A 55-year-old female patient with prior sleeve gastrectomy and subsequent Roux-en-Y gastric bypass conversion presented with progressive dysphagia. Several years prior, a self-expanding metal stent had been placed to manage postbariatric dysphagia. The patient subsequently developed a proximal esophageal B-ring with critical luminal narrowing at the superior margin of the stent. This complication is described in the literature but may be underrecognized in postbariatric patients. Two esophageal balloon dilations provided only temporary relief before stricture recurrence. The clinical course was complicated by upper gastrointestinal bleeding, progressive anemia, and severe malnutrition requiring prolonged total parenteral nutrition. Given the failure of nonoperative interventions, the patient underwent exploratory laparotomy with surgical jejunostomy placement. At the two-week follow-up, the patient tolerated tube feeds and demonstrated early nutritional recovery. The mechanism is hypothesized to involve fibrosis from chronic mechanical irritation at the stent margin, potentially accelerated in postbariatric patients due to nutritional deficiencies and altered esophageal physiology. Clinicians should be aware that new stricture formation has been reported following benign esophageal stent placement. Close endoscopic surveillance of the proximal stent margin may permit early detection of reactive tissue changes in this population.

The majority of patients with cholecystolithiasis are asymptomatic. Hemobilia is a rare complication of cholecystolithiasis. It is also an uncommon cause of upper gastrointestinal hemorrhage, where the source of bleeding may be difficult to diagnose. This case report describes a middle-aged woman who experienced recurrent upper gastrointestinal hemorrhage both in the pre-admission period and during hospitalization. Treatment with medication, endoscopy, and interventional procedures yielded poor results, and the cause of the upper gastrointestinal hemorrhage was difficult to confirm. Ultimately, the diagnosis was confirmed and the condition was treated through exploratory laparotomy. In this report, we analyze the diagnostic and treatment process in this case to improve clinicians' understanding of the causes of upper gastrointestinal hemorrhage, the complications of cholecystolithiasis, and the surgical indications for cholecystolithiasis or upper gastrointestinal hemorrhage.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and highly aggressive hematologic malignancy that commonly presents with skin involvement and may also involve the bone marrow, peripheral blood, and lymph nodes. The coexistence of BPDCN with a primary solid tumor is extremely uncommon and poses substantial diagnostic and therapeutic challenges. We report a 70-year-old man who was first diagnosed with BPDCN after excision of a left forearm lesion and later developed recurrent hematemesis during chemotherapy. Subsequent endoscopic evaluation revealed a bleeding cardia lesion, and repeat biopsy confirmed poorly differentiated gastric cardia adenocarcinoma. After multidisciplinary evaluation, radical gastrectomy was performed first to control tumor-related bleeding, after which systemic chemotherapy for BPDCN was resumed. This case suggests that, in BPDCN patients who develop hematemesis, progressive anemia, or weight loss during treatment, prompt evaluation for a second primary gastrointestinal malignancy is warranted, and control of active tumor-related bleeding may need to precede hematologic therapy.

International Classification of Diseases, Tenth Revision (ICD-10) encounter diagnosis codes are commonly used to identify gastrointestinal bleeding (GIB) in electronic health record (EHR)-based research and clinical decision-support (CDS) tools. However, variability in coding accuracy may introduce misclassification bias, particularly among patients receiving oral anticoagulants (OACs). Contemporary, institution-specific validation of ICD-10 GIB codes is needed in the post-ICD-10 implementation era. We conducted a diagnostic accuracy study of ICD-10 encounter diagnosis codes for GIB among adults receiving warfarin or direct oral anticoagulants (DOACs) within a large academic healthcare system. A random sample of inpatient and emergency department encounters between June and December 2024 was identified. Manual chart review served as the reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic odds ratio (DOR) were calculated overall and stratified by anatomic bleeding site, anticoagulant class, and admission status. Among 656 anticoagulated encounters, 26 (4.0%) had chart-confirmed GIB. Overall sensitivity was 81% (95% CI, 60%-93%), specificity 98% (95% CI, 96%-99%), PPV 64% (95% CI, 45%-79%), and NPV 99% (95% CI, 98%-100%). The DOR was 215.6 (95% CI, 69.6-667.6). Sensitivity was higher for upper versus lower GIB (86% vs. 50%), while specificity remained high across subgroups. Diagnostic performance was similar between DOAC- and warfarin-treated encounters, though estimates for warfarin were imprecise due to small event counts. PPV varied across individual ICD-10 codes, with symptom-specific codes demonstrating higher predictive accuracy. ICD-10 encounter diagnosis codes demonstrated high specificity and NPV for identifying GIB among patients receiving OACs, supporting their use for ruling out bleeding events in EHR-based research and CDS. However, moderate PPV and heterogeneity across codes and clinical contexts indicate that ICD-10 codes alone should be used cautiously when defining GIB outcomes. Local validation remains essential to ensure reliable bleeding identification in anticoagulated populations.

This guideline is an update of the 2021 ESGE Guideline on Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. The following are the new and/or revised recommendations.

Downhill esophageal varices due to superior vena cava (SVC) obstruction are a rare cause of upper gastrointestinal bleeding. An 87-year-old man presented with melena/hematemesis and severe anemia. Emergency endoscopy identified active bleeding from proximal downhill varices, controlled by endoscopic band ligation. Chest CT angiography demonstrated an SVC thrombus (3.7 × 9 mm) with a downstream short-segment high-grade stenosis/occlusion; venography confirmed complete short-segment occlusion at the level of cardiac resynchronisation therapy with defibrillator (CRT-D) leads. Because of the risk of compromising lead function, recanalization/thrombectomy was deferred and therapeutic anticoagulation (heparin, then apixaban) was initiated, with additional ligation of high-risk variceal columns on follow-up endoscopy. This case highlights the need for rapid CT angiographic evaluation for SVC obstruction in proximal varices, particularly in patients with intravascular devices.

Stress-related mucosal damage (SRMD) is a common complication in critical care medicine. The necessity of stress ulcer prophylaxis (SUP) is debated due to advancements in supportive care and challenges in accurately stratifying bleeding risk. This narrative review evaluates contemporary evidence on stress ulcer prophylaxis in critically ill patients, with emphasis on bleeding risk stratification and implications for clinical practice. To construct this narrative review, we searched Embase and PubMed for randomized controlled trials (RCTs) evaluating SUP in adult intensive care unit (ICU) populations. The Population, Intervention, Comparison, and Outcome (PICO) framework was used to guide the search through March 2026. Major trials, relevant subgroup analyses, meta-analyses, and contemporary international clinical practice guidelines were reviewed to contextualize trial-level findings. Large randomized controlled trials demonstrated that acid-suppressive therapy reduces the incidence of clinically significant gastrointestinal bleeding (GIB), without demonstrating a mortality benefit. Inconsistent definitions of risk factors for GIB limit reproducibility and reduce the precision of pooled risk estimates. Meta-analyses confirmed a reduction in GIB and highlighted clinical heterogeneity. Current guidelines recommend stress ulcer prophylaxis for patients with high-risk presentations. However, these recommendations remain conditional due to the absence of a multivariable prediction model. Despite current uncertainty regarding the effects of stress ulcer prophylaxis on gastrointestinal bleeding prevention and mortality, it is recommended to consider SUP in selected critically ill patients based on individual risk assessment. In parallel, clinicians should optimize supportive measures, including early enteral nutrition, hemodynamic stabilization, and discontinuation of prophylaxis once the patient is clinically stable. Further prospective research is needed to guide individualized prophylaxis and avoid unnecessary treatment in low-risk populations.

A male in his 80s presented with abdominal distension and altered mental status after receiving a polyethylene glycol-based mechanical bowel preparation prior to a diagnostic colonoscopy. He had a history of dementia, atrial fibrillation, and thrombocytopenia. Physical exam was significant for peritonitis, and computed tomography imaging revealed pneumoperitoneum. The patient underwent an exploratory laparotomy, where a perforated sigmoid volvulus was identified. Sigmoid colectomy with end colostomy was performed. The post-operative course was complicated by delirium and upper gastrointestinal bleeding due to stress gastritis. The patient was eventually discharged back to his prior assisted-living facility in stable condition. This case highlights that in patients with risk factors for sigmoid volvulus, such as anatomic abnormality, advanced age, and dementia, mechanical bowel preparation may act as a precipitating stressor. It underscores the need for careful assessment of risks and benefits when considering colonoscopy in older adults, including consideration of risk factors for volvulus and bowel perforation following mechanical bowel preparation.

Acute upper gastrointestinal bleeding is a major emergency cause of transfusion and in hospital death but local data on mortality and rebleeding predictors is limited. This prospective observational study included 138 adults, most were males 66.7% and age 31-50 years 40.6% with frequent alcohol use 43.5% and NSAID exposure 36.2%. Peptic ulcer disease was the commonest cause 56.5% followed by variceal bleed 25.4% and severe anaemia Hb <7 g/dL was present in 29% with transfusion required in 63.8%. Endoscopic hemostasis was achieved in 87% but rebleeding occurred in 13% and mortality was 9.4% with variceal bleed contributing most rebleeds and peptic ulcer disease accounting for most deaths, so early risk scoring fast endoscopy and correction of reversible host factors remains important.