Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy's lesion

AIM: To investigate the endoscopic hemostasis for gastrointestinal bleeding due to Dieulafoy’s lesion.METHODS: One hundred and seven patients with gastrointestinal bleeding due to Dieulafoy’s lesion were treated with three endoscopic hemostasis methods: aethoxysklerol injection (46 cases), endoscopic hemoclip hemostasis (31 cases), and a combination of hemoclip hemostasis with aethoxysklerol injection (30 cases).RESULTS: The rates of successful hemostasis using the three methods were 71.7% (33/46), 77.4% (24/31) and 96.7% (29/30), respectively, with significant differences between the methods (P < 0.05). Among those who had unsuccessful treatment with aethoxysklerol injection, 13 were treated with hemoclip hemostasis and 4 underwent surgical operation; 9 cases were successful in the injection therapy. Among the cases with unsuccessful treatment with hemoclip hemostasis, 7 were treated with injection of aethoxysklerol and 3 cases underwent surgical operation; 4 cases were successful in the treatment with hemoclip hemostasis. Only 1 case had unsuccessful treatment with a combined therapy of hemoclip hemostasis and aethoxysklerol injection, and surgery was then performed. No serious complications of perforation occurred in the patients whose bleeding was treated with the endoscopic hemostasis, and no re-bleeding was found during a 1-year follow-up.CONCLUSION: The combined therapy of hemoclip hemostasis with aethoxysklerol injection is the most effective method for gastrointestinal bleeding due to Dieulafoy’s lesion.     

Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre

Background and study aims

Lower gastrointestinal bleeding originates from a site distal to the ligament of Treitz. It can present as an acute life-threatening or chronic bleeding. It is common among older patients and those with comorbidity. The common causes are diverticular disease, angiodysplasias, neoplasms, colitis, ischaemia and anorectal disorders. The aim of this study is to determine the prevalence and causes of acute lower gastrointestinal bleeding among Sudanese patients.

Acute in-vivo evaluation of bleeding with GelfoamTM plus saline and Gelfoam plus human thrombin using a liver square lesion model in swine

Background Management of post-operative bleeding has historically used topical bovine thrombin. However, possible harm through activation of coagulation inhibitors has encouraged investigation with other hemostatic agents. This study utilized a novel ordinal bleeding model to test whether a Gelfoam + human thrombin solution is superior at controlling bleeding when compared to Gelfoam + saline solution at different time intervals. Study design Four swine underwent open laparotomy after receiving unfractionated heparin. Twenty open liver biopsies were performed in each swine; ten biopsies treated with Gelfoam + human thrombin solution and 10 biopsies treated with Gelfoam + saline solution. Three, 6 min, and 12 min after the procedure, bleeding was objectively graded by a four-point model. Results There was a significant (P < 0.017), treatment effect on each success/failure outcome (success = bleeding score ≤ 1; failure = bleeding score > 1) at 3 (P < 0.001), 6 (P < 0.001), and 12 (P = 0.003) min, based on a 2 × 2 Fisher’s exact test. Similarly, there was a significant treatment effect on each success/failure outcome and four-point bleeding score based on a multiple logistic regression analysis controlling for pig, lesion weight, and initial bleeding taking into consideration repeated measures at three time points. Conclusions The results demonstrate a superior treatment effect for control of bleeding using human thrombin compared to a saline solution. Future studies should compare bovine thrombin versus human thrombins ability to control bleeding as well as the hazard of each in activating coagulation inhibitors.     

Massive lower gastrointestinal bleeding from the appendix

Massive rectal bleeding from the appendix, considered a rare case of lower gastrointestinal bleeding, is not easily recognized by various diagnostic modalities. A multidisciplinary approach for both a diagnosis and a differential diagnosis is important because the identification of the bleeding site is crucial to proceed to a proper intervention and there are various causes of appendiceal bleeding. Because early colonoscopy plays an important role in the diagnosis and management of lower gastrointestinal hemorrhage, we report a case of a life threatening massive rectal bleeding from the appendix diagnosed by colonoscopy. We also present a review of the literature.     

Pitfalls in the treatment of massive lower gastrointestinal bleeding with “blind” subtotal colectomy

In 1969, the concept of “blind” subtotal colectomy was introduced for the treatment of patients with colonic diverticulosis and massive lower gastrointestinal (LGI) bleeding. This “policy” was soon extended to include all patients with LGI bleeding from obscure bleeding sources. In a nine-year period, ten patients presented with massive LGI bleeding, had evidence of colonic diverticula on barium-enema examination, and were explored for unrelenting bleeding. In four patients, careful exploration revealed another source for bleeding and three did well after appropriate surgery. One patient died during surgery. Six patients had blind subtotal colectomy, continued to bleed postoperatively, and three of these patients died. With the advent of selective mesenteric angiography and other preoperative diagnostic techniques, all efforts should be made to identify the exact source of bleeding and proceed with the appropriate surgery rather than subject the patient to blind subtotal colectomy. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

An unusual case of both upper and lower gastrointestinal bleeding in a kidney transplant recipient

Background. Tuberculosis (TB) is an uncommon opportunistic infection in immunocompromised patients. Extrapulmonary infection involving the intestine is rare and poses diagnostic difficulties.
Case report. A 49-year-old man with IgA nephropathy underwent a kidney transplantation in 1996 and was put on cyclosporine, azathioprine, and steroid. He suffered from a recurrence of his primary kidney disease and had a gradual deterioration of renal function since 1998. By 2005, he presented with an unusual gastrointestinal (GI) symptom with alternating signs of upper GI bleeding – melena – as well as lower GI bleeding with fresh rectal bleeding, resulting in severe anemia with hemoglobin level down to 5.0 g/dL. At the same time, his renal function further deteriorated and necessitated the initiation of dialysis while he was maintained on low-dose immunosuppressive drugs. Repeated upper and lower GI endoscopies were either unremarkable or revealed non-specific lesions. Symptoms persisted and exploratory laparotomy finally showed a 1 cm submucosal mass at the proximal jejunum and multiple inflammatory lesions at the terminal ileum. Segmental resection of the lesions was performed and confirmed TB infection. However, despite the initiation of anti-tuberculous treatment, the patient eventually died of complications.
Conclusion. Diagnosing TB intestinal infection is a clinical challenge. A high index of suspicion in susceptible subjects is necessary, and early surgical intervention should always be considered when facing diagnostic uncertainties.     

The utility of urgent colonoscopy in the evaluation of acute lower gastrointestinal tract bleeding: a 2-year experience from a single center

OBJECTIVE: Urgent colonoscopy is often recommended to evaluate acute rectal bleeding. However, it may not identify a source because of blood in the lumen or inadequate preparation. Our aim was to determine the utility of urgent colonoscopy as the initial test for acute rectal bleeding. METHODS: This was a retrospective chart review of all patients discharged in 1997 and 1998 with an International Classification of Diseases, 9th Revision, code for hematochezia or rectal bleeding. RESULTS: We identified 514 charts but excluded 424 because of inaccurate coding. In the 90 with confirmed acute rectal bleeding, colonoscopy was the initial test in 39; age, sex, and race distributions were similar to those who did not have colonoscopy. A definite source of bleeding was seen at colonoscopy in only three patients, a probable source in 26, and no source in 10. Therapeutic intervention in four patients with a definite or probable source was successful in three. The commonest reasons for not performing urgent colonoscopy were bleeding from presumed hemorrhoids or bleeding that was clinically insignificant. Spontaneous resolution of bleeding and length of hospital stay were not affected by urgent colonoscopy. Five patients had surgery for unrelated reasons. In-hospital mortality was 2% and was unrelated to bleeding. CONCLUSION: Urgent colonoscopy as the initial investigation in acute lower GI tract bleeding probably does not alter the outcome in most cases. Identification of a definite bleeding source leading to successful therapeutic intervention is rare. Spontaneous resolution is frequent, length of hospital stay is similar, and clinical outcome is excellent regardless of whether or not urgent colonoscopy is performed.     

Excessive prolongation of the bleeding time by aspirin in essential thrombocythemia is related to a decrease of large von Willebrand factor multimers in plasma

 Patients with essential thrombocythemia (ET), who frequently have bleeding complications, may manifest an excessive prolongation of the bleeding time (BT) after ingestion of aspirin (ASA). The reason for this excessive prolongation of the BT is unknown, but it is attributed to qualitative platelet defects. Since patients with ET may also have acquired abnormalities of plasma and platelet von Willebrand factor (vWF), we questioned whether the excessive prolongation of the BT by ASA was related to changes in either plasma or platelet vWF. To that end, we studied BT and plasma and platelet vWF in ten ET patients, ten patients with reactive thrombocytosis (RT), and ten normal individuals, both before and after administration of 500 mg ASA for 7 days. In a second study, the effect of DDAVP infusion on plasma vWF in relation to the BT was studied in ten normal individuals and ten ET patients after treatment with 100 mg ASA for 3 days. In the first study, treatment with ASA resulted in a significant prolongation of the BT in normal subjects, RT patients, and ET patients. However, in five ET patients an excessive (>2 SD) prolongation of the BT by ASA was observed. Although ASA induced no direct changes in either plasma or platelet vWF levels in either normal subjects, RT patients, or ET patients, all five ET patients who showed an excessive prolongation of the BT by ASA had significantly decreased levels of large vWF multimers in plasma. In the second study, infusion with DDAVP resulted in a significant increase in plasma large vWF multimers, paralleled by a normalization of (excessively) prolonged BT. Our data suggest that in ET inhibition of platelet function by ASA in the presence of concurrently decreased levels of large vWF multimers in plasma may have provoked the excessive BT prolongation. Received: 20 April 1997 / Accepted: 8 August 1997     

老年冠心病介入治疗中靶病变近端急性血管事件

目的总结分析择期老年冠心病介入治疗连续病例的靶病变近端发生的急性医源性血管事件及其处理结果。方法对2001-2004年间完成的老年择期冠状动脉介入手术986例进行回顾分析,总结在处理靶血管中、远段靶病变的过程中,因为损伤近端非干预病变造成近端急性血管事件的发生率、特点和处理结果,比较发生和未发生急性血管事件的近端非干预病变的造影特点。主要分析指标包括病变成功率、靶病变近端急性血管事件率、并发症率和病死率。结果986例患者共干预2136根血管和2367个病变,植入2556枚支架。病变成功率100%,病例成功率99.9%,病死率0.1%,并发症率0.5%。2136支靶血管存在261处近端非干预性病变（12.2%）。发生近端急性血管事件24次,发生率9.2%,包括近端夹层11例（45.8%）、急性血栓形成5例（20.8%）、严重血管痉挛8例（33.3%）。近端非干预病变和近端急性事件病变造影特点无显著差异（P〉0.05）。急性血管事件的处理结果为直接植入支架11例（45.8%）,冠脉内溶栓后植入支架4例（16.7%）,急诊静脉溶栓后植入支架1例（4.2%）,冠脉内反复注射硝酸甘油缓解痉挛8例（33.3%）。结论（1）靶病变近端不稳定斑块的识别对介入操作的决策和步骤具有重要影响;（2）靶病变近端不稳定性斑块的机械性激惹和破坏是造成术中和术后近期急性血管事件的重要原因之一;（3）准确识别和有效保护靶病变近端不稳定斑块是防止围术期并发症的重要措施;（4）介入手术后加强稳定斑块的药物治疗具有重要意义。     

Hypercoagulability as a contributor to thrombotic complications in the liver transplant recipient

Traditionally, perioperative bleeding complications were a major concern during orthotopic liver transplantation, but a tremendous decline in transfusion requirements has been reported over the last decade. In recent years, there has been an increasing awareness towards perioperative thrombotic complications, including liver vessel thrombosis, and systemic venous and arterial thromboembolic events. Whereas a number of these thrombotic complications were previously categorized as surgical complications, increasing clinical and laboratory evidence suggest a role for the haemostatic system in thrombotic complications occurring during and after transplantation. High levels of the platelet adhesive protein von Willebrand factor with low levels of its regulator ADAMTS13, an increased potential to generate thrombin, and temporary hypofibrinolysis are all indicative of increased haemostatic potential after transplantation. Clinical evidence for a role of the haemostatic system in post‐operative thromboses includes a higher thrombotic risk in patients with various acquired thrombotic risk factors. Although data on efficacy of anticoagulant therapy after liver transplantation are scarce, one study has shown a significant decrease in the risk for late hepatic artery thrombosis by antithrombotic therapy with aspirin. These findings suggest that antihaemostatic therapy in prevention or treatment of thromboembolic complications after liver transplantation may be relevant. Studies on efficacy and safety of these interventions are required as many of the thrombotic complications have a pronounced negative impact on graft and patient survival.     

Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting

INTRODUCTION Upper gastrointestinal (UGI) bleeding is a common disorder affecting over 100 per 100 000 population yearly[1-7]. The most common etiologies include peptic ulcer disease, mucosal erosive disease and variceal bleeding[8-13]. Because there is a…     

Serious intestinal bleeding from vascular ectasia secondary to portal thrombosis after living-related liver transplantation in a child

Serious intestinal bleeding from vascular ectasia secondary to extrahepatic portal thrombosis is much less frequent than variceal bleeding, and its treatment is not clearly defined. We describe a 4-year-old girl with repeated intestinal bleeding from vascular ectasia, without any varix, with late extrahepatic portal vein thrombosis (PVT) and late hepatic artery thrombosis (HAT) after living-related liver transplantation. The bleeding stopped after simple splenectomy. She has presented neither bleeding nor any serious complications related to splenectomy for 1 year to date. We think uncontrollable hemorrhage from gastrointestinal vascular ectasia secondary to extrahepatic portal thrombosis in a pediatric patient can and should be treated by simple splenectomy, because patients with this complication usually have a normally functioning liver. However, it is not clear whether this procedure is effective for variceal bleeding.     

Prospective evaluation of the risk of upper gastrointestinal bleeding after admission to a medical intensive care unit

One hundred seventy-four patients (179 admissions) were prospectively evaluated for the subsequent occurrence of upper gastrointestinal (“stress”) bleeding after admission to a medical/respiratory intensive care unit. Evidence for either overt or occult gastrointestinal bleeding developed in 25 (14 percent). The group of bleeders had a higher mortality (64 percent versus 9 percent), duration of intensive care unit stay (median 14.2 versus 4.2 days), number of patients requiring mechanical ventilatory support (84 percent versus 26 percent), and duration of such support for those who required it (median 9.5 versus 4.2 days) than the group who did not bleed. In three patients, death was related to bleeding. Upon patients' admission to the intensive care unit, diagnoses of an acute respiratory illness (but not specifically chronic obstructive pulmonary disease), a malignancy, or sepsis were more common among those who subsequently bled. Of factors tested, a coagulopathy and the need for mechanical ventilation were most strongly associated with the risk of bleeding. Other factors did not add to the risk once these two were taken into account. Among patients receiving mechanical ventilation, the risk of overt bleeding was particularly low for those who required such support for less than five days (only 3 percent). It is concluded that (1) significant upper gastrointestinal bleeding occurring after medical intensive care unit admission is an uncommon event, and (2) prolonged mechanical ventilation and/or the presence of a coagulopathy are the most potent risk factors. Medical patients with either of the latter conditions are most likely to benefit from prophylaxis regimens against “stress”-induced upper gastrointestinal bleeding.     

Development and validation of a new scoring system to determine the necessity of small-bowel endoscopy in obscure gastrointestinal bleeding

BackgroundSmall bowel capsule endoscopy (SBCE) is the recommended first-line procedure for obscure gastrointestinal bleeding (OGIB). However, a method for predicting the necessity of subsequent double-balloon endoscopy (DBE) has not been established.AimsWe aimed to develop a new scoring system that predicts the necessity of DBE in OGIB.MethodsA retrospective study was performed in 330 patients who underwent SBCE for OGIB at Nagoya University Hospital. The enrolled patients were randomly assigned to either a development or a validation dataset. The former was used to construct a prediction scoring system to assess the necessity of DBE using independent predictors selected by logistic regression. The diagnostic yield of the prediction model was assessed using the validation dataset.ResultsMultivariate logistic regression analysis of the development dataset identified OGIB type, blood transfusion, and SBCE findings as independent predictors of the necessity of DBE. A prediction score gave an area under the receiver operating characteristics curve of 0.77. The sensitivity, specificity, positive predictive value, and negative predictive value at a cutoff ≥2.5 points were 72.5%, 74.6%, 72.6%, and 74.5%, respectively.ConclusionOur scoring system may aid clinicians in deciding when to recommend DBE for patients with OGIB.     

Time trends and outcome of gastrointestinal bleeding in the Veneto Region: A retrospective population based study from 2001 to 2010

BackgroundGastrointestinal bleeding is the most frequent emergency for gastroenterologists. Despite advances in management, an improvement in mortality is still not evident.AimDetermining time trends of gastrointestinal bleeding hospitalization and outcomes from 2001 to 2010 in the Veneto Region (Italy).Patients and methodsData of patients admitted with gastrointestinal bleeding from Veneto regional discharge records were retrospectively evaluated. Chi-squared and multivariate logistic regression model were used.ResultsOverall, 44,343 patients (mean age 64.2 ± 8.6 years) with gastrointestinal bleeding were analysed: 23,450 (52.9%) had upper, 13,800 (31.1%) lower, and 7093 (16%) undefined gastrointestinal bleeding. Admission rate decreased from 108.0 per 100,000 in 2001 to 80.7 in 2010, mainly owing to a decrease in upper gastrointestinal bleeding (64.4 to 35.9 per 100,000, p < 0.05). Reductions in hospital fatality rate (from 5.3% to 3%, p < 0.05), length of hospital stay (from 9.3 to 8.7 days, p < 0.05), and need for surgery (from 5.6% to 5%, p < 0.05) were observed. Surgery (OR: 2.97, 95% CI: 2.59–3.41) and undefined gastrointestinal bleeding (OR: 2.89, 95% CI: 2.62–3.19) were found to be risk factors for mortality.ConclusionsPatient admissions for gastrointestinal bleeding decreased significantly over the years, owing to a decrease in upper gastrointestinal bleeding. Improved outcomes could be related to regional dedicated clinical gastroenterological management.