medication is not clearly understood. In this report, we describe the case of a 62-year-old Japanese woman who developed acute ischemic colitis after taking baloxavir for influenza A. The day after taking baloxavir (day 2), the patient experienced abdominal pain, diarrhea, and nausea. On day 3, she had developed hematochezia and decided to visit our hospital. Upon presentation, inflammation of the descending and sigmoid colon was detected by abdominal echography and computed tomography. Fluid replacement therapy and dietary restrictions were initiated. On day 4, the inflammation of the descending colon and marked intestinal edema were confirmed by colonoscopy. She was clinically diagnosed with ischemic colitis, from which she recovered completely by day 9. This case suggests that patients taking baloxavir may be at risk of developing ischemic colitis with hematochezia and underscores the need to further study the induction of this condition by commonly used oral anti-influenza agents.

Gastrointestinal varices are associated with cirrhosis and portal hypertension. Variceal hemorrhage is a substantial cause of morbidity and mortality, with esophageal and gastric varices the most common source and rectal varices a much less common cause of severe gastrointestinal bleeding. The goals of managing variceal hemorrhage are control of active bleeding and prevention of rebleeding. This article focuses on reviewing the current management strategies, including optimal medical, endoscopic, and angiographic interventions and their clinical outcomes to achieve these goals. Evidence based discussion is used with current references as much as possible.

Objective: The aim was to review the incidence and clinical presentation of neonates with congenital syphilis requiring surgical consultation at a single tertiary neonatal intensive care unit (NICU). Methods: Between 2014 and 2016, all records incorporating congenital syphilis and syphilis during pregnancy were obtained to establish disease incidence. During this time, neonates with congenital syphilis and a pediatric surgery consultation were reviewed. Demographic data, details of surgical consultation, operations and clinical outcomes were recorded. Results: Between 2014 and 2016, cases of maternal syphilis increased from one to five, and congenital syphilis cases ranged from two to ten. In 2016, four (40%) required surgical consultation. Indications for surgical consultation included: (1) obstructive jaundice, (2) abdominal distension with bilious emesis, (3) distension and hematochezia, and (4) possible anorectal malformation. All were diagnosed by rapid plasma reagin test (RPR) and completed a 10-day course of Penicillin G. One neonate with obstructive jaundice underwent surgery to rule out biliary atresia. Three neonates did not require surgical intervention. Conclusion: An understanding of congenital syphilis is imperative for pediatric surgeons. Hepatic and gastrointestinal manifestations may mimic surgical diagnoses in neonates. Keywords: Congenital syphilis, Surgical consults, Neonates, Syphilis in pregnancy

Highlights • Inflammatory myofibroblastic tumor (IMT) is a rare pathology with uncertain etiology. • Patient with ulcerative colitis affected by synchronous colic IMT and gastric GIST. • In our case, IMT mimicked an adenocarcinoma of colon on an ulcerative colitis (UC). • The relationship between IMT and UC has never been previously described. • The synchronous association between IMT of colon and gastric GIST is another primacy., Introduction Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach. Presentation of case A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given. Discussion Although the relationship between IMT and Crohn’s disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described. Conclusion To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy.

Background: Optimal timing of colonoscopy for acute lower gastrointestinal bleeding is controversial, and it is unclear which patients benefit from early colonoscopy. The reported proportion of hemodynamically unstable patients is lower in randomized controlled trials than in observational studies. Methods: We studied 6,311 patients admitted for acute hematochezia in 49 Japanese hospitals, named the CODE-BLUE J Study. One propensity score-matched cohort comprised patients who underwent early (

The differential diagnosis for bilious emesis and hematochezia in newborns is broad and includes structural abnormalities (malrotation with volvulus, atresia, pyloric stenosis, intussusception), infectious colitis, necrotizing enterocolitis, milk protein intolerance, vascular malformations, and other bleeding disorders. Here we report a case of bilious emesis and hematochezia in an 8-day-old male infant who was ultimately found to have goat's milk protein intolerance after an extensive workup ruling out other pathology. There have been limited studies that examine goat's milk protein intolerance in pediatric patients, and to our knowledge, our paper presents the youngest patient presenting with bilious emesis related to goat's milk intake.

Lower gastrointestinal bleeding is defined as occurring distal to the ligament of Treitz and presents as hematochezia, melena, or with anemia and positive fecal occult blood test. Imaging plays a pivotal role in the localization and treatment of lower gastrointestinal bleeds. Imaging tests in the workup of acute lower gastrointestinal bleeding include computed tomography (CT) angiography, nuclear medicine scintigraphy, and conventional catheter angiography. Catheter angiography can also be used to deliver treatment. Imaging tests in the workup of occult lower gastrointestinal bleeding include CT enterography and nuclear medicine Meckel scan.

Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.

Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.

Objective to describe the clinical presentation of two canines present in anaphylactic shock secondary to rattlesnake envenomation. In both cases, there was no previous documented previous envenomation event and the initial sensitization required for anaphylactic response is believed to be secondary to Crotalus atrox toxoid vaccine. Case description In the first case, a 12-year-old golden retriever present for collapse, severe hematochezia, and vomiting after first time envenomation from a suspected western diamondback rattlesnake. The patient presented in severe hypovolemic shock and required aggressive fluid therapy, antivenom, anti-emetics, and pain management. The patient made a full recovery within 24 hours. In the second case, an 8-year old English setter presented for acute collapse, vomiting, and facial swelling after suspected first time envenomation from a suspected Prairie rattlesnake. The patient presented in severe hypovolemic shock with cardiac arrhythmias and required aggressive fluid therapy, antivenom, pain control, anti-emetics, and antibiotics. The patient made a full recovery after three days of hospitalization. Both patients had been previously vaccinated with the C. atrox vaccine. Conclusion This case report documents suspected anaphylaxis in two canine patients after first time envenomation by a rattlesnake. Both patients were previously vaccinated by the Crotalus atrox toxoid, which is hypothesized to be the initial inciting trigger.

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Idiopathic thrombocytopenic purpura (ITP) is an acquired bleeding disorder, characterized by thrombocytopenia due to autoantibodies against platelet antigens. The pathogenesis is not clearly understood;however, it is thought to be secondary to an inciting event. These events might include systemic conditions or infections. These infections are typically of viral nature, including human immunodeficiency virus, hepatitis C, cytomegalovirus, varicella zoster virus or coronavirus. In addition, ITP has been rarely described in literature after undergoing viral vaccination. CASE PRESENTATION: This is a case of a 61-year-old male patient with history of hypertension and SARS-CoV2 viral infection 5 months earlier, who came to our institution after developing small violaceous spots throughout his body, with associated fever, chills, general malaise, and dark urine, 3 days after receiving the second dose of the mRNA-1273 COVID-19 vaccine. He denied nausea, vomits, rhinorrhea, shortness of breath, cough, chest pain, abdominal pain, hematemesis, hematochezia, melena, or recent illness. Vital signs were temperature of 98.4 F, pulse in 68 bpm, respiratory rate in 18/min and blood pressure in 156/74 mmHg. Laboratories showed leukocytes in 4.9 x 10

Coil migration into the colon is an extremely rare complication of aneurysm embolization and only three cases have been reported. Two of these cases were managed with resection of the involved colon and the remaining case was managed with serial imaging. We present a 70-year-old man who developed hematochezia two years after coil embolization of a ruptured left hypogastric artery aneurysm. The patient was successfully treated with diverting colostomy and endoscopic closure of the sigmoid colon defect. We present the only case report of the use of advanced endoscopy to treat endovascular coil migration.

A 63-year-old male presented to the Emergency Department with weakness and hematochezia. He was found to have a massive gastroepiploic artery pseudoaneurysm that had eroded into the transverse colon. He underwent open en bloc resection of the aneurysm, a portion of the stomach, and a portion of the transverse colon. The case and a brief review of gastroepiploic aneurysms is presented.

Introduction Familial adenomatous polyposis (FAP) is an inherited colorectal cancer syndrome characterized by several adenomatous polyps of the gastrointestinal mucosa with a universal risk of colorectal cancer in a lifetime. FAP is usually asymptomatic in the first decade of life. Case presentation We report a case of a 13-year-old girl diagnosed with FAP who presented in our center with symptoms of hematochezia along with a positive history of the untimely demise of her father and elder sister with similar symptoms. Discussion FAP is an autosomal dominant disease affecting both male and female equally with variable penetrance. Diagnosis is made by finding hundreds to thousands of adenomatous polyps in the colon and rectum, and molecular analysis of the APC gene which forms the definitive diagnosis. Prophylactic laparoscopic total proctocolectomy with ileorectal anastomosis is a safe and feasible surgical option with a low risk of complications among adolescents. An endoscopic/colonoscopic procedure is recommended every 6 to 12 months after surgery to assess the anastomosis site, pouch, and residual rectum. Conclusion FAP, a rare disease entity in adolescents should be managed by appropriate diagnostic procedures, early prophylactic surgery, and regular lifelong follow-up., Highlights • FAP is rarely symptomatic in the first decade of life. • Definitive diagnosis is based on molecular analysis of the APC gene. • Early prophylactic surgery and regular surveillance is imperative.

Venous malformations (VM) of the pelvis are rare and difficult to treat due to extensive lesional feeding vessels. Little exists in the published literature for management of such conditions in children, but lessons learned from congenital causes can help. Herein we discuss the preoperative evaluation and management of an 11-year-old child with a congenital pelvic and perirectal VM that presented as hematochezia. MRI showed extensive malformation with involvement of the calf, leg, perirectal region, and pelvis. The patient had continued hematochezia despite several sclerotherapy and embolization attempts. She eventually underwent transanal and open Swenson type pull-through and resection of colonic and rectal VM with derotation of the transverse colon, and has been doing extremely well since her operation.

Introduction and importance Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. Presentation of case We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. Discussion Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. Conclusion Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy., Highlights • Intestinal varices are rarely developed as new collaterals accompanying portal hypertension with EHPVO (Extrahepatic portal vein obstruction). • Jejunal varices must be considered in patients with a negative source of bleed on upper and lower GI endoscopy.

Background The aim of the study was to explore the correlation between clinical signs and confirmatory tests for cow's milk allergy (CMA) in the neonatal period and their relation to family history and the occurrence of food allergies in the postneonatal period. Methods The medical documentation of 361 newborns with suspected CMA and exclusion of other comorbidities was analyzed. The correlations between clinical signs and methods to confirm CMA [elevated levels of total immunoglobulin E (IgE) and/or specific IgE for cow's milk, improvement after the introduction of a cow's milk-free diet and positive challenge procedure] were studied. In 90 children, the data were additionally analyzed in relation to outcome (at the age of 1–11 years), evaluated by questionnaires, which inquired about signs and symptoms of food allergy, methods of CMA confirmation, and the presence of other food allergies. Results There was a positive correlation between exanthema and confirmed CMA in the neonatal period ( R = 0.184; p = n = 361), and hematochezia and confirmed CMA in the neonatal ( R = 0.203; p n = 361) and postneonatal period ( R = 0.215; p = 0.042; n = 90). Additional food allergies in the postneonatal period were positively correlated with neonatal CMA ( R = 0.275; p = 0.009; n = 90). No correlation was found between a positive family history of food allergies and CMA in the neonatal ( R = −0.66; p = 0.398; n = 165) and postneonatal periods ( R = 0.00; p = 1.000; n = 116). Conclusion Neonatal exanthema and hematochezia were the predominant clinical signs in neonates with CMA. Allergies to other food allergens appeared more frequently in children with CMA in the neonatal period. Neonatal CMA did not occur more frequently in families with food allergies.

There is a broad clinical spectrum of gastrointestinal bleeding in children, ranging from subtle laboratory findings to dramatic clinical presentations. This review provides a framework for the evaluation and management of gastrointestinal hemorrhage for pediatricians. It outlines strategies for obtaining a tailored patient history and conducting a thorough physical examination that can shed light on the location, severity, and likely etiology of bleeding. It appraises blood tests, radiologic tools, and endoscopic modalities frequently used to identify and control a source of bleeding.

Acute lower gastrointestinal bleeding usually presents as hematochezia, rectal bleeding or melena and represents 1-2% of the medical appointments in the Emergency Services. Mortality reaches the 30-40% and it is highly related with the severity and associated comorbidity. Most clinical practice guidelines include colonoscopy at some point in the diagnostic and therapeutic process (urgent for severe cases and ambulatory for mild ones) and look for predictors of severity. In the last years, there have been numerous studies where is clear the relevance and complementarity of advanced diagnostic imaging techniques, gradually incorporated as an alternative or second step in severe cases. Therefore, we have made a review of current scientific evidence to establish a clinical prediction rule for optimal indication of CT angiography in these patients. However, future studies providing greater robustness and level of evidence are necessary.

Heterotopic gastric mucosa is rare in the pediatric population. We present a case of a 14-year-old girl with a 6-month history of intermittent rectal bleeding and failed sclerotherapy. Excision ultimately demonstrated heterotopic gastric mucosa. This reports highlights that while most of the non-congenital pediatric anorectalpathology will continue to be hemorrhoids and prolapse, heterotopic gastric mucosa should be considered in patients with anorectal symptoms refractory to conventional treatment.

In a case of unexplained digestive hemorrhage after normal gastroscopy and colonoscopy, it is necessary to consider hemorrhagic tumors of the small intestine, particularly stromal tumors. We describe the case of a 73-year-old woman who presented with symptoms of massive hematochezia and abdominal pain. Abdominal examination revealed: distension, board-like rigidity, and muscular defense in the right upper quadrant; no liver dullness; and inaudible bowel sounds. In addition, rectal examination revealed an empty ampulla. Colonoscopic and gastroscopic evaluations were normal and did not reveal the origin of the bleeding. An abdominal enhanced computed tomography scan revealed a 9.2 cm × 10 cm solid tumor with a low-density area, suggesting necrosis or abscess. After the overall examination, a gastrointestinal stromal tumor (GIST) of the jejunum was highly suspected. Intraoperative findings showed an excessive bloody fluid collection, approximately 1600 mL in the abdominal cavity. Furthermore, an outgrown mass ruptured in the jejunum, ∼5 cm from the Treitz ligament. We deemed the tumor to be a moderately differentiated GIST originating from the jejunum. In this report, we review the literature on this rare condition and discuss potential strategies for diagnosing and managing patients with a spontaneous rupture of an extremely large GIST of the jejunum.

39-year-old manwithnonotablemedical history presented for evaluation of dysphagia. He reported a several-year history of intermittent but progressive difficulty swallowing both solids and liquids. He had been able to manage his symptoms by using water to flush foods, drinking carbonated beverages, and elevating the head of his bed. He did not experience choking or coughing with swallowing. Two weeks before presentation, he began to feel generally unwell, with worsening dysphagia and regurgitation of undigested food, chest discomfort, and decreased oralintake.Hedidnothavenausea,abdominal pain, diarrhea, constipation, melena, hematochezia, hematemesis, odynophagia, unexplained weight loss, night sweats, exertional chest pain, dyspnea, orthopnea, neck pain, recent trauma, or recent travel outside the United States. Onphysicalexamination,thepatient’sbody

Background The diagnosis of isolated visceral artery dissection (IVAD) has become more common with the increasing use of computed tomography angiography (CTA). We examined the presentation, treatment, and outcomes of patients with IVAD treated at our institution. Methods The records of 72 patients treated for IVAD between January 2010 and August 2014 were analyzed retrospectively. All were treated with antiplatelet or anticoagulant drugs after admission and were continued on oral aspirin for at least 1 year. Four asymptomatic and 52 symptomatic patients were managed conservatively with blood pressure control, bowel rest, fluid supplementation, and nutritional support. Two patients underwent open surgery because of hematochezia and 16 underwent endovascular bare-metal stenting. Results Symptoms gradually resolved in those treated conservatively, and favorable arterial wall remodeling was observed in 16 patients. Twenty-one stents were implanted in 16 patients with superior mesenteric artery dissection; 3 patients required overlapping stents. During follow-up (range, 3–53 months), all patients were symptom-free, and there were no recurrences. Follow-up CTA of patients who underwent endovascular stenting demonstrated satisfactory stent and true lumen patency. Conclusions IVAD is not uncommon. It occurs most frequently between the ages of 46 and 60 years and affects more men than women. A favorable outcome can be achieved in most of the patients with conservative management. Ischemic bowel necrosis is rare but requires open surgery. Endovascular bare-metal stenting is recommended when there is persistent abdominal pain, progression of the lesion, apparent stenosis of a true lumen compressed by a false lumen, or dilation of false lumen at a high risk of rupture.

50-year-old postmenopausal woman with a history of hypothyroidism and obesity presented to her primary care physician with a several-month history of fatigue. On evaluation, she had no history of fever, chills, night sweats, weight change, abdominal pain, peptic ulcer disease, hematochezia, melena, hematemesis, or hemoptysis. Her only medication was levothyroxine (one 75-mg tablet daily). She was a lifelong nonsmoker and drank no alcohol. Her family history was notable for bladder cancer in her father and gastric cancer in her maternal grandmother. Her mother had no medical prob

Myxedema Ascites is a rare finding of primary hypothyroidism, thereby leading to delayed diagnosis. However, prompt treatment with levothyroxine leads to complete resolution of the condition. We present a rare case of myxedema ascites in an elderly female and highlight the importance of early diagnosis and management. We also present ischemic colitis in the same patient, which has not been reported thus far in literature as a complication of myxedema ascites.

X-ray irradiation-induced toxicity to gastrointestinal tract become a significant clinical problem when using radiotherapy for treating abdominal tumors neighbored to gastrointestinal tissue, which not only often prevents these tumors from receiving a definitive therapeutic dose but also causes a series of gastrointestinal diseases, such as anorexia, abdominal pain, diarrhea and hematochezia. And thus it seriously reduces the therapeutic outcome and life quality of patients. Therefore, the development of gastrointestinal radioprotectors is essential. However, the commercial gastrointestinal radioprotectors in clinical are still rare. In view of this, we prepared bovine serum albumin (BSA) modified graphdiyne (GDY) nanoparticles (GDY-BSA NPs) and for the first time studied its gastrointestinal radioprotection ability. The unique advantages of GDY nanomaterial, including high free radical scavenging ability, good chemical stability in gastric acid condition, relatively longer residence time in gastrointestinal tract and good biosafety under oral administration, provide the favorable prerequisites for it to be used as the gastrointestinal radioprotector. In vitro experimental results indicated that the GDY-BSA NPs powerfully reduced DNA damage and improved viability of the irradiated gastrointestinal cells. In vivo results showed that the GDY-BSA NPs significantly decrease radiation-induced diarrhea, weight loss, and gastrointestinal tissue pathological damage of mice. Furthermore, we also deeply studied the gastrointestinal radioprotective mechanism of GDY-BSA NPs, which indicated that the GDY-BSA NPs effectively inhibited reactive oxygen species (ROS)-induced apoptosis signal pathway, and thus reduced gastrointestinal cell apoptosis. Our work for the first time employed BSA-GDY NPs to mitigating radiation-induced gastrointestinal tract damage, which not only promotes the exploration of new gastrointestinal tract radioprotectors, but also is the good guidance for the treatment of gastrointestinal diseases by nano-drug.