S4752 Shocked by a Bleeding Duodenal Polyp: A Case of Stress-Related Mucosal Disease

Introduction: Duodenal polyps are a rare clinical finding, reported in 0.3-4.6% of patients referred for esophagogastroduodenoscopy (EGD). Most of these polyps are found to be adenomatous, and pedunculated polyps are more likely to cause bleeding than sessile polyps. Upper gastrointestinal bleeds (UGIB) can occur when vasopressors are used in the setting of septic shock, due to stress-related mucosal disease (SRMD). Vasopressors lead to mesenteric ischemia due to reduction of splanchnic blood flow which causes mucosal damage, ulceration, and bleeding from GI lesions. Case Description/Methods: An 85-year-old man with a past medical history of asthma presented to the hospital with hypotension, tachycardia, and tachypnea. He was given 2L of intravenous fluids (IVF) and started on a norepinephrine and vasopressin. Pulmonary infiltrates were present on imaging, and increasing respiratory requirements led to intubation. The patient was admitted to the intensive care unit (intensive care unit) for acute hypoxic respiratory failure in the setting of septic shock due to community acquired pneumonia. He completed a course of ceftriaxone and azithromycin, was weaned off pressors, extubated, and downgraded until his nurse noted melena. The patient was readmitted to the intensive care unit for hemorrhagic shock in the setting of UGIB and was given 2U of packed red blood cells, IVF, intravenous pantoprazole, and sucralfate. A computed tomography scan of the abdomen showed no active contrast extravasation. The patient remained stable for several hours with an improvement in hemoglobin, then had a sudden episode of coffee-ground emesis requiring emergent intubation. An emergent EGD was performed, with a singular actively bleeding 6 mm sessile duodenal polyp in the posterior wall of the first portion of the duodenum. Epinephrine was injected at the site and 2 hemostatic clips were placed with resolution of bleeding. Discussion: The incidence of duodenal polyps resulting in frank UGIB after the use of vasopressors is not well-documented in literature. We highlight the importance of including duodenal polyps in the differential for an UGIB, particularly in the setting of septic shock with vasopressor use, due to the bleeding risk associated with exacerbation of SRMD. This case demonstrates that duodenal polyps, specifically those with a visible and actively bleeding vessel, may be amenable to therapeutic options currently used in the setting of ulcerations with actively bleeding vessels.