Special considerations in the management of lower GI bleed by interventional radiology

Despite the rapid development of diagnostic and therapeutic modalities and techniques to manage LGIB patients from interventional radiology’s standpoint, a successful localization of the bleeding site that leads to an effective embolotherapy remains a significant technical challenge. The interventional radiologist’s decisions when managing patients with LGIB may significantly impact the clinical outcomes; therefore, management should be made based on careful and thorough considerations of factors such as etiology, locations, patient’s comorbidities, and potential post-procedure complications, among others. The purpose of this paper is to review the management of LGIB by interventional radiology, focusing on a few challenging and common clinical situations that require special consideration by interventional radiologists.     

Low-dose aspirin and risk of upper/lower gastrointestinal bleeding by bleed severity: a cohort study with nested case-control analysis using primary care electronic health records from the United Kingdom

Introduction: Risks of low-dose aspirin-associated upper and lower gastrointestinal bleeds (UGIB/LGIB) may vary by severity and presence of cardiovascular disease (CVD). No study has quantified these risks for UGIB and LGIB in the same real-world study population.Patients and methods: Using UK primary care data, 199,049 new users of low-dose aspirin (75–300 mg/day) and 1:1 matched non-users were followed to identify incident UGIB (N = 1843)/LGIB (N = 2763) cases. Nested case-control analyses compared current low-dose aspirin vs. non-use on UGIB/LGIB risk.Results: Adjusted incidence rate ratios (ORs; 95% CIs) were 1.62 (1.42–1.86) for non-fatal UGIB, 1.63 (1.47–1.81) for non-fatal LGIB, 0.77 (0.51–1.16) for fatal UGIB, 1.29 (0.50–3.36) for fatal LGIB. For hospitalizations, adjusted ORs (95% CIs) were 1.55 (1.32–1.81) for UGIB and 1.89 (1.58–2.27) for LGIB; for referred only cases, they were 1.52 (1.26–1.84) for UGIB and 1.54 (1.37–1.73) for LGIB. In primary CVD prevention, adjusted ORs (95% CI) were 1.62 (1.38–1.90) for UGIB and 1.60 (1.42–1.81) for LGIB; in secondary CVD prevention, they were 1.16 (0.89–1.50) for UGIB and 1.67 (1.34–2.09) for LGIB.Conclusion: Low-dose aspirin was associated with increased risks of non-fatal but not fatal UGIB/LGIB.

Key message

• Low-dose aspirin is associated with an increased risks of non-fatal UGIB/LGIB but not fatal UGIB/LGIB.

     

Genitourinary emergencies in the nonpregnant woman

Lower abdominal and pelvic pains are common symptoms in women who present to the emergency department (ED). Once pregnancy has been ruled out, attention should focus on other potential life or fertility threats. Ultrasound remains the most helpful initial diagnostic modality. Time-sensitive and serious conditions, such as large ovarian masses or abnormal vaginal bleeding, need gynecologic consultation. Because many patients do not have access to primary care, ED physicians should be familiar with the treatment of sexually transmitted diseases. However, most nonpregnant women with pelvic complaints can safely be managed in the outpatient setting after ED evaluation.     

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over‐utilised or under‐estimated?

Introduction: A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC). Methods: To determine the outcome of STC in this high‐risk group, we retrospectively reviewed the histopathology reports and case records of all subtotal colectomies performed for LGIB over a 8‐year period. Results: Fifty‐eight patients (mean age: 71 years; male to female ratio, 1 : 1) underwent emergency surgery for unlocalised LGIB, 45% of which were massive on admission, and unresponsive to resuscitation. The remainder had persistent or recurrent bleeding during the index hospitalisation. The hospitalisation for colectomy represented the first for LGIB for 56% of the study group, while 38% were on at least their third such admission. All but three patients underwent preoperative rigid proctosigmoidoscopy. Fifty‐five of the 58 patients were treated with STC and primary ileorectal anastomosis. The major causes of bleeding were diverticular disease only (68%), angiodysplasia only (12%) and both diseases (12%). Overall mortality was 17%, with the main contributor being sepsis resulting from anastomotic leak. Non‐fatal complications occurred in 20%, resulting in a mean postoperative length of stay of 13 days. All patients were doing well on their first follow‐up visit with a mean number of four stools per day after 1 month. Conclusion: While emergency STC is an effective and definitive method of treating unlocalised massive LGIB, its associated morbidity and mortality may limit its usefulness.     

Evaluation and management of Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory–Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.     

Abnormal vaginal bleeding

The complaint of abnormal vaginal bleeding in a non‐pregnant patient is not a common presentation to a general ED. However, the bleeding may in itself be significant or it may be a harbinger of serious underlying pathology. A systematic approach to diagnosis is required. An initial approach to vaginal bleeding can be to categorize the bleeding by the anatomical site. This article discusses some of the common causes of upper tract or uterine bleeding and outlines the basic approach to diagnosis and management.     

急性下消化道出血的临床外科诊治分析

目的:探讨下消化道出血的病因及临床外科诊治策略。方法:回顾性分析复旦大学附属中山医院普通外科2012年1月至2017年12月收治的59例下消化道出血患者的临床资料。结果:59例患者经急诊胃肠镜、腹部CT、DSA及急诊剖腹探查等手段,全部明确出血原因及部位,共发现小肠血管畸形19例、小肠间质瘤(GIST)17例、结直肠肿瘤/息肉22例,49例患者行手术治疗。结论:术前采用急诊胃肠镜、腹部CT及DSA检查明确诊断是提高下消化道出血外科治疗效果的关键。     

Value of sonography in the diagnosis of abnormal vaginal bleeding

Abnormal vaginal bleeding is one of the most common presenting complaints in women of any age seeking gynecologic health care. Two of the most frequently used diagnostic tests to investigate the cause of the bleeding are endometrial biopsy and transvaginal sonography. The most worrisome cause of abnormal bleeding is endometrial carcinoma, yet benign etiologies are far more prevalent, including fibroids, polyps, and endometrial atrophy. Endometrial biopsy and transvaginal sonography have equal sensitivities for carcinoma, but sonography is far more effective in diagnosing benign disease. This article reviews the state-of-the-art in the diagnostic evaluation of abnormal vaginal bleeding and analyzes the data, with emphasis on the prevalence of benign and malignant disease as the basis for determining whether sonography or biopsy is more cost-effective in evaluating women with abnormal vaginal bleeding.     

Peristomal variceal bleeding treated by coil embolization using a percutaneous transhepatic approach

Peristomal variceal bleeding due to portal hypertension is an entity that has rarely been reported with 3%-4% risk of death. A 68-year-old woman who had undergone a palliative colostomy (colorectal carcinoma) presented with a massive hemorrhage from the colostomy conduit. Considering her oncological status with medial and right hepatic veins thrombosis due to liver metastasis invasion, an emergency transhepatic coil embolization was successfully performed. Standard treatment modality for these cases has not been established. Percutaneous transhepatic coil embolization of varices is a safe and effective choice in patients who present with life threatening bleeding and exhibit contraindications to transjugular intrahepatic portosystemic shunt.     

The assessment of stroke and bleeding risk in atrial fibrillation: where are we now?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Patients with AF are at increased risk of thromboembolism and ischemic stroke. Many stroke risk factors, including increasing age, diabetes mellitus, hypertension and congestive heart failure, are themselves associated with the development of AF. The risk of stroke in AF is not homogeneous, and many different risk stratification schemas are available for the evaluation of thromboembolic stroke risk in AF patients. In addition, the risk of bleeding associated with anti-thrombotic therapy also needs to be considered during the anti-thrombotic therapy decision-making process. However, there are few published and validated bleeding risk schema available for AF patients. The availability of user-friendly risk stratification schemas could accurately discriminate patients’ risk for stroke and anticoagulant therapy-related bleeding, and improve adherence to guidelines for thromboprophylaxis in AF.     

超声在胆道出血性疾病诊断中的应用

目的探讨超声在胆道出血性疾病诊断中的应用价值。方法对20例肝外伤性患者的胆囊内移动性异常回声的形态、大小、回声水平及其演变进行记录分析,总结胆道出血性疾病的胆囊积血声像图特征及演变规律。结果胆囊积血图像分为3种类型:弥漫细小回声型;成堆等回声型;成团强回声型。胆囊积血完全消失最短时间在外伤后3个月,最长时间在外伤后9个月。结论结合病史及超声对胆囊积血的监测,能为临床提供胆道出血的存在及胆道出血病情变化的依据,具有实际应用价值,为诊断胆道出血的间接有效的方法。     

Bleeding risk secondary to deep vein thrombosis prophylaxis in patients with lower gastrointestinal bleeding

Introduction: Deep vein thrombosis (DVT) and pulmonary embolism (PE) continue to pose a major burden on the health care system in the United States. The precise timing of anticoagulation initiation in critically ill patients with recent or active lower gastrointestinal bleeding (LGIB) is not well defined. We set out to study the safety and efficacy of early heparin administration for DVT prophylaxis in these patients. Methods: A review of all patients admitted to the ICU with a diagnosis of LGIB over a 13-year period was performed. A total of 60 patients received subcutaneous heparin along with mechanical prophylaxis, whereas 59 patients had intermittent pneumatic compression devices alone. Results: There was no difference in morbidity or mortality between the groups who received heparin and the nonheparin cohort. Neither of the groups developed a DVT or PE during the study period. Patients who received heparin had a median ICU LOS of 3 days, when compared with 2 days for patients who did not receive heparin (P < .0118). There was a significant association between units of blood received during the first 24 hours in the ICU and heparin usage (P < .0229). Those administered heparin received more units (median 3) than those who did not receive heparin (median 2). Conclusions: Administration of subcutaneous heparin increases the transfusion requirements and LOS in ICU patients with LGIB. After 24 hours, however, the blood transfusion requirements are equivalent. DVT prophylaxis in patients with a diagnosis of LGIB should be initiated after 24 hours of ICU admission.     

高原地区上消化道出血与饮酒的关系及术后护理

上消化道溃疡伴出血是一种常见急症之一,本文通过对饮酒所致的消化道出血进行调查,发现青海因海拔高、缺氧、酸性棕壤,长期反复大量饮酒而致出血临床多见,故强调从积极预防诱发因素和加强手术护理入手,配合饮食护理,合理用药,心理护理以及健康教育,从而达到预防疾病,维持健康的目的。     

Advances in transfusion medicine: gastrointestinal bleeding

Gastrointestinal bleeding is a common medical and surgical emergency and is the second most common indication for red blood cell (RBC) transfusion in the UK. Most transfusion guidelines recommend the use of restrictive blood transfusion in stable gastrointestinal bleeding. This review explores the evidence supporting this practice, including whether it is safe in lower as well as upper gastrointestinal bleeding, and the risks of restrictive transfusion in patients with cardiovascular disease. There is a lack of evidence supporting the use of platelet and fresh frozen plasma transfusion in gastrointestinal bleeding. The aim of this review is to serve as a practical guide to transfusion in stable gastrointestinal bleeding.     

A diagnostic approach to mild bleeding disorders

Mild inherited bleeding disorders are relatively common in the general population. Despite recent advances in diagnostic approaches, mild inherited bleeding disorders still pose a significant diagnostic challenge. Hemorrhagic diathesis can be caused by disorders in primary hemostasis (von Willebrand disease, inherited platelet function disorders), secondary hemostasis (hemophilia A and B, other (rare) coagulant factor deficiencies) and fibrinolysis, and in connective tissue or vascular formation. This review summarizes the currently available diagnostic methods for mild bleeding disorders and their pitfalls, from structured patient history to highly specialized laboratory diagnosis. A comprehensive framework for a diagnostic approach to mild inherited bleeding disorders is proposed.     

Sonography in first trimester bleeding

Vaginal bleeding is the most common cause of presentation to the emergency department in the first trimester. Approximately half of patients with first trimester vaginal bleeding will lose the pregnancy. Clinical assessment is difficult, and sonography is necessary to determine if a normal fetus is present and alive and to exclude other causes of bleeding (eg, ectopic or molar pregnancy). Diagnosis of a normal intrauterine pregnancy not only helps the physician in terms of management but also gives psychologic relief to the patient. Improved ultrasound technology and high-frequency endovaginal transducers have enabled early diagnosis of abnormal and ectopic pregnancies, decreasing maternal morbidity and mortality. The main differential considerations of first trimester bleeding are spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease. This article reviews the causes of first trimester bleeding and the sonographic findings, including normal features of first trimester pregnancy.     

Slowing the Flow: Management of Benign Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB), specifically heavy menstrual bleeding, is a common condition that can significantly affect women’s lives. AUB can impact women’s health, finances, social engagement, and overall quality of life. Potential causes of AUB can be assessed using a standard mnemonic to identify the origin as structural or nonstructural. The PALM-COEIN mnemonic stands for polyps, adenomyosis, leiomyoma, malignancy, hyperplasia, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes, and those not yet classified that are rare or not clearly defined. Treatment options include medical therapies, procedures, or surgical interventions. Nurse practitioners should partner with patients to individualize their plan of care based on best practices, beginning with the least invasive method. This case challenge highlights an underused treatment option for premenopausal women with heavy menstrual bleeding.     

Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding (OGIB) has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy. OGIB can present as overt bleeding or occult bleeding, and small bowel lesions are the most common causes. The small bowel can be evaluated using capsule endoscopy, device-assisted enteroscopy, computed tomography enterography, or magnetic resonance enterography. Once the cause of small-bowel bleeding is identified and targeted therapeutic intervention is completed, the patient can be managed with routine visits. However, diagnostic tests may produce negative results, and some patients with small bowel bleeding, regardless of diagnostic findings, may experience rebleeding. Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans. Several studies have identified different factors associated with rebleeding, and a limited number of studies have attempted to create prediction models for recurrence. This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding. These models may aid clinicians in forming tailored patient management and surveillance.     

Evaluation and management of variceal bleeding

Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.     

Acquired Hemophilia Presenting as Profound Hematuria: Evaluation,Diagnosis, and Management of Elusive Cause of Bleeding in the Emergency Department Setting

Background

There are numerous causes of bleeding that may present to the Emergency Department (ED). Although rare, acquired hemophilia is a potentially life-threatening bleeding disorder, with reported mortality rates ranging from 6% to 8% among patients who received proper diagnosis and treatment. Approximately two thirds of patients with this condition will present with major bleeding, the magnitude of which may necessitate urgent evaluation and care.

Objectives

The aim of this article is to provide an overview of the evaluation, differential diagnosis, and management of acquired hemophilia for the emergency physician.

Case Report

A case report of a patient who presented to the ED with gross hematuria secondary to undiagnosed acquired hemophilia is described to facilitate a review of the laboratory evaluation, differential diagnosis, and treatment of acquired hemophilia.

Conclusion

Patients with acquired hemophilia–related bleeding may present to the ED for care, given the often serious nature of their bleeding. Delayed diagnosis may postpone the initiation of targeted, effective treatments for achieving hemostasis, with potentially catastrophic consequences, particularly in patients who require emergent invasive procedures. Recognition of the potential for an underlying bleeding disorder and subsequent consultation with a hematologist are critical first steps in effectively identifying and managing a patient with acquired hemophilia who presents with bleeding.