Endovascular Treatment for Lower-extremity Arterial Thrombosis in a Patient with Congenital Afibrinogenemia and a History of Bleeding Complications

Congenital afibrinogenemia is a rare autosomal recessive blood disorder that accompanies thrombotic complications and is associated with bleeding tendency. The management of these opposing complications remains a challenge. Endovascular treatment (EVT) for peripheral arterial thrombosis has not been described in previous studies. A 57-year-old man with congenital afibrinogenemia developed back pain and left lower leg pain. The cause of the pain was confirmed to be renal infarction and lower extremity arterial thrombosis by Doppler ultrasound and contrast-enhanced computed tomography. He was treated with EVT for the lower extremity arterial thrombosis, leading to an excellent short-term improvement without bleeding.     

Efficacy of Intra‐Arterial Treatment for Massive Gastrointestinal Bleeding in Hemodialysis Patients

The incidence of acute nonvariceal massive gastrointestinal bleeding (GIB) is higher in hemodialysis (HD) patients than in healthy individuals, and this is often a life‐threatening event. We evaluated the efficacy of intra‐arterial treatment for GIB in HD patients. Between January 2006 and June 2012, eight HD patients with GIB were treated with superselective transarterial embolization. Of the eight cases, one was duodenal bleeding, two were jejunal bleeding, one was ileocecum bleeding, two were ascending colonic bleeding, and two were sigmoid colonic bleeding. After examining the site of bleeding by endoscopy or contrast‐enhanced computed tomography (CT), embolizations with microcoils, gelatin sponges, or N‐butyl cyanoacrylate were performed through interventional radiology (IVR). In all cases, blood transfusions were frequently administered. Six of the eight patients with GIB were successfully salvaged by transarterial embolization. In one case, duodenal bleeding was refractory to endoscopic treatment. Embolization was performed twice in this case; however, the patient died of an aneurysm rupture at the embolization site 24 days after the embolizations. In another case, massive jejunal bleeding and disseminated intravascular coagulation were identified at the time of the first examination, and the patient died of multiorgan failure 26 days after the embolization. On the basis of our experience, we established an effective treatment strategy for HD patients with acute nonvariceal massive GIB, by immediately identifying the exact site and degree of bleeding using contrast‐enhanced computed tomography and performing early treatment with transarterial embolization.     

颈动脉狭窄患者的血管内治疗

颈动脉支架置入术是一种比内膜切除术创伤较小的颈动脉血运重建技术。不过,颈动脉内膜切除术的临床疗效已通过严格的随机临床试验确定。迄今为止,有关颈动脉支架置入术的临床试验和登记处还没有能力在有症状患者中对与内膜切除术的不同疗效进行比较。因此,在较大样本随机临床试验结果公布之前,建议谨慎采用颈动脉支架置入术。     

Octreotide Treatment in Patients with Severe Acute Pancreatitis

We investigated the effect of octreotide in the treatment of severe acute pancreatitis in a case–control study. Experimental and clinical studies on the effect of octreotide in the treatment of acute pancreatitis have shown controversial results. Since January 1992, we have been conducting a prospective randomized study on the effect of octreotide in severe acute pancreatitis, in three hospitals in Israel. The entering criteria included three or more of the Ranson prognostic signs and CT findings of severe pancreatitis. Patients were randomly assigned to conservative treatment either with or without octreotide (0.1 mg subcutaneously three times a day). The end points of the study included: complication rate (ARDS, sepsis, renal failure, pseudocyst, fistula, and abscess), length of hospital stay, and mortality. From January 1992 to December 1996, 60 patients entered the study. After evaluating the files, 10 patients were excluded due to failure to meet the entering criteria, incomplete data, or incorrect diagnosis. Of the remaining 50 patients, 25 were assigned to octreotide (treatment group) and 25 to conservative treatment only (control group). The two groups matched with regard to age, sex, etiology, and severity of the disease. The complication rate was lower in the treatment group with regard to sepsis (24% vs 76%, P = 0.0002) and ARDS (28% vs 56%, P = 0.04). The hospital stay was shorter in the treatment group (20.6 vs 33.1 days, P = 0.04). Two patients died in the treatment group and eight in the control group (P < 0.019). These results suggest that octreotide may have a beneficial effect in the treatment of severe acute pancreatitis.     

内镜局部注射治疗消化性溃疡出血的临床观察

探讨一种疗效好,可靠,副作用少,操作简单的内镜下止血方法。以高渗盐水立止血内下注射治疗消化性溃疡出血患者７７例为治疗组,立即止血率９７．９％,再出血率２．５％。     

生长抑素治疗重症急性胰腺炎的临床研究

目的观察生长抑素施他宁及其类似物善宁治疗重症急性胰腺炎(SAP)的治疗效果及评估其临床价值。方法按Ranson标准判断病情严重程度,将106例病情大致相近的SAP患者分成施他宁治疗组37例,善宁治疗组36例及对照组33例。对照组用一般常规治疗方法,治疗组在一般常规治疗方法治疗的基础上加用施他宁6mg／d或善宁0．6mg／d,维持治疗7～14d。观察3组血尿淀粉酶变化、平均腹痛持续时间、禁食天数、住院天数、并发症、手术率及住院费用等多项指标。结果施他宁和善宁治疗SAP均能显著降低血尿淀粉酶水平,控制腹痛,缩短禁食时间和住院天数,减少并发症和手术率,并且没有明显的增加住院费用。结论生长抑素施他宁和善宁对SAP有明显疗效,可以阻止病情进展和恶化,减少并发症,改善预后。     

生长抑素对急性胰腺炎患者血小板参数的影响

目的：研究血小板参数在急性水肿型胰腺炎（ＡＥＰ）和出血坏死型胰腺炎（ＡＨＮＰ）中的变化特点及生长抑制（ＳＳ）治疗后对其影响。方法;血细胞自动分析仪检测血小板计数（ＰＬＴ）、平均血小板体积（ＭＰＶ）和血小板分布宽度（ＰＤＷ）。结果：ＡＥＰ患者血小板参数无明显变化。１周后,ＰＬＴ无明显升高,ＭＰＶ和ＰＤＷ有显著性升高;常规治疗后,对血小板参数无影响;ＳＳ治疗后,ＭＰＶ和ＰＤＷ有显著性升高。而ＡＨＮＰ患     

Postprandial Cholecystokinin Response in Patients with Chronic Pancreatitis in Treatment with Oral Substitutive Pancreatic Enzymes

Cholecystokinin (CCK) response to a test mealshould be increased in patients with pancreaticinsufficiency, as trypsin is absent from the duodenum.If pancreatic enzymes are added, a restoration of the inhibitory feedback should result in lowerlevels of CCK. Ten patients with chronic pancreatitisand steatorrhea were studied. CCK basal and postprandiallevels were evaluated the day before and 45 and 90 days after treatment with oral pancreatin.Twelve healthy volunteers were included as referencegroup. CCK basal levels did not vary. CCK response to atest meal was increased in patients before treatment and diminished when oral enzymes weremaintained for months even after three days of therapywithdrawal. We conclude that long-term therapy with oralenzymes induces changes in CCK response that do not regress after three days of treatmentsuspension.     

Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis

The incidence of acute bleeding is reported to be 13.5% in patients with acute necrotizing pancreatitis. However, of all the bleeding events, intra-abdominal bleeding was less studied in the literature and its risk factors have not been well defined yet. The purpose of the present study was to investigate the risk factors for massive intra-abdominal bleeding among the patients with infected necrotizing pancreatitis and assessed the outcome of these patients.Both univariate and multivariate logistic regression models were applied for evaluating risk factors for intra-abdominal bleeding using 33 indices, including age, sex, etiology of acute pancreatitis (AP), APACHE II score, etc. Outcome assessments such as mortality, hospital and intensive care unit (ICU) durations, and cost were also compared between patients with or without intra-abdominal bleeding.Acute kidney injury (AKI) (odds ratio [OR]: 7.54, 95% confidence interval [CI]: 2.53–22.52, P < 0.001) and number of operation (OR: 8.84, 95% CI: 2.01–38.86, P = 0.004) were 2 predictors for massive intra-abdominal bleeding in the patients with infected necrotizing pancreatitis. In addition, AP patients with intra-abdominal bleeding also showed significantly higher mortality rate, prolonged hospital and ICU durations, more complications and invasive treatments, as well as increased cost.Our study revealed that AKI and multiple operations were 2 critical factors increasing the risk of intra-abdominal bleeding among patients with infected necrotizing pancreatitis. Additionally, massive intra-abdominal bleeding was also associated with poor prognosis.     

Long-term Outcomes of Acute Gastric Variceal Bleeding in 48 Patients Following Treatment with Cyanoacrylate

Objectives (1) Study the effectiveness of intravariceal injection of n-butyl-2-cyanoacrylate to treat acute gastric variceal (GV) bleeding and (2) study the impact of the type of GV and hepatic function on endoscopic hemostasis and mortality outcomes. Methods Fourty-eight patients with acute GV bleeding underwent intravariceal injection of n-butyl-2-cyanoacrylate and were followed until death or study conclusion (12–52 months). Results Primary hemostasis (no re-bleeding within 48 h) was accomplished in 42 patients (87.5%). Appearance of the bleeding site at the time of initial endoscopy, grade of cirrhosis and location of GV were not significant predictors of immediate hemostasis. Early re-bleeding (48 h to 6 weeks) occurred in 20.5% of patients and late re-bleeding (beyond 6 weeks) in 20.5% of patients. While the Child-Pugh score was predictive of re-bleeding and mortality, the type of GV and stigmata at initial endoscopy were not significant predictors of re-bleeding and mortality. Over a mean follow-up of 18 months, mortality rates were 43.9% and bleeding was the commonest cause of death. Conclusion Endoscopic injection of n-butyl-2-cyanoacrylate is effective and safe for treating bleeding GV. Patients with poor hepatic function are at higher risk of re-bleeding and death after acute gastric variceal bleed. Petruska Marques, Fauze Maluf-Filho and Atul Kumar contributed equally to the article.     

Acute Pancreatitis in Patients with Ulcerative Colitis

Twenty-two patients (13 men and 9 women; median age, 34 years; range, 15–64 years) with ulcerative colitis (UC) were evaluated to determine the incidence of acute pancreatitis with UC at the First Department of Internal Medicine, Mie University School of Medicine, during 1989–2001. Among these, three patients (14%) were diagnosed as having had episodes of acute pancreatitis during the mean follow-up period of 6 years. One patient presented with acute pancreatitis and UC simultaneously. Two patients had drug-induced pancreatitis (one due to azathioprine and the other due to 5-ASA). In conclusion, acute pancreatitis is not a frequent, but an occasional extraintestinal manifestation of UC.     

Arterial Thrombosis in Patients with Cancer

Purpose of review

Cancer is a common cause of morbidity and mortality in the USA. While the association between venous thrombosis and malignancy is well established, arterial thrombosis has more recently been recognized as a serious complication of cancer and certain chemotherapeutic agents. This review aims to summarize the most recent literature regarding the incidence and risk factors for cancer-related arterial thrombosis, understand the pathophysiologic mechanisms of thrombosis, and highlight the specific diagnostic and treatment considerations relevant to cancer patients.

Recent findings

Based on a recent study looking at the Surveillance, Epidemiology, and End Results (SEER) database, the incidence of arterial thromboembolic events (ATEs) in patients with cancer at 6 months is 4.7%; the presence of an ATE is predictive of worse outcomes. Certain drugs such as platinum-based agents, vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, and taxanes have been associated with high rates of ATEs. Increased platelet reactivity appears crucial to development of arterial thrombosis in cancer patients.

Summary

Cancer patients have an increased risk of arterial thrombosis that is likely due to both a cancer-associated procoagulant state as well as the adverse effects of certain chemotherapeutic agents. Treatment of arterial thromboembolism in cancer patients typically requires a multidisciplinary approach in part due to high rates of thrombocytopenia and stent thrombosis in the setting of percutaneous interventions. More studies are needed to investigate optimal prophylaxis, surveillance strategies, and treatments of cancer-related arterial thromboembolic disease.

     

Gut Permeability in Patients with Acute Pancreatitis

Background: The bacterial contamination of pancreatic necrosis in acute pancreatitis is supposed to occur through translocation of intestinal bacteria. Increased gut permeability may be the initial phenomenon in this process. To test the hypothesis that gut permeability is increased in acute pancreatitis a clinical study was made where gut absorption and permeability were assessed with multi-sugar probes in patients with acute pancreatitis within 2 days after admission to hospital and again after recovery of disease. Methods and Results: Twenty-three patients with acute pancreatitis and 20 healthy controls were studied. According to Atlanta classification, 15 patients had mild and 8 patients severe pancreatitis. Gut absorption, assessed as the 5-h urine excretion of L-rhamnose, D-xylose and 3-O-methylglucose, was decreased in patients with acute pancreatitis and more pronounced in patients with severe pancreatitis (L-rhamnose and D-xylose: P &lt; 0.001; 3- O -methylglucose: P     

Characteristics of Patients with Bleeding Peptic Ulcer Requiring Emergency Endoscopy and Aggressive Treatment

Objectives: Patients with an ulcer and active bleeding or a nonbleeding, visible vessel are high-risk for further bleeding and should receive aggressive therapy. In this study, we tried to identify clinical parameters that predict these high-risk groups. Methods: Over a 7-nionth period, 16 clinical parameters were analyzed prospectively in 316 patients with bleeding peptic ulcer. A multivariate analysis was used to find the independent predictors for the high-risk patients. Resutts: A total of 114 patients (36%) was found to have a spurting hemorrhage (eight patients), oozing hemorrhage (27 patients), or a nonbleeding visible vessel (79 patients). Using an univariate analysis, a statistically signiHcant predictor was the appearance of coffee ground fluid or blood from the nasogastric tube. This predictor also emerged as an independent factor (odds ratio, 0.4333; 95% confidence interval, 0.263–0.714). Conctusions: Patients with bleeding peptic ulcer who have coffee ground fluid or blood from the nasogastric tube should receive an emergency endoscopy and aggressive treatment.     

Upper Gastrointestinal Bleeding in Patients with CKD

Background and objectives

Patients with CKD receiving maintenance dialysis are at risk for upper gastrointestinal bleeding. However, the risk of upper gastrointestinal bleeding in patients with early CKD who are not receiving dialysis is unknown. The hypothesis was that their risk of upper gastrointestinal bleeding is negatively linked to renal function. To test this hypothesis, the association between eGFR and risk of upper gastrointestinal bleeding in patients with stages 3–5 CKD who were not receiving dialysis was analyzed.

Design, setting, participants, & measurements

Patients with stages 3–5 CKD in the CKD program from 2003 to 2009 were enrolled and prospectively followed until December of 2012 to monitor the development of upper gastrointestinal bleeding. The risk of upper gastrointestinal bleeding was analyzed using competing-risks regression with time-varying covariates.

Results

In total, 2968 patients with stages 3–5 CKD who were not receiving dialysis were followed for a median of 1.9 years. The incidence of upper gastrointestinal bleeding per 100 patient-years was 3.7 (95% confidence interval, 3.5 to 3.9) in patients with stage 3 CKD, 5.0 (95% confidence interval, 4.8 to 5.3) in patients with stage 4 CKD, and 13.9 (95% confidence interval, 13.1 to 14.8) in patients with stage 5 CKD. Higher eGFR was associated with a lower risk of upper gastrointestinal bleeding (P=0.03), with a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.87 to 0.99) for every 5 ml/min per 1.73 m² higher eGFR. A history of upper gastrointestinal bleeding (P<0.001) and lower serum albumin (P=0.004) were independently associated with higher upper gastrointestinal bleeding risk.

Conclusions

In patients with CKD who are not receiving dialysis, lower renal function is associated with higher risk for upper gastrointestinal bleeding. The risk is higher in patients with previous upper gastrointestinal bleeding history and low serum albumin.