The role of the radiologist in acute gastrointestinal bleeding

Angiography is valuable in the diagnostic and therapeutic management of the patient with acute gastrointestinal bleeding. It should be preceded by endoscopy in acute upper gastrointestinal bleeding, but in acute lower gastrointestinal bleeding, angiography is firmly established as the primary diagnostic modality. Although angiography is less useful in chronic gastrointestinal bleeding, it may show the underlying pathologic lesion. Vasoconstrictive and embolic therapeutic angiographic procedures are particularly valuable in the patient with multiple system disease.     

Use of anticoagulation during wireless capsule endoscopy for the investigation of recurrent obscure gastrointestinal bleeding

Detecting the source of obscure gastrointestinal bleeding can be difficult. Capsule endoscopy is a promising diagnostic tool for investigating patients with this condition, although identifying the source of intermittent or low-grade bleeding remains a diagnostic challenge. We present case reports of two patients with obscure gastrointestinal bleeding, in whom the source of recurrent bleeding episodes was diagnosed by capsule endoscopy while they were on anticoagulation therapy. The first patient, an 81-year-old white woman, was on long-term oral anticoagulation because she had chronic atrial fibrillation. Capsule endoscopy demonstrated a bleeding tumor in the region of the terminal ileum. The second patient, a 59-year-old white man, underwent an initial capsule endoscopy, which was negative. After initiation of anticoagulation with heparin, a second capsule endoscopy procedure in this patient revealed several small bleeding lesions in the proximal small bowel. In both cases a gastrointestinal stromal tumor was identified as the bleeding source and was resected. These two cases demonstrate that provocation of bleeding during capsule endoscopy may increase its sensitivity.     

老年上消化道出血200例临床分析

目的：总结老年上消化道出血的临床特点.方法：将我院2010年1月至2012年12月收治的上消化道出血患者422例分为老年组（n=200）和非老年组（n=222）,比较两组的临床资料.结果：引起上消化道出血最主要的原因均为消化性溃疡,老年组中胃溃疡、胃癌的发生率均明显高于非老年组（P＜0.05）,而十二指肠溃疡和食管静脉曲张的发生率则均明显低于非老年组（P＜0.05）;老年组患者无腹痛率及伴随疾病率均显著高于非老年组（P＜0.01）.结论：老年上消化道出血以胃溃疡和胃癌多见,同时伴有较多的并发症,死亡率较高.     

Diagnosis of gastrointestinal bleeding in adults

The clinical evaluation of gastrointestinal bleeding depends on the hemodynamic status of the patient and the suspected source of the bleeding. Patients presenting with upper gastrointestinal or massive lower gastrointestinal bleeding, postural hypotension, or hemodynamic instability require inpatient stabilization and evaluation. The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is esophagogastroduodenoscopy; for acute lower gastrointestinal bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk. When bleeding cannot be identified and controlled, intraoperative enteroscopy or arteriography may help localize the bleeding source, facilitating segmental resection of the bowel. If no upper gastrointestinal or large bowel source of bleeding is identified, the small bowel can be investigated using a barium-contrast upper gastrointestinal series with small bowel follow-through, enteroclysis, push enteroscopy, technetium-99m-tagged red blood cell scan, arteriography, or a Meckel's scan. These tests may be used alone or in combination.     

Primary aortoenteric fistula

We describe a case of primary aortoenteric fistula (PAEF) in a patient with upper gastrointestinal bleeding. Primary aortoenteric fistula is a rare but clinically important cause of catastrophic gastrointestinal bleeding. The diagnosis of PAEF is difficult and sometimes not made until laparotomy. Primary aortoenteric fistula should be considered in any patient known to have an abdominal aortic aneurysm who presents with upper gastrointestinal bleeding when no identifiable source of bleeding is found on upper endoscopy. Computed tomography may confirm the diagnosis and emergency exploratory laparotomy should be done as soon as the diagnosis is considered clinically.     

Massive pelvic hemangioma in a patient with blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by gastrointestinal and cutaneous hemangiomas. Patients typically present with gastrointestinal bleeding and anemia. Management of gastrointestinal bleeding may be challenging, since these lesions may be diffusely distributed throughout the gastrointestinal tract. The most common location is the small bowel, and recurrence is common. We describe a patient with BRBNS and lower gastrointestinal bleeding resulting from a large pelvic hemangioma eroding into the rectal wall.     

Life-threatening gastrointestinal bleeding due to a jejunal lesion of Henoch-Schönlein purpura

The case of a 56-year-old patient with Henoch-Sch?nlein purpura (HSP) and fulminant gastrointestinal bleeding is reported. The patient was admitted to hospital because of palpable purpura on both legs, painful joints and diffuse abdominal pain. Suspected HSP was histologically proven and treated with prednisolone. Despite recovery, acute gastrointestinal bleeding, with melena and a drop in hemoglobin concentration from 11.2 to 4.2 g/dl, occurred 30 days after medication was started. Immediate endoscopic examination of the upper gastrointestinal tract showed no signs of bleeding whereas colonoscopy showed fresh blood and blood clots in the terminal ileum and the colon. Since the bleeding source could not be detected endoscopically, mesenteric angiography was performed, demonstrating active bleeding from a jejunal artery. Thereafter the bleeding source was located by intraoperative peroral enteroscopy and treated by resection of a short segment of jejunum.     

Posttraumatic splenic artery aneurysm presenting as occult gastrointestinal bleeding

A 53-year-old man presented with a 19-month history of gastrointestinal bleeding. Repeated endoscopic investigation of the upper and lower intestine showed no source of bleeding. When the patient collapsed due to massive gastrointestinal hemorrhage he was referred to our center. Gastroscopy showed a large, bulging tumor protruding from the posterior gastric wall. The consistency of this tumor was soft and the overlying mucosa appeared smooth and intact. Endoscopic ultrasound and contrast-enhanced computerized tomography scan identified a partly thrombosized splenic artery aneurysm (SAA). Arteriography of the celiac trunk confirmed the SAA diagnosis; the SAA was subsequently occluded by coils. So far, four months after discharge, the patient is in excellent health and no further episode of gastrointestinal bleeding has occurred. SAA is a very rare cause of upper gastrointestinal bleeding, but it must be considered when no other common bleeding source can be detected.     

Upper Gastrointestinal Bleeding: Etiologies and Management

Upper gastrointestinal bleeding is a medical condition routinely encountered in clinical practice. Overt upper gastrointestinal bleeding usually presents as melena or hematemesis but can also present as hematochezia in cases of brisk bleeding. The initial evaluation of a patient with suspected upper gastrointestinal bleeding begins with assessment of hemodynamic status, identification of potential risk factors, and appropriate triage of level of care. After resuscitation measures, endoscopic evaluation can be performed to diagnose and potentially treat the source of bleeding. Risk factors that increase the propensity for recurrent bleeding should be identified and addressed.     

Vascular ectasia of the whole intestine as a cause of recurrent gastrointestinal bleeding after high-dose chemotherapy

We present the first case in the literature of vascular ectasia of the whole intestine as a cause of recurrent and profuse gastrointestinal bleeding in a patient with relapsing Hodgkin's disease. The 17-year-old patient experienced early relapse of his Hodgkin's disease after first-line chemotherapy. Salvage chemotherapy was followed by high-dose chemotherapy and autologous stem cell transplantation. Complete remission was achieved after another relapse by means of a second transplant. The patient presented with profuse gastrointestinal bleeding 5 months later, however. Gastric antral vascular ectasia following hematopoietic stem cell transplantation was diagnosed by endoscopy, with histological confirmation. Similar lesions were found in the duodenum, the ileum, and throughout the entire colon. In conclusion, vascular ectasia of the whole intestine should be considered as cause of acute gastrointestinal bleeding after stem cell transplantation. Physicians should be aware of this complication because its onset is typically delayed. Importantly, this disease is not limited to patients who have undergone allogeneic transplantation, but can also occur after autologous transplantation.