Angiodysplasia in the gastrointestinal haemorrhage of the elderly patient. Our experience

Angiodysplasia of the digestive tract is one of the main causes of acute bleeding and is a frequent reason for admittance to the emergency surgery unit. This pathology, previously considered rare and often not recognised, has only recently acquired a precise anatomo-pathology thanks to endoscopy. Besides having a decisive diagnostic role, endoscopy also allows the control and successful treatment of lesions, often in a definitive way, which were previously only dealt with surgery, with significant advantages for the elderly patient, reducing the rate of morbidity and mortality. There are still many discussions today, above all on the priority of various diagnostic investigations to be carried out in digestive bleeding and on the choice of treatment in the case of angiodysplasic lesions in geriatric age. Some cases of acute bleeding from intestinal angiodysplasia, observed by the Authors, have led them to study the etiopathogenesis, diagnosis and emergency treatment of such lesions.     

急性下消化道出血52例临床分析

目的分析急性下消化道出血的临床特征,探讨其诊断和治疗措施。方法对52例急性下消化道出血病人的临床资料进行回顾性分析。结果 52例经结肠镜检、选择性动脉造影、手术探查及病理检查证实其病因分别为:结肠肿瘤15例(28.8%),小肠肿瘤9例(17.3%),肠道血管病变9例(17.3%),直肠癌8例(15.4%),息肉5例(9.6%),炎症性肠病4例(7.7%),原因不明2例(3.8%)。其中43例行手术治疗,9例行非手术治疗。51例治愈或成功止血,1例死于手术后多器官功能衰竭(multiple organ failure,MOF)。结论急性下消化道出血的大部分病例可通过结肠镜检、选择性动脉造影、手术探查及病理检查明确病因及出血部位,术中肠镜检查有助于确诊;手术切除病灶是最有效的治疗方法。     

Value and limits of emergency colonoscopy in cases of severe lower gastrointestinal haemorrhage

Acute bleeding of the lower gastrointestinal tract causes complex diagnostic problems. Colonoscopy is subject to discussion as the first method of diagnosing lower digestive tract bleeding. From June 1998 to September 2001 we observed 80 patients with acute bleeding (45 males and 35 females; mean age: 65.5 years). All patients underwent an emergency colonoscopy. In 15 cases we carried out an angiography and in 9 a scintigraphy (always after colonoscopy). Colonoscopy detected the cause of the bleeding in 69 patients (86.2%) during the first examination. Angiography and scintigraphy revealed the haemorrhage in 8 (53%) and 7 (77.7%) cases, respectively. Ten cases were treated during colonoscopy; 31 underwent surgery. We consider an emergency colonoscopy as the first method for diagnosing the causes of bleeding. If this examination fails we consider arteriography and scintigraphy as second-line approaches for obtaining a diagnosis.     

Gastric polyps: a clinical contribution

The incidence of diagnosis of gastric polyps is now higher than in past years owing to the introduction of endoscopy in the diagnosis and treatment of upper digestive tract disease. One hundred and sixty-four polyps removed from January 1984 to August 2000 were analyzed. The median age of the patients was 61.4 years (range: 16-84 yrs). Polypoid lesions were more frequent in males (M:F = 1.5:1). Seventy-nine patients were asymptomatic (48.2%). Sixty-four percent of the polyps were located in the antrum. We diagnosed 73 hyperplastic polyps, 27 adenomatous lesions, 8 inflammatory polyps and 56 pseudopolyps. Malignant lesions were detected in 9 adenomatous polyps (4 type I and 5 type II early gastric cancers). Endoscopy is the examination of choice in the diagnosis and treatment of gastric polyps. We confirm that there is a relationship between histological type, neoplastic change and the size of the polyps.     

Less frequent causes of upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.     

Angiodysplasie colique et hémodialyse chronique. Traitement par coagulation au plasma argon. À propos d’un cas

IntroductionGastrointestinal angiodysplasia is a very common cause of digestive haemorrhage among patients with chronic renal insufficiency. It is well known that bleeding from angiodysplasias can be a difficult therapeutic problem since therapeutic possibilities are scarce and surgery is scolded with high mortality rate. Endoscopic argon plasma ablation therapy is a new, effective and safe treatment in the management of gastrointestinal angiodysplasia.Case reportWe reported a case of a female haemodialysis patient aged 40 years. She was haemodialysed since 6 years in our center from unknown nephropathy. In March 2006, she complained of black stools and melena, and developed severe anaemia (Haemoglobin at 4 g/dL). Exploratory endoscope examination of the digestive tract showed the presence of bleeding from angiodysplastic lesions of the right colon. The patient had severe clinical picture extension of angiodysplastic lesions and frequent bleeding episodes. Bleeding arrest was observed after argon plasma coagulation, with a significant decrease of blood transfusions and improvement of anaemia.ConclusionGastrointestinal angiodysplasia was reported to be an important complication in dialysis patients and was recognized as an important cause of erythropoietin-resistant anaemia. It can worsen vital prognosis. Argon plasma coagulation is an effective treatment in these patients.     

胃肠间质瘤合并消化道癌六例诊治体会

目的 探讨胃肠间质瘤合并消化道癌的临床特征、诊治及预后.方法 回顾性分析武汉协和医院2005年1月-2010年9月收治的6例胃肠间质瘤合并消化道癌的临床病理资料.结果 6例患者中有4例2种肿瘤发生在同一脏器,2例发生于相邻器官.术前检查只有1例发现胃肠间质瘤与消化道癌同时存在,其余5例只发现消化道癌.6例患者中胃肠间质...     

胆囊切除术前上消化道检查的临床意义

目的: 调查术前上消化道检查对预测胆囊切除术后综合征的意义. 方法: 回顾调查了1997年1月~2000年10月在我院行胆囊切除术的患者1245例,其中522例术前行上消化道内镜检查,178例行上消化道钡餐造影检查,232例行上腹部平片检查.其中53例行胆囊造漏术,764例行胆囊切除术,52例行其他手术. 结果: 上消化道内镜检查发现166例合并浅表性胃炎,36例合并肥厚性胃炎,12例合并萎缩性胃炎,5例合并霉菌性胃炎,6例合并胃息肉,4例合并胃癌,25例合并上消化性溃疡,11例合并十二指肠乳头旁憩室,10例合并十二指肠滞留,2例合并轻中度食道静脉曲张,245例上消化道内镜检查无异常.上消化道钡餐造影检查发现8例合并十二指肠滞留,7例合并十二指肠乳头旁憩室,22例合并上消化性溃疡,141例上消化道钡餐造影检查正常.腹部平片检查对术前诊断无临床指导意义.术后59例产生了并发症及后遗症,如:胆道感染、急性胰腺炎、胆道蛔虫感染、胆瘘、胆道损伤以及肠粘连等. 结论: 胆囊术后综合征的发生与外科技术和其他上消化道并存疾病有关.术前上消化道检查对于预测胆囊术后综合征具有重要意义.     

Vascular malformations of the digestive tract: a cause of severe digestive hemorrhage. Apropos of 2 cases

We report on two cases of angiodysplasia of the digestive tract complicated by serious acute bleeding. The preoperative diagnoses were made by angiography. One case concerned a voluminous jejunal lesion which was macroscopically visible; the other concerned a punctiform lesion detected only by angiography and not found on the pathology specimen. The authors insist on the potential gravity of these angiodysplastic lesions, the necessity to perform an emergency celio-mesenteric angiogram when confronted with a serious digestive tract hemorrhage non-explained by conventional methods of exploration when they can be performed.     

泛影葡胺造影在诊断上消化道穿孔中的应用

目的：探讨泛影葡胺造影对上消化道穿孔者的诊断价值。方法：对临床上怀疑上消化道穿孔的112例患者,术前使用泛影葡胺造影,并对该组的临床资料进行回顾性分析。患者在透视下动态观察有无造影剂经胃、十二指肠漏出并摄片分析,有造影剂漏出为阳性,无则为阴性。结果：112例患者行泛影葡胺造影,阳性者72 例：胃穿孔31 例,其中胃溃疡穿孔27例,胃癌穿孔4例;十二指肠球部穿孔 41例。阴性者40例,其中39例经CT、急诊胃镜检查及剖腹探查确诊为其他疾病,但有1例阴性者行剖腹探查诊断为胃后壁穿孔。该法的诊断符合率99.1 %,敏感性98.6%,特异性100%,全组假阴性1例,无假阳性。结论：泛影葡胺在诊断上消化道穿孔中安全、有效、方便、价廉,有其重要应用价值。     

Evaluation of urinary cytology for upper urinary tract disease

One hundred and seventy-two patients with upper urinary tract disease were examined by cytological study of ureteral urine which was taken by ureteral catheterization. Of 139 patients with benign disease or ureteral stricture due to non-urological cancer, only one case with renal cyst revealed positive findings (false positive rate: 0.7%). Two positive cases, which were a renal hemorrhage without followup and a uterine cervical cancer with squamous cancer cells in the ureteral urine, were excluded. Although 6 of 17 (35%) uroepithelial cancers in the upper urinary tract were registered as positive, this examination was little use for detecting stage pTa, grade 1 or papillary non-invasive tumors. However, 2 out of 12 (17%) renal pelvic or ureteral cancer patients with negative results of voided urine were cytologically detected by ureteral urine. Five out of 6 cases of these cancers demonstrated malignant cells in the renal pelvic urine sampled from surgical specimen. We have recently experienced aspiration cytology for upper urinary tract disease, using the percutaneous puncture method, and five of 7 upper urinary tract patients were cytologically diagnosed. This procedure could be valuable for detecting even patients with associated bladder cancer or failure of ureteral catheterization.     

Tailored surgical treatment for post-caustics stenosis of the upper digestive tract with complicated lesions. Clinical experience at our department in the last ten years

The ingestion of caustic substances generates severe lesions of superior digestive tract, leading to stenosis in 50% of patients, of which almost 50% will require surgical treatment. A number of 29 patients with caustic lesions were treated in the IIIrd Surgical Unit from 1993 to 2004. The most frequent corrosive agent was a strong alkaline solution. The location of the post caustics strictures was esophageal in 18 cases, esophagogastric in 7 cases and laryngo-pharyngo-esophageal in 4 cases. Surgical procedures consisted of 8 esophagoplasties with ascending colon and ileum, 12 with left colon, 3 with transverse colon and splenic flexure, and in 5 cases transhiatal resection with cervical esophago-gastric anastomosis. 5 patients required gastric resections of variable extent, in addition to the esophageal reconstruction: antrectomy with trunk vagotomy--1 case, subtotal gastrectomy--3 cases and total gastrectomy--1 case. In the group with pharyngeal lesions, esophageal reconstruction followed pharyngoplasty with cutaneous tube performed in the ENT department. Hospital mortality rate was 3,4 % (1 case). Postoperative morbidity of 20,6 % consisted of cervical anastomosis leakages in 2 cases and pleural effusions in 4 cases. Surgical treatment of the post caustics strictures of the upper digestive tract must be adapted to the location and severity of the lesions, requiring adequate operative experience and special pre- and postoperative care.     

Distribution of recurrent lesions after radical resection of cancer of the thoracic esophagus

In 150 patients who got cancer recurrence after curative resection for cancer of the thoracic esophagus, the sites where recurrent lesions were clinically detected for the first time were examined. The distribution of recurrent lesions in patients who did not undergo neck dissection at the operation (group A) differed from the distribution in those who underwent neck dissection (group B). Cervical and/or upper mediastinal recurrence occurred in 49% of cases in group A and in 11% of group B. On the contrary, middle or lower mediastinal recurrence was more often in group B. The distribution of recurrent lesions varied depending on the state of lymph node metastasis detected at surgery. Cervical and upper mediastinal recurrence was much more frequent than hematogenic recurrence in cases without lymph node involvement in group A, while hematogenic recurrence was more frequent in cases with both mediastinal and abdominal lymph node metastasis. In the upper mediastinum, recurrence along the recurrent laryngeal nerves was most frequent and it was supposed to have developed from residual lymphatic metastases. In the middle and lower mediastinum, recurrent lesions were located around the left main bronchus and descending aorta, and cancer infiltration of the neighboring organs was frequent. Recurrence at the abdominal paraaortic nodes was observed mainly in cases with perigastric lymph node involvement.     

Pulmonary resection for inflammatory complications due to benign oesophageal disease

Benign oesophageal disease is sometimes causes an irreversible damage to the pulmonary parenchyma. The earliest symptoms often occur when the respiratory tract is involved. Primary oesophageal disease can only be detected by taking an accurate and precise medical history of the patient, so that oesophageal contrast radiography can provide the correct diagnosis. In this article we present two cases in which it was necessary to carry out a diverticulectomy with pulmonary resection, left lower lobectomy and left pneumonectomy. Reports from the literature agree that diverticular disease of the oesophagus, if misdiagnosed, can have serious consequences for the pulmonary parenchyma, even if this is rare. In both cases we present the contrast radiographic study of the oesophagus together with a double endoscopic examination of the airways and upper digestive tract which played a crucial role in the diagnosis. We can therefore conclude that respiratory symptoms in an otherwise healthy patient may constitute the basis for the diagnosis of a benign oesophageal lesion.     

Angiodysplasia of the small bowel: a method of intraoperative identification.

Two cases of recurrent bleeding from the gastro-intestinal tract are described. The initial diagnosis and the identification of the lesions at laparotomy were difficult problems. In both cases the bleeding was due to a vascular lesion of the small bowel, referred to as angiodysplasia. The lesions were detected before operation by selective angiography and identified at laparotomy by a preoperative and an intraoperative injection of a vital stain through the catheter into the feeding vessels.     

A comparison of the pathology of transitional cell carcinoma of the bladder and upper urinary tract

OBJECTIVE: To clarify the histopathological patterns of upper and lower urinary tract transitional cell carcinomas (TCCs), as previous reports suggest that upper urinary tract TCCs have a greater tendency towards high-grade disease than bladder TCCs, of which most are low-grade and low-stage tumours. PATIENTS AND METHODS: All patients presenting with TCC of bladder or upper urinary tract between February 1991 and December 2001 at one institution were identified. Further patient information was obtained from the hospital database and case-note review. RESULTS: In all, 164 patients with upper urinary tract TCC and 2197 with bladder TCC were identified. There was a correlation between grade and stage of both upper urinary tract and bladder TCCs. 35% of the upper tract TCCs were classified as grade 2 and 44% as grade 3, while for bladder TCCs, 31% of lesions were classified as grade 2 and 35% as grade 3 (P = 0.003). Of the upper urinary tract lesions 33% were stage pT2-T4, compared with only 20% of bladder TCCs (P = 0.001). CONCLUSIONS: Upper urinary tract TCC is a higher grade and stage disease than bladder cancer, a finding that emphasizes the need for aggressive treatment of upper urinary tract TCC. If endourological management of upper urinary tract TCC is considered, histopathological determination of tumour grade before treatment is essential.     

小肠出血35例临床诊治

目的分析小肠出血的病因,总结其临床表现特点、诊断及治疗方法。方法回顾性分析1995年1月至2009年9月间收治的35例小肠出血病人的临床资料。结果除出血和贫血表现外,62.9%(22/35)不伴其他症状,85.7%(30/35)不伴腹部阳性体征。35例中急性大出血4例,慢性显性出血29例,慢性隐性出血2例。入院时合并失血性休克4例(11.4%)。出血病因中小肠肿瘤为首位,占37.1%(13/35),其次为小肠憩室31.4%(11/35),小肠炎症22.9%(8/35),血管疾病8.6%(3/35)。35例中,33例手术,2例行内镜下止血治疗。33例手术治疗病人中,28例均行小肠部分切除肠吻合术,5例行腹腔镜下憩室局部切除。术中肠镜7例。结论小肠出血的症状与体征无特异性,小肠肿瘤、小肠憩室、小肠炎症是小肠出血常见原因。术中肠镜检查为最后诊断隐匿性小肠出血的有效方法。外科手术治疗是治疗小肠出血最有效的方法。     

Severe acute intestinal hemorrhage. Value of investigation tests

Episodes of intestinal bleeding likely to endanger vital functions require detailed etiological and topographical examination before surgical intervention. Forty-two cases of serious haemorrhage of the lower digestive system in adults were studied retrospectively. The origin of the bleeding was localized preoperatively in 37 cases (88%). Four exploratory laparotomies were carried out after etiological examination including at least digestive arteriography. Hence it was always possible to localize the source of bleeding. We found it convenient to establish the order of the complementary pretherapeutic tests by taking into account two symptoms, acute active bleeding (AAB) and haemorrhage with acute anemia (HAA).     

右半结肠癌并发急性阑尾炎：附51例报告

目的 总结右半结肠癌并发急性阑尾炎的诊治经验.方法 回顾性分析经手术和病理证实的右半结肠癌并发急性阑尾炎51例临床资料.结果 右半结肠癌2400例中并发急性阑尾炎51例(2.1%).有内科合并症者39例(76.5%).术前诊断13例(25.5%),漏诊结肠癌38例(74.5%).结肠腺癌40例(78.4%),黏液腺癌7例(13.7%),未分化癌4例(7.8%).Dukes B期2例(3.9%),C期29例(56.9%),D期20例(39.2%).单纯性阑尾炎28例(54.9%),化脓性阑尾炎11例(21.6%),坏疽性阑尾炎8例(15.7%),蜂窝织炎性阑尾炎4例(7.8%).3,5年生存率分别为95.2%,40.0%.结论 右半结肠癌并发急性阑尾炎发生率低,误诊率高,5年生存率较低,中老年阑尾炎伴有消瘦、贫血及消化道症状、右下腹肿块者,应做相应检查,避免右半结肠癌漏诊.     

不同部位消化道梗阻的内支架治疗特点与对策

目的探讨不同部位消化道梗阻的内支架治疗特点与对策。方法消化道恶性梗阻63例采用71枚内支架治疗，全部使用永久性部分带膜镍钛合金支架，均在数字减影血管造影（digital subtraction angiography，DSA）监视下经口或肛门将支架置于梗阻部位，预扩张和后扩张分别为6例和3例，术前术后均做造影对照，根据进食和排便情况评价疗效，并做临床随访3～24个月，平均11个月。结果单次成功放置支架60例；胃窦部、十二指肠空肠曲及乙状结肠首次操作失败再次置入支架各1例。56例上消化道支架置入后恢复饮食47例，7例乙状结肠和直肠支架置入后肠梗阻症状即刻解除；8例食管-支气管瘘置入食管支架后瘘管完全封堵；1例残胃-纵隔-支气管瘘置入支气管支架后轻度呛咳，3周后瘘口基本闭塞。出现剧烈疼痛1例，轻度疼痛12例，大出血1例，支架移位2例，术后再狭窄2例，声音嘶哑1例。结论部分带膜镍钛合金支架置入术是消化道恶性梗阻和食管一支气管瘘的有效治疗方法。但对不同部位消化道恶性梗阻均应区别对待，必须使用相应的材料和操作方法，以提高其有效性和安全性。