小肠血管畸形致下消化道出血

目的：探讨小肠血管畸形的诊断和治疗。方法：回顾性分析21例小肠血管畸形患者的临床资料。结果：病程长，反复出血是小肠血管畸形的临床特征。出血呈间歇性，自限性，多为黑便和大便潜血试验阳性。术前血管造影15例中发现病变12例，可疑病变1例，21例均行手术治疗，其中14例经术中触摸，透照，美蓝等方法发现病变，7例经术中内镜检查确诊。结论：血管造影是有效的检查方法，透照检查应列为术为常规，注射美蓝简便有效，术中内窥镜检查具有重要诊断价值。     

小肠出血临床分析

目的　探讨小肠出血的诊断及治疗措施。方法　作者回顾分析自 1 979～ 2 0 0 0年收治的小肠出血性疾病 4 5例 ,均经单项或多项检查手段及手术探查证实。结果　采用动脉造影、核素扫描、小肠钡灌、小肠镜等手段发现良性疾病 38例 ,恶性疾病 7例。肿瘤占小肠出血比例最大。结论　血管造影具有较高的诊断率 ,并对手术有重要的指导价值。本组血管造影 2 0例 ,1 5例阳性。对诊断不清 ,一次出血量不大的病例剖腹探查需慎重考虑     

Lower gastrointestinal hemorrhage in renal transplant recipients

A review of the literature and our own series revealed 38 patients with lower gastrointestinal (LGI) hemorrhage among 4086 renal transplant recipients (0.9%). These patients represent 30% of 128 patients with major colorectal complications in this group. Of the 32 patients whose treatment and outcome were reported, only 12 (38%) were treated operatively. The overall mortality rate was 72%. The causes of LGI hemorrhage included colitis from opportunistic infections (42%); pseudomembranous, ischemic, or uremic colitis (40%); and idiopathic ulcers of the colon (18%). Colonoscopic, gross, and histopathologic findings of a patient with massive LGI hemorrhage from a fungal ulcer of the colon are the focus of this study, as are the implications of such findings. We propose an algorithm for diagnostic and therapeutic management decisions. We emphasize prompt diagnosis and the importance of colonoscopy. We propose withdrawal of immunosuppression and early operative intervention if the patient survival rate is to improve.     

Scintigraphy in the diagnosis of intestinal hemorrhage

13 patients with gastrointestinal hemorrhage underwent a scintigraphic examination to localize the bleeding. In 6 patients Tc-99m labeled red blood cells, in 7 patients Tc-99m sulfur colloid were used. Scintigraphy could demonstrate an intestinal bleeding in ten patients, in whom the conventional examinations, and among them 7 abdominal angiographies had failed. 5 of them had to be operated after that, whereby the scintigraphic findings were verified. One of the three patients with negative scintigraphy had to undergo an operation because of continuous bleeding. The methods of scintigraphy and their indication in gastrointestinal hemorrhage are discussed.     

Lower intestinal bleeding in the elderly.

Increasing recognition of bleeding vascular ectasias of the right colon prompted the present reevaluation of the importance classically attributed to diverticulosis as a cause of lower intestinal hemorrhage in the elderly.The records of all patients more than age sixty-five years admitted to Montefiore Hospital and Medical Center with lower intestinal bleeding from 1971 to 1976 were reviewed. Of 183 such patients, ninety-nine had major and eighty-four had minor bleeding. Of the ninety-nine patients with major bleeding, forty-three were discharged with a diagnosis of diverticular bleeding, and twenty were discharged with a diagnosis of vascular ectasias of the right colon.In most cases of diverticulosis, there was insufficient evidence to support this conclusion, and in only 18 per cent was the diagnosis based upon the angiographic demonstration of extravasation of contrast material into a diverticulum. In patients in whom a bleeding diverticulum was identified on angiography, segmental colectomy was not followed by recurrent hemorrhage. When no bleeding site was identified, colectomy was associated with a high incidence of rebleeding and subtotal colectomy with a high postoperative mortality. In all twenty patients with vascular ectasias, the lesion was identified on angiography, although extravasation was seen only twice. Eighteen patients were operated on: sixteen underwent right hemicolectomy and two subtotal colectomy; only two have rebled.Segmental colectomy will usually prevent recurrent hemorrhage when a site of diverticular bleeding or a vascular ectasia has been identified angiographically. Subtotal colectomy should be used only as a last resort.This study gives further support to the importance of vascular ectasias as a cause of bleeding in elderly patients and demonstrates the essential role of angiography in the diagnosis and management of this problem. Angiography is used to locate bleeding sites, to identify nonbleeding vascular ectasias, and for infusion of vasopressors into the mesenteric circulation to arrest bleeding.     

Clinical features and treatment of lower intestinal hemorrhage

We have experienced 471 patients with anal bleeding during the past seven years. The Results are as follows: 1. As for the types of disease, incidence of hemorrhoid, colorectal cancer and ulcerative colitis (UC) was high, while that of small intestinal problems was low. 2. In the cases of remarkable bleeding from the lower intestinal tract, massive or acute progressive bleeding was less frequent than expected. 3. Inflammatory diseases were the main causes of massive bleeding. Bleeding by UC was the major indication for urgent operation. In the cases with acute massive hemorrhage, basic complications were often found and the possibility of the diseases of small intestine and blood vessel disorders also should be considered. 4. At the examination of bleeding patients, it is efficient to explore the lower colon and rectum first by colonoscopy or sigmoidoscopy, for most of the bleeding lesions are found in these portions. 5. As for surgical treatment, most of colorectal cancer patients with hemorrhage are able to be operated with wait- and -see management. For UC patients, complete cure operation is possible even if they have high-dose steroid medication.     

The surgical treatment concept in acute intestinal hemorrhage

A clinically developed and prospectively verified therapeutic concept for acute intestinal bleeding is presented in this paper. Emphasis is laid on orthograde lavage likely to enable sooner and more effective use of diagnostic means and to provide optimal conditions for surgical therapy. Prognosis can be further improved by differentiated use of therapeutic endoscopy and early elective surgery. The effectiveness of this new therapeutic concept has been successfully verified on 81 patients, between 1975 and 1986. Lethality amounted to five per cent.     

Lower intestinal bleeding secondary to colonic vascular ectasia

Because multiple lesions, including colonic malignancies, vascular lesions of the colon, and diverticuli may coexist, identifying the cause of lower gastrointestinal bleeding in an elderly patient can be difficult. A case that demonstrates this clinical problem is reported. Right-sided colonic vascular ectasia eventually was detected angiographically and was treated successfully with hemicolectomy. Colonic vascular ectasia is an increasingly recognized cause of gastrointestinal hemorrhage. The pathologic findings, proposed theories of pathogenesis, and clinical association between colonic vascular ectasia and aortic stenosis are discussed.     

Lower gastrointestinal hemorrhage: etiologic assessment and surgical concept

Due to its occurence in patients at higher ages with comorbidities, lower gastrointestinal bleeding remains a challenge in terms of diagnostic and therapeutic strategies. In this series (1994-1997, n = 40) the source of bleeding was in the upper gastrointestinal tract in 38% and in the lower gastrointestinal tract in 62%. The source of bleeding could be localized in 58%. Bleeding stopped spontaneously in 40% of all patients but 60% required intervention (54% radiologic or endoscopic intervention, 46% surgery). Segmental resection was the procedure most frequently employed (8/11 patients), 3 patients underwent a subtotal colectomy. In-hospital mortality and surgical morbidity were 0/11 each. Following a staged diagnostic approach and segmental surgical resection, lower gastrointestinal bleeding can be treated with a low morbidity, mortality and a low rebleeding rate.     

Severe acute intestinal hemorrhage. Value of investigation tests

Episodes of intestinal bleeding likely to endanger vital functions require detailed etiological and topographical examination before surgical intervention. Forty-two cases of serious haemorrhage of the lower digestive system in adults were studied retrospectively. The origin of the bleeding was localized preoperatively in 37 cases (88%). Four exploratory laparotomies were carried out after etiological examination including at least digestive arteriography. Hence it was always possible to localize the source of bleeding. We found it convenient to establish the order of the complementary pretherapeutic tests by taking into account two symptoms, acute active bleeding (AAB) and haemorrhage with acute anemia (HAA).     

急性小肠出血的诊断分析

目的　探讨急性小肠出血的诊断方法。方法　对 17例急性小肠出血病人分别采用X线钡餐检查 ,99mTc标记的红细胞核素扫描 (ECT) ,选择性肠系膜血管造影 (DSA ) ,术中肠镜检查 ,比较各种诊断方法对判断出血部位的优劣。结果　对出血部位的定位阳性率 :ECT为 ( 7/14 )5 0 % ;DSA为 ( 8/12 ) 66.7% ,X线钡餐为 ( 3 /8) 3 7.5 %。术前不能确诊的 5例病人 ,术中肠镜均明确出血部位 ( 10 0 % )。结论　ECT和DSA有较高的诊断价值。对于术前辅助检查不能明确出血部位的病人 ,剖腹探查结合术中内镜检查是确定出血部位的关键。     

Selective superior mesenteric embolization for small intestinal hemorrhage.

A 25-year-old white woman who had previously undergone two operations for peptic ulcer disease, and was addicted to drugs and alcohol, had massive hemorrhage from the small intestine. Angiography pinpointed the jejunum as the source of bleeding. Because the patient had a coagulopathy she was considered a poor risk for surgery. Bleeding was controlled by embolization with sterile, commercially available Gelfoam (Upjohn) which was injected into the offending branch of the superior mesenteric artery. This is believed to be only the third documented case of embolization of small intestinal vessels. A review of the available literature is presented and the value of Gelfoam embolization as an adjunct in the control of hemorrhage in selected patients is stressed.