Examining the frequency of endoscopic findings in patients with covid-19 with upper gastrointestinal bleeding referred to al-Zahra Hospital of Isfahan.

Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan. Method(s): In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings. Result(s): Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion(s): The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.Copyright © 2022 Tabesh et al. Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.

THE NOVEL CORONAVIRUS INFECTION (COVID-19) CONCURRENT WITH PSEUDOMEMBRANOUS COLITIS IN THE EARLY POSTPARTUM PERIOD: A CLINICAL CASE.

Background: Women are most at risk for Clostridium difficile infection in the early postpartum period. Clostridium difficile-associated colitis may be mistaken for the intestinal form of COVID-19 during the ongoing novel coronavirus infection pandemic. Case report: The paper describes a clinical case of a female patient diagnosed with the novel coronavirus infection and Clostridium difficile-associated pseudomembranous colitis in the early postpartum period. It depicts the diagnosis and treatment of the identified concurrent pathology. It demonstrates data from of an endoscopic examination of the colon and spiral computed tomography of the chest and provides laboratory confirmation of the infectious etiology of comorbidity. There are data available in the literature on the high rate and recurrent course of pseudomembranous colitis in the early postpartum period. It is noted that timely C. difficile eradication and pathogenetic treatment for the novel coronavirus infection allow relief of clinical symptoms. Conclusion(s): The case of the novel coronavirus infection concurrent with Clostridium difficile-associated pseudomembranous colitis in the early postpartum period is of interest in connection with the need for differential diagnosis of the etiology of diarrheal syndrome, the precise identification of which determines the further tactics of patient management and the nature of anti-epidemic measures.Copyright © A group of authors, 2021.

Whipple's Disease, An Overlooked Diagnosis

Whipple disease is a rare multisystem inflammatory disease. Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse. We are reporting a case of a 46-year-old man who presented with fever, weight loss, and polyarthralgia for 2 months, and 1 month of diarrhea. The patient was thoroughly investigated for collagen diseases and COVID-19, with no definite diagnosis. A therapeutic trial by immunosuppressive drugs provided partial remission followed by a marked rebound of the symptoms. His occult blood in stool was positive and subsequent upper endoscopy with proximal small intestinal biopsies showed the pathological features of Whipple's disease. The patient showed a dramatic improvement following treatment with ceftriaxone and trimethoprim-sulfamethoxazole. Despite the rarity of Whipple's disease, its course mimics many rheumatological diseases, inflammatory bowel disease, and COVID-19 disease. It should always be a part of the differential diagnosis of obscure polyarthralgia and chronic diarrhea.Copyright © 2023 The Author(s).

Subacute Enteritis Two Months After COVID-19 Pneumonia With Mucosal Bleeding, Perforation, and Internal Fistulas.

Chronic sequelae of COVID-19 remain undetermined. We report a case of postinfection sequelae in a patient presenting with subacute obstruction 2 months after COVID-19 infection. A 34-year-old man with a prior prolonged hospital stay due to COVID-19 complicated by upper gastrointestinal (GI) bleed presented with subacute obstruction and failure to thrive. Upper GI push enteroscopy revealed residual ulcers and multiple proximal jejuno-jejunal fistulae. Midline laparotomy revealed strictures with dense intra-abdominal adhesions, a large jejuno-jejunal fistula, and evidence of prior jejunal perforation following severe COVID-19 infection. The patient recovered after small bowel resection with anastomoses and was discharged home. Histopathological examination of resected specimen confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcers, and multifocal inflammation. This is the first report of a chronic GI sequelae resulting from COVID-19. As the pandemic evolves, medical professionals must be vigilant to consider alternative GI diagnoses in the COVID-19 survivors.

Influence of the COVID-19 pandemic on the timing of surgical triage, tumor stage, and therapy of patients with colon carcinoma.

PURPOSE: With the onset of the COVID pandemic in Germany in March 2020, far-reaching restrictions were imposed that limited medical access for patients. Screening examinations such as colonoscopies were greatly reduced in number. As rapid surgical triage after diagnosis is prognostic, our hypothesis was that pandemic-related delays would increase the proportion of advanced colon cancers with an overall sicker patient population. METHODS: A total of 204 patients with initial diagnosis of colon cancer were analyzed in this retrospective single-center study between 03/01/2018 and 03/01/2022. Control group (111 patients, pre-COVID-19) and the study group (93 patients, during COVID-19) were compared in terms of tumor stages, surgical therapy, complications, and delays in the clinical setting. The data were presented either as absolute numbers or as median for constant data. RESULTS: A trend towards more advanced tumor stages (T4a p = 0.067) and a significant increase of emergency surgeries (p = 0.016) with higher rates of ileus and perforation (p = 0.004) as well as discontinuity resections (p = 0.049) during the pandemic could be observed. Delays in surgical triage after endoscopic diagnosis were seen during the 2nd lockdown (02/11/20-26/12/20; p = 0.031). CONCLUSION: In summary, the results suggest delayed treatment during the COVID-19 pandemic, with the infection pattern of COVID appearing to have a major impact on the time between endoscopic diagnosis and surgical triage/surgery. Adequate care of colon cancer patients is possible even during a pandemic, but it is important to focus on structured screening and tight diagnosis to treatment schedules in order to prevent secondary pandemic victims.

Temporal Analysis of Medicare Physician Reimbursement for Common Gastroenterology Procedures From 2007 to 2022

Introduction: As the U.S. population ages, gastroenterologists will provide care for an increasing number of older patients - many of whom use Medicare. In recent years there have been significant policy changes surrounding Medicare reimbursement for physicians. Understanding reimbursement trends can help reveal the financial impact of these policies on gastroenterologists. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services from 2007 to 2022. Method(s): The top 10 GI procedures and their respective CPT codes were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association. The top 5 5 CPT codes relating to office/inpatient visits provided by gastroenterologists to Medicare Part B beneficiaries was identified using data from CMS. The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022, to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were adjusted to January 2022 U.S. dollars using the U.S. Department of Labor's Bureau of Labor Statistics' consumer price index inflation calculator. Result(s): The unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% CI, 29.9% to 24.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, 235.1% to 230.9%). The mean annual growth rate in reimbursement was 22.6% (95% CI, 22.8% to 22.4%). The unadjusted physician reimbursement for inpatient and outpatient visits exhibited an average increase of 32.1% (95% CI, 4.8% to 59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.92% (Figure 1). Conclusion(s): The analysis revealed a steady decline in adjusted and non-adjusted reimbursement between 2007 and 2022. Decreasing Medicare reimbursement may impact health outcomes, healthcare access, and patient satisfaction. Reimbursement policies must be scrutinized particularly in the light of high inflation and increased costs due to additional costs associated with care during the COVID-19 pandemic, staffing shortages, and increased staffing salaries. (Figure Presented).

Neurogastroenterology & Motility Manifestations After COVID-19 Infection: A Case Series

Introduction: In a subset of Covid19-convalescent patients, a multitude of long-term sequelae are increasingly being reported. We report 4 cases with varying neuro-GI and motility manifestations after recent COVID-19 infection. Case Description/Methods: Case 1: A 23-year-old man contracted COVID-19 and had a protracted course of respiratory illness. Despite resolution of respiratory symptoms and dysgeusia, he continued to experience early satiety, postprandial nausea, vomiting and unintentional weight loss. Gastric Emptying Scan (GES) revealed gastroparesis (Figure A). Dietary modification and metoclopramide led to symptomatic improvement. Case 2: A 39-year-old woman with migraines, suffered from Covid-19 infection where anosmia and respiratory symptoms lasted for 2 weeks. Despite resolution of initial symptoms, she started experiencing nausea and vomiting, and reported stereotypical symptoms with complete absence of vomiting between episodes. Endoscopic examination, CT head and GES were normal. Urine tox screen was negative for cannabinoids. She responded favorably to amitriptyline and ondansetron. Case 3: A 47-year-old man started experiencing severe constipation associated with abdominal pain and bloating soon after being diagnosed with COVID-19. Three months after resolution of respiratory symptoms, in addition to constipation, he began reporting postprandial fullness, early satiation and epigastric pain. GES showed gastroparesis ( figure B) and a Sitzmarks Study revealed delayed colonic transit (Figure C). Prucalopride was started, leading to improvement in symptoms. Case 4: A 74-year-old woman with obesity and diabetes, was hospitalized and intubated for severe respiratory distress due to COVID-19. After discharge, she had persistent symptoms of brain fog, fatigue, dyspnea as well as diarrhea and abdominal cramping, persisting despite loperamide and dicyclomine. C. difficile toxin, random colonic biopsies and H2 breath test were unremarkable. Her symptoms eventually improved with rifaximin. Discussion(s): We report 4 cases with post-COVID gastroparesis, cyclical vomiting syndrome, pan-gut dysmotility, and post-infectious IBS phenotypes.The pathophysiology of post-infectious-gut-brain disorders is still obscure. The current conceptual framework implicates acquired neuropathy, altered motility, intestinal barrier disruption and persistent intestinal inflammation. Similar pathophysiology may be involved in COVID-19 infection leading to sustained neurogastroenterological dysfunction and gut dysmotility.

Ndegree35 - Neurophysiology solving the vomiting dilemma

Objectives: Post Covid severe vomiting together with proximal muscle weakness is a misleading combination, this describes a rare but definite clinical association between myasthenia gravis and autonomic failure and strengthen the concept that subacute autonomic neuropathy is an autoimmune disorder. Content: A 39 ys old adult female presented with postCovid severe vomiting for one year with 40 kgs loss Upper gastrointestinal endoscopy revealed gastric dilatation associated with eosophageal and gastric stasis and hypertrophic pyloric stenosis. the gastroenterologist sought neurological consultation for the coexisting unexplained limb weakness before operation EMG & NCV was all normal except instability of the MUAPs Slow rate Repetitive supramaximal stimulation (RNS) revealed significant decremental response with no significant high rate stimulation incrementation Chest CT revealed an anterior mediastinal mass Surprisingly, She had an old CT during the covid infection that showed the same mass. Thoracoscopic resection revealed type B1 thymoma Following tumor resection, the patient improved gradually, Few months later endoscopy revealed a normal stomach with strong peristaltic waves and the patient was symptom free Infections are recognized to trigger exacerbations and crisis in MG Dysautonomia is not a commonly recognized feature of myasthenia gravis, but there have been rare reports of myasthenia gravis coexisting with autonomic failure, usually in association with thymoma. The autonomic dysfunction can present as isolated gastroparesis these observations support a rare but definite clinical association between myasthenia gravis and autonomic failure Neurophysiology could reveal undiagnosed MG with thymoma causing autonomic dysfunction in the form of gastroparesis and agonizing vomiting. Keywords: Myasthenia gravis;Gastroparesis;Autonomic failure;Thymoma;PostCovid vomiting. French language not detected for EMBFRA articles source xmlCopyright © 2023

Improving Barrett's Diagnosis and Surveillance Service at a District General Hospital in the United Kingdom

Introduction: Barrett's oesophagus is a well identified precursor for oesophageal adenocarcinoma, with the risk of malignant transformation being 0.5% annually. It is therefore crucial that diagnosis and surveillance standards meet national guidelines. This audit was carried out to assess if our District General Hospital was meeting the standards set by the British Society of Gastroenterology with regards to Barrett's diagnosis and surveillance. Method(s): Data was collected looking at 143 OGDs carried out for Barrett's diagnosis and surveillance at a District General Hospital in the United Kingdom from 01/01/2018 to 30/06/2018. The OGD reports were compared against recommended national standards set by the British Society of Gastroenterology. A proforma was created and was put into use from August 2020. It was utilized by all endoscopists when carrying out OGDs for Barrett's diagnosis and surveillance. The proforma was added to the end of the hospital's standard endoscopy report. Following the intervention and use of the proforma, the second cycle of the audit was carried out looking at 58 OGDs completed between 05/08/2020-27/02/2021 to see if they met the standards set out by the British Society of Gastroenterology. The Barrett's surveillance service and the volume of OGDs carried out following the introduction of the proforma was affected by the Covid-19 pandemic. Result(s): The first cycle of the audit found that only 34% of OGDs had a Prague classification documented correctly. 0% of OGDs had the correct biopsy protocol followed and 12.6% of endoscopies did not have any biopsies taken. 26% of patients had no follow up or surveillance endoscopy interval documented or organised. Following the intervention, it was found that 96% of endoscopies now had a Prague classification documented, an increase of 62%. There was a 65% increase in correct biopsy technique being followed and 100% of OGD reports now had surveillance interval documented if deemed appropriate. Conclusion(s): The audit clearly displays that following our intervention there was a significant improvement in the quality of Barrett's diagnostic and surveillance endoscopies, when compared to national guidelines. Given its potential for malignant transformation, correct surveillance is exceptionally important to improve patient care and reduce mortality. The introduction of a proforma drastically improved the standard of the service provided at our District General Hospital and is one that can be transferable to other hospitals.

Insurance Status Predicts Endoscopy No-Show

Introduction: Lyndon B. Johnson (LBJ) hospital is a part of the Harris Health System, which provides comprehensive care to the uninsured and underinsured population in Harris County, TX. LBJ serves a population with 55% unemployment and a median household income of $22000. Access to endoscopy is limited by resource availability, and the completion of scheduled endoscopies is essential for public health. We aimed to assess if insurance status was associated with no- show for scheduled endoscopic procedures at the LBJ GI Lab. Method(s): All patients scheduled for outpatient endoscopy during the year 2021 were collected. Included patients must have completed a GI clinic appointment, anesthesia screening, pre-procedural COVID test, confirmed attendance on pre-procedure call, and not showed for scheduled endoscopy (Figure 1). Patient's insurances statuses were: FAP (county payment assistance), Harris County Prisoners (no costs), Medicare/Medicaid (variable costs), Private Insurance (variable costs), Self-Pay, and Texas Family Planning/HCHD Presumed (temporary FAP) (Table 1). Result(s): Comparative analysis of insurance types demonstrated that patients who were Self-Pay were 5.96 times more likely (P< 0.002) not to show up for previously scheduled endoscopic procedures, while patients with the TFP/HCHD insurance were 10.1 times more likely (P< 0.001) to not show when compared to patients who were covered by the county's FAP. Conclusion(s): Our analysis demonstrated a statistically significant association between insurance status and the incidence of no-showing for endoscopy. Upon literature review, there was limited data on rates of endoscopy no-shows in relation to the out-of-pocket commitment for individuals. Further investigation into this topic would significantly affect both the academic and private practice of gastroenterologists. We plan to continue this quality assessment by meeting with the patient eligibility department to assess if modifications of benefit profiles could optimize procedural attendance.

Patient Navigator Pilot to Improve Completion of FIT Testing in Primary Care

Introduction: Colorectal cancer (CRC) screening is a critical preventative service and part of routine patient care. CRC is the second leading cause of cancer death in the US, and yet a third of the eligible population does not undergo routine screening. Endoscopy centers have been stretched thin by both COVID-19 and the recent drop in screening initiation age to 45. Fecal immunochemical testing (FIT), a sensitive and specific CRC screening modality, may be used to reach and risk-stratify more patients to increase the yield for detecting advanced neoplasia and cancer, reducing pressure on colonoscopy centers. Unfortunately, FIT is often suboptimal as patients inconsistently complete and return the test for analysis. Method(s): We performed a retrospective analysis of 5211 individuals at a single internal medicine clinic who had FIT ordered as part of USPSTF recommended care from 01/2017 through 12/2021. Starting in 01/2021 we instituted a dedicated patient navigator to support patients in completing FIT. Chi-square, Fisher exact test, and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to compare FIT kit drop off rates pre- and post-intervention, with the model adjusted by age, gender, race, ethnicity, language, and insurance status. Analysis was performed in SAS version 9.4. (Table) Results: The post-intervention period included 1181 (22.7%) patients. The predominant reasons cited for failure to complete testing were forgot (25%), too busy (13%), and lost kit (11%). Our intervention improved drop off rates from 46.4% to 51.3% at 2 weeks (OR 1.19, 95%CI 1.01-1.41), 56.7% to 73.7% at 1 month (2.14 [1.78-2.58]), 64.7% to 89.7% at 3 months (4.73 [3.66-6.12]), and 78.9% to 98.2% at 1 year (14.39 [8.25-25.12]). Overall, our intervention improved FIT kit drop off rates by 53.4% (1.53 [1.30-1.81]). FIT was positive in 4.9% (p=0.0529). (Figure) Conclusion(s): FIT can increase CRC screening rates, particularly in resource-limited settings, and may decrease the burden on endoscopy centers nationwide by improving the efficiency of colonoscopy in the average risk screening population. The addition of a dedicated patient navigator is a simple intervention that, by providing culturally competent care and personalized attention, improves completion rates and return time, allowing FIT to be a reliable method of screening. The ability to increase screening rates and prioritize patients for diagnostic colonoscopies will ultimately lead to earlier detection and treatment of CRC.

Management of Acquired von Willebrand Syndrome During Prolonged VV-ECMO

Acquired von Willebrand syndrome (AVWS) contributes to bleeding during extracorporeal membrane oxygenation (ECMO) support. Although it is recognized that AVWS rapidly resolves after ECMO decannulation, this approach may often be clinically unsuitable. In such cases, optimal AVWS management during ECMO support is not well established. We report our approach to managing AVWS in a patient on veno-venous (VV) ECMO for 59 days. A 19-year-old male developed hypoxemic respiratory failure from SARS-CoV-2 pneumonia. Following intubation, he progressed to VV-ECMO support for refractory hypoxemia and was started on bivalirudin for systemic anticoagulation. Two days later, he developed refractory gastrointestinal and oro-nasopharyngeal bleeding despite blood product transfusions and discontinuing bivalirudin. He was started on pantoprazole along with infusions of octreotide and aminocaproic acid. Upper endoscopy on ECMO day 5 revealed an ulcerative bleeding vessel in the duodenum that was clipped. Recurrent mucosal bleeding precluded resumption of systemic anticoagulation. On ECMO day 23, AVWS was diagnosed based on elevated von Willebrand factor (VWF) activity (207%, normal 55-189%) and antigen (234%, normal 50-210%) levels with abnormally low VWF high-molecular-weight multimers. Factor VIII complex was administered twice over the following week. Between doses, the ECMO circuit was exchanged to empirically mitigate suspected shear-related VWF consumption from the fibrin burden, and a repeat endoscopy controlled additional intestinal bleeding with local hemostatic agents. He received 36 units of red blood cells, 2 units of platelets, 2 units of plasma, and 7 pooled units of cryoprecipitate over 31 days leading into these combined interventions. In the 28 days afterwards, he received 3 units of red blood cells, 3.5 pooled units of cryoprecipitate, and no additional platelets or plasma. Our patient was maintained off systemic anticoagulation for 54 of 59 days of VV-ECMO support without any thrombotic complications occurring. With no subsequent clinical evidence of bleeding, repeat VWF testing was done two months post-decannulation and showed near-normal VWF activity (54%) and normal multimer distribution. Our patient rehabilitated well without any neurologic deficits and on discharge was requiring supplemental oxygen with sleep and strenuous activity. Avoiding systemic anticoagulation, repleting VWF, maintaining circuit integrity, and providing local hemostasis, when possible, may be a safe and effective management strategy of AVWS on ECMO support when decannulation is not a viable option.

Impact of Time-Motion Patient Flow Analysis on the Productivity of an Endoscopy Unit in a Large Safety-Net Health Center

Introduction: The COVID-19 pandemic disrupted health care delivery, particularly for high-volume procedural areas. To improve productivity in the Los Angeles County 1 University of Southern California Medical Center (LAC + USC) Endoscopy Unit, we initiated an iterative rapid cycle quality improvement process to identify inefficiencies and implement changes to our workflow. Method(s): A time-motion analysis of patient flow through the LAC + USC Endoscopy Unit was used to construct a time-tracked flow sheet to track individual patients as they moved through the Unit. Data were collected weekly over 3 9-10 week phases, and intervening plan-do-study-act (PDSA) cycles were conducted to direct interventions for subsequent phases. Following phase 1 (9/1/21 to 11/9/21) we implemented targeted interventions at the start of phase 2 (12/1/21 to 2/1/22) and phase 3 (3/15/22 to 5/31/22). Phase 2 was focused on our anesthesia supported endoscopy room which requires greater resource coordination. Metrics were compared to published benchmarks. Linear regression was used to compare outcome parameters for the lean process flow improvement project. Result(s): Our phase 1 analysis showed operational delays in room turnover time for all procedures and pre-operative assessment and first-case on time start percentage for procedures supported by anesthesia, when compared to published benchmarks (Table 1). In phase 2 we implemented an intervention of combining pre-anesthesia visits with endoscopy teaching visits for patients designated to have anesthesia support. This significantly improved both turnover time and throughput for the anesthesia room (Table 1). In phase 3 we initiated a policy of preparing the first patient of the day in the procedure room which dramatically increased first-case on time start percentage. We further streamlined inter-procedure processes by simultaneously consenting, placingmonitoring equipment and documenting in the time between procedures, leading to a greater than 20% increase in total procedure volume (Table 1). Procedure throughput for the anesthesia supported procedure room increased from 4.5 to 7 to 9 procedures per room per day for phases 1, 2, and 3 respectively (Table 1). EndoscopyUnit staffing remained unchanged throughout the study period. Conclusion(s): Time-motion analysis of patient flow may be used to perform targeted interventions with significant improvements in Endoscopy Unit efficiency. This may be achieved without costly interventions such as hiring additional support staff or faculty. (Table Presented).

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

The 'Tic'king Bleeder: A Rare Case of Bleeding Dieulafoy's Lesion in a Jejunal Diverticulum

Introduction: Dieulafoy lesion (DL) is a relatively rare and arguably under-recognized condition, accounting for 1-2% of acute GI bleeding. Most bleeding DLs occur in the stomach, followed by the small intestine, with less than 1% occurring in the jejunum. Bleeding DL on a jejunal diverticulum is even more rare, with a handful cases described in the literature. Here we present a rare case of a bleeding DL in a jejunal diverticulum with its endoscopic management. Case Description/Methods: A 65-year-old female with history of COVID-19 infection one month prior to presentation treated with steroids and therapeutic anticoagulation presented to the ED after having multiple episodes of coffee-ground emesis and two episodes of syncope at home. Last dose of Apixaban was 12 hours prior to admission. Physical exam revealed BP of 90/60 on Norepinephrine infusion, HR of 96, abdominal exam was soft and nontender, DRE revealed melena. Hemoglobin/hematocrit was significantly decreased at 3.6/12.8. Patient was appropriately resuscitated with blood products and fluids, and she was scheduled for an EGD. Initial EGD did not identify a clear source of her bleeding, and she was scheduled for colonoscopy. Colonoscopy with deep cannulation of the terminal ileum up to 40cm revealed significant amounts of fresh blood all throughout the colon and terminal ileum. Decision was made for push enteroscopy, which revealed a jejunal diverticulum containing a Dieulafoy lesion with an overlying clot (Image A). The lesion was first injected with epinephrine at 2 sites followed by a clot removal overlying the lesion using 13-0 circular snare. A clear stigma of recent bleeding was noticed from the lesion after clot removal (Image B), after which 2 metallic clips were placed over the lesion to achieve hemostasis (Image C). The patient had no further episodes of bleeding and was follow up in clinic eventually, recovering well. Discussion(s): Because of the life-threatening nature of Dieulafoy lesions, identification is of paramount importance for treatment purposes. Jejunal DLs are a rare entity but should be considered in cases with negative bidirectional endoscopies. In our case, push enteroscopy helped identify the bleeding lesion. DL in a diverticulum can pose a challenge to the endoscopist due to difficulty of access to the lesion. Epinephrine injection followed by mechanical clipping showed a positive outcome in our case which can be considered while approaching bleeding DLs in a diverticulum. (Figure Presented).