Massive rectal bleeding from a Dieulafoy's ulcer of the rectum

Massive per rectal bleeding caused by a Dieulafoy's ulcer located within the rectum is extremely rare. We herein report such a case occurring in a 76-year-old male patient with a history of chronic renal failure, who presented with massive fresh bleeding in the rectum. He was diagnosed during an endoscopic inspection and was promptly treated by clipping at the same time. Although this is a rare entity, Dieulafoy's ulcer should therefore be taken into consideration in the differential diagnosis of patients presenting with massive lower gastrointestinal bleeding.     

Rectal bleeding by Dieulafoy-like lesion: successful endoscopic treatment

A 81-year old woman affected by chronic renal failure, non insulin-dependent diabetes mellitus (NIDM) and hypertension, had an severe anemia massive hematochezia. The colonoscopy could not localize the bleeding site except some blood spots in the rectum. The patient was readmitted after 1 month with hypovolemic shock by massive hematochezia and required several blood transfusions. The endoscopic examination showed an important arterial bleeding treated successfully with epinephrine and bipolar elettro-coagulation (BICAP). We suggested that the patient presented a Dieulafoy-like lesion; this is an uncommon gastrointestinal cause of bleeding due to a defect of a submucosal artery without evidence of atherosclerosis or vasculitis. Both chronic renal failure and age could be considered as predisponent factors in this patient. Hematochezia is the most important sign and is often complicated by haemorrhagic shock. The diagnosis was delayed due to the difficulty in localizing the bleeding site; moreover, the patient needed several blood transfusions. The arteriographic diagnosis associated to endoscopic treatment by epinephrine and BICAP enabled a successful therapy.     

Massive bleeding from Dieulafoy's lesion of the small intestine in a child--therapy for the bleeding from gastrointestinal tract out of endoscopic observation

Dieulafoy's lesion is recognized as a submucosal artery associated with a minute mucosal defect and a rare cause of severe gastrointestinal hemorrhage. Especially, that of distal jejunum or ileum is extraordinarily rare. It is very difficult to detect the lesion in these parts. We experienced massive bleeding from Dieulafoy's lesion of the distal jejunum in a 12-year-old girl. Preoperative angiography and intraoperative palpation detected the point of bleeding. She was rescued by partial jejunectomy. Compiled reports suggested that careful palpation was useful for detection of the location of the bleeding point, which was enhanced as vascular dilatation by the angiogram, during the operation comparatively.     

Massive low gastrointestinal bleeding due to a Dieulafoy rectal lesion

Massive low gastrointestinal bleedings are often difficult diagnostically and in terms of management. Sometimes, it is not possible to identify the bleeding point after performing diverse diagnostic tests and the patient undergoes a blind subtotal colectomy. With rectal bleeding, this form of surgery is completely useless, as it will not solve the cause of the haemorrhage. The Dieulafoy lesion has been widely described in the stomach, but in the rectum is a very rare entity that can cause massive lower gastrointestinal bleeding. In the literature, there are only 25 described cases of rectal Dieulafoy lesion.     

Massive bleeding from a rectal dieulafoy lesion: combined multidetector-row CT diagnosis and endoscopic therapy

Dieulafoy lesion is an uncommon cause of acute gastrointestinal bleeding. The diagnosis is usually carried out endoscopically. We report a 77-year-old woman with rectal Dieulafoy lesion. A recent endoscopic examination missed the lesion because it was small and the bleeding was intermittent. In our case, prompt colonoscopic therapy was allowed after locating the bleeder by multidetector-row computed tomography. On the basis of the success of this procedure, we suggest that an emergent multidetector-row computed tomography could have a role in the management of patients with massive lower gastrointestinal bleeding.     

Massive bleeding during spine surgery in a patient with ankylosing spondylitis

Purpose

Ankylosing spondylitis is associated with pathophysiology that has important anaesthetic implications. We report a case where the sequelae of ankylosing spondylitis may have been responsible for massive bleeding during emergency spine surgery.

Clinical Features

A 69 yr old man with long standing ankylosing spondylitis sustained a complex fracture of the lumbar spine in a fall, and was scheduled for stabilization of the spine. Under general anaesthesia, prone positioning was difficult because of the extreme spinal deformity. During exploration, dilatation of epidural veins was encountered and sustained haemorrhage was encountered throughout,the surgical procedure. Estimated blood loss was 17,000 ml which was replaced with 31 units of packed red blood cells, 3200 ml of salvaged blood, 18 units of fresh frozen plasma, 26 units of platelets, 1,000 ml of albumin and 9,000 ml of crystalloid.

Conclusions

Extreme deformity of the spine led to positioning difficulties that may have contributed to massive blood loss during complex spine surgery. Difficulties with placement in the prone position in-patients with advanced ankylosing spondylitis should be anticipated.     

Massive scalp myiasis with bleeding in a patient with multiple malignancies

Most cases of myiasis in association with cancer are reported in patients with squamous cell carcinoma of the head and neck region. They are not emergencies. We report a case of massive myiasis of the scalp with bleeding in a patient with an ulcerated squamous cell carcinoma of the scalp, haematological and colorectal malignancies. Treatment of myiasis is based on local disinfection and mechanical removal of larvae. Other options of treatment are discussed.     

Massive haemorrhage due to rectosigmoid ulcers in a patient with extensive burns.

A 36-year-old white-skinned male was admitted with 45.5 per cent burns, mostly of full skin thickness. Severe rectal bleeding from rectal ulcerations developed on postburn day 12. Various conservative attempts at management failed, and after multiple transfusions, abdominoperineal resection was carried out with eventual complete recovery. Complications during his acute phase included Pseud. aeruginosa sepsis and Clostridium difficile diarrhoea. Extensive skin grafts were required. The cause of the rectal ulcerations is unclear.     

Dieulafoy's lesion of the rectum

Dieulafoy's lesion is an uncommon cause of gastrointestinal haemorrhage. It may present with massive and life threatening bleed and although more common in the upper gastrointestinal tract, it is being increasingly reported as affecting the lower gastrointestinal tract. Diagnosis is usually achieved during proctoscopic and endoscopic visualization. In cases where there is profuse and torrential hemorrhage, angiography may help to confirm the diagnosis. There are a few treatment options available, all of which have a varying degree of success. More commonly than not, a combination of treatment is warranted as illustrated by our case. Recurrent bleeding may occur just as in cases of Dieulafoy's lesion affecting the upper gastrointestinal tract. Even though endoscopic visualization of the lower gastrointestinal tract in the presence of profuse lower gastrointestinal haemorrhage may not be possible, this important procedure should not be omitted as the bleeding source may be lying in a low and accessible location for prompt interventional haemorrhage control.     

Massive gastrointestinal bleeding due to isolated jejunal varices in a patient without portal hypertension

INTRODUCTIONIsolated ectopic varices located in the small bowel are uncommon. Portal hypertension caused by liver cirrhosis is the most common predisposing risk factor.PRESENTATION OF CASEWe present an unusual case of massive gastrointestinal bleeding from idiopathic jejunal varices in a 73-year-old Caucasian male without portal hypertension. Exploratory laparotomy disclosed ectopic varices located in the small intestine. Segmental resection of the jejunum with end to end anastomosis resulted in a complete resolution of the haemorrhage. During a 5 year follow up, the patient is stable with no bleeding recurrence.DISCUSSIONInformation on aetiology, diagnosis and management of jejunal varices is reviewed.CONCLUSIONDiagnosis and management of isolated jejunal varices is challenging. Surgeons as well as acute care physicians have to consider idiopatic form of jejunal varices as a potential cause of gastrointestinal bleeding when gastroduodenoscopy and colonoscopy are negative.     

Massive hemorrhage from presacral veins during resection of the rectum]

During the last 53 abdominoperineal amputations of the rectum for carcinoma, we had to control 5 massive hemorrhages. 4 of which were due to a lesion of the presacral venous plexus and caused a mean blood-loss of 4750 ml. During a "normal" Mile's operation our 49 other patients lost an average of 1750 ml (median 1200 ml) of blood. The negative effects of this type of complication and the following need for massive transfusion is not only local, circulatory and pulmonary, but also due to the immunodepressive effects of massive transfusion. We describe the different methods of control of these hemorrhages and insist on the advantage of using sterilised metallic thumbtacks, a method which was described 1984 by doctor Wang Qinyao of Shanghai.     

Massive upper gastrointestinal bleeding from haemorrhagic gastritis in the newborn

A case is reported of massive upper gastrointestinal bleeding in a newborn on the second day. Failure to control the bleeding by conservative measures necessitated an exploration. Haemorrhagic gastritis was found to be the cause of bleeding. Vagotomy and pyloroplasty was performed with satisfactory results. Management of this condition in the newborn is discussed.     

Massive bleeding from a ruptured superior mesenteric artery aneurysm duodenum.

A traumatic false aneurysm of the superior mesenteric artery resulting from a gunshot wound five years previously, caused massive hemorrhage into the second portion of the duodenum. Dissection, resection, and end-to-end anastomosis was successful in controlling bleeding into the gastrointestinal tract, but immediate postoperative angiography showed a reappearance of the aneurysm, and three months later, it bled into the retroperitoneum. The patient underwent further resection and two subsequent reconstructions of the superior mesenteric artery, the first with a Dacron graft, which clotted, and the second with autologous saphenous vein, which was successful. Three years later, the patient is well. The case shows that adequate reconstruction of an arterial injury is best performed immediately after it is diagnosed.     

Massive gastric bleeding from a blunt abdominal trauma: Report of a case

Blunt gastric injury (BGI) is a rare condition that accounts for 0.02%–1.7% of all blunt abdominal trauma cases. Blunt gastric rupture, which occurs in less than 40% of all BGI cases, presents unstable vital signs and symptoms of peritonitis due to massive peritoneal contamination. This article presents the case of a patient with BGI who did not present with symptoms of peritonitis in spite of presenting with persistent hypovolemic shock.     

Massive lower gastrointestinal bleeding from intestinal varices.

Lower gastrointestinal bleeding from intestinal varices cannot readily be detected at operation; hence, preoperative identification is important. Our experience with six patients having sudden, massive bleeding per rectum from intestinal varices suggests a group of common findings. These patients had cirrhosis, no blood in the stomach or duodenum, characteristic mucosal imprints on barium enema, or direct visualization of varices on sigmoidscopy or colonoscopy. Only two had demonstrable esophageal varices. The diagnosis was confirmed and the site of the varices localized on the venous phase of selective mesenteric angiography in five patients. Varices were located in the duodenojejunum in two, in the cecum and ascending colon in two, and in the rectum and sigmoid colon in two patients. Three patients were treated nonoperatively with transfusion and intraarterial infusion of vasopressin into the superior mesenteric artery; one died. One patient with cecal varices had a right hemicolectomy that controlled the bleeding, but progressive hepatic failure resulted in postoperative death. The remaining two patients had successful decompression of left colonic varices by portasystemic shunt.