Feasibility of a Palliative Care Intervention Utilizing Community Health Workers to Facilitate Delivery of Home-based Palliative Care in India

Objectives: The purpose of this study was to evaluate the feasibility of a home-based palliative care program delivered by community health workers (CHW) in rural areas outside of Kolkata, India. The specific aims were to assess CHWs’ ability to implement the intervention protocol and maintain records of care, to characterize patient problems and CHW activities to assist patients, and to assess change in patient pain scores over the course of the intervention. Materials and Methods: Four CHWs were hired to facilitate delivery of home-based palliative care services. CHWs were trained using the Worldwide Hospice and Palliative Care Alliance’s Palliative Care Toolkit. CHWs provided care for patients for 3-months, making regular home visits to monitor health, making and implementing care plans, and referring patients back to the cancer center team for serious problems. Results: Eleven patients enrolled in the intervention, with ten of these patients participating in the intervention and one patient passing away before starting the intervention. All ten participants reported physical pain, for which CHWs commonly recommended additional or higher dose medication and/or instructed patients how to take medication properly. For two patients, pain levels decreased between baseline and end of study, while pain scores did not decrease for the remaining patients. Other symptoms for which CHWs provided care included gastro-intestinal, bleeding, and respiratory problems. Conclusion: The study findings suggest that utilization of CHWs to provide palliative care in low-resource settings may be a feasible approach for expanding access to palliative care. CHWs were able to carry out the study visit protocol and assess and document patient problems and their activities to assist. They were also able to alleviate many common problems patients experienced with simple suggestions or referrals. However, most patients did not see a decrease in pain levels and more emphasis was needed on the emotional aspects of palliative care, and so CHWs may require additional training on provision of pain management and emotional support services.

Experience of serious intestinal hemorrhage and perforation in small bowel lymphoma: a case report

There have been several reports of complications of small bowel lymphoma, such as bleeding, obstruction, and perforation, often require emergency surgery. It is hardly showed complications of bleeding and wound dehiscence for diffuse large B cell lymphoma with distal ileum involvement, which needed urgent surgery and medical management. A 65-year-old man with diffuse large B-cell lymphoma with distal ileum involvement experienced both intestinal bleeding and perforation during the course of treatment. As the patient was diagnosed with stage III disease, resection before chemotherapy was not considered due to the resulting delay in chemotherapy, which necessitated sufficient tissue healing. Chemotherapy is important when treating small bowel lymphoma, complications such as bleeding and perforation should always be considered for the treatment of small bowel lymphoma, and surgery is necessary in this situation. After surgery of the small bowel, subsequent chemotherapy could cause wound dehiscence and perforation; therefore, adequate recovery time should be given before chemotherapy.

Interleukin-10 knockout mice do not reliably exhibit macroscopic inflammation: a natural history endoscopic surveillance study

Background: Interleukin (IL)-10 knockout (KO) mice, used as a model for inflammatory bowel disease (IBD), develop chronic enterocolitis. Endoscopy, the gold standard for evaluation of human mucosal health, is not widely available for murine models. We aimed to assess the natural history of left-sided colitis in IL-10 KO mice via serial endoscopies. Methods: BALB/cJ IL10 KO mice underwent regular endoscopic assessments from 2 up to 8 months of age. Procedures were recorded and blindly evaluated using a 4-component endoscopic score: mucosal wall transparency, intestinal bleeding, focal lesions and perianal lesions (0-3 points each). An endoscopic score ≥1 point was considered as the presence of colitis/flare. Results: IL-10 KO mice (N=40, 9 female) were assessed. Mean age at first endoscopy was 62.5±2.5 days; average number of procedures per mouse was 6.0±1.3. A total of 238 endoscopies were conducted every 24.8±8.3 days, corresponding to 124.1±45.2 days of surveillance per mouse (13.6 years cumulative surveillance). Thirty-three endoscopies in 24 mice (60%) detected colitis, mean endoscopy score 2.5±1.3 (range: 1-6.3). Nineteen mice (47.5%) had one episode of colitis and 5 (12.5%) had 2-3 episodes. All exhibited complete spontaneous healing on subsequent endoscopies. Conclusions: In this largest endoscopic surveillance study of IL-10 KO mice, 40% of mice did not develop endoscopic left-sided colitis. Furthermore, IL-10 KO mice did not exhibit persistent colitis and universally exhibited complete spontaneous healing without treatment. The natural history of colitis in IL-10 KO mice may not be comparable with that of IBD in humans and requires careful consideration.

P-EGS03 Curious Case of Life Threatening Gastrointestinal Bleed

Background Gastrointestinal stromal tumors are mesenchymal in origin, being derived from the interstitial cells of Cajal. These can be found anywhere in the gastrointestinal tract and are commonly found in the stomach followed by the small bowel. Gastrointestinal stromal tumors are usually asymptomatic and are often found incidentally. Chronic bleeding is one of the most common presentation. Gastrointestinal stromal tumors presenting with massive gastro intestinal haemorrhage and mimicking arteriovenous malformation on radiology are rare with only few cases reported. Methods Herein we present such a case of a 45-year-old gentleman with massive gastro intestinal bleeding. At presentation, patient was in congestive heart failure due to severe anaemia with a hemoglobin of 2.9g/dL. CECT Angiography localised the bleed to be from a jejunal mass lesion with radiological features consistent with those of arteriovenous malformation. Patient underwent laparoscopy assisted resection and anastomosis. Results Histopathology examination revealed a low risk jejunal gastrointestinal stromal tumor with no evidence of arteriovenous malformation. The mass was removed completely and the patient was discharged on 5th post-operative day. Patient was followed up in the out-patient department and was found to be doing well. Conclusions Gastrointestinal stromal tumors though relatively uncommon should be kept as important differentials for acute torrential gastrointestinal bleeding. It is highlighted that a presentation of gastrointestinal stromal tumors similar to that of arteriovenous malformations on cross sectional imaging should be kept in mind. The present case is reported in hope of expanding the knowledge of a rare occurrence, its aetiology, clinical impact and treatment.

637 Real-world experience with the new watchman FLX device: data from two high volume sicilian centres. The FLX-iest registry

Aims Left Atrial Appendage closure (LAAC) represents a standard therapy for patients with Atrial Fibrillation and contraindication to oral anticoagulation (OAC). The ‘Watchman FLX’ presented innovative features: higher conformability to LAA shapes, reduced length of the device, closed ‘atraumatic’ distal end with ‘flex-ball’ shape during deployment, flattened covered external surface. We report the early ‘real-world’ experience with the innovative Watchman-FLX device, in two centres at high-procedural volume with consolidated LAAC experience. Methods and results From May 2019 to January 2021, we enrolled 200 consecutive patients treated with Watchman FLX in a non-randomized double-centre registry. We collected procedural data and followed up the patients for mid-term clinical outcomes. Mean age was 77 ± 7.18 years (67.5% male). Patients presented hypertension in 93% of cases, CKD in 57.5% (mean creatinine level 2 ± 1.1), Diabetes mellitus in 41.5%, Coronary artery disease and Heart failure in 55%. 29% had previous stroke and 56.5 bleeding events. Mean CHA2DS2-VASc was 5 ± 1.40 and HAS-BLED 4 ± 1.01. LAAC indication was: 39.5% of cases symptomatic Haemorrhage, 39% need for Triple antithrombotic therapy, 32% gastro-intestinal bleeding; 18% of patients presented OAC intolerance. TEE guidance was feasible in 186 cases (93%), of which 96 (48%) in general anesthesia and 90 (45%) in conscious sedation (MID-DEX) protocol. 14 ICE cases (7%) were performed in local anesthesia. FLX device repositioning after first attempt was required in 40 cases (20%) without any complication. Device size change, after first choice was needed in eight cases (4%). In one exceptional case simultaneous implant of two Watchman FLX devices was performed in a bi-lobed LAA. Peri-device leak was found in two cases (1%), one solved by changing FLX size (31 to 35 mm). Final procedural success was 99.5%; one unsuccessful case due to LAA reverse chicken-wing with very short depth; no device embolization. Six complications were related to access-site (3%), two cases of combined LAAC-Mitraclip procedure; two major bleedings occurred and one in-hospital death due to hemorrhagic shock (HAS-BLED = 6). At mean follow-up of 272 ± 172.76 days, only 2% of (non-device-related) stroke and 0.6% fatal bleeding resulted. Conclusions Our registry in a high-risk population treated with the innovative Watchman FLX device, showed high technical procedural success with easy implant and repositioning, no embolization, good LAA sealing and low rate of ischaemic/bleeding complications. 637 Figure

Colonic ganglioneuromatous polyposis in a 6-year-old girl – A case report and review of literature

Ganglioneuroma of the gastrointestinal tract is a rare mesenchymal tumor of neural origin, especially in childhood. They are categorized into three different morphological subtypes, namely, polypoid ganglioneuroma, ganglioneuromatous polyposis (GP), and diffuse ganglioneuromatosis. Patients with ganglioneuromas have different presentations depending on the location, extent, and size of the lesion. We report here a case of colonic ganglioneuromatous polyposis, presenting as abdominal pain and chronic constipation in a 6‑year‑old girl. Although GP cases are reported in adult age group, cases in pediatric age group are rare. Only a few cases are reported in the literature of GP in the pediatric age group. Although rare, this disorder must be taken into consideration in the differential diagnosis in every patient with symptoms such as abdominal pain, constipation, and lower intestinal bleeding, to avoid a delayed diagnosis.

Meckel’s Diverticulum, A Unique Presentation in the Neonate

Meckel’s diverticulum (MD) is the most prevalent gastrointestinal congenital malformation, occurring in 2% to 4% of all live births. Typical symptoms of MD include intestinal bleeding and bowel obstruction, but MD can also present with many atypical symptoms of varying severity, posing a diagnostic challenge with severe complications if left untreated. Neonates presenting with symptomatic MD are uncommon. In this report, we describe a neonatal case of MD in which the patient presented with atypical symptoms including distended abdomen and constipation mimick necrotizing enterocolitis. This case emphasizes the importance of clinically correlating a provisional diagnosis while maintaining a broad differential, including uncommon conditions in this age group such as MD.

Meckel's diverticulum and the introduction of the intestines ''

Meckel's diverticulum, according to various statistics, is found in cases of celiac disease in approximately 0.1-1.0% of patients. PN Yurovskaya observed 14 cases of Meckel diverticulum among 1126 patients who underwent laparotomy. During gluttony, the specified diverticulum comes across not only as an accidental find, but often turns out to be the cause of catastrophes in the abdominal cavity: intestinal obstruction, peritonitis, intestinal bleeding, etc. T. Bachinskaya and others).

Causes and Management of Lower Gastro-Intestinal Bleeding

Gastrointestinal (GI) bleeding from the colon is a communal reason for hospitalization and is being more frequent in older patients. Gastrointestinal bleeding is known as any bleeding that takes place in the GIT from mouth to anus. Lower GI bleeding is defined as bleeding distal to the ligament of Treitz. Lower GI bleed is typically presented as hematochezia which is the passing of bright red blood clots or burgundy stools through the rectum. The causes of lower GI bleeding are changing over the past several decades from diverticulosis (which is the protrusion of the colon wall at the site of penetrating vessels), infectious colitis, ischemic colitis, angiodysplasia, inflammatory bowel disease, colon cancer, hemorrhoids, anal fissures, rectal varices, dieulafoy lesion, radiation-induced damage following cancer treatment to post-surgical. Management of lower GI bleeding is done through assessing the severity of symptoms and the condition of the overall case.