We report a 48-year-old man with poorly controlled ulcerative colitis (UC) who presented with severe rectal pain, hematochezia, and a chronically draining lesion on the left buttock. Initial cross-sectional imaging revealed active colitis, and targeted ultrasound of the left buttock suggested a benign epidermal inclusion cyst. Colonoscopy demonstrated continuous Mayo 3 proctosigmoiditis with a normal proximal colon and terminal ileum. While he clinically improved with intravenous corticosteroids, the gluteal lesion persisted. Before discharge, pelvic magnetic resonance imaging unexpectedly revealed a rectocutaneous fistula extending from the distal rectum into the left gluteal soft tissues. This case illustrates that, although rare, rectocutaneous fistulas can complicate UC. Clinicians should include fistulizing disease in the differential diagnosis of any chronically draining perianal or gluteal lesion in UC, and consider early pelvic magnetic resonance imaging when symptoms are discordant with endoscopic findings or fail to resolve with standard therapy.

Non-variceal upper gastrointestinal bleeding remains a major clinical challenge in aging societies, driven by increasing life expectancy and the widespread use of antithrombotic and ulcerogenic medications. Although conventional endoscopic hemostatic techniques-including injection therapy, thermal modalities, and mechanical clipping-remain the cornerstone of management, rebleeding continues to occur in a substantial proportion of patients, particularly in large, fibrotic, or difficult-to-access lesions. In recent years, novel therapeutic devices such as over-the-scope clips and topical hemostatic agents have expanded the endoscopic armamentarium and have demonstrated promising clinical outcomes, especially in high-risk bleeding scenarios and tumor-related hemorrhage. In parallel, adjunctive diagnostic technologies, including red dichromatic imaging and Doppler endoscopic probes, have emerged to improve the localization of bleeding sources and refine rebleeding risk stratification by assessing residual submucosal blood flow. This review summarizes currently available endoscopic hemostatic devices and adjunctive diagnostic tools, highlighting their mechanisms of action, clinical efficacy, and limitations. An integrated approach combining advanced therapeutic modalities with complementary diagnostic techniques may facilitate individualized endoscopic management and improve hemostatic success while reducing rebleeding in patients with non-variceal upper gastrointestinal bleeding.

Peptic ulcer disease remains one of the leading causes of non-variceal upper gastrointestinal bleeding. Despite advances in endoscopic therapy and pharmacological management, recurrent bleeding continues to represent a major cause of morbidity and mortality. Risk stratification is traditionally based on endoscopic stigmata according to the Forrest classification; however, ulcers with similar endoscopic findings may exhibit markedly different clinical outcomes. Increasing evidence suggests that ulcer-related anatomical factors, including size, location, and depth of penetration, may influence the risk of severe or recurrent hemorrhage, particularly in cases involving adjacent arterial structures. In this conceptual, hypothesis-generating review, we propose a conceptual bi-dimensional framework integrating endoscopic and anatomical determinants of bleeding risk. This approach aims to improve patient stratification by identifying a subgroup at "very-high-risk" of recurrent bleeding, in whom standard endoscopic therapy alone may be insufficient. Although this framework is hypothesis-generating and not yet validated, it may provide a conceptual basis for future studies aimed at improving individualized management strategies, including early imaging assessment and consideration of transarterial embolization in selected high-risk patients.

Anorectal melanomas are rare and agressive malignant tumors of the anorectal region of the digestive tract. Due to their rarity and similarity to other more benign and common conditions, such as hemorrhoids, their diagnosis is often delayed, which worsens the prognosis of this aggressive disease. Histological evaluation with special immunohistochemical (IHC) staining is often essentiel to establish a confirmed diagnosis. In the localized stage, the primary treatment for this condition consists primarily of surgical resection combined with adjuvant immunotherapy.

Acquired von Willebrand Syndrome (AVWS) is a rare bleeding disorder characterized by quantitative or qualitative defects of von Willebrand factor (VWF) in patients without a personal or family history of bleeding. It is frequently associated with systemic diseases, particularly lymphoproliferative disorders (LPDs) and myeloproliferative neoplasms (MPNs). In this single-center, retrospective cross-sectional study, we included patients diagnosed with AVWS at the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center between April 2014 and March 2025. Bleeding severity was assessed using the ISTH-BAT score. Laboratory tests included FVIII:C, VWF:Ag, VWF:GPIbR, VWF:RCo, VWF:CB, VWFpp, and multimer analysis. Among 140 patients, 106 (76%) had MPNs and 26 (19%) LPDs. At least one bleeding symptom was observed in 70% of patients, with clinically significant bleeding occurring in 24% of the cohort. Clinically relevant bleeding (mainly mucocutaneous and gastrointestinal) was more frequent and severe in LPDs (58%) than in MPNs (13%). LPDs showed severe VWF functional defects, marked HMWM loss, and elevated VWFpp/VWF:Ag ratios (median 6.7), consistent with accelerated clearance. MPNs displayed mild HMWM reduction, normal clearance (median VWFpp/VWF:Ag ratio 1.0), and an inverse correlation between platelet count and the degree of HMWM depletion (ρ = -0.48, p < 0.001). Bleeding severity correlated inversely with VWF:GPIbR in LPDs (ρ = -0.50, p = 0.02) and with VWF:RCo in MPNs. Anti-VWF antibodies were found in 30% of tested LPDs or autoimmune cases. The two main phenotypes presented in AVWS were immune-mediated in LPDs and platelet-mediated in MPNs. Understanding the underlying mechanism is crucial for accurate diagnosis and targeted treatment to reduce bleeding risk and improve outcomes.

BackgroundDual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stenting is standard of care but increases bleeding risk, particularly in patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction-cardiogenic shock. Evidence guiding optimal antithrombotic strategies in this high-risk population remains limited.MethodsWe conducted a retrospective observational study at a high-volume ECMO center. From January 2018 to December 2022, 351 VA-ECMO patients were screened, and 72 who underwent PCI immediately prior to or during ECMO were included. Patients were grouped by initial post-PCI antiplatelet strategy: aspirin alone (n = 33), augmented therapy (n = 25), or no antiplatelet therapy (n = 14). The primary objective was to evaluate the safety and efficacy of an aspirin-only strategy for preventing in-stent thrombosis. Efficacy was assessed by the incidence of in-stent thrombosis during ECMO hospitalization, and safety was assessed by the occurrence of major bleeding events.ResultsGroups were similar in age, race, gender, and BMI. No patient developed clinically overt in-stent thrombosis. Major bleeding occurred in 33.3% of aspirin, 48% of augmented, and 50% of no-antiplatelet patients (p = 0.396). Most common bleeding events were hemoptysis, intracranial hemorrhage, and gastrointestinal bleeding.ConclusionsAmong patients undergoing PCI with concurrent VA-ECMO support, no differences in stent thrombosis or major bleeding were observed between aspirin monotherapy, augmented antiplatelet therapy, or no antiplatelet therapy. However, intracranial hemorrhage occurred more frequently in the Augmented AP group. These findings suggest that aspirin monotherapy may provide adequate protection against stent thrombosis while potentially minimizing bleeding risk in this critically ill population.

The black fat tailed scorpion (Androctonus bicolor) is one of the most venomous native scorpion species in Israel. Its venom induces widespread autonomic overstimulation, resulting in severe cardiovascular, respiratory, and neuromuscular manifestations. Veterinary scorpion envenomation reports are scarce, and Canine Androctonus bicolor envenomation remains undocumented in the literature. A 10-year-old male dog was presented three hrs. following a witnessed Androctonus bicolor envenomation. Immediate clinical signs included dyspnea, hypersalivation, and collapse. The scorpion was identified by the Israeli Nature and Parks Authority. On presentation, the dog was non-ambulatory, and tachypneic. A small puncture wound was observed over the right hind paw. Immediate treatment included analgesia, antihistamine, and intravenous fluids. The dog developed nystagmus, muscle spasms, and generalized hypertonicity with tachycardia and high systolic blood pressure. Midazolam and phenobarbital were required to achieve muscle relaxation. Three days post admission the dog presented marked clinical improvement and was discharged, however, five days after discharge, the dog was re-presented with tremors, inappetence, hematochezia, hyperthermia, mild tachycardia with occasional ventricular premature complexes, and labored breathing. Bloodwork revealed an elevated C-reactive protein concentration and mild increased pancreatic lipase activity, consistent with systemic inflammation and mild pancreatitis. Supportive therapy was instituted, and clinical improvement was observed within 24 hours from the second admission. The dog was discharged and remained well. This is the first documented case of Androctonus bicolor envenomation in a dog. It highlights the prominent neurological and autonomic manifestations associated with this species in a canine patient, and importantly, identifies concurrent pancreatitis as a newly recognized potential sequela in veterinary patients.

Introduction Ticagrelor is a widely used potent P2Y12 inhibitor in patients aged ≥75 years with acute coronary syndromes. Despite its widespread use, data on ticagrelor's safety in older adults remain limited. Material & methods We performed a retrospective pharmacovigilance analysis using the FDA Adverse Event Reporting System (FAERS) from 2010 to 2024. Disproportionality analysis compared ticagrelor with clopidogrel, assessing predefined adverse events in adults (<75 years) and older adults (≥75 years). For each group, reporting odds ratios (RORs) with 95% confidence intervals (CI) were calculated, and differences between age groups were evaluated interaction analysis. Results A total of 6,476 ticagrelor-related adverse event reports were included: 4,795 (74%) adults and 1,681 (26%) older adults. In older adults, ticagrelor was not associated with increased reporting of dyspnea, intracranial hemorrhage, complete atrioventricular block, or gout. Acute kidney injury (AKI) was the only event reported more frequently in older adults (ROR 2.3 [95% CI 1.5-3.6] vs. 0.6 [95% CI 0.4-0.9]; p<0.001). Ticagrelor was associated with lower reporting of gastrointestinal bleeding, hematuria, hemoptysis, and anemia in both age subgroups. Bradycardia and syncope were reported more frequently among adults (p=0.002 and p<0.001, respectively). Conclusion Ticagrelor appears generally safe in older adults (≥75 years), with no excess reporting of major adverse events compared to younger adults, aside from a higher reporting of AKI. Keywords ACS, anti-platelets, Ticagrelor, elderly, adverse effect.

Jejunal diverticulosis is a rare cause of obscure gastrointestinal bleeding (OGIB) that can present with life-threatening hemorrhage. We report a 69-year-old male with recurrent melena, severe anemia, and hemodynamic instability requiring multiple transfusions. Upper and lower endoscopy were nondiagnostic, and CT angiography failed to localize the bleeding source. Capsule endoscopy showed distal small bowel bleeding without clear localization. The patient developed transfusion-dependent bleeding complicated by Klebsiella pneumoniae sepsis. Due to persistent hemorrhage, diagnostic laparoscopy was performed and revealed two jejunal diverticula with engorged mesenteric vessels. Segmental small bowel resection was done with complete resolution of bleeding. This case highlights the limitations of noninvasive modalities in intermittent small bowel bleeding and supports early surgical intervention when the bleeding source cannot be identified.