Clinical Vignette Abstracts NASPGHAN 2017 Poster Session I Thursday, November 2, 2017 5:00pm – 7:00pm 1 SOLITARY RECTAL ULCER SYNDROME IN A TEENAGER REQUIRING MULTIPLE BLOOD TRANSFUSIONS. A.M. McClain, J. Pohl, R.A. Patel, A. Lowichik, K. Jensen, Pediatric Gastroenterology, Hepatology & Nutrition, University of Utah, Salt Lake City, Utah, UNITED STATES. A previously healthy 17-year-old female presented to an outside hospital after two days of bloody diarrhea, stooling urgency and rectal bleeding. She was found to have a hemoglobin of 6 g/dL and received a blood transfusion. Over the next 8 months, similar symptoms occurred four more times, requiring two more blood transfusions. The patient was referred to our GI clinic and underwent an extensive evaluation including upper endoscopy, colonoscopy on two separate occasions, Meckel’s scan, capsule endoscopy and CT angiography.On initial colonoscopy she had a sessile appearing lesion on the left wall of the rectum. Pathology of the rectal lesion showed replacement of lamina propria by collagen and smooth muscle bundles and distortion of the crypts, consistent with solitary rectal ulcer syndrome [SRUS]. She was started on a bowel program. Due to continued bleeding, CT angiography was done and showed nonspecific thickening of the left lateral sidewall of rectum with increased vascularity. Repeat colonoscopy seven months later demonstrated a deep rectal ulcer on the left side of rectum; pathology showed hyperplastic epithelium and crypt distortion again with fibrosis in the lamina propria. Surgical consultation believed this large, worsening ulcer was the cause of recurrent bleeding. Surgical resection at that time was felt to be extremely challenging and a more intensive laxative bowel program recommended with surgical follow up for possible defecography.SRUS has been well described in the adult literature with several theories to explain the pathophysiology. Pediatric cases of SRUS are rare with less than 200 reported cases in previous case reports. Diagnosis usually is through endoscopic visualization and biopsy and treatment ranges from conservative treatment with laxatives and biofeedback to surgical resection, rectopexy or fecal diversion. Our case is unusual in that the patient had recurrent anemia requiring blood transfusions. Most literature regarding SRUS report infrequent need for blood transfusion. 2 OBSCURE GI BLEEDING SECONDARY TO GASTRIC HETEROTOPIA IN A CHILD WITH SEVERE IRON DEFICIENCY ANEMIA. A.A. Shah, A. Kastl, B. Godwin, P. Mamula, K. Fiorino, Gastroenterology, Hepatology, & Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, UNITED STATES. Introduction: Ectopic gastric mucosa, which can be either congenital or acquired, has been reported throughout the entire alimentary tract. It is most commonly encountered in the form of either Meckel’s diverticulae or duplication cysts and is typically symptomatic leading to obstruction, intussusception, and gastrointestinal bleeding. Case: A 7 year old girl with history of neonatal small bowel obstruction secondary to a jejunal web s/p partial jejunal resection with tapering jejunoplasty and primary reanastomosis presented to the ED with three weeks of headaches, shortness of breath, and lethargy. Upon evaluation, her heart rate was 214 beats per minute with EKG showing supraventricular tachycardia, and she was found to have severe iron deficiency anemia with Hgb 2.3 g/dl, reticulocyte count 0.2%, MCV 59 fL, and iron 11 mcg/dL. Patient stabilized after pRBC transfusions, which also resolved her SVT. She then underwent testing with CXR, FOBT, stool studies, and laboratory studies including viral testing all of which were unremarkable and was discharged home on iron supplementation without a conclusive diagnosis. However, since her anemia persisted, she underwent a thorough GI evaluation. Her initial UGI with small bowel follow-through, EGD, and colonoscopy were completely normal. Push enteroscopy visualized edema, ulceration, friability, and exudates within the jejunum with biopsies consistent with fragments of small bowel mucosa intermixed with extensive fields of gastric epithelium but no ulcers. MRE demonstrated small bowel thickening in the proximal jejunum. Video capsule endoscopy visualized abnormal jejunal mucosa with edema, fissuring, and fresh blood seen. Meckel’s scan showed ectopic gastric mucosa throughout the abdomen suggestive of multiple enteric duplication cysts. After another hospitalization for symptomatic anemia, our patient underwent exploratory laparotomy with intra-operative push enteroscopy culminating in resection of 25 cm of jejunum with primary reanastomosis. Pathology illustrated multifocal polypoid gastric heterotopia with reactive gastropathy and serosa with focal areas of hemorrhage. Since resection over one year ago, she has been asymptomatic with stable hemoglobin and no other GI complaints. Conclusion: The differential diagnosis of anemia in school-aged children is broad but includes multiple gastrointestinal etiologies of blood loss. Ectopic gastric mucosa such as Meckel’s diverticulum or duplication cysts must be considered, particularly if initial evaluation is non-diagnostic, and in rare cases, such as this instance, may effect an extensive portion of the alimentary tract. Once identified, surgical treatment may be indicated, especially if symptomatic. 6 TREATMENT OF PORTAL VENOUS GAS EMBOLISM WITH HYPERBARIC OXYGEN AFTER ACCIDENTAL INGESTION OF HYDROGEN PEROXIDE: A CASE REPORT. S. Ali, Pediatric Gastroenterology, Stanford Children's Health, Walnut Creek, California, UNITED STATESJ. Davis, Hyperbaric Medicine, John Muir Medical Center, Walnut Creek, California, UNITED STATES. Yeh, K. Haas, Pediatric Gastroenterology, Stanford University, Stanford, California, UNITED STATES. 4 year old female with no prior medical history was brought in by her parents to the emergency department with complaint of vomiting after an accidental ingestion of concentrated hydrogen peroxide (35% H2O2). Within a few minutes after ingestion patient had non bloody non bilious emesis. She was taken to the emergency department (ED) where an urgent CT scan with contrast was completed that showed marked portal venous air throughout the liver and pneumatosis (figure 1) and hyperemia of the gastric wall. Also had scattered foci of air in the submucosal layer of the lower esophageal sphincter (LES) and at gastroesophageal junction to about 3cm above the LES. No evidence of perforation. CT of head showed no evidence of hemorrhage or infarction. Patient had 2 episodes of hematemesis in the ED. She was alert and oriented and well-appearing. Vital signs were normal. Abdomen on exam was soft and non-tender. Oral pharynx with two small lesions on the posterior hard palate. Neurologic exam was normal. Laboratory data included complete blood count and comprehensive metabolic panel that were unremarkable. The patient was transferred to the closest hospital with an available hyperbaric oxygen (HBO) chamber for treatment of the portal venous air emboli. Patient underwent emergent HBO treatment followed by three subsequent HBO treatments. Upper GI study showed no evidence of esophageal and gastric abnormality. Abdominal Ultrasound on second day of hospitalization showed complete resolution of the portal venous air. Patient did well during the treatment with symptom resolution. Diet was advanced slowly and was discharged home on day 7 on continued acid blockade therapy. Conclusion: It is well known that hydrogen peroxide ingestion can cause gas embolism. This is a case report of the successful use of hyperbaric oxygen therapy to treat portal venous gas embolism caused by hydrogen peroxide ingestion in a pediatric patient. Hyperbaric oxygen therapy can be considered for the treatment of symptomatic hydrogen peroxide ingestion. 7 GASTRIC HYPERPLASTIC POLYPS CAUSING UPPER GASTROINTESTINAL BLEED POST CARDIAC TRANSPLANT. A.E. Ferguson, D.S. Vitale, P. Putnam, S. Kocoshis, K. El-Chammas, Gastroenterology, Cincinnati Children's Hospital, Cincinnati, Ohio, UNITED STATESK.E. Bove, Pathology , Cincinnati Children's Hospital Medical Center, Cincinnati , Ohio, UNITED STATES. Background: Hyperplastic gastric polyps are a rare complication in post-transplant patients. Significant bleeding caused by multiple gastric hyperplastic polyps, however, has not been reported in pediatric post-transplant patients. A case series published in 2002 described acquired hyperplastic polyps in solid organ transplant recipients, but most patients were asymptomatic or presented with mild symptoms such as nausea. Our case highlights the unusual occurrence of multiple gastric hyperplastic polyps causing an upper GI bleed in a post cardiac transplant patient, reviews the histopathologic findings of these polyps, and discusses the gaps in knowledge open for future research.Case Presentation:A 15 year-old male with history of acute myeloid leukemia (AML) in remission, chemotherapy-induced cardiomyopathy status post cardiac transplant 5 years prior, renal insufficiency, pulmonary hypertension, and autism presented to the emergency room with acute onset of hematemesis. He denied blood per rectum or melena. He had no fevers or upper respiratory symptoms, and he was not on anticoagulation. His medications included prednisone and cellcept for immunosuppression, and daily prevacid. Patient had a previous endoscopy 3 years prior for failure to thrive that identified multiple hyperplastic gastric polyps of various sizes, two of which were excised.