P-EGS18 The outcomes of upper gastrointestinal bleeds with unsuccessful endoscopy in a district hospital with no interventional radiology

Background Acute upper gastrointestinal bleeding (UGIB) is a common emergency estimated to occur in 80 to 150 out of 100,000 people each year. First line management is endoscopy and pharmacological but those who fail this can pose a challenge. Current NICE guidelines recommend repeat endoscopy to patients who re-bleed, those unstable consider interventional radiology (IR) or emergency surgery. The estimated mortality rate is approximately 10%. This study was conducted to review our current surgical outcomes and whether referral for IR is appropriate and could reduce mortality. Methods Retrospective study of 11 patients who underwent surgery for refractory non- variceal UGIB between November 2015 and March 2021 with a mean age of 61. Data was collected from the electronic records. Results All patients underwent an emergency laparotomy, 82% had an ASA of 4 the remainder ASA 3, a mean NELA mortality of 31.1% and a mean Blatchford 11.1. The initial OGD was performed on the day of admission in 54% of patients. 45% during initial OGD became hemodynamically unstable and transferred to theatre, one patient re-bleed 3 days after and taken to theatre the remainder (45%) re-bleed and had a 2nd OGD. 2 patients unstable during OGD went to theatre, 3 re-bleed within 24hrs 1 within 48hrs and taken to theatre. Mortality rate was 27%, complication rate 45%, mean LOS 24.6. Conclusions These findings highlight the high rate of morbidity and mortality associated with surgical treatment for UBIB. A small number of cases occurred over 7 years requiring surgical intervention,45% had two OGD’s and 9% went on to have a 3rd. Was there a window of opportunity to use IR if it were available. Recent studies have shown that transcatheter arterial embolization is safer than surgical intervention in the high risk patient population and has a lower 30-d mortality rate.

EndoConf: real-time video consultation during endoscopy; telemedicine in endoscopy at its best

Background and study aims The aim of this study was to introduce EndoConf, a reliable and easy-to-use tool capable of optimizing clinical care in endoscopy by reducing the number of repeat endoscopy procedures, providing continuous on-the-job clinical education, and allowing a smooth transition to the next level of artificial intelligence-supported systems. Patients and methods We prospectively developed and improved a real-time conference system (EndoConf). EndoConf enables endoscopists to contact on-demand and in real time experienced endoscopists across other sites. After the initial introduction period, we registered all EndoConf-assisted procedures from our unit (Surgical Department of Odense University Hospital) over a 3-month period (Autumn of 2019). Results Of 84 EndoConf-supported procedures, 58 were eligible for further analysis. Eventually, 38 calls were made, of which only four were technically of low quality (10.5 %) while three were not answered (7.9 %). Of the 35 (92.1 %) completed EndoConf calls; 24 were referred for endoscopic mucosal resection, six were referred for transanal microsurgery preceded by transrectal ultrasonography and three were referred for multidisciplinary conference, whereas in two cases, the lesion was resected during EndoConf. Conclusions We found the EndoConf system to provide support that could reduce the number of unnecessary repeat endoscopic procedures while at the same time ensuring avoidance of any hazardous attempt at polypectomy.

A Case of Esophageal Squamous Papilloma, an Unusual Cause of Dysphagia and Hematemesis in a Patient with Concurrent Malignancies

Introduction: The oesophageal squamous papilloma (ESP) is a rare cause of dysphagia and hematemesis. The malignant potential of this lesion is uncertain; however, the malignant transformation and concurrent malignancies have been reported in the literature. Case description: We report a case of oesophageal squamous papilloma in a 43-year-old female who had a background diagnosis of metastatic breast cancer and liposarcoma of the left knee. She presented with dysphagia. Upper gastrointestinal (GI) endoscopy showed a polypoid growth, and its biopsy confirmed the diagnosis. Meanwhile, she presented again with hematemesis. A repeat endoscopy showed that the previously seen lesion had likely broken off, leaving behind a residual stalk. This was snared and removed. The patient remained asymptomatic, and a follow-up upper GI endoscopy at six months did not show any recurrence. Practical implications: To our knowledge, this is the first case of ESP in a patient with two concurrent malignancies. Moreover, the diagnosis of ESP should also be considered when presenting with dysphagia or hematemesis.

Extending treatment criteria for Barrett’s neoplasia: results of a nationwide cohort of 138 ESDs

Objective The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett’s esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed inNL. Design We retrospectively assessed ESD outcomes in NL, where treatment for BE neoplasia is centralized in 9 expert centers with jointly trained endoscopists and pathologists, and treatment/follow-up data collected in a joint database. ESD is restricted for selected cases. Results During median 121 minutes (p25-p75 90-180), 130 complete ESDs were performed with 97% (126/130) removed en-bloc. Pathology was HGD (5%), T1a-EAC (43%) or T1b-EAC (52%; 19%sm1, 33%≥sm2). The combined en-bloc and R0 rate was 87% [95%-CI 77-94%] for HGD/T1a-EAC and 49% [37-62%] for T1b-EAC. Upon R1 resection, 29% had residual cancer, in all cases detected at first follow-up endoscopy, while the remaining 71% had no residual cancer in esophagectomy specimen (n=6) or during median 9 months endoscopic FU (p25-p75 4-22) (n=18). Upon R0 resection, local recurrence rate during median 17 months (8-30) was 0% [0-5%]. Adverse events: 1% perforation [0-4%], 3% post-procedural bleeding [1-7%], 13% strictures [8-20%]. Conclusion In expert hands, ESD is safe and allows for removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter is, however, associated with a positive deep resection margin in half of the patients, yet only one third had actual persisting neoplasia at endoscopic FU. To better stratify R1-patients with an indication for additional surgery, repeat endoscopy after healing of the ESD wound may help in predicting residual cancer.

Real world management of esophageal ulcers : analysis of their presentation, etiology, and outcomes

Background and study aims : Esophageal ulcers are a rare cause of upper gastrointestinal morbidity and may be due to different etiologies. We sought to systematically evaluate patients with esophageal ulcers and describe their presentations, endoscopic findings, etiologies, treatments, and outcomes. Patients and methods : Patients diagnosed with esophageal ulcers over an 11-year period were retrospectively identified from our institution’s electronic medical records. Results : We identified 100 patients with esophageal ulcers (0.49% of patients undergoing upper endoscopy). Half of them presented due to gastrointestinal bleeding and three-quarters were admitted to the hospital. The majority were in the lower esophagus. Twenty-two unique etiologies, including multiple iatrogenic causes, were diagnosed in 91 of the cases. The most common etiology was gastroesophageal reflux disease (57%), followed by non-steroidal anti-inflammatory drug use (7%), malignancies (3%), vomiting (3%), caustic ingestion (2%), pill esophagitis (2%) and radiation (2%). Many etiologies showed a predilection for specific segments of the esophagus. Nine ulcers required endoscopic intervention and all were treated successfully. Repeat endoscopies were performed 5 times for diagnostic or “second look” reasons, none of which changed the patients’ diagnosis or treatment. No patients required surgery or stricture dilation. One patient’s ulcer was complicated by perforation and he subsequently died. Four other patients died from non-ulcer related causes. Conclusions : While the majority of ulcers were due to gastro-esophageal reflux disease, 22 different etiologies were identified. Many were due to medication or iatrogenic causes. Repeat endoscopy did not appear to be helpful. While the incidence was low, they were frequently associated with significant morbidity.

Endoscopic Evaluation for Stricture Formation Post Button Battery Ingestion

Every year, there are over 3300 ingestions of button batteries, mostly by young children. Initial presentation of button battery ingestion may be nonspecific, with a delay in diagnosis and removal resulting in increased risk of complications. We present the case of a five-year-old female who presented with vomiting following unwitnessed button battery ingestion. The battery was impacted in the middle esophagus for at least six hours. Endoscopy was performed for immediate removal and showed a Grade 2B erosion, warranting nasogastric tube placement. The patient remained asymptomatic following discharge and had a barium swallow that was read as normal. However, a repeat endoscopy one month later visualized stricture formation at the previous battery injury site. This case highlights the importance of both clinician and parent awareness of button battery ingestion and demonstrates that endoscopy provides the most accurate assessment of esophageal injury and complication development, even in asymptomatic patients.

Acute oesophageal necrosis in a patient with recent SARS-CoV-2

A 57-year-old Hispanic man with diabetes presented with dyspnoea. He had a positive SARS-CoV-2 PCR. He was intubated for severe hypoxia and treated with intermittent pressors, methylprednisolone and supportive care. He was extubated on hospital day (HD) 9 and discharged to a skilled nursing facility (SNF) on HD 18. Approximately 1 month later, he presented with melena. Endoscopy revealed two large 1.5–2 cm wide-based distal oesophageal ulcers without active bleeding. Histology showed ulcerated squamous mucosa with extensive necrosis extending to the muscularis propria and coccoid bacterial colonies with rare fungal forms suggestive of Candida. He was treated with fluconazole and pantoprazole and was discharged to a SNF. Approximately 3 weeks later, he was readmitted for complications. Repeat endoscopy demonstrated improvement and histology revealed chronic inflammation with reactive epithelial changes. Incidentally, SARS-CoV-2 PCR was positive during this visit without any respiratory symptoms.

Gastric amyloidosis presenting as acute upper gastrointestinal bleeding: a case report

Background Amyloidosis is characterized by extracellular tissue deposition of fibrils, composed of insoluble low-molecular-weight protein subunits. The type, location, and extent of fibril deposition generates variable clinical manifestations. Gastrointestinal (GI) bleeding due to amyloid deposition is infrequent. Previous literature describes upper GI bleeding (UGIB) in patients with known amyloid disease. Here, we describe a case of recurrent UGIB that ultimately led to a diagnosis of GI amyloidosis and multiple myeloma in a patient with no history of either. Case presentation A 76-year-old male presented to the emergency department with frank hematemesis, melena, and a decreased level of consciousness. Management required intensive care unit (ICU) admission with transfusion, intubation, and hemodynamic support. Upper endoscopy revealed gastritis with erosions and nodularity in the gastric cardia and antrum. Hemostasis of a suspected bleeding fundic varix could not be achieved. Subsequently, the patient underwent computerized tomography (CT) angiography and an interventional radiologist completed embolization of the left gastric artery to address potentially life-threatening bleeding. Complications included development of bilateral pleural effusions and subsegmental pulmonary emboli. Pleural fluid was negative for malignancy. He was transferred to a peripheral hospital for continued care and rehabilitation. Unfortunately, he began re-bleeding and was transferred back to our tertiary center, requiring re-admission to the ICU and repeat endoscopy. Repeat biopsy of the gastric cardial nodularity was reported as active chronic gastritis and ulceration. However, based on the unusual endoscopic appearance, clinical suspicion for malignancy remained high. He exhibited symptoms of congestive heart failure following standard resuscitation. Transthoracic echocardiogram (TTE) demonstrated a reduced ejection fraction of 35–40% and a strain pattern with apical sparing. Following discussions between the treating gastroenterologist, consulting cardiologist, and pathologist, Congo Red staining was performed, revealing submucosal amyloid deposits. Hematology was consulted and investigations led to diagnosis of multiple myeloma (MM) and immunoglobulin light-chain (AL) amyloidosis. The patient was treated for MM for four months prior to cessation of therapy due to functional and cognitive decline. Conclusions GI amyloidosis can present with various non-specific clinical symptoms and endoscopic findings, rendering diagnosis a challenge. This case illustrates GI amyloidosis as a potential—albeit rare—etiology of UGIB.

Mid-oesophageal traction diverticulum in a patient with systemic lupus erythematosus

In this report, a case of a large mid-oesophageal traction diverticulum in a 66-year-old woman with systemic lupus erythematosus has been presented. She was initially managed conservatively with active surveillance for 6 years. When her symptoms progressed, she had repeat endoscopy and CT scan which showed an increase in size of the diverticulum to 6 cm in diameter. Her dysphagia had progressively deteriorated and she was only managing a liquid diet. She, therefore, proceeded to resection of the diverticulum by right thoracotomy and stapled diverticulectomy. She made an excellent postoperative recovery and at last review, 5 months after the operation, she was back at work, had put on weight, and was tolerating a normal diet.

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE.

Background Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated. Aims To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE. Methods An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020. Results 62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of >50 new patients per year; 9/16 centres have >100 patients in follow-up. An EoE Clinic is present in 5 centres. Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1). Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings. Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children <10 and >10 years, respectively. Conclusions The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research. Funding Agencies None