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SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Dieulafoy lesions are abnormally dilated submucosal vessels remain uncommon cause of upper gastrointestinal bleeding, accounting for approximately 1.5% of all GI bleeds [1]. Although the exact etiology remains unknown, multiple co-morbid conditions have been attributed to this condition, including heart diseases, hypertension, chronic kidney disease, diabetes, or excessive alcohol use [2].In our case, it was identified as a cause of lower GI bleed in a critically ill Covid patient. CASE PRESENTATION: A 49-year-old male with a history of diabetes, internal hemorrhoids, and diverticulosis was admitted to the hospital due to hypoxic respiratory failure from COVID pneumonia with characteristic CT findings of bilateral ground-glass opacification. On admission, the patient was afebrile, normotensive, tachypneic with a respiratory rate of 34.The physical examination was unremarkable except for coarse crackles in upper and middle lung zones. We treated patient with Dexamethasone and Remdesivir. His hypoxia deteriorated, and he was eventually intubated. On admission patient hemoglobin was within normal range. During the patient's hospital course, he had a significant drop in hemoglobin, requiring multiple blood transfusions. Blood clots were found on perianal examination. Flexible sigmoidoscopy revealed blood in the rectosigmoid colon. A visible vessel without apparent ulcer was seen in the rectum, which was actively oozing blood. It was determined to be a Dieulafoy lesion. The affected area was injected with epinephrine for hemostasis, and subsequently, hemostatic clips were placed. After the procedure patient did not have any repeat episodes of hematochezia or drop in hemoglobin. DISCUSSION: Dieulafoy lesions are an uncommon cause of GI bleeding and are usually present in the upper gastrointestinal tract. Furthermore, they caused hemodynamically significant bleeding from the lower gastrointestinal tract in our case. Dieulafoy lesions can be asymptomatic or may bleed intermittently to cause severe hemodynamic compromise. They may be missed on endoscopy due to the small size and intermittent bleeding [2]. In up to 9-40% of the cases, these lesions tend to rebleed. Therefore the patients need close monitoring [3]. In our case, after the intervention with the clips, the patient's bleeding stopped, and he had no further blood loss from the lesion. CONCLUSIONS: Dieulafoy's lesion is an infrequent cause of gastrointestinal bleeding, and it is challenging to diagnose [3]. It is a rare cause of GI bleeding, and even in those instances, it is found chiefly in upper GI bleed cases but can also be the cause of lower GI bleeding. Knowing that GI bleeding in Covid patients leads to worse outcomes, it is prudent to account for rare causes of GI bleed during the work-up. Reference #1: Van Zanten SV, Bartelsman J, Schipper M, Tytgat G. Recurrent massive haematemesis from Dieulafoy vascular malformations–a review of 101 cases. Gut. 1986;27(2):213. Reference #2: Shin HJ, Ju JS, Kim KD, et al. Risk factors for Dieulafoy lesions in the upper gastrointestinal tract. Clinical Endoscopy. 2015;48(3):228. Reference #3: Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy's disease: endoscopic treatment and follow up. Gut. 1993;34(10):1418-1421. DISCLOSURES: No relevant relationships by Swe Swe Hlaing No relevant relationships by Joyann Kroser No relevant relationships by Hui Chong Lau No relevant relationships by Sze Jia Ng No relevant relationships by Subha Saeed No relevant relationships by Muhammad Moiz Tahir
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DDW 2022 Author Disclosures: Dennis Jensen: NO financial relationship with a commercial interest ;Rome Jutabha: NO financial relationship with a commercial interest ;Gareth Dulai: NO financial relationship with a commercial interest ;Noam Jacob: NO financial relationship with a commercial interest ;Jeffrey Gornbein: NO financial relationship with a commercial interest Background and Aims: The best strategy to prevent DPPIUH is controversial. Some colonoscopists recommend hemoclip closure of PPIU’s but this has mixed success rates in different RCT’s and is reported not to be cost effective. In addition to known risks, arterial blood flow detected in PPIU’s is an important predictor of DPPIUH. Our AIMS are to report study methods and interim results of a RCT of blood flow monitoring to prevent DPPIUH. Methods: This is an ongoing blinded RCT at several major Los Angeles Medical Centers by experienced colonoscopists. Outpatients having colonoscopies are screened and consented for enrollment. Sessile and multilobulated polyps are removed by EMR techniques. Thermal coagulation is used for polypectomies in this study. Randomized patients are stratified by whether they take chronic anti-platelet or anti-thrombotic drugs and have PPIU’s of 10-40 mm;or those without bleed drugs and have PPIU’s between 15-40 mm. By opening a sealed envelope after polypectomies, randomization is to either standard management (e.g. following ASGE guidelines of bleed drugs) or DEP interrogation of the PPIU and guided treatment of the artery with hemoclips or multipolar probe coagulation in the PPIU until blood flow is eradicated. Patients and their care givers were blinded to treatments allocated during colonoscopy. Prospective follow-up is by a research coordinator contacting each patient at 7, 14, and 30 days to record whether any complications (e.g. pain, vomiting, or bleeding);or rectal bleeding and its severity (e.g. # and days of bloody BM’s);whether they sought ER, clinic, or telemedicine care for bleeding;or were hospitalized. Major DPPIUH was diagnosed in patients with hospitalization for severe bleeding and/or for 3 or more days of ongoing severe rectal bleeding but refusal of hospitalization because of high rates of COVID here. Demographic, laboratory, colonoscopic, and pathology results are recorded on standard forms along with 30-day outcomes. Patients are assigned a code, data are entered onto HIPAA compliant computer files by a data manager and managed with SAS. With half the projected sample size randomized and followed up (e.g. 133 of 268 total), this is a planned interim analysis of the primary outcome - rates of DPPIUH by treatment. Severe adverse events (SAE’s) were also reviewed. Results: For 133 high risk patients randomized to date, 67 are in the standard group and 66 in the DEP group. The groups were well matched in risk factors – see Table 1. Overall, the Doppler group had lower rates of delayed PPIU bleeding – both major and total- see Table 2. There were no SAE’s. Conclusions: The major DPPIUH rate was higher with standard treatment than DEP treatment (7.46 % vs. 0 %), as was the rate of Total DPPIUH (10.45 % vs. 1.52%). Based upon these promising results, this RCT will continue. [Formula presented] [Formula presented]