This report of two cases confronts the longstanding perception of Sickle Cell Trait (SCT) as a clinically benign condition, highlighting its complex and severe clinical manifestations, particularly in the context of blood loss anemia and vaso-occlusive crises (VOCs). The hallmark of sickle cell disease is the severe pain caused by acute vaso-occlusion of the microvasculature that leads to bone marrow infarction. We report two cases of patients with SCT and severe anemia in the setting of blood loss secondary to uterine fibroids subsequently causing VOCs with likely bone sequestration. The occurrence of VOCs in SCT, while infrequent, can be serious and demands a high index of suspicion, particularly when patients appear in significant distress and cardiac or vascular etiologies are ruled out as a source. Reversal of anemia in this case provided quick resolution to symptoms, and we recommend other clinicians not disregard a differential of VOC in SCT carriers, and urge to treat patients as they would if they had sickle cell disease. This report challenges the conventional view of SCT as a condition of clinical benignity, calling for a recalibration in the clinical understanding, management strategies, and focus on this genetic trait under similar circumstances.

A 51-year-old male presented to the hospital with recurrent gastrointestinal bleeding. Prior work up with an esophagogastroduodenoscopy (EGD), colonoscopy, and video capsule endoscopy failed to reveal a bleeding source. Given a history of a terminal ileum diverticulum noted on previous colonoscopy and persistence of hematochezia, a Meckel\'s scan was performed, which revealed abnormal uptake suspicious for a Meckel\'s diverticulum containing ectopic gastric mucosa. After surgical resection, pathology confirmed a Meckel\'s diverticulum with gastric heterotopia. This case highlights the importance of considering Meckel\'s diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. Moreover, it is important to note that a Meckel\'s diverticulum can be missed on video capsule endoscopy.

Gastric glomus tumors (GGTs) are rare mesenchymal neoplasms that arise from cells of the glomus body. These occur in the submucosa of the gastric wall and are usually benign in nature. However, it is difficult to predict tumor behavior due to the lack of reliable histological features. Diagnosis can be challenging due to the lack of specific clinical features, and radiologic and endoscopic findings. Computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), and endoscopic ultrasound (EUS) are key diagnostic modalities. However, the final diagnosis depends on the postoperative immunohistochemical and pathological analysis. Most GGTs can be cured by surgical or endoscopic resection. We report a case of GGT in a middle-aged woman who presented with new-onset anemia and was found to have a gastric mass that was later diagnosed as GGT after immunohistochemical staining.

It is rare for patients to have hemorrhagic complications after abdominal paracentesis. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. The incidence rate of hemorrhage-related complications is unknown. The risk of hemorrhage-related complications can be elevated in patients with underlying kidney disease and those who are thrombocytopenic or coagulopathic. However, there is no correlation between the degree of thrombocytopenia or coagulopathy and the risk of bleeding. It is important to identify the high-risk patients to prevent these hemorrhage-related complications. In rare instances, secondary complications can develop from hemoperitoneum. We present a case of a cirrhotic patient who underwent a diagnostic paracentesis leading to subsequent intra-abdominal hematoma followed by small bowel obstruction (SBO) due to large abdominal hematoma compressing small bowel loops.

Dieulafoy lesions are vessels that erode the overlying epithelium without the presence of an ulcer. When these lesions bleed, they can frequently be self-limited, but bleeding can be recurrent and prolonged. Although most commonly found in the lesser curvature of the proximal stomach, there are reports of these lesions in other gastrointestinal tract regions. This case identifies a Dieulafoy lesion found in the rectum, which was the source of this patient\'s profuse rectal bleeding.

Acute blood loss anemia occurs due to many variants. The standard of care in managing acute blood loss anemia is challenged in this case. Jehovah\'s Witnesses\'s (JW) management of blood loss anemia continues to remain a controversy in medicine since they do not allow the use of blood products. This case highlights the management of acute blood loss anemia, utilizing a multidisciplinary bloodless approach in a JW who underwent an endovascular aneurysmal repair (EVAR) of an impending rupture of abdominal aortic aneurysm (AAA). The severity of anemia with hemoglobin of 2.7 g/dL and survival outcome is unique; however, the minimal hemoglobin level required to sustain life is still unclear.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a member of the coronavirus family, which comprises enveloped positive sense ribonucleic acid (RNA) viruses responsible for pandemic outbreaks including Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV), Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV), and most recently coronavirus disease 2019 (COVID-19). A 30-year-old previously healthy male diagnosed 11 days earlier with COVID-19 presented with right-sided weakness and dysarthria. The patient was found to have an acute left carotid thrombus with embolic multifocal infarcts throughout the left cerebral hemisphere. He was treated acutely with intravenous heparin however developed gastrointestinal bleeding, prompting discontinuation of anticoagulation. Follow up CT angiography 12 days following his stroke demonstrated complete resolution of the thrombus. Since discharge, the patient has been managed with antiplatelet therapy alone with complete neurologic recovery. Large vessel strokes amongst young patients have been a growing concern during the SARS-CoV-2 outbreak. The use of acute therapeutic and prophylactic anticoagulation is based on risk assessment. Albeit, the utility of anticoagulation in COVID-19 patients remains undetermined.  Prevention of stroke recurrence is a clinical priority for providers treating large vessel stroke patients. More research is required to establish the effectiveness of anticoagulation and antiplatelet therapy for stroke prevention in patients diagnosed with COVID-19.

Hyperplastic polyps are the second most common type of gastric polyp in the United States with equal incidence in both genders, usually found incidentally during endoscopic examinations. It is a well-known fact that they are associated with iron-deficiency anemia due to chronic blood loss. We present a case of a 69-year-old man with a relatively small hyperplastic gastric polyp with acute upper gastrointestinal bleeding, presenting with melena and acute blood loss anemia requiring admission to intensive care unit and urgent endoscopic intervention with hot snare removal of the polyp and cautery of surrounding area with excellent hemostasis. The pathology revealed focal intestinal metaplasia and low-grade dysplasia with no evidence of malignancy. He was subsequently discharged with outpatient follow-up with gastroenterology.

OBJECTIVE: To determine whether patients hospitalized with gastrointestinal (GI) blood loss anemia are being checked and treated for iron deficiency.
METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 μg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females.
RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those (91.9%) had anemia during their hospital stay. Ninety-five patients (30.9%) had iron studies performed during hospitalization, and 45 of those (47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50 (17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia (IDA), only 22 (48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes.
CONCLUSIONS: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.