Frequency of infections in cirrhotic patients presenting with acute gastrointestinal haemorrhage

The frequency of infection at the time of admission with upper gastrointestinal haemorrhage has been determined in 149 successive cirrhotic patients admitted to an intensive care unit. Infection status was investigated by clinical examination, chest X-ray, and blood, urine and ascitic fluid culture. At initial examination infection was present in 32 patients (22 per cent) and was often in the form of septicaemia or spontaneous peritonitis; the bacteria responsible were frequently digestive in origin. At endoscopy, acute lesions of gastroduodenal mucosa were more frequent among infected patients, whereas gastro-oesophageal varices and chronic gastroduodenal ulcers were more frequent among the non-infected patients. Acute mucosal lesions were observed in 70 per cent of infected patients and in 19 per cent of non-infected patients. The mortality rate was higher in infected patients. Infection and the frequency of acute mucosal lesions were related to the severity of the cirrhosis. It is suggested that these lesions could be due to stress secondary to infection.     

Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage

BACKGROUND: In the treatment of acute upper gastrointestinal (GI) bleeding, endoscopic band ligation (EBL) may be performed for nonfibrotic superficial lesions. This method has recently gained popularity in the treatment of nonvariceal upper GI bleeding. PATIENTS AND METHODS: Band ligation was performed in 13 patients who were admitted with active upper GI bleeding between December 1998 and February 2001. The sources of the bleeding were Mallory-Weiss syndrome in four patients, Dieulafoy's ulcer in five patients, gastric ulcer near a gastrojejunostomy anastomosis in two patients, gastric angiodysplasia in one patient, and the primary repair site in the stomach of a gunshot wound in one. RESULTS: Bleeding from all lesions except one was managed successfully with EBL. The single failure was in bleeding from a gastric Dieulafoy's lesion. Injection sclerotherapy with 1:10,000 epinephrine solution and EBL was not successful. Rebleeding occurred twice in one patient, and the second rebleeding necessitated surgical treatment. CONCLUSION: Our results revealed that EBL is a very promising technique in acute nonvariceal upper GI bleeding. Its effectiveness and safety with few complications will allow this modality to be used more widely.     

Dieulafoy's lesion of esophagus

Dieulafoy's lesion is a rare arterial malformation that can cause massive gastrointestinal hemorrhage. The lesion occurs most commonly in the proximal stomach. The esophagus is not a common location for this lesion. We present the case of a 25-year-old woman who was admitted to our emergency unit with the findings of hematemesis and melena. Early upper gastrointestinal endoscopic examination revealed a Dieulafoy's lesion, which was located in the distal esophagus. Endoscopic band ligation stopped the bleeding successfully. The patient was discharged 3 days after the band ligation without any complications. Dieulafoy's lesion may cause severe, life-threatening bleeding. Endoscopic diagnosis can be difficult because of the small size and obscure location of the lesion. An abnormally dilated artery that penetrates through the mucosa constitutes the etiology. Endoscopy plays an important role in the diagnosis and treatment of this pathology. Despite widespread awareness of this entity, it may present a real challenge for the endoscopist due to the small size and hidden location of the lesion. The endoscopic approach to occult gastrointestinal bleeding for the diagnosis of vascular malformations is accepted as a quick and safe diagnostic method.     

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.     

Dieulafoy lesion endoscopically rubber banded, with further severe haematemesis requiring emergency laparotomy - Case report

Dieulafoy lesion is a rare cause of massive gastrointestinal haemorrhage that can be fatal. We report a case of a sixty-year-old lady who presented to the emergency department with haematemesis and melaena. During oesophagogastroduodenoscopy (OGD), an active bleeding vessel was seen on the lesser curvature of the stomach, near the gastro-oesophageal junction and a diagnosis of Dieulafoy's lesion made. The lesion was managed with the application of two rubber bands. Our patient re-presented to the emergency department ten days later with severe haematemesis requiring an emergency laparotomy.A search of the entire English literature using PubMed with the phrase 'Dieulafoy' has been performed. Papers were reviewed in relation to management of this lesion with rubber banding via endoscopy. The current available haemostatic methods are described.     

Primary tumours of the small intestine--the diagnostic problem

The records of 43 patients with 32 malignant and 11 benign neoplasms of the small intestine were reviewed in order to improve early diagnosis. The malignant tumours comprised of 14 carcinoids, 10 carcinomas and 8 sarcomas. The benign tumours constituted 7 different histological types. An increasing frequency of malignant tumours through the bowel was found. Thirty-three per cent of all patients had a sudden onset of symptoms leading to acute explorative laparotomy, whereas the remaining 67 per cent were characterized by a long history. The predominant symptoms were abdominal pain, nausea and vomiting, weight loss and a palpable abdominal mass. An exact preoperative diagnosis was made in 41 per cent of the cases. Upper gastrointestinal X-ray contrast examination with small bowel follow through and ultrasonography gave the greatest sensitivity. A diagnostic strategy was difficult to recommend considering the rarity of these tumours and the low sensitivity of the employed diagnostic modalities. Recently developed Japanese enteroscopes capable of exploring the entire small bowel seem to offer the most promising diagnostic method for the future.     

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.     

Possibilities for using emergency abdominal ultrasound study and its significance in acute diseases of the abdominal cavity

Studies were conducted by the authors' of this paper into the diagnostic value of ultrasonic examination to clear up suspicion of acute abdominal problems, with 381 examinations being actually evaluated. Definitely valid diagnosis was obtained from the method in 37.7 per cent of these cases. The tentative diagnosis was invalidated in 18.2 per cent. The results are compared with literature data. Continued systematic use of the approach is recommended. It would bring down the time required for diagnosis and might provide another possibility of supporting the diagnostic effort which is quite difficult, when it comes to acute abdominal problems.     

Use of radioisotope scan in evaluation of intrascrotal lesions.

There were 98 patients with a variety of intrascrotal lesions studied with a radioisotope 99mtechnetium-pertechnetate scanning technique. Retrospective analysis in 50 patients subjected to an operation revealed a 94 per cent accuracy of the scan in the differential diagnosis of testicular torsion and epididymitis as compared to a clinical accuracy of 48 per cent. In 7 patients with a scan diagnosis of epididymo-orchitis with abscess the diagnosis was confirmed during the operation or by followup examination. While the scan has been a simple, safe, rapid and reliable technique to differentiate acute and subacute lesions, it has proved to be of limited diagnostic significance in cases of chronic intrascrotal lesions and carcinoma.     

A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding

We have assessed the value of the BICAP electrocoagulation probe in reducing the incidence of further bleeding in patients with upper gastrointestinal haemorrhage. One hundred and twenty-nine patients were studied in a prospective randomized controlled trial. There were 85 male and 44 female patients, age range 16-92 years. Forty-five patients had stigmata of recent haemorrhage (visible vessel or spot) and were randomized during endoscopy to 24 control and 21 treatment patients. Seven control patients rebled compared with nine treated patients (Fisher's exact probability test P = 0.44). The transfusion requirements of control patients (3.9 +/- 3.2 units) was not different from that of treated patients (5.7 +/- 3.7 units): Mann Whitney U test, P = 0.06. In the treatment group there was no difference in the operation rate. Also, the number of probe applications between patients with further bleeding and those with no further bleeding was similar (11.6 +/- 5.5 and 11.0 +/- 5.75 respectively). Access with the probe was considered inadequate in 50 per cent of lesions, but this did not correlate with the incidence of rebleeding. Stigmata of recent haemorrhage were significant in predicting rebleeding (P = 0.0019 Fisher's exact probability test). Overall mortality rate of 3.2 per cent was low and was not influenced by electrocoagulation or presence of stigmata of recent haemorrhage. We have not shown that BICAP bipolar electrocoagulation reduces the incidence of rebleeding in upper gastrointestinal haemorrhage.     

Autopsy analysis in surgical patients: a basis for clinical audit.

An autopsy study was performed to quantify diagnostic fallibility in clinical surgery. Autopsy results in 312 surgical patients were compared with clinical findings. The primary clinical diagnosis was correct in 93 per cent of patients; complications had been correctly diagnosed in 60 per cent and error in treatment was found in 16 per cent. Error in treatment had an adverse impact on the course of disease in 11 per cent of patients. Infective complications such as abdominal sepsis and bronchopneumonia were encountered most often. Sensitivity was low for the clinical diagnosis of pulmonary embolism, bronchopneumonia, myocardial infarction and terminal haemorrhage. Statistical analysis showed that sudden unexpected death is the most obvious condition in which a high yield is expected from a post-mortem examination. Autopsy remains a valuable means of quality control in clinical surgery and could be a basis for surgical audit.     

Dieulafoy病的诊治体会

目的　探讨如何改进Dieulafoy病的诊断和治疗。 方法　回顾分析近 3年收治的 6例患者。 6例术前均行胃镜检查 ,其中 4例出血时进行。所有患者都行手术缝扎止血。结果　术前确诊 4例 ,5例治愈出院 ,1例术后死于急性肾功能衰竭。结论　急诊胃镜是最佳诊断方法 ,缝扎止血是较佳治疗方法。     

Use of Sengstaken-Blakemore tube to stop massive upper gastrointestinal bleeding from Dieulafoy's lesion in the lower oesophagus

Massive upper gastrointestinal bleeding from Dieulafoy's lesion in the gastrointestinal tract is uncommon. The use of the Sengstaken-Blakemore tube in acute gastrointestinal bleeding has become less common since endoscopic sclerotherapy and banding procedures have become widely available. The successful use of a Sengstaken-Blakemore tube to control acute massive upper gastrointestinal bleeding from a Dieulafoy's lesion in the lower oesophagus in an elderly man with severe coronary artery disease and heart failure is described.     

Dieulafoy's lesion: rare cause of massive upper gastrointestinal bleeding

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.     

Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis.

The accurate clinical diagnosis of acute appendicitis is difficult, and many techniques have been suggested to improve diagnostic accuracy such as laparoscopy, ultrasonography and barium enema examination. In this study serial total leucocyte counts and serial C-reactive protein (CRP) concentrations in acute appendicitis were measured. The sensitivity and specificity of serial leucocyte counts in acute appendicitis were 92 and 100 per cent, and for CRP concentrations 69 and 75 per cent, respectively. The sensitivity and specificity of serial total leucocyte counts fulfilled the criteria for a diagnostic test. It is suggested that in patients with equivocal clinical findings, clinical observation combined with serial leucocyte counts may improve decision making.     

Wounding,shock and stress lesions of the upper gastrointestinal tract

This retrospective study included 2532 wounded, of whom 354 (14 per cent) were treated in surgical intensive care units. In 32 patients, 1.3 per cent of all admissions, upper gastrointestinal bleeding was detected. It occurred on average 8.9 days (3–21 days) after the wounding or surgical procedure in severely injured patients and those treated in intensive care units, respectively (32 of 354 patients, 9.0 per cent). All patients received different analgesic drugs and 17 of a group that presented with bleeding were given psychotropic agents as well. The majority of patients (96.3 per cent) were administered H₂-receptor antagonists as prophylaxis against stress ulcer disease. There was a statistically significant difference between these patients treated with H₂-receptor antagonists and those on no prophylactic therapy. No statistically significant difference was found between cimetidine and ranitidine in terms of their efficacy. Endoscopic examination revealed multiple bleeding gastric and duodenal erosions. The lesions were most commonly located in the corpus of the stomach. In the majority of patients (56.25 per cent), the haemorrhage stopped spontaneously and rebleeding presented in four of 32 (12.5 per cent) patients. Of 354 patients treated in intensive care units, five (1.4 per cent) had to be operated on because of bleeding arrest. Despite all therapeutic and surgical procedures undertaken, five of 32 (15.6 per cent) patients died.     

Sixty-three cases of traumatic injury of the diaphragm

In the examination of patients with severe thoracic and/or abdominal trauma not requiring surgical exploration, special attention should be given to signs of traumatic diaphragmatic herniation (TDH). We analysed the hospital records of 63 patients with traumatic injuries of the diaphragm. Of these patients, 39 had suffered a blunt trauma in a traffic accident, 21 penetrating trauma, and three had fallen from a great height. There were 51 patients (81 per cent) with left-sided diaphragmatic injuries, ten (16 per cent) with right-sided injuries, and in two patients (3 per cent) the injuries to the diaphragm were bilateral. There were 22 patients (35 per cent) who had intrathoracic migration of abdominal viscera. Surgical treatment was given in all cases. Twelve patients (19 per cent) died due to massive haemorrhage, neurological lesions, or septicaemia. Based on the literature and our own experience, we developed a diagnostic protocol for the management of diaphragmatic injuries. Chest radiographs should be made routinely. If diaphragmatic injury is suspected, ultrasound investigation must be performed. If the physician is still in doubt, computed tomography should be performed. At laparotomy, the diaphragm should always be thoroughly examined for lacerations.     

Epidemiology and outcome of acute pancreatitis

Acute pancreatitis in North-East Scotland from January 1983 to December 1985 was examined. The criteria for diagnosis were a serum amylase greater than 1000 units/l with a consistent clinical presentation, or acute pancreatitis confirmed at laparotomy or post mortem. All serum amylase assays were performed in one regional laboratory. The commonly used diagnostic coding search for pancreatitis yielded only half the cases found. We identified 378 episodes of acute pancreatitis (196 males and 182 females). The mean annual incidence for first attacks of acute pancreatitis was 242 per million of the population. The commonest aetiology was biliary tract disease (30 per cent of males and 53 per cent of females). Alcohol related pancreatitis occurred in 26.5 per cent of males but only 3 per cent of females. Complications included 26 pseudocysts, 11 pancreatic abscesses, 9 patients with respiratory failure, 11 patients with renal failure and 6 patients with disseminated intravascular coagulation.     

Selective visceral angiography in the diagnosis and treatment of gastrointestinal hemorrhage

Visceral angiography has been proved to be a valuable addition to the diagnostic armamentarium for acute and chronic gastrointestinal bleeding. Selective visceral arterial infusion of Pitressin is helpful in the control of acute gastrointestinal bleeding. In those patients who received Pitressin, 67 per cent had control of bleeding and in nine of eighteen (50 per cent) surgery was avoided. In patients whose bleeding was controlled by Pitressin there were no deaths resulting from recurrent bleeding of the original lesion.The use of Pitressin seems especially indicated in the management of acute gastrointestinal bleeding in a patient who is a poor surgical risk because of systemic disease, abdominal wall or intraperitoneal sepsis, stress ulcer syndrome, hemorrhagic gastritis, esophagogastric varices, and colonic lesions such as diverticulosis.     

Primary tumors of the small bowel

Primary tumors of the small bowel are uncommon, representing less than 6 per cent of all gastrointestinal tumors and less than 2 per cent of all malignant gastrointestinal tumors. This report concerns a twenty-five year survey of our clinical records from 1946 to 1971 which revealed 140 primary small bowel tumors, excluding periampullary tumors. Fifty-two of the neoplasms (37 per cent) were benign; eighty-eight (63 per cent) were malignant and included twenty-eight adenocarcinomas (31.8 per cent), twenty-four lymphosarcomas (27.3 per cent), nineteen carcinoids (21.6 per cent), and ten leiomyosarcomas (11.4 per cent). The average age at the time of diagnosis was 56.9 years for patients with benign tumors and 55.9 years for those with malignant tumors. The illusive and obscure nature of small bowel tumors is illustrated by the fact that 63.3 per cent of patients with benign lesions and 47.6 per cent of those with malignant lesions had symptoms for more than six months before the diagnosis was made. Bleeding was the most common present complaint in patients with benign neoplasms (52.9 per cent) whereas patients with malignant lesions more often had symptoms of obstruction (50.6 per cent). Most of the benign lesions were located proximally in the small bowel (duodenum, 34.6 per cent; ileum, 11.5 per cent), and most of the malignant lesions were located distally (duodenum, 17.0 per cent; ileum, 61.4 per cent). Treatment of patients with malignant lesions was radical excision whenever possible. Adjunctive radiation therapy was used for those with lymphoma. A second benign or malignant tumor occurred in 42.9 per cent of the patients with primary small bowel tumors. The average period of survival after diagnosis of a malignant small bowel tumor was 5.03 years: for patients with adenocarcinoma, 3.6 years; lymphosarcoma, 1.3 years; carcinoid, 6.8 years; and leiomyosarcoma, 8.3 years.