Background and Aim Patients with end‐stage renal disease (ESRD) on hemodialysis are considered to be at higher risk of gastrointestinal bleeding (GIB) as compared with those without renal disease (NRD). We conducted a population‐based study using the National Inpatient Sample (NIS) database to study the outcomes of GIB in ESRD. Methods Patients admitted with GIB (upper and lower) from 2005 to 2013 were extracted from the NIS database using ICD‐9 codes. Patients were divided into NRD and ESRD groups, and a 1:1 propensity matched analysis was performed. Various outcomes were compared in both groups, and subgroup analysis based on the timing of endoscopy was also performed. Results A total of 218 032 patients were included in the study. There was an increase in inpatient admissions among ESRD patients with GIB with significant reduction in mortality (P < 0.001). In‐hospital mortality, length of stay, and total costs were significantly higher in ESRD patients as compared with NRD. ESRD patients were less likely to undergo endoscopic evaluation compared with NRD (P < 0.001). Late endoscopy (> 48 h) was associated with increased need for transfusion and health‐care utilization but without a significant difference in mortality as compared with early endoscopy. On multivariate analysis, endoscopy was associated with significantly lower rate of mortality in ESRD patients with GIB (odds ratio 0.28, P < 0.0001). Conclusion End‐stage renal disease patients with GIB had a significantly higher rate of mortality and a higher health‐care utilization with a lower rate of endoscopic evaluation. Endoscopy was associated with a lower mortality rate on multivariate analysis.

BACKGROUND The Black/African Ancestry (AA) population has a higher prevalence of type 2 diabetes mellitus (T2DM) and a higher incidence and mortality rate for colorectal cancer (CRC) than all other races in the United States. T2DM has been shown to increase adenoma risk in predominantly white/European ancestry (EA) populations, but the effect of T2DM on adenoma risk in Black/AA individuals is less clear. We hypothesize that T2DM has a significant effect on adenoma risk in a predominantly Black/AA population. AIM To investigate the effect of T2DM and race on the adenoma detection rate (ADR) in screening colonoscopies in two disparate populations. METHODS A retrospective cohort study was conducted on ADR during index screening colonoscopies (age 45-75) performed at an urban public hospital serving a predominantly Black/AA population (92%) (2017-2018, n = 1606). Clinical metadata collected included basic demographics, insurance, body mass index (BMI), family history of CRC, smoking, diabetes diagnosis, and aspirin use. This dataset was combined with a recently reported parallel retrospective cohort data set collected at a suburban university hospital serving a predominantly White/EA population (87%) (2012-2015, n = 2882). RESULTS The ADR was higher in T2DM patients than in patients without T2DM or prediabetes (35.2% vs 27.9%, P = 0.0166, n = 981) at the urban public hospital. Multivariable analysis of the combined datasets showed that T2DM [odds ratio (OR) = 1.29, 95% confidence interval (CI): 1.08-1.55, P = 0.0049], smoking (current vs never OR = 1.47, 95%CI: 1.18-1.82, current vs past OR = 1.32, 95%CI: 1.02-1.70, P = 0.0026 ) , older age (OR = 1.05 per year, 95%CI: 1.04-1.06, P < 0.0001), higher BMI (OR = 1.02 per unit, 95%CI: 1.01-1.03, P = 0.0003), and male sex (OR = 1.87, 95%CI: 1.62-2.15, P < 0.0001 ) were associated with increased ADR in the combined datasets, but race, aspirin use and insurance were not. CONCLUSION T2DM, but not race, is significantly associated with increased ADR on index screening colonoscopy while controlling for other factors.

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Introduction: Dieulafoy lesions (DL) consist of dilated aberrant submucosal arteries which may potentially lead to life-threatening gastrointestinal (GI) bleeding upon erosion of overlying mucosa. They are most commonly located in the lesser curvature of the stomach followed by duodenum and colon. The esophagus is an exceedingly rare location for DL. We report a hemodynamically unstable patient with distal esophageal DL who presented with massive hematemesis. Case Description/Methods: A 57-year-old man was brought to the hospital with massive hematemesis and unresponsiveness requiring intubation in the field. His medical history was significant for alcoholinduced cirrhosis decompensated with ascites. Previous upper endoscopy revealed LA class D esophagitis but no evidence of varices. Upon presentation, the patient was tachycardic to 130 bpm and hypotensive to 89/56 mmHg. Physical exam was remarkable for distended abdomen and positive fluid wave. Initial blood work showed hemoglobin of 4.3 g/dL and platelet of 36/uL. Nasogastric tube suction aspirated 2000 ml of coffee ground content and frank blood. The patient was emergently resuscitated with intravenous fluid and massive transfusion protocol. Subsequently, bedside esophagogastroduodenoscopy revealed active pulsatile bleeding from an exposed vessel in the distal portion of the esophagus (Figure A). Two hemostatic clips were successfully deployed and hemostasis was achieved (Figure B). The patient was then transferred to the critical care unit and maintained on proton pump inhibitor infusion. Hospital course was further complicated by hepatic encephalopathy and hepatorenal syndrome. Given MELD-Na score of 40, the patient was eventually transferred to an advanced center for liver transplantation. Discussion: DL in the esophagus is an extremely rare entity with few cases published to date. Lesions are due to persistently dilated caliber of submucosal artery, as opposed to normal narrowing, as the vessel approaches overlying mucosa. Continuous arterial pulsation may damage the mucosa with a stream of arterial bleeding, as in our case. Upper endoscopy is the mainstay of diagnosis and treatment for DL. Band ligation, electrocautery or hemoclips can be deployed through endoscopy, as with our case. Due to the intermittent nature of bleeding, endoscopy is not always diagnostic and angiography with embolization is an alternative option. Surgery is always a last resort.[2439] Figure 1. A) Active pulsatile bleeding from an exposed vessel in the distal portion of the esophagus. B) Hemostatic clip successfully deployed with complete hemostasis.

Key Clinical MessageIn patients with known risk factors for hepatocellular carcinoma and an elevated AFP, the diagnosis should remain on the differential even in the absence of hepatic lesions. High index of suspicion is needed, and aggressive diagnostic approaches are needed to not miss this entity.

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