Hereditary hemorrhagic telangiectasia (HHT) also known as Rendu Osler syndrome is a vascular hereditary autosomal dominant disease, leading to a dysfunction in the development of arteriovenous capillaries, usually resulting in epistaxis, gastrointestinal (GI) bleeding, and iron deficiency anemia. It is believed that by interfering and stopping angiogenesis, anti-vascular endothelial growth factor molecules could be an option for HHT patients. Indeed, an intranasal treatment regime of diluted Avastin (bevacizumab; recombinant humanized antivascular epithelial growth factor immunoglobin G1) has proven clinically efficacious in patients with HHT1. However, there are no data available regarding bevacizumab's effect in patients with HHT and GI bleeding. We report here the case of an 85-year-old woman, suffering from life-threatening GI bleeding due to HHT with an impressive clinical response using anti-vascular endothelial growth factor infusion.

Background & Aims: Anemia is the most frequent systemic complication in inflammatory bowel diseases. It affects the quality of life and can interact with working capacity. Our objectives were to identify the prevalence of anemia, its main causes and its management in patients with inflammatory bowel disease from Romania.Methods: We conducted a multicenter prospective study from March 2013 to August 2014. We enrolled 291 patients from three referral centers: 115 (39.52%) with Crohn's disease (CD) and 176 (60.48%) with ulcerative colitis (UC). We defined anemia according to the WHO criteria.Results: Median age of the patients was 41 years and the median time period since diagnosis was 3 years (0.75-7). The median activity index for UC (UCAI) was 4 and the median CD activity index (CDAI) was 96. More patients with CD were on antiTNFα therapy (p < 0.01), corticosteroids (p =0.18) or azathioprine (p=0.05) and required surgery for their underlying disease at study enrollment (p < 0.01). Anemia was present in 31.27% of the patients, more often in those with CD (35.65%) than with UC (28.41%) (not statistically significant); 53.26% of the patients had iron deficiency while 4.12% had folic acid and 8.59% vitamin B12 deficiency; 9.62% of the patients had received anti-anemic therapy at inclusion in the study or in the last three months prior to study enrollment.Conclusions: About one in three Romanian patients with inflammatory bowel disease has anemia, which is frequently associated with iron deficiency. About 30% of the patients with anemia are under therapy and the most frequent route for iron supplementation is the oral one. This might contribute to the high prevalence of iron deficiency and the low level of compliance.

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Objective: Gastrointestinal (GI) fistula, a life-threatening condition, represents a therapeutic challenge. Rescue surgery could be hazardous and/or impact quality of life justifying endoscopic con-servative approach including mucosal abrasion, clip closure or stent diversion with moderate success rates in the long term. We assessed whether Fistulas Endoscopic Submucosal Dissection with clip Closure (FESDC) could lead to complete resolution of fistulas even if previous endoscopic therapy failed. Results: 23 patients with GI fistulas were retrospectively included, 57% of those were defined as refractory fistulas since previous endoscopic treatment failed. Tight immediate sealing was obtained for 19 patients (83% [95% CI: 61%, 95%]) who received FESDC. Long term closure (>3 months) was obtained in 14 cases (61% [95% CI: 39%, 80%]) with a median follow-up of 20 months. Ad-verse events occurred in 9% of cases. Previous local malignancy (p=0.077) or radiation therapy (p=0.047) were associated with a higher risk of failure. Conclusion: The new FESDC strategy is safe and allows permanent endoscopic closure of GI fistulas in 61% of the patients, and 54% of those with previous attempt. Further studies are war-ranted to determine the place of this technic in the management of chronic GI fistula.

Endoscopic submucosal dissection with triangulated traction with clip and rubber band: the "wallet" strategy Endoscopic submucosal dissection (ESD) is the reference method for the curative endoscopic resection of colorectal tumors [1, 2]. Nevertheless, it is technically challenging, and new strategies to facilitate the procedure are requested. Counter-traction strategies, such as the clip and rubber band approaches, allow the enlargement of the submucosal space [3, 4]. In the colon, line traction makes a tangential traction without triangulation, and is not really adaptive as the dissection progresses [5]. We report a case of ESD for a colonic laterally spreading tumor in a patient with a history of pancolonic ulcerative colitis. For this resection, we used the "wallet strategy" (▶ Video 1) in order to obtain a strong counter-traction to achieve en bloc resection in this fibrotic situation of ulcerative colitis. First, the two edges (oral and anal) of the lesion were incised. Then, trimming was performed at both edges in direct and retroflexed approaches, in order to achieve deep access to the submucosa and to release both mucosal edges (▶ Fig. 1). After this step, two elastic rubber bands were fixed with hemoclips to both proximal and distal mucosal flaps. By trapping both rubber bands with a third metallic clip, we used triangulation traction and fixed the clip to the opposite mucosal wall (wallet aspect) (▶ Fig. 2). The submucosa was fibrotic and fatty, which is typical in ulcerative colitis. Thanks to this double traction, the submucosa was strongly stretched perpendicularly to the muscular layer plan (▶ Fig. 3 d, ▶ Fig. 4), facilitating dissection. This strategy must be compared prospectively with other traction strategies, but seems to offer a strong counter-traction with a perpendicular angle with the muscular layer. Stretching both proximal and distal edges allows the removal of the muscle from the cutting line and could improve safety. Furthermore, this strategy is adaptive, as the strength of This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.the rubber band traction changes with insufflation and with dissection progression (▶ Fig. 2 c). Endoscopy_UCTN_Code_TTT_1AQ_2AZCompeting interests E257This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.