Unterschätzte NSA-Nebenwirkungen im distalen Intestinum

NSAID-induced adverse effects are diagnosed less frequently in the distal intestine than in the gastroduodenal area. During long-term NSAID use, however, the development of life-threatening ulcerations, perforations or fibrotic stenoses must be expected from the middle segment of the small intestine to the rectum. Although the clinical symptoms are not specific, together with careful examination, endoscopy, contrast x-ray studies, or computed tomography they can provide orientation, at least with regard to stenotic processes. Diarrhea, weight loss, anorexia, irregular bowel movements, obstruction symptoms, ocoult blood loss, hypoalbuminemia, and iron deficiency may be regarded as possible signs of gastrointestinal adverse effects associated with long-term NSAID therapy. Except in the case of NSAID suppository abuse, no risk indicators are known. The pathogenesis of NSAID-induced adverse effects in the lower gastrointestinal tract has not been elucidated. As the potential of nonselective NSAIDs to cause adverse effects in distal segments of the small intestine cannot be reliably reduced by prophylactic measures in the upper gastrointestinal tract such as comedication with prostaglandin analogs or proton pump inhibitors, the indication for the use of conventional NSAIDs, in any case, must be considered with caution.     

Diagnostic value of push-type enteroscopy: a report from India

OBJECTIVE: We sought to assess the diagnostic value of push-type enteroscopy in relation to indications. METHODS: Ninety-nine consecutive patients (mean age, 42+/-15 yr; 65 men) with suspected small bowel disorders underwent push enteroscopy. The indications were chronic diarrhea (n = 54), obscure gastrointestinal (GI) bleeding (n = 21), abdominal pain (n = 10), abnormal radiological studies of small bowel (n = 5), iron deficiency anemia (n = 5), and others (n = 4). Push enteroscopy was performed using the Olympus SIF-10 (160-cm) enteroscope. RESULTS: Endoscopic examination of the jejunum was successful in all the patients, except one with a distal duodenal stricture. The length of the jejunum examined ranged from 10 to 70 cm. The time taken to complete the procedure varied from 2 to 30 min. Lesions were found in nine (42.8%) patients with obscure GI bleeding; six (28.5%) had worms (Ascaris lumbricoides [n = 3], Ankylostoma duodenale [n = 3]) in the jejunum, producing multiple erosions and bleeding points. In the chronic diarrhea group, a diagnosis was made in 13 (24%) patients on enteroscopic visualization and jejunal histology: celiac disease (n = 6), tropical sprue (n = 3), Crohn's disease (n = 1), secondary lymphangiectasia (n = 1), strongyloidiasis (n = 1), and nodular lymphoid hyperplasia with giardiasis (n = 1). In patients with abdominal pain, enteroscopy provided a diagnosis in one (10%) patient. No positive diagnosis could be made on enteroscopy in patients with iron deficiency anemia and abnormal radiological studies of small bowel. CONCLUSION: Push-type enteroscopy is a useful test in the evaluation of patients with obscure GI bleeding and chronic diarrhea. In developing countries, in patients with obscure GI bleeding, the presence of worms in the jejunum is an important finding on enteroscopy. Tropical sprue, giardiasis, and strongyloidiasis are distinct findings in patients with chronic diarrhea in the present series.     

Treatment of iron deficiency anemia associated with gastrointestinal tract diseases

The gastrointestinal (GI) tract is a common site of bleeding that may lead to iron deficiency anemia (IDA). Treatment of IDA depends on severity and acuity of patients’ signs and symptoms. While red blood cell transfusions may be required in hemodynamically unstable patients, transfusions should be avoided in chronically anemic patients due to their potential side effects and cost. Iron studies need to be performed after episodes of GI bleeding and stores need to be replenished before anemia develops. Oral ...     

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding

AIM: 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. Ninetyfive 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. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.     

The role of video capsule endoscopy in the evaluation of iron deficiency anaemia.

It is widely accepted that chronic occult blood loss from the gastrointestinal tract is a major cause of iron deficiency anaemia. Endoscopists are often asked to evaluate iron deficiency anaemia and identify the source of bleeding. This review offers an effective diagnostic strategy for this common clinical problem. After investigating the normal upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in about 10% of patients. The existing guidelines for evaluation of iron deficiency anaemia in patients above the age of 45, who have undergone standard upper and lower gastrointestinal examinations, are limited to a "treat and observe" phase. Small bowel X-ray series fail to detect many mucosal lesions, particularly vascular ectasias. While enteroscopy offers direct visual inspection of the small bowel mucosa beyond the reach of the standard upper endoscopes, this instrument reaches only 80-120 cm beyond the ligament of Treitz and its sensitivity in identifying the source of bleeding varies (24-75% of patients). A new and conceptually simple approach to examining the entire small intestine is video capsule endoscopy of the small bowel. This review addresses the optimal role of video capsule endoscopy in iron deficiency anaemia patients and offers guidelines for the appropriate gastrointestinal evaluation in such patients.     

Microbial flora in NSAID-induced intestinal damage: a role for antibiotics?

Upper gastrointestinal (GI) complications are well-recognized adverse events associated with non-steroidal anti-inflammatory drug (NSAID) use. However, NSAID-induced damage to the distal GI tract is also common and more frequent than previously recognized. These untoward effects include increased mucosal permeability, mucosal inflammation, anemia and occult blood loss, malabsorption, protein loss, ileal dysfunction, diarrhea, mucosal ulceration, strictures due to diaphragm disease as well as active bleeding and perforation. Studies with selective COX-2 inhibitors have shown that, in the short term, these agents do not increase mucosal permeability and display a reduced by 50% incidence of serious lower GI side effects compared to traditional NSAIDs. However, the long-term use of this therapeutic strategy is limited by the increased risk of serious cardiovascular events, especially in patients with multiple risk factors. Several studies have suggested that intraluminal bacteria play a significant role in the pathogenesis of small-bowel damage induced by NSAIDs and that enterobacterial translocation into the mucosa represents the first step that sets in motion a series of events leading to gross lesion formation. Experimental and clinical investigations indicate that in the short term, antibacterial agents either reduce or abolish NSAID enteropathy. However, potential adverse effects of systemic antimicrobials and the possible occurrence of drug resistance have so far precluded this interesting approach. The availability of poorly absorbed and effective antibiotics, like rifaximin, may represent an attractive alternative to prevent or limit NSAID-associated intestinal damage.     

Iron-deficiency anemia due to chronic gastrointestinal bleeding.

AIMS: chronic gastrointestinal bleeding is the most common cause of iron deficiency anemia (IDA) in the general population. The objectives of this study were to determine the most frequent gastrointestinal lesions in IDA, the frequency and localization of potentially bleeding lesions, the value of the clinical history in diagnosis, the value of fecal occult blood testing, and the most appropriate diagnostic procedure for these patients. METHODS: we prospectively studied 80 patients older than 40 years with IDA, using upper gastrointestinal tract (GI) endoscopy and colonoscopy, beginning with the former (group A) or the latter (group B) depending on the clinical findings. Barium enema was done when colonoscopy was incomplete or unsatisfactory. If all these tests were negative, conventional barium contrast study of the small intestine and arteriography were done, if necessary. RESULTS: upper GI endoscopy found at least one lesion in 50 patients (72%), 13 in association with a colonic lesion (26%). Colonoscopy detected at least one lesion in 31 patients (45%), among whom 11 had another upper GI lesion (35.5%). Barium enema was positive in 4 out of 24 patients (17%). Barium contrast study of the small intestine detected lesions in 1 out of 7 patients (14%), and arteriography in 1 out of 4 patients (25%). The most common upper GI lesions were of peptic origin (esophagitis in 10, gastroduodenal erosions in 10, and peptic ulcer in 8). Neoplasms (17 cancers and 3 polyps) were the most common colonic lesion. Thirteen out of 38 patients (34%) with a potentially bleeding benign upper GI lesion had another lesion in the colon. The fecal occult blood test was positive in 9 out of 10 patients with colonic cancer and in 5 out of 9 with gastric cancer (74% positive predictive value). Nonsteroid antiinflammatory drug use did not correlate with the presence, location or type of lesion. The reliability of the clinically suspected origin of bleeding was 96% sensitivity, 43% specificity and 74% positive predictive value in group A, and 34%, 93% and 80% respectively in group B. CONCLUSIONS: lesions that cause chronic bleeding were more frequently located in the upper digestive tract than in the colon. There was a high prevalence of neoplasms in patients with IDA. One-third of the patients with a potentially bleeding benign lesion in the upper digestive tract had another lesion in the colon. A positive fecal occult blood test correlated highly with neoplastic lesions, and the presence of blood in the stool did not indicate whether bleeding originated in the upper or lower GI tract. Clinical history was of limited value in predicting the location of a bleeding lesion, but can be suggestive of a prior upper GI tract exploration. These patients need a complete study of both the upper and lower GI tracts. In patients in whom the aforementioned explorations are negative, the small bowel should be studied.     

Iron deficiency anemia caused by nonspecific (idiopathic) small bowel ulceration: an uncommon presentation of an uncommon disease.

Ulcers of the small bowel are rare, and in most cases are due to infections, inflammatory bowel diseases, malignancies or drugs. When none of these causes is recognized, they are classified as 'nonspecific' or idiopathic. Such lesions are uncommon, and in most cases present with occlusion. A case of a middle-aged woman with iron deficiency anemia due to occult bleeding, with negative gastroscopy and colonoscopy is presented. The diagnosis of a small bowel pathology resembling Crohn's disease was made by small bowel follow through and small intestine contrast ultrasonography. An ileal ulcer was identified at surgery, and after resection the patient experienced a stable recovery from the anemia without ulcer recurrence. Neither histology nor clinical or biochemical features suggested the diagnosis of an inflammatory bowel disease. Other possible causes were unlikely and the lesion was therefore diagnosed as idiopathic. This report also focuses on the need and the modality to investigate the small bowel in iron deficiency anemia patients.     

The role of iron repletion in adult iron deficiency anemia and other diseases

Iron deficiency anemia (IDA) is the most prevalent and treatable form of anemia worldwide. The clinical management of patients with IDA requires a comprehensive understanding of the many etiologies that can lead to iron deficiency including pregnancy, blood loss, renal disease, heavy menstrual bleeding, inflammatory bowel disease, bariatric surgery, or extremely rare genetic disorders. The treatment landscape for many causes of IDA is currently shifting toward more abundant use of intravenous (IV) iron due to its effectiveness and improved formulations that decrease the likelihood of adverse effects. IV iron has found applications beyond treatment of IDA, and there is accruing data about its efficacy in patients with heart failure, restless leg syndrome, fatigue, and prevention of acute mountain sickness. This review provides a framework to diagnose, manage, and treat patients presenting with IDA and discusses other conditions that benefit from iron supplementation.     

Gastrointestinal tract evaluation in patients with iron deficiency anemia.

Iron deficiency anemia is the most common form of anemia encountered in clinical practice and is an extremely common manifestation of chronic occult gastrointestinal bleeding. Current evidence suggests that a large proportion of men and postmenopausal women with iron deficiency anemia harbor significant gastrointestinal tract pathological lesions as the source of blood loss. As such, the evaluation of patients with iron deficiency anemia is generally focused on the gastrointestinal tract. Importantly, the diagnosis of iron deficiency anemia should be firmly established before an extensive evaluation is undertaken. Management strategies for patients with iron deficiency anemia are reviewed; an important general point is that clinical features (ie, symptoms) may help direct specific investigation. The role of small-intestinal investigation in patients with iron deficiency anemia is controversial and should probably be reserved for patients with iron deficiency anemia and persistent gastrointestinal symptoms or those who fail to respond to appropriate therapy. The treatment and prognosis of patients with iron deficiency anemia and the majority of gastrointestinal tract lesions are straightforward. However, patients with vascular ectasias as the source of blood loss can represent a true management challenge.     

Helicobacter pylori infection and gastroduodenal diseases in Vietnam: a cross-sectional,hospital-based study

Background

There is very small occurrence of adenocarcinoma in the small bowel. We present a case of primary duodenal adenocarcinoma and discuss the findings of the case diagnostic modalities, current knowledge on the molecular biology behind small bowel neoplasms and treatment options.

Case

The patient had a history of iron deficiency anemia and occult bleeding with extensive workup consisting of upper endoscopy, colonoscopy, capsule endoscopy, upper gastrointestinal series with small bowel follow through and push enteroscopy. Due to persistent abdominal pain and iron deficiency anemia the patient underwent push enteroscopy which revealed adenocarcinoma of the duodenum. The patient underwent en-bloc duodenectomy which revealed T3N1M0 adenocarcinoma of the 4th portion of the duodenum.

Conclusions

Primary duodenal carcinoma, although rare should be considered in the differential diagnosis of occult gastrointestinal bleeding when evaluation of the lower and upper GI tract is unremarkable. We discuss the current evaluation and management of this small bowel neoplasm.     

Nonsteroidal anti-inflammatory drug gastropathy at the new millennium: mechanisms and prevention

OBJECTIVES: Nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) toxicity remains the most frequent adverse drug event in the United States. The objective of this review is to update clinicians in recent advances in basic and clinical investigation regarding the pathogenesis and management of NSAID gastropathy. METHODS: Based upon an extensive review of the published literature and abstracts of key work within the past decade, the framework for new approaches to the prevention and treatment of NSAID-associated ulceration is summarized. RESULTS: The pathophysiology of NSAID-induced injury to the GI tract is multifaceted and includes both prostaglandin-dependent and independent components. The pharmaceutical industry has capitalized on the identification of two different isoforms of cyclooxygenase, enabling the development of specific inhibitors of one isoform that minimizes prostaglandin-dependent mechanisms that contribute to NSAID-induced injury. Clinical trials support the efficacy and reduced toxicity of these agents. Because acid exacerbates the injury initiated by NSAIDs, potent acid suppressive therapy, typically with proton pump inhibitors, is another common approach to the treatment of NSAID-related dyspepsia as well as NSAID-induced ulcer disease. CONCLUSIONS: Recent improvements in the understanding of NSAID-induced damage and new drug development have provided the opportunity for effective anti-inflammatory therapy with reduced GI toxicity. This illustrates the importance of identifying patients at risk for potential complications and the appropriate use of strategies to prevent and treat NSAID-induced complications.     

Can patient characteristics predict the outcome of endoscopic evaluation of iron deficiency anemia: a multiple logistic regression analysis

BACKGROUND: The purpose of this study was to identify clinical and biochemical variables that predict the outcome of upper/lower endoscopy in outpatients with iron deficiency anemia and to determine which endoscopic procedure should be performed first. METHODS: Ninety-eight patients (74 women, 24 men; mean age 55 years) with iron deficiency anemia referred from the hematology department were interviewed and responded to a questionnaire that included clinical and biochemical variables, and underwent EGD (with biopsies) and colonoscopy. The endoscopic findings were recorded as presence/absence of GI cancer, upper/lower GI tract lesions and bleeding/non-bleeding-associated GI lesions. A multiple logistic regression analysis was applied to identify variables significantly related with the outcome of the investigations. Multiple analyses were performed so that a Bonferroni correction for multiple testing removed significance except where p<0.01. RESULTS: A likely cause of iron deficiency anemia was found in 86.7% of patients. The risk factors for GI malignancies were: male gender (OR 7.5: 95% CI[1.7, 31.9]; p<0.01), advanced age (OR 1.1/y: 95% CI[1, 1.2]; p<0.01), and lower mean corpuscular volume (OR 1.1/unit: 95% CI[1, 1.2]; p<0.002). The risk factors for bleeding-related diseases were the following: greater age (OR 1.1/y: 95% CI[1.1, 1.2]; p<0.001), absence of lower-GI tract symptoms (OR 4.7: 95% CI[1.3, 16.6]; p<0.05), and a positive fecal occult blood test (OR 4.1: 95% CI[1.2, 14.3]; p<0.05). The risk factors for non-bleeding-related GI tract diseases were the following: negative fecal occult blood test (OR 4.5: 95% CI[1.16, 20]; p<0.05) and higher Hb level (OR 1.4/unit: 95% CI[1.1, 1.8]; p<0.05). CONCLUSIONS: For non-hospitalized patients with iron deficiency anemia, colonoscopy should be the initial investigation in those greater than 50 years of age, particularly men, and those without upper-GI tract symptoms and with lower values for mean corpuscular volume and Hb. EGD should be performed first in younger patients, particularly those with a mild decrease in Hb and a negative fecal occult blood test.     

Double-balloon enteroscopy in patients with GI bleeding of obscure origin

BACKGROUND: Small-bowel bleeding is difficult to treat and diagnose. The recent introduction of wireless capsule endoscopy permits examination of the entire small intestine, but this method lacks tissue sampling and therapeutic capabilities. Recently, Yamamoto et al established a double-balloon insertion method for enteroscopy that allows examination of the entire small bowel and interventional options. OBJECTIVE: To evaluate double-balloon enteroscopy in patients with obscure GI bleeding. SETTING: Single-center prospective study. PATIENTS: Thirty-one consecutive patients with obscure GI bleeding (13 females, 18 males; mean age 56.4 +/- 3.2 years). Criteria for inclusion in the study were documented iron deficiency anemia (hemoglobin level <10 g/dL or a decrease of >2 g/dL over > or =2 months); upper endoscopy not revealing a site/cause of blood loss; and similarly uninformative lower endoscopy including examination of the terminal ileum. INTERVENTIONS: Endoscopic biopsy or therapy was performed as clinically indicated. MAIN OUTCOME MEASUREMENTS: Diagnostic yield for patients with obscure GI bleeding and patient follow-up. RESULTS: Double-balloon enteroscopy was completed without complications in all patients. Bleeding points were identified in 23 patients (74.2%). In 21 (91.3%) of these 23 patients the cause of blood loss was identified and treated with no further bleeding at 8.5 +/- 0.6 months of follow-up. LIMITATIONS: Small number of patients. CONCLUSIONS: These data suggest that double-balloon enteroscopy is useful for evaluation and treatment of patients with GI bleeding of obscure origin.     

The European experience with double-balloon enteroscopy: indications, methodology, safety, and clinical impact

BACKGROUND: Double-balloon enteroscopy (DBE) is a new technique that allows high-resolution visualization, biopsies, and therapeutic interventions in all segments of the GI tract. The objective of the study was to evaluate the indications, the safety, and the clinical impact of DBE. METHODS: This is a retrospective analysis conducted at 4 European medical centers. A total of 62 patients with suspected or documented small-bowel diseases were investigated by DBE. A total of 89 procedures were performed (26 and 9 patients from the oral or the anal route, respectively; 27 patients from both). The main outcome measurements were complications, depth and time of insertion, diagnostics, and therapeutics rates. RESULTS: No complications occurred. Mean time was 70 +/- 30 minutes and 90 +/- 35 minutes from the oral and the anal route, respectively. Length of insertion was 254 +/- 174 cm beyond the pylorus, 180 +/- 150 cm beyond the ileocecal valve, whereas the entire small bowel was completely explored in 10 patients. DBE was diagnostic in 80% of the patients: in 29 of 33 of patients with GI bleeding, in one of 5 patients with iron deficiency anemia and positive fecal occult blood testing, in 3 of 5 patients with chronic diarrhea, in two of 3 patients with abdominal pain, in two of 3 patients with GI cancer (follow-up), in all patients with suspected or refractory celiac disease, and in two of 3 patients with Crohn's disease. Treatment was performed in 41.9% of patients (22 polyps and 29 angioectesias). CONCLUSIONS: DBE is a safe and feasible diagnostic and therapeutic tool for suspected or documented small-bowel diseases. At present, the best candidates for the procedure appear to be those with obscure GI bleeding.     

Inflammatory bowel disease registries for collection of patient iron parameters in Europe

Iron deficiency without anemia and iron deficiency anemia are common and frequently overlooked complications of inflammatory bowel disease. Despite the frequency and impact of iron deficiency in inflammatory bowel disease, there are gaps in our understanding about its incidence, prevalence and natural history and, consequently, patients may be undertreated. Medical registries have a key role in collecting data on the disease's natural history, the safety and effectiveness of drugs in routine clinical practice, and the quality of care delivered by healthcare services. Even though iron deficiency impacts inflammatory bowel disease patients and healthcare systems substantially, none of the established European inflammatory bowel disease registries systematically collects information on iron parameters and related outcomes. Collection of robust iron parameter data from patient registries is one way to heighten awareness about the importance of iron deficiency in this disease and to generate data to improve the quality of patient care, patient outcomes, and thus quality of life. This objective could be achieved through collection of specific laboratory, clinical, and patientreported measurements that could be incorporated into existing registries. This review describes the status of current European inflammatory bowel disease registries and the data they generate, in order to highlight their potential role in collecting iron data, to discuss how such information gathering could contribute to our understanding of iron deficiency anemia, and to provide practical information in regard to the incorporation of accumulated iron parameter data into registries.     

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia(IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.     

Incidence and Etiology of Overt Gastrointestinal Bleeding in Adult Patients with Aplastic Anemia

Patients with thrombocytopenia caused by various neoplastic and primary bone marrow diseases are susceptible to major hemorrhage. There are few reports addressing the incidence and outcome of gastrointestinal (GI) bleeding in patients with aplastic anemia characterized by long-standing thrombocytopenia. We sought to retrospectively determine the incidence, etiology, clinical outcomes, and risk factors associated with overt GI bleeding in patients with aplastic anemia. We analyzed the medical records of 508 patients with aplastic anemia after excluding patients below 15 years of age or those who underwent stem cell transplantation between January 1, 2002, and December 31, 2007. A total of 32 patients developed overt GI bleeding during this period. We evaluated the site, etiology, outcomes, and major risk factors in these patients who developed GI bleeding episodes. The incidence of GI bleeding was 6.3% (32 of 508 patients) in adult patients with aplastic anemia. The incidence increased to 12.6% (28 of 222 patients) in patients with severe disease. One patient died from massive GI bleeding. Bleeding sites included the esophagus (two patients, 6.3%), stomach (five, 16.3%), duodenum (two, 6.3%), small intestine (five, 15.6%), large intestine (seven, 21.6%), and unknown site (11, 34.4%). Lower GI bleeds mainly caused by neutropenic enterocolitis (NEC) and solitary ulcer developed more frequently than upper GI bleeds. The major risk factors for GI bleeding included old age (P = 0.004, odds ratio (OR) = 1.039), severe aplastic anemia (P < 0.001, OR = 11.934), non-response to therapy (P = 0.001, OR = 5.652), and major bleeding history in another organ (P < 0.001, OR = 6.677). Overt GI bleeding in patients with aplastic anemia more frequently develops in the lower tract than in the upper tract. The risk of GI bleeding is higher in patients with the following risk factors: older age, severe disease, poor response to treatment, and major bleeding history in another organ.     

Technetium-99m-labeled red blood cell scans in the investigation of gastrointestinal bleeding

PURPOSE: Technetium-99m-labeled red blood cell scans (Tc99m RBC scan) are recommended to confirm gastrointestinal (GI) bleeding. It is controversial whether these scans are sufficient to localize the site of bleeding. This study evaluated the efficacy of RBC scans in confirming and localizing GI bleeding. Our hypothesis was that these scans were effective in localizing GI bleeding if positive within the continuous phase of imaging. METHOD: Tc99m RBC scans were performed on a total of 80 patients over a four-year period to localize GI bleeding (59 male, 21 female; age range 6–88 (mean, 48) years). Films of 75 of the 80 patients were reread by a nuclear medicine physician who was blinded to the original reading and identity and history of the patient. Results of scans were compared with confirmatory studies. RESULTS: A total of 21 patients had positive scans (28 percent). Of these, the site of bleeding in 16 of 21 patients (76 percent) was confirmed by angiography (4/16), endoscopy (10/16), surgery (10/16), or a combination of these. In 14 of the 16 confirmed studies (88 percent), RBC scan correctly localized site of bleeding by our rigid definition. In six patients (4 not confirmed, 2 erroneously localized), scans were positive only at greater than 15 hours. Ten of the 14 correctly localized studies and none of the incorrectly localized studies were positive in the continuous phase of imaging. CONCLUSION: Tc99m RBC scan is effective in localizing GI bleeding when positive within the continuous phase of imaging. In this population supplemental angiography or endoscopy for the purpose of localization would seem unnecessary.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.