Background and study aims Ulcers with high-risk stigmata have significant rebleeding rates despite standard endoscopic therapy. Data on over-the-scope clip (OTSC) for recurrent bleeding is promising but data on first line therapy is lacking. We report comparative outcomes of OTSC as first-line therapy versus standard endoscopic therapy in ulcers with high-risk stigmata. Patients and methods Consecutive adults who underwent endoscopic therapy for ulcers with high-risk stigmata between July 2019 to September 2020 were included. Patients were grouped into OTSC or standard therapy based on first-line therapy used on index endoscopy. Outcomes measured included: 1) intra-procedural hemostasis based on endoscopic documentation of adequate hemostasis; 2) 7-day rebleeding (> 2 g/dL drop in hemoglobin, hematochezia or hemorrhagic shock); 3) cost of endoscopic interventions; and 4) procedure duration measured as endoscope insertion to removal time. Cost of tools used during the index endoscopy was included. Results Sixty-eight patients were included, 47 were in standard therapy and 21 in the OTSC group. Hemostasis was achieved in 95.2 % in the OTSC group compared to 83.0 % in the standard therapy group (P = 0.256, number needed to treat [NNT]: 9). Procedure time was shorter in the OTSC group (23 vs. 16 minutes, P = 0.002). Cost of endoscopic interventions were comparable, P = 0.203. Early rebleeding was less often in OTSC group, two (9.5 %) compared to 10 (21.3 %) in standard therapy group, NNT 9. Conclusions Use of OTSCs as first-line treatment for ulcers bleed probably improves hemostasis and decreases early rebleeding. Use of OTSC as first-line therapy shortened procedure duration without increasing the cost of endoscopic interventions.

A 53-year-old non-distressed Caucasian female complains of dyspnea and palpitations for 5 days. Past medical history includes Stage IV melanoma with adequate resection 23 years prior. The patient suddenly became increasingly tachycardic in mild respiratory distress while maintaining hemodynamic stability. TTE depicted 10.5 × 7.5 × 9.5 cm3 mass within her left ventricle and a large volume of pericardial effusion, which progressed to cardiac tamponade. Pericardial window was performed. Metastatic involvement should be ruled out for all symptomatic patients with a history of melanoma.

SUMMARYA 26-year-old Hispanic man with no significant medical history presented to our emergency room with gradual onset weakness of his lower extremities. He was haemodynamically stable and examination revealed loss of motor function in his lower limbs up to the level of hips. Laboratory data revealed hypokalaemia. The patient was started on potassium supplementation and he recovered his muscle strength. Differential diagnosis included familial hypokalaemic periodic paralysis and thyrotoxic periodic paralysis (TPP). Further investigations revealed a low thyroid-stimulating hormone and high free thyroxine levels. Radio iodine 123 scan revealed an enhanced homogeneous uptake in the thyroid suggesting Graves' disease. Thyroid stimulating antibodies were also found to be elevated. The patient was started on methimazole and propranolol and he never had another attack of TPP even at 1 year follow-up. BACKGROUND

We present a case of a dialysis-dependent end-stage renal disease patient who originally presented with sepsis and later developed heparin-induced thrombocytopenia-related upper extremity deep venous thrombosis that rapidly progressed to phlegmasia. Argatroban, a direct thrombin inhibitor, was initiated without delay. Argatroban restored the venous patency completely but did not reverse his two gangrenous fingers. The patient finally underwent digital amputation. The management of this uncommon, but life-threatening, situation of upper limb phlegmasia cerulea dolens secondary to heparin-induced thrombocytopenia leading to gangrene is discussed in this case report.

SUMMARYA 69-year-old man presented to our emergency room with malena and symptoms suggestive of anaemia. He was on chronic anticoagulation with warfarin for a mechanical aortic valve. He was haemodynamically stable. Laboratory investigations revealed a low haemoglobin level of 7.1 g/dL and a low-ferritin level of 6 ng/dL suggesting chronic gastrointestinal bleeding. Oesophagogastroduodenoscopy and colonoscopy were performed to identify the source of bleeding but were unfruitful. Video capsule endoscopy was performed. Fifteen hours after ingesting the capsule endoscope, the patient started having severe abdominal pain, nausea and vomiting. Abdominal X-ray did not show any bowel perforation. CT of the abdomen revealed impaction of the capsule endoscope at the appendiceal orifice and an inflamed appendix. The patient underwent laparoscopic appendectomy and made a good recovery. BACKGROUND