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Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.
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The outbreak of coronavirus disease 2019 (COVID-19) in December 2019 was associated with new challenges in many fields of medicine. Preventing transmission of the virus and infection of professional healthcare workers became of major concern in our daily clinical practice during the pandemic. Viral particles within aerosols can be detected up to 3h after aerosolization. Recent work defined endoscopic procedures of the upper gastrointestinal tract as being aerosol-generating procedures (AGPs);thus, they can carry the possibility of transmitting airborne viruses to personnel. Because severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is primarily transmitted by aerosols and/or droplets, the use of personal protective equipment (PPE) is warranted. Guideline recommendations from the WHO and other societies were also modified early to include PPE as an infection prevention measure. The strict use of PPE has proven to be an effective prevention strategy over the 3 years since its implementation. With the introduction of vaccinations against SARS-CoV-2, increasing immunization of the population, and a changing pandemic infection pattern, the requirements for endoscopic departments in hospitals and outpatient care settings continued to change. In the postpandemic situation, there are only minor restrictions that affect the new "postpandemic reality", thus, allowing endoscopic services to be performed without major restrictions. Here, we present a review of recent and most relevant knowledge to summarize the prophylactic measures that must be taken to perform endoscopy under safe conditions during the COVID-19 pandemic.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.
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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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A foreign body can be intentionally or accidentally ingested. Timing of endoscopy relies on foreign body shape and size, location in gastrointestinal tract, patient's clinical conditions, occurrence of symptoms or onset of complications. In this short case, we present a middle age woman, who accidentally swallowed a portion of a nasopharyngeal swab half-broken during a diagnostic test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Upper gastrointestinal endoscopy was promptly performed to prevent the swab from crossing the pylorus leading to serious complications and, therefore, risk of surgical intervention. The broken nasopharyngeal swab was detected in the gastric body, and immediately removed with a foreign body forceps. Our hospital performs many nasopharyngeal swabs and to our knowledge, this is only the second reported swab ingestion during SARS-CoV-2 test.
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BACKGROUND: COVID-19 patients can have persistent viral stool positivity despite negative respiratory samples, irrespective of symptoms. These patients could potentially go undetected under the current pre-endoscopy COVID-19 testing guidance recommendations. However, the clinical significance of viral RNA in the stool remains unclear. AIMS: We aimed to prospectively determine whether SARS-CoV-2 is detected via real-time reversetranscriptase polymerase chain reaction (rRT-PCR) in the GI tract of patients scheduled for endoscopy and if the virus obtained from these clinical specimens could be isolated in culture. METHODS: All patients underwent symptom screening and had negative nasopharyngeal testing for SARS-CoV-2 within 72 hours of their scheduled procedure. Study samples were collected via repeat nasopharyngeal swab, rectal swab, and fluid from the upper GI tract and/or colon based on their endoscopic procedure(s). Samples were tested for SARSCoV-2 via rRT-PCR. Clinical specimens confirmed to be positive for SARS-CoV-2 RNA were then isolated and cultured in Vero-E6 cells. RESULTS: 243 patients (mean age 63.1 years;54.3% men) were enrolled from July 15th, 2020 to September 2nd, 2020 (Table 1). Most patients (177;72.8%) were asymptomatic, with nausea/vomiting (23;9.5%) being the most commonly reported COVID-19 related symptom. SARS-CoV-2 testing was performed from 242(99.6%) nasopharyngeal, 243(100%) rectal, 183(75.3%) upper GI tract and 73(30%) colon samples. Only 1 patient (0.4%), with a history of COVID-19 infection 45 days prior to endoscopy, tested positive for SARS-CoV-2 on all the GI clinical specimens (fluid from upper GI tract, colon, and rectal swab), despite being asymptomatic and having 3 negative nasopharyngeal swabs 40, 37 and 3 days before her procedure (Figure 1). After 14-day incubation period, there was no evidence of virus growth in cells incubated with any of these specimens. CONCLUSIONS: SARS-CoV-2 is rarely detected in the GI tract of patients with negative screening nasopharyngeal COVID-19 testing prior to endoscopy. Infectious virus was not detected by culture from any of the GI specimens positive for SARS-CoV-2 RNA by rRT-PCR. Our results further highlight that presence of viral genome on its own is not sufficient proof of infectivity. Additional studies are needed to evaluate the temporal association between COVID-19 symptom onset and potential infectivity duration in the GI tract. (Table Presented)(Figure Presented)