Clinical usefulness and acceptability of small-bowel capsule endoscopy with panoramic imaging compared with axial imaging in Japanese patients.

Objectives: We aimed to evaluate the usefulness and acceptability of CapsoCam Plus (CapsoCam) in Japanese patients. Methods: This retrospective single-center study enrolled 930 patients with suspected small-bowel bleeding (SSBB) who underwent capsule endoscopy. Thirty-three patients using CapsoCam and PillCam SB3 (SB3) were matched using propensity score matching. The diagnostic yield and the acceptability of CapsoCam were evaluated. Results: There was no SSBB case where capsule endoscopy was performed within 48 h of bleeding. CapsoCam had a significantly higher observation rate of the entire small bowel (97% vs. 73%, p = 0.006) and Vater's papilla (82% vs. 15%, p < 0.001) than SB3. The reading time of CapsoCam was significantly longer than that of SB3 (30 vs. 25 min, p < 0.001), and CapsoCam's time from the capsule endoscopy swallowing to read completion was longer than that of SB3 (37 vs. 12 h, p < 0.001). The two groups showed no difference in the capsule endoscopy findings according to the P classification. Notably, 85% of the patients using CapsoCam reported examination distress as "not at all" or "almost not," and 94% reported swallowing difficulty as "very easy" or "easy." Conclusions: CapsoCam took time to read; however, it is a well-tolerated examination with a high observation rate of Vater's papilla and entire small-bowel mucosa. Detectability of bleeding sources was comparable in both modalities for cases of occult SSBB and overt SSBB more than 48 h after bleeding. CapsoCam is a useful modality for patients with SSBB.

Racial Differences in Non-variceal Upper Gastrointestinal (GI) Bleeding: A Nationwide Study.

Background and aims Knowledge about the impact of race on non-variceal upper GI bleeding (NVUGIB) is limited. This study explored the racial differences in the etiology and outcome of NVUGIB. Methods We conducted a study from 2009 to 2014 using the Nationwide Inpatient Sample (NIS) database. NIS is the largest publicly available all-payer inpatient database in the USA with more than seven million hospital stays each year. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for NVUGIB, esophagogastroduodenoscopy (EGD) and demographics were obtained. The outcomes of interest were in-hospital mortality, hospital length of stay (HLOS), total hospital charges, admission to the intensive care unit (ICU), and patient disposition. Analysis was conducted using Chi-square tests and Tukey multiple comparisons between groups. Results Among 1,082,516 patients with NVUGIB, African American and Native Americans had the highest proportions of hemorrhagic gastritis/duodenitis (8.2% and 4.2%, respectively) and Mallory-Weiss bleeding (10.4% and 5.4%, respectively; p<0.01). African Americans were less likely to get an EGD done within 24 hours of admission compared to Whites and Latinxs (45.9% vs 50.1% and 50.4%, respectively; p<0.001). In-hospital mortality was similar among African Americans, Latinxs, and Whites (5.8% vs 5.6% vs 5.9%, respectively; p=0.175). Asian/Pacific Islanders and African Americans were more likely to be admitted to the ICU (9.6% and 9.0%, respectively; p<0.001). Moreover, African Americans had a longer HLOS compared to Latinxs and Whites (7.5 vs 6.5 and 6.4 days, respectively; p<0.001). Conversely, Asian/Pacific Islanders and Latinx incurred the highest hospital total charges compared to African Americans and Whites ($81,821 and $69,267 vs $61,484 and $53,767, respectively; p<0.001). Conclusion African Americans are less likely to receive EGD within 24 hours of admission and are more likely to be admitted to the ICU with prolonged hospital lengths of stay. Latinxs are more likely to be uninsured and incur the highest hospital costs.

An update on oral antiplatelet drug interactions with proton pump inhibitors: what are the risks?

INTRODUCTION: Aspirin and anti-P2Y12 are widely prescribed in cardiovascular patients, often in combination with proton pump inhibitors (PPIs) to limit the risk of upper gastrointestinal bleedings. The potential interaction between PPIs and antiplatelet agents has been widely discussed, but doubts remain as to whether PPIs may reduce the cardiovascular protection provided by aspirin, prasugrel, ticagrelor, and clopidogrel. AREAS COVERED: Many pharmacokinetic (PK) and pharmacodynamic (PD) studies have confirmed the interaction, especially between PPIs and clopidogrel, but with uncertain consequences on clinical outcomes. Therefore, we aimed to summarize the evidence for the widespread combined use of oral antiplatelet drugs and PPIs, to outline the current evidence supporting or opposing drug-drug interaction, and to discuss the clinical implications of such interactions. EXPERT OPINION: A large body of evidence describes the PK/PD interaction of antiplatelet drugs with PPIs and its potential role in increasing clinical cardiovascular adverse events, but no solid clinical data have confirmed these effects. In the light of the published studies, there seems to be no restriction on the choice of PPI with aspirin, prasugrel and/or ticagrelor. The choice of a PPI with no (or minimal) interference with the hepatic cytochrome P450 2C19 is preferred in patients receiving clopidogrel.

Clinical outcomes of endoscopic detachable snare ligation for colonic diverticular hemorrhage: Multicenter cohort study.

OBJECTIVES: The hemostatic mechanism of endoscopic detachable snare ligation (EDSL) for colonic diverticular hemorrhage (CDH) is similar to that of endoscopic band ligation, which is effective and safe. However, because reports on EDSL are scarce, we conducted a two-center cohort study to evaluate its effectiveness. METHODS: This study analyzed 283 patients with CDH treated with EDSL at two Japanese hospitals between July 2015 and November 2021. Patient characteristics and clinical outcomes were retrospectively evaluated. A Kaplan-Meier analysis was performed to evaluate the cumulative probability of rebleeding after EDSL. A Cox proportional hazards regression analysis was performed to compare the effects of complete and incomplete ligation on rebleeding. RESULTS: The initial hemostasis success and early rebleeding rates were 97.9% and 11.0%, respectively. The time to hemostasis after identification of the bleeding site and total procedure time were 9 min and 44 min, respectively. Red blood cell transfusion was required for 32.9% of patients. The median hospital length of stay after EDSL was 5 days. The complete ligation rate of the early rebleeding group was significantly lower than that of the group without early rebleeding (P < 0.01). The 1-year cumulative rebleeding rate with EDSL was 28.2%. Complete ligation was associated with decreased cumulative rebleeding after EDSL (P < 0.01). One patient experienced colonic diverticulitis; however, colonic perforation was not observed. CONCLUSION: Complete ligation is associated with reduced short-term and long-term rebleeding. EDSL could be valuable for CDH because of its low rebleeding rate and the absence of serious adverse events.

Hemospray® (hemostatic powder TC-325) as monotherapy for acute gastrointestinal bleeding: a multicenter prospective study.

Background: Hemostatic powders are used as second-line treatment in acute gastrointestinal (GI) bleeding (AGIB). Increasing evidence supports the use of TC-325 as monotherapy in specific scenarios. This prospective, multicenter study evaluated the performance of TC-325 as monotherapy for AGIB. Methods: Eighteen centers across Europe and USA contributed to a registry between 2016 and 2022. Adults with AGIB were eligible, unless TC-325 was part of combined hemostasis. The primary endpoint was immediate hemostasis. Secondary outcomes were rebleeding and mortality. Associations with risk factors were investigated (statistical significance at P≤0.05). Results: One hundred ninety patients were included (age 51-81 years, male: female 2:1), with peptic ulcer (n=48), upper GI malignancy (n=79), post-endoscopic treatment hemorrhage (n=37), and lower GI lesions (n=26). The primary outcome was recorded in 96.3% (95% confidence interval [CI]: 92.6-98.5) with rebleeding in 17.4% (95%CI 11.9-24.1); 9.9% (95%CI 5.8-15.6) died within 7 days, and 21.7% (95%CI 15.6-28.9) within 30 days. Regarding peptic ulcer, immediate hemostasis was achieved in 88% (95%CI 75-95), while 26% (95%CI 13-43) rebled. Higher ASA score was associated with mortality (OR 23.5, 95%CI 1.60-345; P=0.02). Immediate hemostasis was achieved in 100% of cases with malignancy and post-intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received TC-325 for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions: TC-325 monotherapy is safe and effective, especially in malignancy or post-endoscopic intervention bleeding. In patients with peptic ulcer, it could be helpful when the primary treatment is unfeasible, as bridge to definite therapy.

Predictors of in-hospital outcomes for diverticular bleeding patients: a retrospective analysis of National Inpatient Sample data (2016-2020).

Background: Diverticular bleeding is the leading cause of lower gastrointestinal bleeding, affecting 3-5% of patients with diverticulosis. Current management protocols include resuscitation, diagnosis via direct visualization, computed tomography imaging, endoscopic interventions, angioembolization, and surgery when needed. However, predictive factors for outcomes and optimal interventions remain ambiguous. Methods: This retrospective cohort study analyzed data from the National Inpatient Sample (NIS) database (2016-2020) to determine predictors of adverse in-hospital outcomes in diverticular bleeding patients without perforation or abscess. Demographic and clinical data were extracted, and multivariate regression models were applied. Analysis was conducted using R statistical software (version 4.1.3), with significance set at P<0.05. Results: A total of 28,269 patients hospitalized for diverticular bleeding were identified. Age >85 years, moderate to severe Charlson Comorbidity Index, hypovolemic shock, blood transfusion requirement, and requirement for colectomy were significantly associated with greater in-hospital mortality. Factors such as late colonoscopy timing and colon resection led to longer hospital stays, while arterial embolization was predicted by older age, Black race, hypovolemic shock, and blood transfusion. Predictors of colon resection included advanced age, presence of colon cancer, and hypovolemic shock. Conclusions: Our retrospective study identified significant predictors of in-hospital outcomes among patients with diverticular bleeding, informing risk stratification and management strategies. Further research is warranted to validate these findings and refine management algorithms for improved patient care. Integrating these insights into clinical practice may enhance outcomes and guide personalized interventions in diverticular bleeding management.

Etiologies of Splenic Venous Hypertension: A Review.

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

Radiofrequency Ablation for Internal Hemorrhoids: A Case Series.

Internal hemorrhoids are a common issue in general surgery and are one of the leading causes of lower gastrointestinal bleeding globally. Numerous treatment options exist for managing this challenging condition. One relatively new treatment method is radiofrequency ablation for internal hemorrhoids (RAFAELO). According to the limited publications, this method is described as simple, quick, and safe. In this case series, we present five patients with internal hemorrhoids who were treated using the RAFAELO method and discuss their management and outcomes.

Outcomes of Upper Gastrointestinal Bleeding in Hospitalized COVID-19 Patients in the United States: A Propensity-score Matched Analysis of a Large National Database.

Patients with cirrhosis that are hospitalized with COVID-19 infection have been found to have worse outcomes. No comparative study has been conducted between gastrointestinal (GI) bleeding in patients with cirrhosis who are diagnosed with COVID-19. We utilized the National Inpatient Sample (NIS) database to perform a retrospective analysis of 24, 050 patients diagnosed with cirrhosis and COVID-19. The identified patients were separated into variceal bleeding, nonvariceal bleeding, and no (or neither) GI bleeding groups. After performing propensity sample matching and multivariate analysis of mortality, we found no significant differences in mortality among the three groups. However, the variceal bleed group had a shorter length of stay (5.67 days lower than the no-bleed group). Esophagogastroduodenoscopy (EGD) with intervention was associated with reduced mortality in the variceal and nonvariceal bleeding groups. Acute kidney injury was a strong predictor of mortality in both bleeding groups. A native American race was found to be associated with higher mortality in the nonvariceal bleeding group. Our study suggests that there are various pathophysiological processes among the three groups, with no significant mortality differences with cirrhosis complications of GI bleeding.

A Rare Case of Acquired Factor VIII Inhibition in an Elderly Female.

Acquired hemophilia A is a rare condition characterized by the development of autoantibodies against coagulation factor VIII. It often initially presents as serious bleeding in the absence of risk factors and carries high morbidity and mortality if not diagnosed early. Due to its rare nature, data is limited, and guidelines are primarily based on expert opinion. Here we present a case of an elderly patient with severe gastrointestinal bleeding found to have activated partial thromboplastin times, plasma mixing studies, and coagulation factor activity levels consistent with acquired hemophilia A. We hope to bring awareness of this rare disease and promote its consideration in the differential of unexpected bleeding to improve safety outcomes.

Association and temporal sequence of pneumonia and gastrointestinal bleeding after acute ischemic stroke.

BACKGROUND: Stroke-associated pneumonia (SAP) and gastrointestinal bleeding (GIB) are common medical complications after stroke. The previous study suggested a strong association between SAP and GIB after stroke. However, little is known about the time sequence of SAP and GIB. In the present study, we aimed to verify the association and clarify the temporal sequence of SAP and GIB after ischemic stroke. METHODS: Patients with ischemic stroke from in-hospital Medical Complication after Acute Stroke study were analyzed. Data on occurrences of SAP and GIB during hospitalization and the intervals from stroke onset to diagnosis of SAP and GIB were collected. Multiple logistic regression was used to evaluate the association between SAP and GIB. Kruskal-Wallis test was used to compare the time intervals from stroke onset to diagnosis of SAP and GIB. RESULTS: A total of 1129 patients with ischemic stroke were included. The median length of hospitalization was 14 days. Overall, 86 patients (7.6%; 95% CI, 6.1-9.2%) developed SAP and 47 patients (4.3%; 95% CI, 3.0-5.3%) developed GIB during hospitalization. After adjusting potential confounders, SAP was significantly associated with the development of GIB after ischemic stroke (OR = 5.13; 95% CI, 2.02-13.00; P < 0.001). The median time from stroke onset to diagnosis of SAP was shorter than that of GIB after ischemic stroke (4 days vs. 5 days; P = 0.039). CONCLUSIONS: SAP was associated with GIB after ischemic stroke, and the onset time of SAP was earlier than that of GIB. It is imperative to take precautions to prevent GIB in stroke patients with SAP.

Neurofibromatosis Type 1 Presenting as Bleeding Jejunal Gastrointestinal Stromal Tumour.

Introduction: Gastrointestinal stromal tumours (GISTs) are an important, though uncommon, cause of obscure gastrointestinal bleeding and may rarely be associated with genodermatoses such as neurofibromatosis type 1 (NF1). NF1-related GISTs have unique phenotypic features compared with sporadic GISTs and may elude diagnosis due to their predilection for the small bowel. Case Presentation: We report a case of a 45-year-old Singaporean woman with café-au-lait macules and cutaneous neurofibromas who presented with occult obscure gastrointestinal bleeding and was eventually discovered to have a bleeding jejunal GIST. This finding, considered together with her cutaneous signs, eventually led to the diagnosis of NF1. Conclusion: Genodermatoses and their gastrointestinal complications are likely under-reported in adult Southeast Asian populations and deserve greater awareness from gastroenterologists practising in this region.

Computed tomography three-dimensional reconstruction in the diagnosis of bleeding small intestinal polyps: A case report.

BACKGROUND: Computed tomography (CT) small bowel three-dimensional (3D) reconstruction is a powerful tool for the diagnosis of small bowel disease and can clearly show the intestinal lumen and wall as well as the outside structure of the wall. The horizontal axis position can show the best adjacent intestinal tube and the lesion between the intestinal tubes, while the coronal position can show the overall view of the small bowel. The ileal end of the localization of the display of excellent, and easy to quantitative measurement of the affected intestinal segments, the sagittal position for the rectum and the pre-sacral lesions show the best, for the discovery of fistulae is also helpful. Sagittal view can show rectal and presacral lesions and is useful for fistula detection. It is suitable for the assessment of inflammatory bowel disease, such as assessment of disease severity and diagnosis and differential diagnosis of the small bowel and mesenteric space-occupying lesions as well as the judgment of small bowel obstruction points. CASE SUMMARY: Bleeding caused by small intestinal polyps is often difficult to diagnose in clinical practice. This study reports a 29-year-old male patient who was admitted to the hospital with black stool and abdominal pain for 3 months. Using the combination of CT-3D reconstruction and capsule endoscopy, the condition was diagnosed correctly, and the polyps were removed using single-balloon enteroscopy-endoscopic retrograde cholangiopancreatography without postoperative complications. CONCLUSION: The role of CT-3D in gastrointestinal diseases was confirmed. CT-3D can assist in the diagnosis and treatment of gastrointestinal diseases in combination with capsule endoscopy and small intestinal microscopy.

The Safety of Novel Therapies in Chronic Lymphocytic Leukemia in the Era of Intermittent Fasting: A Pharmacology-Based Review.

Intermittent fasting (IF) has recently gained popularity due to its emerging benefits in reducing weight and improving metabolic health. Concurrently, novel agents (NAs) like venetoclax and Bruton tyrosine kinase inhibitors (BTKIs) have revolutionized the treatment of chronic lymphocytic leukemia (CLL). Unfortunately, it is unclear whether the associated risks of tumor lysis syndrome (TLS) and gastrointestinal bleeding (GIB) are increased in IF practitioners receiving NAs. This review explored the literature available on the permissibility of IF in CLL patients undergoing treatment with first-line NAs (FLNAs). Literature was scoped to identify IF patterns and the available data on TLS and GIB risks associated with food and fluid intake in CLL patients receiving FLNAs. Although current evidence is insufficient to recommend IF in this population, it may be possible for patients on venetoclax to conservatively practice fluid-liberal IF, provided that adequate hydration and the consistent administration of food are achieved. In contrast, considering the significant risk of TLS and the pharmacokinetics of venetoclax, patients should be discouraged from practicing fluid-restricted IF, especially during the ramp-up phase. Moreover, patients on BTKIs ought to refrain from IF due to the possible risk of GIB until further data are available. Further research is needed to provide conclusive recommendations.

The novel use of resuscitative endovascular balloon occlusion of the aorta for uncontrolled bleeding in a surgically inaccessible abdomen: The ruptured proper hepatic artery in a frozen abdomen.

Hemorrhage is among the leading causes of death for trauma patients. Adjunct techniques used to control bleeding include use of aortic cross clamping, application of a pelvic binder, rapidly expanding hemostatic sponges, and extra-peritoneal packing. Additionally, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide life-saving proximal control for patients with massive internal hemorrhage. This study concerns a patient treated with Zone 1 REBOA for class IV hemorrhagic shock from a spontaneous common hepatic artery rupture. REBOA was performed at bedside in the Surgical Intensive Care Unit (SICU) prior to definitive selective embolization. A healthy 28-year-old male suffered a grade 4 liver laceration and pancreatic head transection with associated duodenal injury after a high-speed motor vehicle collision. On arrival, the patient required a damage control laparotomy with multiple reoperations for management of his intra-abdominal injuries. By hospital day 11, significant visceral adhesions resulted in a frozen abdomen. On hospital day 20, the patient developed massive hematemesis, hematochezia, and class IV hemorrhagic shock. Vascular surgery was called to bedside in the SICU to perform REBOA. The patient received massive transfusion protocol while a 12 Fr sheath was inserted, and an aortic occlusion balloon was inflated in Zone 1 allowing for hemodynamic stabilization for transport and definitive management in the angiography suite. This case reports a novel use of REBOA, at bedside in the SICU, for the management of a massive gastrointestinal bleed in a patient with frozen abdomen. In this case, REBOA allowed us to achieve temporary hemodynamic stability prior to definitive control in the angiography suite. Bedside use of REBOA in the SICU prevented certain exsanguination and death.

Unusual causes of gastrointestinal bleeding in the intensive care unit through the radiology lens.

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management.

Associations between enteral nutrition and outcomes in the SUP-ICU trial: Results of exploratory post hoc analyses.

BACKGROUND: Enteral nutrition may affect risks of gastrointestinal bleeding, pneumonia and mortality in critically ill patients and may also modify the effects of pharmacological stress ulcer prophylaxis. We undertook post hoc analyses of the stress ulcer prophylaxis in the intensive care unit trial to assess for any associations and interactions between enteral nutrition and pantoprazole. METHODS: Extended Cox models with time-varying co-variates and competing events were used to assess potential associations, adjusted for baseline severity of illness. Potential interactions between daily enteral nutrition and allocation to pantoprazole on outcomes were similarly assessed. RESULTS: Enteral nutrition was associated with lower risk of clinically important gastrointestinal bleeding (cause-specific hazard ratio [HR]: 0.29, 95% confidence interval: [CI] 0.19-0.44, p < .001), higher risk of pneumonia (HR: 1.44, 95% CI: 1.14-1.82, p = .003), and lower risk of all-cause mortality (HR: 0.22, 95% CI: 0.18-0.27, p < .001). Enteral nutrition with allocation to pantoprazole was associated with a lower risk of mortality (HR: 0.27, 95% CI: 0.21-0.35, p < .001), similar to enteral nutrition with allocation to placebo (HR: 0.17, 95% CI: 0.13-0.23, p < .001). Allocation to pantoprazole with no enteral nutrition had little effect on mortality (HR: 0.83, 95% CI: 0.63-1.09, p = .179), whilst allocation to pantoprazole and receipt of enteral nutrition was mostly compatible with increased all-cause mortality (HR: 1.27, 95% CI: 0.99-1.64, p = .061). The test of interaction between enteral nutrition and pantoprazole treatment allocation for all-cause mortality was statistically significant (p = .024). CONCLUSIONS: Enteral nutrition was associated with an increased risk of pneumonia and a reduced risk of gastrointestinal bleeding. The interaction between pantoprazole and enteral nutrition suggesting an increased risk of mortality requires further study.

External validation of the SHA2PE score and its comparison to the Oakland score for the prediction of safe discharge in patients with lower gastrointestinal bleeding.

BACKGROUND: The growing incidence of lower gastrointestinal bleeding (LGIB) is leading to a rise in-hospital admissions even though most LGIB episodes are self-limiting. The Oakland and SHA2PE scores were designed to identify patients best suited to outpatient care. Our aim is explore the validity of the SHA2PE score and compare both of these scores in terms of predictiveness of safe discharge. METHODS: Retrospective observational study of LGIB patients admitted to a tertiary hospital between June 2014 and June 2019. Safe discharge was defined as the absence of all the following: blood transfusion, haemostatic intervention, re-bleeding, in-hospital death, and re-admission due to LGIB within 28 days after discharge. RESULTS: From 595 hospital admissions for LGIB, 398 episodes were included. Fifty-four per cent met safe discharge criteria, with these cases being younger, with a lower score in the Charlson's index and significantly higher haemoglobin concentration upon arrival. The performance of both scores was good, with an AUC for the Oakland score of 0.85 (95% CI 0.82-0.89) and of 0.797 (95% CI 0.75-0.84) for the SHA2PE score. The Oakland score performed better in terms of prediction of safe discharge, with a positive predictive value and specificity of 100% when a cut-off value of ≤ 8 points was used; however, only a minority of patients might benefit from its implementation given its low sensitivity. CONCLUSIONS: Almost half of the patients admitted for LGIB met criteria for safe discharge. However, the available indexes only allow for the identification of a small proportion of those patients candidates for outpatient care.

Discrimination of pediatric cryptogenic multifocal ulcerous stenosing enteritis from small bowel Crohn's disease and gastrointestinal tuberculosis: A retrospective study (with videos).

INTRODUCTION: Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare entity that mimics various inflammatory strictures of the small intestine. Pediatric literature is scarce. We analyzed the clinical, radiological, endoscopic and histopathological features of children with CMUSE that differentiate it from small bowel Crohn's disease (SBCD) and gastrointestinal tuberculosis (GITB). METHODS: CMUSE was diagnosed by the following criteria: (1) unexplained small bowel strictures with superficial ulcers, (2) chronic/relapsing ulcers of small bowel after resection, (3) no signs of systemic inflammation, (4) absence of other known etiologies of small bowel ulcers. SBCD and GITB were diagnosed based on standard criteria. The clinical features, laboratory parameters, radioimaging, endoscopy (including video capsule endoscopy [VCE], intra-operative endoscopy), histopathological features and treatment outcome were noted. RESULTS: Out of 48, CMUSE was diagnosed in 13 (27%) isolated small bowel and ileocecal strictures, while GITB and SBCD accounted for 41% and 21% cases, respectively. Common presentations were sub-acute obstruction (46%), obscure gastrointestinal bleeding (38%) and protein-losing enteropathy (38%). CMUSE patients had significantly longer disease duration compared to SBCD and GITB (p < 0.001). SBCD (90.0%) and GITB (85%) cases had elevated C-reactive protein (CRP), none with CMUSE had elevated CRP (p < 0.001). The disease was localized in jejunum (100%) and proximal ileum (56%) in CMUSE, ileocecal region (85%) in GITB, but evenly distributed in small intestine in SBCD. Endoscopy showed evenly placed, superficial, circumferential ulcers with strictures in CMUSE, deep linear ulcers in SBCD and circumferential ulcers in GITB. Upfront immunosuppression was given in four; three (75%) of them relapsed. Only surgery was done in three with one (25%) having relapse. Upfront surgery followed by immunosuppression was used in six, but all relapsed and two required repeat surgery. CONCLUSION: CMUSE is important but underdiagnosed in children. Lack of constitutional symptoms, normal inflammatory parameters and characteristic ulcers with strictures helped in differentiating CMUSE from GITB and SBCD.

Acute esophageal necrosis following cardiac arrest: A rare and lethal syndrome with diagnostic challenges.

INTRODUCTION AND CLINICAL RELEVANCE: Acute esophageal necrosis (AEN) is a condition characterized by the necrosis of the distal portion of the esophageal mucosa. Risk factors predisposing to this condition are associated to compromised vascular perfusion (e.g. diabetes mellitus, chronic kidney disease, advanced age, and hypertension, shock states). Complications of AEN can be severe including UGI stricture, perforation and overall increased mortality. The true incidence of AEN remains uncertain due to potential subclincal presentations and early resolution. CASE PRESENTATION: The case outlined involves a 66-years-old obese male with history of alcoholism and lymph-edema of the left leg who presented to the emergency department with hematemesis, haemodynamic instability and impaired consciousness. Shortly after initial assessment, the patient went into cardiac arrest with pulse-less electrical activity (PEA). Return of spontaneous circulation (ROSC) was achieved following instigation of ALS protocol, fluid resuscitation and the administration of a total of 5 mg of adrenaline. Following stabilization, a CT scan was performed which reported a moderately enlarged esophagus with a thickened wall, liquid hypodense material within the esophagus and stomach, and liver cirrhosis. The emergent esophagogastroduodenoscopy (EGDS) revealed extensive mucosal findings indicative of diffuse necrosis with initial scarring, which was later diagnosed as AEN. The patient unfortunately deceased in ICU after developing progression of the AEN, post-cardiac arrest syndrome and liver failure. CLINICAL DISCUSSION: The presented case highlights several crucial clinical issues and management problems related to AEN. To diagnose AEN, EGDS is still the gold-standard since it allows direct inspection of the esophageal mucosal layer. The management of AEN necessitates a multidisciplinary approach that includes aggressive resuscitation, treatment of underlying comorbidities, and supportive care (e.g. proton pump inhibitors). The mortality rate for AEN remains high despite improvements in diagnosis and treatment highlighting the need to recognize this condition early and intervene promptly in the patients affected. Moreover, long-term sequelae like stricture formation of the esophagus and impaired esophageal motility may contribute to morbidity requiring continuos monitoring. Therefore, to optimize outcomes while reducing complications among affected patients, prompt identification associated with appropriate medical measures are essential. More research needs to be done aiming to better understand the pathophysiology of AEN thereby identifying strategies for its prevention or cure. CONCLUSIONS: AEN is a rare syndrome characterized by upper gastrointestinal bleeding and hypoxic damage of the esophageal mucosa, often associated with ischemia, gastric outlet obstruction, and compromised protective barriers. Treatment involves aggressive resuscitation, proton pump inhibitors, and monitoring for infection or perforation. However, despite intensive efforts, the mortality rate for AEN remains high at 32 %.